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Published on: March 26, 2019
Mean Arterial Pressure and Discharge Outcomes in Severe Pediatric Traumatic Brain Injury
Scott L Erickson1,2,3, Elizabeth Y Killien4,5, Mark Wainwright6
1Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.
Insights
Hypotension, indicated by low mean arterial pressure (MAP) in children with severe traumatic brain injury (TBI), is linked to poor outcomes. Early MAP monitoring is crucial for predicting discharge results in pediatric TBI patients.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Clinical outcomes assessment
Background:
- Optimizing blood pressure is vital post-pediatric traumatic brain injury (TBI).
- Systolic blood pressure (SBP) associations with outcomes are documented.
- Mean arterial pressure (MAP) is a superior indicator of organ perfusion and cerebral perfusion pressure, yet its role in pediatric TBI outcomes is understudied.
Purpose of the Study:
- To assess the association between MAP-based hypotension within 12 hours of admission and discharge outcomes in pediatric TBI.
- To compare the strength of association between MAP-based and SBP-based hypotension and outcomes.
Main Methods:
- Examined lowest age-specific MAP percentile within 12 hours of PICU admission against poor discharge outcomes (death or SNF transfer) in severe TBI survivors.
- Used Poisson regression adjusted for injury severity and vasoactive medications.
- Employed ROC analysis to evaluate predictive ability and contrasted MAP and SBP percentiles.
Main Results:
- Poor discharge outcome was significantly more common with MAP < 10th percentile (42.9%).
- Lowest MAP percentile was moderately predictive of poor discharge outcome (AUC: 0.75).
- Lowest SBP percentile showed association only for <5th percentile, with slightly higher predictive ability (AUC: 0.82).
Conclusions:
- A single MAP < 10th percentile within 12 hours post-PICU admission is associated with poor discharge outcomes in severe pediatric TBI.
- Lowest MAP percentile demonstrated a stronger association with outcome than SBP but had slightly lower predictive ability.
- MAP monitoring is critical for predicting outcomes in pediatric TBI.
Background And Objective:
Optimizing blood pressure is an important target for intervention following pediatric traumatic brain injury (TBI). The existing literature has examined the association between systolic blood pressure (SBP) and outcomes. Mean arterial pressure (MAP) is a better measure of organ perfusion than SBP and is used to determine cerebral perfusion pressure but has not been previously examined in relation to outcomes after pediatric TBI. We aimed to evaluate the strength of association between MAP-based hypotension early after hospital admission and discharge outcome and to contrast the relative strength of association of hypotension with outcome between MAP-based and SBP-based blood pressure percentiles.
Methods:
We examined the association between lowest age-specific MAP percentile within 12 h after pediatric intensive care unit admission and poor discharge outcome (in-hospital death or transfer to a skilled nursing facility) in children with severe (Glasgow Coma Scale score < 9) TBI who survived at least 12 h. Poisson regression results were adjusted for maximum head Abbreviated Injury Scale (AIS) severity score, maximum nonhead AIS, and vasoactive medication use. We also examined the ability of lowest MAP percentile during the first 12 h to predict discharge outcomes using receiver operating curve characteristic analysis without adjustment for covariates. We contrasted the predictive ability and the relative strength of association of blood pressure with outcome between MAP and SBP percentiles.
Results:
Data from 166 children aged < 18 years were examined, of whom 20.4% had a poor discharge outcome. Poor discharge outcome was most common among patients with lowest MAP < 5th percentile (42.9%; aRR 5.3 vs. 50-94th percentile, 95% CI 1.2, 23.0) and MAP 5-9th percentile (40%; aRR 8.5, 95% CI 1.9, 38.7). Without adjustment for injury severity or vasoactive medication use, lowest MAP percentile was moderately predictive of poor discharge outcome (AUC: 0.75, 95% CI 0.66, 0.85). In contrast, lowest SBP was associated with poor discharge outcome only for the < 5th percentile (50%; aRR 5.4, 95% CI 1.3, 22.2). Lowest SBP percentile was moderately predictive of poor discharge outcome (AUC: 0.82, 95% CI 0.74, 0.91).
Conclusions:
In children with severe TBI, a single MAP < 10th percentile during the first 12 h after Pediatric Intensive Care Unit admission was associated with poor discharge outcome. Lowest MAP percentile during the first 12 h was moderately predictive of poor discharge outcome. Lowest MAP percentile was more strongly associated with outcome than lowest SBP percentile but had slightly lower predictive ability than SBP.
