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Does adherence to treatment targets in children with severe traumatic brain injury avoid brain hypoxia? A brain
Anthony A Figaji1, A Graham Fieggen, Andrew C Argent
1Division of Neurosurgery, School of Child and Adolescent Health, University of Cape Town, Red Cross Children's Hospital, Cape Town, South Africa. anthony.figaji@uct.ac.za
Insights
Brain tissue oxygen monitoring (PbtO2) in children with severe traumatic brain injury (TBI) shows that low PbtO2 is linked to poor outcomes. Many patients had low PbtO2 even when conventional targets were met.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Intensive care unit management
Background:
- Conventional treatment targets for pediatric severe traumatic brain injury (TBI) include intracranial pressure, cerebral perfusion pressure, systemic oxygenation, and hemoglobin.
- Brain tissue oxygen tension (PbtO2) monitoring offers a more direct measure of brain oxygenation.
Purpose of the Study:
- To examine the association between PbtO2 values and outcomes in pediatric severe TBI.
- To determine the incidence of compromised PbtO2 in patients meeting conventional treatment targets.
Main Methods:
- Prospective observational study of 26 children with severe TBI.
- Continuous PbtO2 monitoring was used.
- Analysis of PbtO2 values in relation to outcome and time below specific thresholds (20, 15, 10, 5 mmHg).
Main Results:
- A significant association was found between poor outcome and the lowest 6-hour PbtO2 and time PbtO2 was < 15 and < 10 mmHg.
- Low PbtO2 independently predicted poor outcome.
- 80% of patients had compromised PbtO2 (< 20 mmHg) and nearly one-third had brain hypoxia (PbtO2 < 10 mmHg) despite meeting conventional targets.
Conclusions:
- Reduced PbtO2 is significantly associated with poor outcomes in pediatric severe TBI.
- Conventional treatment targets may not adequately ensure sufficient brain oxygenation, as many patients experience episodes of compromised PbtO2.
Objective:
Most physicians rely on conventional treatment targets for intracranial pressure, cerebral perfusion pressure, systemic oxygenation, and hemoglobin to direct management of traumatic brain injury (TBI) in children. In this study, we used brain tissue oxygen tension (PbtO2) monitoring to examine the association between PbtO2 values and outcome in pediatric severe TBI and to determine the incidence of compromised PbtO2 in patients for whom acceptable treatment targets had been achieved.
Methods:
In this prospective observational study, 26 children with severe TBI and a median postresuscitation Glasgow Coma Scale score of 5 were managed with continuous PbtO2 monitoring. The relationships between outcome and the 6-hour period of lowest PbtO2 values and the length of time that PbtO2 was less than 20, 15, 10, and 5 mmHg were examined. The incidence of reduced PbtO2 for each threshold was evaluated where the following targets were met: intracranial pressure less than 20 mmHg, cerebral perfusion pressure greater than 50 mmHg, arterial oxygen tension greater than 60 mmHg (and peripheral oxygen saturation > 90%), and hemoglobin greater than 8 g/dl.
Results:
There was a significant association between poor outcome and the 6-hour period of lowest PbtO2 and length of time that PbtO2 was less than 15 and 10 mmHg. Multiple logistic regression analysis showed that low PbtO2 had an independent association with poor outcome. Despite achieving the management targets described above, 80% of patients experienced one or more episodes of compromised PbtO2 (< 20 mmHg), and almost one-third experienced episodes of brain hypoxia (PbtO2 < 10 mmHg).
Conclusion:
Reduced PbtO2 is associated with poor outcome in pediatric severe TBI. In addition, many patients experience episodes of compromised PbtO2 despite achieving acceptable treatment targets.
