State of Cerebrovascular Autoregulation Correlates with Outcome in Severe Infant/Pediatric Traumatic Brain Injury

Nagel, Carmen; Diedler, Jennifer; Gerbig, Ines; Heimberg, Ellen; Schuhmann, Martin U.; Hockel, Konstantin

doi:10.1007/978-3-319-22533-3_48

Cited by 25 publications

(13 citation statements)

References 20 publications

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“…Previous studies have shown that a positive PRx is associated with disturbance of cerebral autoregulation ( 10 , 11 ). Importantly, PRx has also been demonstrated to independently predict outcome after TBI in children ( 12 , 13 ).…”

Section: Introductionmentioning

confidence: 99%

Glycemia Is Related to Impaired Cerebrovascular Autoregulation after Severe Pediatric Traumatic Brain Injury: A Retrospective Observational Study

et al. 2017

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IntroductionA strong association exists between hyperglycemia and outcome in pediatric traumatic brain injury (TBI). Herein, we describe observations of serum markers of glucose metabolism in a cohort of pediatric TBI patients and how these variables are related to parameters of intracranial pathophysiology.MethodsA retrospective analysis was performed on pediatric severe TBI patients admitted to Addenbrookes Hospital Paediatric Intensive Care Unit (PICU) between January 2001 and December 2013. Demographic, outcome, systemic physiological, and cerebral autoregulatory data were extracted for patients who had received continuous invasive monitoring (ICM+, Cambridge Enterprise, Cambridge, UK). Data were analyzed using a mixed linear model.ResultsForty-four patients with an average age of 12.2 years were admitted to the PICU with a TBI requiring invasive neurosurgical monitoring. Thirty-two patients (73%) survived, with favorable outcomes in 62%. The mean (SD) intracranial pressure (ICP) was 17.6 + 9.0 mmHg, MAP was 89.7 + 9.0 mmHg, and pressure-reactivity index (PRx) was −0.01 + 0.23 a.u. The mean (SD) serum lactate was 2.2 (3.3) mmol/L. and the mean (SD) serum glucose was 6.1 (1.6) mmol/L. Early hyperglycemia was strongly associated with both PRx (Pearson correlation 0.351, p < 0.001) and ICP (Pearson correlation 0.240, p = 0.002) death (p = 0.021) and impaired cerebral autoregulation (p = 0.02). There was a strong association between ICP and serum lactate (p = 0.001).ConclusionIncreases in systemic glucose are associated with impaired cerebrovasular autoregulation after severe pediatric TBI. Moreover, deranged blood glucose is a marker of poor prognosis. Further studies are required to delineate putative mechanisms of hyperglycemia induced cerebral harm.

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Section: Introductionmentioning

confidence: 99%

Glycemia Is Related to Impaired Cerebrovascular Autoregulation after Severe Pediatric Traumatic Brain Injury: A Retrospective Observational Study

et al. 2017

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“…When autoregulation is impaired patients are at greater risk at both lower and upper ranges of BP. Therefore, it is unsurprising that impaired autoregulation is associated with worse outcomes ( 113 ). Currently, there are no recommendations of how autoregulatory capacity should be considered in the management of pediatric TBI.…”

Section: Brain Physiology and Monitoringmentioning

confidence: 99%

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

Figaji

2017

Front. Neurol.

138

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General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.

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“…27,28 Over the years, a dynamic protocol for monitoring CPP based on the autoregulatory capacity of the cerebral vascular system (pressure reactivity index [PRx]) has been proposed to determine optimal CPP (CPP opt ) for each patient. The PRx correlates well with Glasgow outcome scale 29 and is associated with improved survival. 30 In contrast, CPP opt is significantly correlated with patient's age 31 and when optimized, it is associated with better outcomes.…”

Section: Discussionmentioning

confidence: 74%

Severe Traumatic Brain Injury in French-Speaking Pediatric Intensive Care Units: Study of Practices

Denis

Lauzier

Roumeliotis

et al. 2022

J Pediatr Intensive Care

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Best strategies for managing severe pediatric traumatic brain injury (TBI) are not established, with wide variations among professional practices. The main objective of this study was to assess compliance with updated pediatric TBI management guidelines (2019). A survey was distributed among French-speaking pediatric intensive care physicians from April 1 to June 30, 2019. The survey was based on a clinical case with a total of 70 questions that cover the 15 items of the 2019 TBI guidelines. The questions evaluated the assessment and management of TBI during the acute and intensive care phases. Of 487 e-mails sent, 78 surveys were included. Guidelines were adhered to (> 60%) for 10 of 15 items in the guidelines. Strong adherence to recent guideline changes was achieved for seizure prophylaxis with levetiracetam (n = 21/33, 64%) and partial pressure of carbon dioxide threshold (n = 52, 67%). However, management of the sodium and glucose thresholds and the role of transcranial Doppler were not consistent with the guidelines. Assessment of brain tissue oxygenation (n = 12, 16%) and autoregulation (n = 35, 45%) was not a common practice. There was strong agreement among clinicians on the intracranial pressure (> 80%) and cerebral perfusion pressure (> 70%) thresholds used according to age. Overall, stated practices for the management of TBI appear to be relatively standardized among responders. Variations persist in areas with a lack of evidence and pediatric-specific recommendations.

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State of Cerebrovascular Autoregulation Correlates with Outcome in Severe Infant/Pediatric Traumatic Brain Injury

Cited by 25 publications

References 20 publications

Glycemia Is Related to Impaired Cerebrovascular Autoregulation after Severe Pediatric Traumatic Brain Injury: A Retrospective Observational Study

Glycemia Is Related to Impaired Cerebrovascular Autoregulation after Severe Pediatric Traumatic Brain Injury: A Retrospective Observational Study

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

Severe Traumatic Brain Injury in French-Speaking Pediatric Intensive Care Units: Study of Practices

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