Autoregulation in paediatric TBI-current evidence and implications for treatment
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Published on: April 1, 2019
Joseph E Donnelly1, Adam M H Young1, Ken Brady2
1Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
Insights
Children surviving traumatic brain injury (TBI) need optimal brain pressure management. Autoregulation monitoring may identify personalized targets, but methods require validation for better pediatric TBI outcomes.
Area of Science:
- Pediatric neurocritical care
- Traumatic brain injury management
Background:
- Children surviving traumatic brain injury (TBI) face risks from secondary brain injury.
- Maintaining optimal cerebral perfusion pressure (CPP) is critical but targets for children remain unknown.
- Autoregulation monitoring is explored for individualized CPP but methods lack universal validation.
Purpose of the Study:
- To review the history and methods of autoregulation monitoring in TBI.
- To assess the available validation data for autoregulation monitoring techniques.
- To inform future research on CPP targets in pediatric TBI.
Main Methods:
- Historical overview of autoregulation monitoring.
- Categorization of current autoregulation measurement methods.
- Review of validation studies for autoregulation monitoring techniques.
Main Results:
- Impaired autoregulation in TBI correlates with poor prognosis.
- Observational data links optimal CPP (via autoregulation monitoring) to improved outcomes.
- No randomized controlled trials exist for autoregulation monitoring in pediatric TBI.
Conclusions:
- Autoregulation monitoring shows promise for optimizing CPP in TBI patients.
- Further research, including randomized trials, is needed to validate these methods for pediatric TBI.
- Establishing validated autoregulation monitoring could improve survival and neurologic outcomes in children with TBI.
Background:
Children who survive acute traumatic brain injury are at risk of death from subsequent brain swelling and secondary injury. Strict physiologic management in the ICU after traumatic brain injury is believed to be key to survival, and cerebral perfusion pressure is a prominent aspect of post brain injury care. However, optimal cerebral perfusion pressure targets for children are not known. Autoregulation monitoring has been used to delineate individualized optimal perfusion pressures for patients with traumatic brain injury. The methods to do so are diverse, confusing, and not universally validated.
Methods:
In this manuscript, we discuss the history of autoregulation monitoring, outline and categorize the methods used to measure autoregulation, and review the available validation data for methods used to monitor autoregulation.
Conclusions:
Impaired autoregulation after traumatic brain injury is associated with a poor prognosis. Observational data suggests that optimal neurologic outcome and survival are associated with optimal perfusion pressure defined by autoregulation monitoring. No randomized, controlled, interventional data is available to assess autoregulation monitoring after pediatric traumatic brain injury.
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