Influence of definition and location of hypotension on outcome following severe pediatric traumatic brain injury*

Abstract

Objective-To examine the influence of definition and location (field, emergency department [ED] or Pediatric Intensive Care Unit [PICU]) of hypotension on outcome following severe pediatric Traumatic Brain Injury (TBI). Participants-93 children < 14 years of age with TBI following injury, head abbreviated injury score (AIS) ≥ 3, and PICU admission Glasgow Coma Sale (GCS) score < 9 formed the analytic sample. Data sources included the Harborview Trauma Registry and Hospital Records. Design-Retrospective Cohort study. Setting-HarborviewOutcome Measures-The relationship between hypotension and outcome was examined comparing two definitions of hypotension: 1) systolic blood pressure (SBP) < 5 th percentile for age and 2) SBP < 90 mmHg. Hospital discharge Glasgow Outcome score (GOS) < 4, or disposition of either death or discharge to a skilled nursing facility were considered poor outcomes. PICU and hospital length of stay (LOS) were also examined.Results-SBP < 5 th percentile for age was more highly associated with poor hospital discharge GOS (p = 0.001), poor disposition (p = 0.02), PICU LOS (RR 9.5; 95% CI 6.7-12.3) and hospital LOS (RR 18.8;) than SBP < 90mmHg. Hypotension occurring in either the field or ED, but not in the PICU, was associated with poor GOS (p = 0.008), poor disposition (p= 0.03) and hospital LOS (RR 18.7; 95% CI 13.1-24.2).Conclusions-Early hypotension, defined as SBP < 5 th percentile for age in the field and/or ED, was a better predictor of poor outcome than delayed hypotension or the use of SBP < 90 mmHg.

Impaired Cerebral Autoregulation and 6-Month Outcome in Children with Severe Traumatic Brain Injury: Preliminary Findings

“…Although we examined autoregulation only once, testing occurred early in the course of TBI. This is relevant because our previous work suggests that early secondary hemodynamic insults may have more influence on outcome compared with delayed insults [19] and because autoregulation is impaired during the first 8 days after TBI [9] . Finally, we examined a select subset of patients with severe TBI and cannot draw any conclusions regarding the relationship between autoregulation and outcome in children with focal contusions.…”

Time of Hypotension and Discharge Outcome in Children with Severe Traumatic Brain Injury

“…T RAUMATIC BRAIN INJURY (TBI) is the leading cause of morbidity and mortality in children over 1 year of age (Langlois and Gotsch, 2001), and after TBI, children with hypotension have higher case fatality than patients who have blood pressure appropriate for age (Pigula et al, 1993;Kokoska et al, 1998;Chiaretti et al, 2002;Vavilala et al, 2003;Coates et al, 2005). In 2003, practice guidelines were published, recommending that systolic blood pressure (SBP) of Ͻ5 th percentile be avoided in children with severe TBI because the worst outcomes were associated with this definition of hypotension (Adelson et al, 2003).…”

tPA-S481A Prevents Impairment of Cerebrovascular Autoregulation by Endogenous tPA after Traumatic Brain Injury by Upregulating p38 MAPK and Inhibiting ET-1

“…For example, hypotension is an important predictor of poor outcome after TBI in children and adults. 37,38 Hypotension may be more detrimental to immature than to mature brain. 39 Cerebral autoregulation during hypotension is known to be impaired after TBI in the pediatric population.…”