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Differences in medical therapy goals for children with severe traumatic brain injury-an international study
Michael J Bell1, P David Adelson, James S Hutchison
11Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA. 2Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA. 3Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA. 4Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ. 5Department of Critical Care Medicine, University of Toronto, Toronto, CA. 6Department of Neurology, Harvard Medical School, Boston, MA. 7Department of Anesthesia, Harvard Medical School, Boston, MA. 8Division of Critical Care, Boston Children's Hospital, Boston, MA. 9Department of Anesthesia, University of Washington, Seattle, WA. 10Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA. 11Department of Epidemiology and Biostatistics, University of Pittsburgh, Pittsburgh, PA.
Insights
Medical practice goals for pediatric severe traumatic brain injury (TBI) vary significantly across international centers. These differences highlight a need for further research to establish evidence-based standards of care for TBI therapies.
Area of Science:
- Pediatric critical care medicine
- Pediatric neurosurgery
- Traumatic brain injury research
Background:
- Severe traumatic brain injury (TBI) in children presents complex management challenges.
- Current medical therapies for pediatric TBI lack universally standardized treatment protocols.
- International collaboration is crucial for understanding variations in clinical practice.
Purpose of the Study:
- To delineate and compare the clinical practice goals for managing pediatric severe TBI across international medical centers.
- To identify areas of significant variation in therapeutic strategies for intracranial hypertension, hypoxia, and metabolic support.
- To provide a foundation for future research aimed at standardizing TBI care.
Main Methods:
- A survey was administered to representatives from 32 pediatric TBI centers in the US, UK, France, and Spain.
- The survey gathered free-form responses on usual practice goals for specific TBI management areas.
- Data focused on intracranial hypertension, hypoxia/ischemia, and metabolic support strategies.
Main Results:
- Significant variability was observed in cerebrospinal fluid diversion strategies.
- Mannitol and hypertonic saline were widely used for hyperosmolar therapy, with diverse concentrations of hypertonic saline employed.
- Routine hyperventilation was uncommon, and only 31.3% of centers monitored cerebral oxygenation (PbO2).
- Nutritional support and glucose administration timing varied considerably among centers.
Conclusions:
- Marked differences exist in medical goals for pediatric severe TBI management across international centers.
- These discrepancies are most pronounced in therapeutic areas with limited supporting scientific literature.
- Further research is essential to determine the superiority of various medical therapies, potentially leading to new standards of care and improved clinical trial designs.
Objectives:
To describe the differences in goals for their usual practice for various medical therapies from a number of international centers for children with severe traumatic brain injury.
Design:
A survey of the goals from representatives of the international centers.
Setting:
Thirty-two pediatric traumatic brain injury centers in the United States, United Kingdom, France, and Spain.
Patients:
None.
Interventions:
None.
Measurements And Main Results:
A survey instrument was developed that required free-form responses from the centers regarding their usual practice goals for topics of intracranial hypertension therapies, hypoxia/ischemia prevention and detection, and metabolic support. Cerebrospinal fluid diversion strategies varied both across centers and within centers, with roughly equal proportion of centers adopting a strategy of continuous cerebrospinal fluid diversion and a strategy of no cerebrospinal fluid diversion. Use of mannitol and hypertonic saline for hyperosmolar therapies was widespread among centers (90.1% and 96.9%, respectively). Of centers using hypertonic saline, 3% saline preparations were the most common but many other concentrations were in common use. Routine hyperventilation was not reported as a standard goal and 31.3% of centers currently use PbO(2) monitoring for cerebral hypoxia. The time to start nutritional support and glucose administration varied widely, with nutritional support beginning before 96 hours and glucose administration being started earlier in most centers.
Conclusions:
There were marked differences in medical goals for children with severe traumatic brain injury across our international consortium, and these differences seemed to be greatest in areas with the weakest evidence in the literature. Future studies that determine the superiority of the various medical therapies outlined within our survey would be a significant advance for the pediatric neurotrauma field and may lead to new standards of care and improved study designs for clinical trials.
