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Published on: August 16, 2019
Adherence to Guidelines for Managing Severe Traumatic Brain Injury in Children
Hengameh B Pajer1, Anthony M Asher2, Dennis Leung3
1Hengameh B. Pajer is a medical student, Campbell University School of Osteopathic Medicine, Buis Creek, North Carolina.
Insights
Pediatric traumatic brain injury (TBI) management protocols show significant institutional variation, particularly in cerebrospinal fluid drainage, hyperventilation, and neuromuscular blockade timing, despite published guidelines for severe TBI care.
Area of Science:
- Pediatric Critical Care Medicine
- Neurotrauma Management
- Hospital Protocol Analysis
Background:
- Published guidelines for pediatric traumatic brain injury (TBI) management exist.
- Significant institutional variation in pediatric TBI protocols has been observed.
- Standardized care is crucial for optimal patient outcomes.
Purpose of the Study:
- To identify and compare significant differences in severe pediatric TBI management protocols across multiple institutions.
- To assess adherence to existing guidelines in institutional TBI protocols.
- To highlight areas of variability in pediatric TBI care.
Main Methods:
- Collected severe pediatric TBI protocols from major US pediatric hospitals.
- Compared 9 institutional protocols against 2019 guidelines from SCCM and WFPICCS.
- Analyzed intervention variables, focusing on treatment tiers and specific therapies.
Main Results:
- First-line therapies (e.g., seizure prophylaxis, normoglycemia, normothermia) were largely consistent.
- Significant institutional variations were identified in the timing of cerebrospinal fluid drainage, hyperventilation, and neuromuscular blockade.
- Most protocols aligned with 2019 guidelines, with exceptions in CSF diversion, hyperventilation, CPP maintenance, and neuromuscular blockade.
Conclusions:
- While core TBI management is similar, specific interventions show considerable variation.
- Institutional preferences may influence protocol differences.
- Further research is needed to determine the clinical impact of these TBI management variations on patient outcomes.
Abstract:
Pediatric traumatic brain injury (TBI) protocols vary widely among institutions, despite the existence of published guidelines. This study seeks to identify significant differences in management of pediatric TBI across several institutions. Severe pediatric TBI protocols were collected from major US pediatric hospitals through direct communication with trauma staff. Of 24 institutions identified and contacted, 10 did not respond and 5 did not have a pediatric TBI protocol. Pediatric TBI protocols were successfully collected from 9 institutions. These 9 protocols were separated into treatment tiers analogous to those in the 2019 Society of Critical Care Medicine and World Federation of Pediatric Intensive and Critical Care Societies guidelines, and the intervention variables were identified and compared across the 9 institutions. First-line therapies were similar between institutions, including seizure prophylaxis, maintenance of normoglycemia and normothermia, and avoidance of hypoxia, hyponatremia, and hypotension. However, significant variation across institutions was found regarding timing of cerebrospinal fluid drainage, hyperventilation, and neuromuscular blockade. When included in institutional protocols, most therapies are in line with the 2019 guidelines, except for diversion of cerebrospinal fluid, hyperventilation, maintenance of cerebral perfusion pressure, and use of neuromuscular blocking agents. Although these variations may represent differences in style or preference, the optimal timing of these specific treatment variations should be studied to determine the impact of each protocol on clinical outcomes.
