Abstract
ABSTRACTObjective:To determine the events associated with the occurrence of intracranial hypertension (ICH) in pediatric patients with severe cranioencephalic trauma.Methods:This was a prospective cohort study of patients 18 years old and younger with cranioencephalic trauma, scores below nine on the Glasgow Coma Scale, and intracranial pressure monitoring. They were admitted between September, 2005 and March, 2014 into a Pediatric Intensive Care Unit. ICH was defined as an episode of intracranial pressure above 20 mmHg for more than five minutes that needed treatment.Results:A total of 198 children and adolescents were included in the study, of which 70.2% were males and there was a median age of nine years old. ICH occurred in 135 (68.2%) patients and maximum intracranial pressure was 36.3 mmHg, with a median of 34 mmHg. A total of 133 (97.8%) patients with ICH received sedation and analgesia for treatment of the condition, 108 (79.4%) received neuromuscular blockers, 7 (5.2%) had cerebrospinal fluid drainage, 105 (77.2%) received mannitol, 96 (70.6%) received hyperventilation, 64 (47.1%) received 3% saline solution, 20 (14.7%) received barbiturates, and 43 (31.9%) underwent a decompressive craniectomy. The events associated with the occurrence of ICH were tomographic findings at the time of admission of diffuse or hemispheric swelling (edema plus engorgement). The odds ratio for ICH in patients with Marshall III (diffuse swelling) tomography was 14 (95%CI 2.8–113; p<0.003), and for those with Marshall IV (hemispherical swelling) was 24.9 (95%CI 2.4–676, p<0.018). Mortality was 22.2%.Conclusions:Pediatric patients with severe cranioencephalic trauma and tomographic alterations of Marshall III and IV presented a high chance of developing ICH.
Highlights
External causes kill about one million children and adolescents worldwide each year, and among them, traumatic brain injury (TBI) is the leading cause of death, permanent disability, and intensive care hospitalization.[1,2] Once trauma has occurred, it is up to the health care team to prevent and correct secondary brain damage,[3] which includes intracranial hypertension (ICH), which may compromise perfusion pressure and brain flow and cause herniations, leading to focal ischemia and brainstem compression.[4,5,6]In the acute phase of trauma, ICH results from swelling, hematomas, bruises, edema and, less often, obstructive hydrocephalus
Some authors have related the occurrence of ICH to a worse prognosis in adults and children suffering from severe TBI, and reported improved outcomes with aggressive control of intracranial pressure (ICP).[5,6]
Between September 2005 and March 2014, 362 patients with blunt severe TBI were admitted to the pediatric intensive care unit (ICU), 200 of whom underwent ICP monitoring, and two of whom were excluded from the study because the family did not provide consent
Summary
In the acute phase of trauma, ICH results from swelling (edema and engorgement), hematomas, bruises, edema and, less often, obstructive hydrocephalus. Some authors have related the occurrence of ICH to a worse prognosis in adults and children suffering from severe TBI, and reported improved outcomes with aggressive control of ICP.[5,6] the results of studies comparing the outcome of patients who had their treatment guided by ICP monitoring with those who did not are inconclusive.[7,8,9] In addition, monitoring has complications such as infections, bleeding, measurement errors and malfunctions, with variable frequency, depending on the device used.[8,10,11] Reports of prolonged mechanical ventilation, length of stay, unnecessary institution of harmful treatments, and increased hospital costs with and without ICP monitoring are contradictory. Some authors have related the occurrence of ICH to a worse prognosis in adults and children suffering from severe TBI, and reported improved outcomes with aggressive control of ICP.[5,6] the results of studies comparing the outcome of patients who had their treatment guided by ICP monitoring with those who did not are inconclusive.[7,8,9] In addition, monitoring has complications such as infections, bleeding, measurement errors and malfunctions, with variable frequency, depending on the device used.[8,10,11] Reports of prolonged mechanical ventilation, length of stay, unnecessary institution of harmful treatments, and increased hospital costs with and without ICP monitoring are contradictory. 8,12,13
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