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Cerebral oxygenation in major pediatric trauma: its relevance to trauma severity and outcome
Pradeep K Narotam1, Sathyaprasad C Burjonrappa, Stephen C Raynor
1Division of Neurosurgery and Trauma, Creighton University Medical Center, Omaha, NE 68131, USA. narotam@creighton.edu
Insights
Brain tissue oxygen monitoring (Pbto(2)) helps identify low oxygen delivery in pediatric trauma patients. Early intervention based on Pbto(2) levels improves outcomes and guides critical care decisions.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Trauma surgery
Background:
- Trauma is a leading cause of death in children, often involving primary brain injury exacerbated by secondary insults like hypoxia.
- Standard monitoring (ICP, CPP) fails to accurately assess cerebral oxygenation (Do(2)).
- Brain tissue oxygen monitoring (Pbto(2)) offers a direct measure of oxygen delivery to the brain.
Purpose of the Study:
- To evaluate the utility of brain tissue oxygen monitoring (Pbto(2)) in guiding critical care for pediatric trauma patients.
- To identify predictors of low oxygen delivery (Do(2)) in this population.
- To assess the impact of Pbto(2)-directed therapy on patient outcomes.
Main Methods:
- A prospective study involving 16 pediatric trauma patients (Injury Severity Score >16/Pediatric Trauma Score <7).
- Placement of a brain tissue oxygen monitor (Pbto(2)) for continuous monitoring.
- Therapeutic interventions (ventilation, inotropes, transfusions) were guided by Pbto(2) levels.
Main Results:
- 70% of patients presented with low Do(2) (Pbto(2) <20 mm Hg) despite standard resuscitation.
- Revised Trauma Score and Pediatric Trauma Score correlated with Pbto(2) levels and predicted low Do(2).
- Survivors had significantly higher Pbto(2) levels compared to non-survivors.
Conclusions:
- Brain tissue oxygen monitoring (Pbto(2)) enables early detection of critically low cerebral oxygen delivery in pediatric trauma.
- Pbto(2) monitoring facilitates timely therapeutic interventions, potentially improving patient outcomes.
- Pbto(2) serves as a valuable tool for optimizing critical care in severe pediatric trauma.
Introduction:
Trauma is the commonest cause of death in the pediatric population, which is prone to diffuse primary brain injury aggravated by secondary insults (eg, hypoxia, hypotension). Standard monitoring involves intracranial pressure (ICP) and cerebral perfusion pressure, which do not reflect true cerebral oxygenation (oxygen delivery [Do(2)]). We explore the merits of a brain tissue oxygen-directed critical care guide.
Methods:
Sixteen patients with major trauma (Injury Severity Score, >16/Pediatric Trauma Score [PTS], <7) had partial pressure of brain tissue oxygen (Pbto(2)) monitor (Licox; Integra Neurosciences, Plainsboro, NJ) placed under local anesthesia using twist-drill craniostomy and definitive management of associated injuries. Pbto(2) levels directed therapy intensity level (ventilator management, inotrops, blood transfusion, and others). Patient demographics, short-term physiological parameters, Pbto(2), ICP, Glasgow Coma Score, trauma scores, and outcomes were analyzed to identify the patients at risk for low Do(2).
Results:
There were 10 males and 6 females (mean age, 14 years) sustaining motor vehicle accident (14), falls (1), and assault (1), with a mean Injury Severity Score of 36 (16-59); PTS, 3 (0-7); and Revised Trauma Score, 5.5 (4-11). Eleven patients (70%) had low Do(2) (Pbto(2), <20 mm Hg) on admission despite undergoing standard resuscitation affected by fraction of inspired oxygen, Pao(2), and cerebral perfusion pressure (P = .001). Eubaric hyperoxia improved cerebral oxygenation in the low-Do(2) group (P = .044). The Revised Trauma Score (r = 0.65) showed moderate correlation with Pbto(2) and was a significant predictor for low Do(2) (P = .001). In patients with Pbto(2) of less than 20 mm Hg, PTS correlated with cerebral oxygenation (r = 0.671, P = .033). The mean 2-hour Pbto(2) and the final Pbto(2) in survivors were significantly higher than deaths (21.6 vs 7.2 mm Hg [P = .009] and 25 vs 11 mm Hg [P = .01]). Although 4 of 6 deaths were from uncontrolled high ICP, PTS and 2-hour low Do(2) were significant for roots for mortality.
Conclusions:
Pbto(2) monitoring allows for early recognition of low-Do(2) situations, enabling appropriate therapeutic intervention.
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