Predictors of outcome in severely head-injured children
1Division of Pediatric Critical Care Medicine, Children's National Medical Center, Washington DC, USA.
Insights
Higher 6-hour Glasgow Coma Scale scores and systolic blood pressure >or=135 mm Hg predict survival in children with severe traumatic brain injury. Mannitol use prolonged pediatric intensive care unit length of stay without improving survival.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Clinical outcomes research
Background:
- Severe traumatic brain injury (TBI) in children presents significant challenges in acute care management.
- Identifying prognostic factors is crucial for optimizing treatment strategies and improving patient outcomes.
Purpose of the Study:
- To determine variables during the acute care period associated with survival and pediatric intensive care unit (PICU) length of stay (LOS) in children with severe TBI.
- To identify predictors of survival and resource utilization in this vulnerable population.
Main Methods:
- Retrospective cohort study of 136 children (0-17 years) admitted with severe TBI (Glasgow Coma Scale score ≤8) between 1991 and 1995.
- Analysis focused on the first 72 hours of hospitalization, examining survival, PICU LOS, and cost.
- Key variables included Glasgow Coma Scale scores, blood pressure, injury severity scores, CT findings, and medication use.
Main Results:
- The overall fatality rate was 24%.
- Survival was independently predicted by a higher 6-hour Glasgow Coma Scale score (OR 4.6) and maximum systolic blood pressure ≥135 mm Hg (OR 1.05, 19-fold increase in odds).
- Mannitol use was associated with increased hospital costs and prolonged PICU LOS (OR 7.9) but did not confer a survival advantage.
Conclusions:
- Higher initial Glasgow Coma Scale scores and achieving supranormal systolic blood pressure (≥135 mm Hg) are associated with improved survival in pediatric severe TBI.
- Mannitol administration should be reevaluated due to its association with prolonged PICU LOS and lack of survival benefit.
- These findings suggest potential modifications to blood pressure management and medication protocols in pediatric TBI care.
Objective:
Determine variables in the acute care period associated with survival and pediatric intensive care unit (PICU) length of stay (LOS) for children with severe traumatic brain injury.
Design:
Retrospective cohort.
Setting:
Level 1 pediatric trauma center.
Patients:
Children (0-17 yrs) admitted 1991 to 1995 with nonpenetrating traumatic brain injury and admission Glasgow Coma Scale score of
Interventions:
None.
Measurements And Main Results:
The first 72 hrs of hospitalization were analyzed in detail for 136 patients. The primary end point was survival; secondary end points were PICU LOS, cost, and day at which Glasgow Coma Scale score was >or=14. Predictors of outcome were abstracted, including Pediatric Trauma Score, Glasgow Coma Scale score, Pediatric Risk of Mortality, physiologic variables, computed tomography evidence of brain injury, and neuroresuscitative medications. The fatality rate was 24%. Age and gender were similar between groups (p >or= .1). Survival was independently predicted by 6-hr Glasgow Coma Scale score (odds ratio [OR] 4.6; 95% confidence interval [CI] 2.06-11.9; p < .001) and maximum systolic blood pressure (OR 1.05; 95% CI 1.01-1.09; p < .02). Odds of survival increased 19-fold when maximum systolic blood pressure was >or=135 mm Hg (OR 18.8; 95% CI 2.0-178.0; p < .01). By discharge, 67% of patients had an age-appropriate Glasgow Coma Scale score. Median hospital costs were 8,798 dollars for survivors: only mannitol use independently predicted high cost (odds ratio 4.9; 95% CI 1.2-19.1; p < .01). For survivors, median PICU LOS was 2 days, although 25% had LOS >6 days. Six-hour Glasgow Coma Scale score (OR 0.62; 95% CI 0.48-0.80; p < .001) and mannitol (OR 7.9; 95% CI 2.3-27.3; p < .001) were each independently associated with a prolonged LOS among survivors.
Conclusions:
Patients with higher 6-hr Glasgow Coma Scale scores were more likely to survive. Adjusting for severity of injury, survival was associated with maximum systolic blood pressure >or=135 mm Hg, suggesting that supranormal blood pressures are associated with improved outcome. Mannitol administration was associated with prolonged LOS, yet conferred no survival advantage. We suggest reevaluation of blood pressure targets and mannitol use in children with severe traumatic brain injury.
