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Blood Pressure Thresholds and Mortality in Pediatric Traumatic Brain Injury
Pratthana Suttipongkaset1,2, Nophanan Chaikittisilpa2,3, Monica S Vavilala2,4
1Department of Anesthesiology, Sirindhorn Hospital, Bangkok, Thailand.
Insights
Hypotension in pediatric traumatic brain injury (TBI) is linked to worse outcomes. Using percentile-based systolic blood pressure (SBP) definitions may better identify at-risk children than traditional thresholds.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Clinical epidemiology
Background:
- Hypotension following pediatric traumatic brain injury (TBI) is a known predictor of adverse outcomes.
- Current definitions of hypotension in pediatric TBI lack standardization, leading to varied clinical practice.
- Age- and sex-specific, percentile-based definitions may offer improved identification of at-risk children.
Purpose of the Study:
- To evaluate the association between percentile-based definitions of hypotension and in-hospital mortality in children with severe TBI.
- To compare percentile-based hypotension definitions with the traditional American College of Surgeons (ACS) definition.
- To determine optimal systolic blood pressure (SBP) targets for pediatric TBI management.
Main Methods:
- Retrospective cohort study utilizing the National Trauma Data Bank (2007-2014).
- Inclusion of children with isolated severe TBI.
- Classification of admission SBP into five percentile categories and comparison with ACS definition.
- Multivariable Poisson regression analysis to assess the association between SBP percentiles and in-hospital mortality.
Main Results:
- A total of 10,473 children with severe TBI were analyzed, with 22.8% in-hospital mortality.
- Systolic blood pressure (SBP) below the 75th percentile was associated with increased mortality risk across all age groups.
- Relative risks for mortality were significantly higher for SBP <5th percentile (RR 3.2) and 5th-24th percentile (RR 2.3) compared to the 75th-94th percentile.
- ACS hypotension definition targets were higher than the 5th percentile but lower than the 75th percentile definition.
Conclusions:
- Admission SBP <75th percentile is a significant predictor of in-hospital mortality in pediatric severe TBI.
- Percentile-based SBP targets, particularly those based on the 75th percentile, may provide more accurate identification of hypotension than traditional ACS criteria.
- Consideration of percentile-based SBP targets is recommended for defining and managing hypotension in pediatric TBI.
Background:
Hypotension after pediatric traumatic brain injury (TBI) is associated with poor outcomes, but definitions of low systolic blood pressure (SBP) vary. Age- and sex-specific, percentile-based definitions of hypotension may help to better identify children at risk for poor outcomes compared with traditional thresholds recommended in pediatric trauma care.
Methods:
Using the National Trauma Data Bank between 2007 and 2014, we conducted a retrospective cohort study of children with isolated severe TBI. We classified admission SBP into 5 percentile categories according to population-based values: (1) SBP less than the fifth percentile, (2) SBP in the fifth to 24th percentile, (3) SBP in the 25th to 74th percentile, (4) SBP in the 75th to 94th percentile, and (5) SBP ≥95th percentile. These definitions were compared with the American College of Surgeons (ACS) hypotension definition. The association between SBP percentiles and in-hospital mortality was analyzed by using multivariable Poisson regression models.
Results:
There were 10 473 children with severe TBI included in this study. There were 2388 (22.8%) patients who died while in the hospital. Compared with SBP in the 75th to 94th percentile, mortality was higher with SBP less than the fifth percentile (relative risk [RR] 3.2; 95% confidence interval [CI] 2.9-3.6), SBP in the fifth to 24th percentile (RR 2.3; 95% CI 2.0-2.7), and SBP in the 25th to 74th percentile (RR 1.4; 95% CI 1.2-1.6). An increased risk of mortality with SBP <75th percentile was present across all age subgroups. SBP targets using the ACS hypotension definition were higher than the fifth percentile hypotension definition, but were lower than the 75th percentile hypotension definition.
Conclusions:
Admission SBP <75th percentile was associated with a higher risk of in-hospital mortality after isolated severe TBI in children. SBP targets based on the 75th percentile were higher compared with traditional ACS targets. Percentile-based SBP targets should be considered in defining hypotension in pediatric TBI.
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