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Published on: March 26, 2019
Monitoring and Measurement of Intracranial Pressure in Pediatric Head Trauma
Sarah Hornshøj Pedersen1, Alexander Lilja-Cyron1, Ramona Astrand1
1Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.
Insights
Intracranial pressure (ICP) monitoring is crucial for children with severe traumatic brain injury (TBI). Current guidelines lack age-specific normal ICP values, necessitating personalized treatment thresholds for better outcomes.
Area of Science:
- Pediatric critical care medicine
- Neurotraumatology
- Intensive care unit management
Background:
- Intracranial pressure (ICP) monitoring is integral to managing severe traumatic brain injury (TBI) in children.
- Current guidelines recommend ICP monitoring with a treatment threshold of 20 mmHg.
- Normal ICP reference values in children, considering age and body size, are lacking.
Purpose of the Study:
- To review ICP monitoring technologies and practices in pediatric severe TBI.
- To evaluate the evidence supporting current ICP guideline recommendations.
- To explore future directions for establishing normal ICP values in children to refine treatment decisions.
Main Methods:
- Focused review of existing literature on ICP monitoring in pediatric severe TBI.
- Analysis of prospective and retrospective observational studies on ICP thresholds and treatment strategies.
- Examination of evidence supporting current guideline recommendations.
Main Results:
- Current evidence for ICP monitoring and treatment thresholds in pediatric severe TBI is of low quality.
- High ICP is associated with worse outcomes, but optimal thresholds remain undefined.
- Existing guidelines lack age-specific ICP values, and treatment thresholds may need to be personalized.
Conclusions:
- ICP monitoring is vital, but current guidelines require refinement due to low-quality evidence and lack of age-specific normal values.
- Future research should focus on establishing normal ICP ranges in healthy children and "pseudonormal" pediatric cohorts.
- Personalized and dynamic treatment algorithms, considering age, disease, and cerebral autoregulation, are needed for improved outcomes in pediatric TBI.
Abstract:
Purpose of Review: Monitoring of intracranial pressure (ICP) is an important and integrated part of the treatment algorithm for children with severe traumatic brain injury (TBI). Guidelines often recommend ICP monitoring with a treatment threshold of 20 mmHg. This focused review discusses; (1) different ICP technologies and how ICP should be monitored in pediatric patients with severe TBI, (2) existing evidence behind guideline recommendations, and (3) how we could move forward to increase knowledge about normal ICP in children to support treatment decisions. Summary: Current reference values for normal ICP in adults lie between 7 and 15 mmHg. Recent studies conducted in "pseudonormal" adults, however, suggest a normal range below this level where ICP is highly dependent on body posture and decreases to negative values in sitting and standing position. Despite obvious physiological differences between children and adults, no age or body size related reference values exist for normal ICP in children. Recent guidelines for treatment of severe TBI in pediatric patients recommend ICP monitoring to guide treatment of intracranial hypertension. Decision on ICP monitoring modalities are based on local standards, the individual case, and the clinician's choice. The recommended treatment threshold is 20 mmHg for a duration of 5 min. Both prospective and retrospective observational studies applying different thresholds and treatment strategies for intracranial hypertension were included to support this recommendation. While some studies suggest improved outcome related to ICP monitoring (lower rate of mortality and severe disability), most studies identify high ICP as a marker of worse outcome. Only one study applied age-differentiated thresholds, but this study did not evaluate the effect of these different thresholds on outcome. The quality of evidence behind ICP monitoring and treatment thresholds in severe pediatric TBI is low and treatment can potentially be improved by knowledge about normal ICP from observational studies in healthy children and cohorts of pediatric "pseudonormal" patients expected to have normal ICP. Acceptable levels of ICP - and thus also treatment thresholds-probably vary with age, disease and whether the patient has intact cerebral autoregulation. Future treatment algorithms should reflect these differences and be more personalized and dynamic.
