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ICP, PRx, CPP, and ∆CPPopt in pediatric traumatic brain injury: the combined effect of insult intensity and duration
Teodor Svedung Wettervik1, Fartein Velle2, Anders Hånell2
1Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden. teodor.svedung-wettervik@neuro.uu.se.
Insights
Understanding insult intensity and duration is key for pediatric traumatic brain injury (TBI) outcomes. Prolonged high intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) negatively impact recovery in children with TBI.
Area of Science:
- Neuroscience
- Pediatric Critical Care
- Trauma Surgery
Background:
- Severe pediatric traumatic brain injury (TBI) presents complex management challenges.
- Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) are critical neuromonitoring parameters.
- Understanding the interplay of insult intensity and duration is vital for optimizing outcomes.
Purpose of the Study:
- To investigate the combined effect of insult intensity and duration of intracranial pressure (ICP), pressure reactivity index (PRx), cerebral perfusion pressure (CPP), and optimal CPP (CPPopt) on clinical outcomes in pediatric TBI.
- To visualize the relationship between these physiological insults and neurological recovery in pediatric TBI patients.
Main Methods:
- Observational study of 61 pediatric patients with severe TBI.
- Data collected included ICP, PRx, CPP, and CPPopt over the first 10 days post-injury (minimum 12 hours of ICP data).
- Insults were visualized using 2-dimensional plots to analyze the combined effect of intensity and duration on outcome.
Main Results:
- Adolescent TBI patients (median age 15) were the primary cohort.
- Brief episodes of high ICP (>25 mmHg) and longer episodes of moderately elevated ICP (20-25 mmHg) correlated with unfavorable outcomes.
- Low CPP (<50 mmHg) and CPP below CPPopt by more than -10 mmHg were associated with worse outcomes. Higher PRx for longer durations also indicated poorer outcomes.
Conclusions:
- A visualization method effectively illustrated the combined impact of insult intensity and duration on pediatric TBI outcomes.
- Avoiding prolonged periods of high ICP and low CPP is crucial.
- Autoregulatory-oriented management, considering PRx and CPP relative to CPPopt, may improve outcomes in pediatric TBI.
Purpose:
The aim was to investigate the combined effect of insult intensity and duration, regarding intracranial pressure (ICP), pressure reactivity index (PRx), cerebral perfusion pressure (CPP), and optimal CPP (CPPopt), on clinical outcome in pediatric traumatic brain injury (TBI).
Method:
This observational study included 61 pediatric patients with severe TBI, treated at the Uppsala University Hospital, between 2007 and 2018, with at least 12 h of ICP data the first 10 days post-injury. ICP, PRx, CPP, and ∆CPPopt (actual CPP-CPPopt) insults were visualized as 2-dimensional plots to illustrate the combined effect of insult intensity and duration on neurological recovery.
Results:
This cohort was mostly adolescent pediatric TBI patients with a median age at 15 (interquartile range 12-16) years. For ICP, brief episodes (minutes) above 25 mmHg and slightly longer episodes (20 min) of ICP 20-25 mmHg correlated with unfavorable outcome. For PRx, brief episodes above 0.25 as well as slightly lower values (around 0) for longer periods of time (30 min) were associated with unfavorable outcome. For CPP, there was a transition from favorable to unfavorable outcome for CPP below 50 mmHg. There was no association between high CPP and outcome. For ∆CPPopt, there was a transition from favorable to unfavorable outcome when ∆CPPopt went below -10 mmHg. No association was found for positive ∆CPPopt values and outcome.
Conclusions:
This visualization method illustrated the combined effect of insult intensity and duration in relation to outcome in severe pediatric TBI, supporting previous notions to avoid high ICP and low CPP for longer episodes of time. In addition, higher PRx for longer episodes of time and CPP below CPPopt more than -10 mmHg were associated with worse outcome, indicating a potential role for autoregulatory-oriented management in pediatric TBI.
