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Published on: March 26, 2019
Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury
Yasuki Fujita1, Nelson N Algarra, Monica S Vavilala
1Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
Insights
Intraoperative secondary insults like hypotension and hypoxia are common in pediatric traumatic brain injury (TBI) surgery. These insults can lead to increased intracranial pressure after surgery, highlighting the need for preventative strategies.
Area of Science:
- Pediatric neurosurgery
- Traumatic Brain Injury (TBI) research
- Critical care medicine
Background:
- Intraoperative secondary insults in pediatric traumatic brain injury (TBI) are not well-documented.
- Extracranial surgery in children with moderate-severe TBI and polytrauma presents unique challenges.
- Understanding these insults is crucial for improving patient outcomes.
Purpose of the Study:
- To examine the incidence of intraoperative secondary insults during extracranial surgery in pediatric TBI patients.
- To investigate the association between these insults and postoperative outcomes, including head CT scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores.
- To identify specific insults linked to adverse postoperative neurological status.
Main Methods:
- Retrospective review of medical records for children under 18 with moderate-severe TBI undergoing extracranial surgery within 72 hours of injury.
- Defined secondary insults including systemic/cerebral hypotension, intracranial hypertension, hypoxia, hypercarbia, hypocarbia, hyperglycemia, and temperature dysregulation.
- Analyzed associations with postoperative ICP, head CT findings, and TIL scores 24 hours post-surgery.
Main Results:
- Systemic hypotension occurred in 78% of surgeries, hypocarbia in 46%, and hypercarbia in 25%.
- Intracranial hypertension was observed in 64% of surgeries with ICP monitoring.
- Intraoperative cerebral hypotension and hypoxia were significantly associated with postoperative intracranial hypertension (p=0.02 and p=0.03, respectively).
Conclusions:
- Intraoperative secondary insults are frequent during extracranial surgery in pediatric TBI.
- Cerebral hypotension and hypoxia during surgery are linked to increased intracranial pressure postoperatively.
- Developing strategies to mitigate intraoperative secondary insults is essential for managing pediatric TBI patients.
Purpose:
Data on intraoperative secondary insults in pediatric traumatic brain injury (TBI) are limited.
Methods:
We examined intraoperative secondary insults during extracranial surgery in children with moderate-severe TBI and polytrauma and their association with postoperative head computed tomography (CT) scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores 24 h after surgery. After IRB approval, we reviewed the records of children <18 years with a Glasgow Coma Scale score <13 who underwent extracranial surgery within 72 h of TBI. Definitions of secondary insults were as follows: systemic hypotension (SBP <70 + 2 × age or 90 mmHg), cerebral hypotension (cerebral perfusion pressure <40 mmHg), intracranial hypertension (ICP >20 mmHg), hypoxia (oxygen saturation <90 %), hypercarbia (end-tidal CO2 >45 mmHg), hypocarbia (end-tidal CO2 <30 mmHg without hypotension and in the absence of intracranial hypertension), hyperglycemia (blood glucose >200 mg/dL), hyperthermia (temperature >38 °C), and hypothermia (temperature <35 °C).
Results:
Data from 50 surgeries in 42 patients (median age 15.5 years, 25 males) revealed systemic hypotension during 78 %, hypocarbia during 46 %, and hypercarbia during 25 % surgeries. Intracranial hypertension occurred in 64 % and cerebral hypotension in 18 % surgeries with ICP monitoring (11/50). Hyperglycemia occurred during 17 % of the 29 surgeries with glucose monitoring. Cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension (p = 0.02 and 0.03, respectively). We did not observe an association between intraoperative secondary insults and postoperative worsening of head CT scan or TIL score.
Conclusions:
Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.
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