Objective To describe acute cerebral hemodynamic effects of medications commonly used to treat intracranial hypertension in children with traumatic brain injury (TBI). Currently, data supporting the efficacy of these medications are insufficient. Design In this prospective observational study, intracranial hypertension (intracranial pressure [ICP] ≥ 20 mm Hg for > 5 min) was treated by clinical protocol. Administration times of medications for intracranial hypertension (fentanyl, 3% sodium chloride [HTS], mannitol and pentobarbital) were prospectively recorded and synchronized with an automated database that collected ICP and cerebral perfusion pressure (CPP) every 5 seconds. ICP crises confounded by external stimulation or mechanical ventilator adjustments were excluded. Mean ICP and CPP from epochs following drug administration were compared to baseline values using Kruskal-Wallis ANOVA and Dunn's test. Frailty modeling was used to analyze the time to ICP crisis resolution. Mixed effect models compared ICP and CPP 5min after the medication vs. baseline, and rates of treatment failure. Setting A tertiary care children's hospital. Patients Children with severe TBI (Glasgow Coma Scale score ≤ 8). Interventions None. Measurements and Main Results We analyzed 196 doses of fentanyl, HTS, mannitol and pentobarbital administered to 16 children (median: 12 doses/patient). Overall, ICP significantly decreased following fentanyl, HTS and pentobarbital. After controlling for administration of multiple medications, ICP was decreased following HTS and pentobarbital administration; CPP was decreased following fentanyl and was increased following HTS. After adjusting for significant covariates (including age, GCS score and ICP), HTS was associated with a two-fold faster resolution of intracranial hypertension than either fentanyl or pentobarbital. Fentanyl was significantly associated with the most frequent treatment failure. Conclusions ICP decreased after multiple drugs, but HTS may warrant consideration as the first-line drug for treating intracranial hypertension, as it was associated with the most favorable cerebral hemodynamics and fastest resolution of intracranial hypertension.

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Background: Venovenous extracorporeal membrane oxygenation (ECMO) has become the ultimate supporting technique for the rescue of severe acute respiratory distress syndrome (ARDS) patients. Although tracheostomy during ECMO has proven to be beneficial, the proper time point for performing the tracheostomy remains unclear. The purpose of our study was to demonstrate whether early tracheostomy (ET; within 7 days of ECMO initiation) outweighs delayed tracheostomy (DT; 8 days of more after ECMO initiation).Methods: A retrospective cohort study was established. All ARDS patients who underwent tracheostomy during V-V ECMO support in the intensive care unit (ICU) of a tertiary hospital from December 2013 to November 2020 were reviewed.Results: Of the 187 ARDS patients who received V-V ECMO support, 30 (16%) underwent tracheostomy—18 (60%) during ECMO support and the other 12 after ECMO decannulation. Among the 18 patients who underwent tracheostomy while receiving ECMO, 11 (61.1%) received ET, and 7 received DT. No significant difference was found between the ET and DT groups in terms of demographic data, medical history, disease severity (estimated based on the RESP, PRESERVE, APACHE Ⅱ, SOFA and Murray scores), ARDS risk factors or mechanical ventilation duration before ECMO. The ET group showed a decreased incidence of ventilator-associated pneumonia (VAP) during ECMO support (45.5% vs. 100%; P= 0.038) and shortened durations of ECMO (9.0 vs. 27.0 days; P= 0.011) and mechanical ventilation (16.0 vs. 56.0 days; P= 0.027). ET did not significantly alter the all-cause ICU mortality rate (54.5% vs. 28.6%; P= 0.367), all-cause hospital mortality rate (which was the same as the ICU mortality rate), length of ICU stay (336 vs. 627 hours; P= 0.085), or length of hospital stay (26 vs. 37 days; P= 0.285). Local bleeding at the tracheostomy wound did not differ between the two groups (27.3% vs. 42.9%, P= 0.627) .Conclusion: Compared with delayed tracheostomy, ET performed within 7 days of ECMO cannulation for severe ARDS patients could decrease the VAP incidence during ECMO support and shorten the durations of ECMO and mechanical ventilation; However, it may not improve the outcome. Prospective and multicenter studies are needed for further research.