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ICP monitoring in children: why are we not adhering to guidelines?
Nadia Roumeliotis1, Géraldine Pettersen2, Louis Crevier3
1Department of Critical Care, Sainte-Justine Hospital, University of Montréal, 3175 Cote Sainte-Catherine, Montréal, Québec, Canada, H3T 1C5. nadia.roumeliotis@gmail.com.
Insights
Many children with severe traumatic brain injury (TBI) do not receive intracranial pressure (ICP) monitoring due to rapid improvement or critical condition. Further research is needed to clarify ICP monitoring indications in pediatric TBI.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Pediatric neurosurgery
Background:
- Severe traumatic brain injury (TBI) management guidelines recommend intracranial pressure (ICP) monitoring, yet adherence varies significantly in pediatric cases.
- Between 7% and 60% of children with severe TBI undergo ICP monitoring, with reasons for low adherence remaining unclear.
- This study evaluates current ICP monitoring practices for severe TBI in children at CHU Sainte-Justine and identifies barriers to its implementation.
Purpose of the Study:
- To assess the current utilization of ICP monitoring in pediatric severe TBI cases.
- To explore the specific reasons why ICP monitoring is not performed in eligible pediatric patients.
- To inform future guidelines and clinical practice regarding ICP monitoring in severe TBI.
Main Methods:
- A retrospective review of pediatric patients (1 month to 18 years) diagnosed with severe TBI (Glasgow Coma Scale ≤8) between 2007 and 2014.
- Data collected included the presence of ICP monitoring, head imaging reports, and documented reasons for the absence of monitoring.
- Analysis focused on identifying trends in monitoring use and factors influencing clinical decisions.
Main Results:
- Out of 64 severe TBI patients, 20 (31%) received ICP monitoring within 6 hours, and 5 more within 24 hours.
- The primary reasons for not initiating ICP monitoring were rapid improvement in Glasgow Coma Scale (GCS) upon arrival (20%) and moribund status (20%).
- Fourteen patients (21%) with non-indicative cerebral CT scans (Rotterdam scores 1-3) and a median GCS of 7 were initially managed with clinical surveillance, with 5 eventually receiving ICP monitoring after 6 hours.
Conclusions:
- The study confirms that a significant proportion of children with severe TBI do not undergo ICP monitoring, often due to clinical improvement or critical status.
- A notable subgroup of patients with seemingly reassuring cerebral CT scans were also not monitored.
- Further investigation is warranted to determine if neuroimaging findings should influence ICP monitoring indications in pediatric TBI, mirroring adult guidelines.
Background:
Despite pediatric guidelines, variability exists in the management of severe traumatic brain injury (TBI), as somewhere between 7 and 60% of children undergo intracranial pressure (ICP) monitoring. Reasons for this low adherence to TBI management guidelines remain unclear. The objective of this study was to evaluate the current practices at CHU Sainte-Justine with regards to ICP monitoring in severe TBI and explore the reasons why ICP monitoring is not undertaken.
Methods:
A retrospective review was conducted of all patients age 1 month to 18 years, with severe TBI (Glasgow Coma Scale (GCS) ≤8) from 2007 to 2014. Presence of ICP monitoring, head imaging reports, and reasons for lack of monitoring were recorded.
Results:
Sixty-four patients with severe TBI were admitted. Twenty (31%) patients had invasive ICP monitoring in the first 6 h and 5 in the following 24 h. Improvement of the GCS on arrival to tertiary care center (20%, n = 13) and moribund status (20%, n = 13) were the two main reasons ICP monitoring was not undertaken. Fourteen patients (21%) with reassuring cerebral tomography (Rotterdam scores 1-3) and median GCS 7 (IQR 6-8) were initially followed with clinical surveillance, five of which ended up with an ICP monitor (>6 h).
Conclusion:
Our study confirms that many children with severe TBI do not undergo ICP monitoring, mainly due to rapid improvement or moribund status. A subgroup of patients, with reassuring cerebral CT scan, was not monitored. Further research is necessary to assess if imaging should be considered in ICP indication, as in adult guidelines.
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