ICP monitoring in children: why are we not adhering to guidelines?

Abstract

Our study confirms that many children with severe TBI do not undergo ICP monitoring, mainly due to rapid improvement or moribund status. A subgroup of patients, with reassuring cerebral CT scan, was not monitored. Further research is necessary to assess if imaging should be considered in ICP indication, as in adult guidelines.

Update in Pediatric Neurotrauma

“…Notably, ICP monitoring in this study was associated with decreased mortality only when the GCS was 3 but was associated with longer ICU stay, longer hospitalization, and more days on the ventilator, potentially reflecting the population most likely to be chosen to undergo monitoring [39]. In the past decade, reported rates of ICP monitoring in the pediatric population have ranged from 7.7 to 59 % [39][40][41][42][43]. It has been shown that infants less than 1 year are less likely to undergo ICP monitoring [41,42] than are older children.…”

“…In the past decade, reported rates of ICP monitoring in the pediatric population have ranged from 7.7 to 59 % [39][40][41][42][43]. It has been shown that infants less than 1 year are less likely to undergo ICP monitoring [41,42] than are older children. Additionally, children hospitalized at adult-only trauma centers are more likely to have ICP monitors placed than are pediatric patients cared for at pediatric trauma centers [41].…”

“…Additionally, children hospitalized at adult-only trauma centers are more likely to have ICP monitors placed than are pediatric patients cared for at pediatric trauma centers [41]. The reasons for variable compliance with guideline recommendations likely include, in addition to factors related to implementation, dissemination, culture and communication, meaningful questions about guideline credibility, and the applicability of specific recommendations for an individual patient [42,44]. In one study, rapid early improvement in GCS, decision to pursue clinical surveillance, and moribund status, for example, were the most common reasons found for why ICP monitoring was not implemented.…”

“…In addition, in this study, radiologic (CT or MRI) features were also noted to be an important factor in the decision whether or not to place an ICP monitor-a factor not included in the current guidelines. All of the patients who underwent clinical surveillance in this study had Rotterdam CT scores of 1, 2, or 3 (most often 1-2) [42].…”

Noninvasive epicutaneous transfontanelle intracranial pressure monitoring in children under the age of 1 year: a novel technique

“…10 The decision not to monitor ICP often depends on analysis of clinical risks and potential benefits; it may be considered too invasive and risky in patients with improving Glasgow Coma Scale scores, and futile in moribund patients with catastrophic brain injuries. 16 The method that we present here may provide an alternative that allows for more frequent use of ICP monitoring to screen for and help in the management of elevated ICP in very young patients.…”