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Early Prognostication in Pediatric Severe Traumatic Brain Injury in South America: Development of a Local
Madeline E Greil1, Omar Abdelmaksoud2, Lauren L Agoubi2,3
1Department of Neurological Surgery, Harborview Medical Center, Seattle, Washington, USA.
Insights
A new pediatric severe traumatic brain injury (sTBI) model developed in South America accurately predicts outcomes. This model, the PEGASUS core model, is useful even without head CT scans, aiding prognostication in low-resource settings.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Global health disparities in healthcare
Background:
- Accurate prognostication in severe traumatic brain injury (sTBI) is crucial for pediatric patients.
- Existing prognostic models often lack pediatric specificity and applicability in low- and middle-income countries (LMICs).
- Limited availability of head computed tomography (CT) scans in LMICs hinders the use of current models.
Purpose of the Study:
- To develop and validate a pediatric-specific prognostic model for sTBI in South America.
- To assess intensive care unit admission risk factors for early mortality and unfavorable outcomes in children with sTBI.
- To compare the performance of models with and without CT scan data.
Main Methods:
- Secondary analysis of 115 children with sTBI from the PEGASUS Argentina trial (September 2019 - July 2020).
- Development of two logistic regression models (core clinical variables only, full clinical + CT variables) for 14-day mortality and 3-month Glasgow Outcome Scale-Extended for Pediatrics (GOS-E Peds).
- Evaluation of model fit and predictive comparison using area under the receiver operating characteristic curve (AUROC).
Main Results:
- The locally derived PEGASUS core model demonstrated strong prediction for 14-day mortality (AUROC: 0.92) and 3-month outcomes (AUROC: 0.82).
- No significant difference in prognosticating 14-day mortality between core and full models.
- Full models (IMPACT and PEGASUS) showed improved prediction for 3-month GOS-E Peds compared to their respective core models.
Conclusions:
- The PEGASUS core model provides good prognostication for pediatric sTBI in South America, even without CT scans.
- Full models incorporating CT data are preferred for predicting 3-month outcomes.
- External validation of the PEGASUS model is recommended for broader applicability.
Abstract:
Prognostication in severe traumatic brain injury (sTBI) is important, but few models are pediatric-specific and from low- and middle-income countries where head computed tomography (CT) scans may not be routinely available. We assessed intensive care unit admission risk factors for early mortality and unfavorable outcome in a secondary analysis of 115 children (mean 7.0 years, standard deviation [sd] 5.3) receiving sTBI (Glasgow Coma Scale [GCS] total score ≤8 or GCS motor ≤5) care in South America who participated in the 16 hospital Pediatric Guideline Adherence and Outcomes (PEGASUS) Argentina trial between September 1, 2019, and July 13, 2020. Outcomes were 14-day mortality and 3-month Glasgow Outcome Scale-Extended for Pediatrics (GOS-E Peds). First, we examined univariate associations of predictors with the two outcomes. Then, two PEGASUS logistic regression models (core model with only clinical variables and full model with both clinical and CT variables) for each of the outcomes were derived. Models were examined for fit and compared for prediction. The locally derived PEGASUS model shows a good core prediction of 14-day (area under the receiver operating characteristic curve [AUROC]: 0.92; confidence interval [CI]: 0.85-0.99) and 3-month (AUROC 0.82 CI 0.73-0.91) outcomes; findings are similar to the International Mission on Prognosis and Analysis of Randomized Controlled Trials in TBI (IMPACT), Corticosteroid Randomization after Significant Head Injury (CRASH), and Petroni models. There was no difference between core and full models in prognosticating 14-day mortality, but IMPACT (p = 0.01) and PEGASUS (p = 0.01) full models outperformed their respective core models for 3-month GOS-E Peds. Core models, including PEGASUS, can be used but full models are preferred to prognosticate outcomes after pediatric sTBI in South America. PEGASUS model validation against external datasets is needed.
