Updates in Pediatric Trauma Brain Injury

Welcome to the Forum Sharing Practices World I am Dr

Jeff Burns, dean of intensive care at Boston Children's Hospital and Harvard Medical School My discussion today is Dr Robert Tasker He is currently chair of the standard Neonatal Care Unit at Boston Children's Hospital, He is Professor of Anesthesia and Neurology at Harvard Medical School The subject he will tell us today is the brain injury (TBI) The purpose of this forum is not just to listen to sharing from international experts on popular topics and topics that we are interested in but also to exchange global knowledge and find out what people practice there

So during the presentation, we will pause to ask about your practice at the center From there we can learn and exchange knowledge Dr Tasker Thank you, Jeff I think the first thing to mention is that 2012 is an important year with new insights into brain injury

And I want to take you to this first slide, You will see the Cranio Trauma Foundation website On the left, you will see some guides accessible At the top 4, you will see instructions for serious brain injury in the child The new guide echoed again the first edition with more publicity Things are listed in this slide, as you can see below are selection criteria and exclusion criteria

As you read the guide, it is important to understand Why did a series of articles come up and still others? We only talked about a number of articles included in which more than 25 studies were conducted in the hospital Age bracket is for children under 18 years of age and the diseases described in the articles are traumatic brain injury and not other causes Dear BS Tasker, I know that many of us are familiar with these guidelines

I think three questions are often asked Specific pressure of CO2 in practice? Do you use hypothermia? If so, when should start and at which temperature? And finally, there are concerns about the management of intracranial pressure Can you answer these questions? Let's start with PaCO2 In this slide I have summarized all the guidelines according to the therapeutic ladder At the start of intracranial pressure monitoring (ICP), CO2 targets will become relevant Guidance on adults and children is summarized in this slide with evidence in Levels II and III

There is a difference that you should note, that is In adults, 25 mmHg ventilation is not recommended for prophylaxis Similarly, we should avoid increased prophylaxis in infants, but the limit is 30 mmHg instead of 25 mmHg However, you may consider increasing ventilation as a temporary measure In case of surgery and surgery So where do we get these numbers from? Probably the most important article by Active Pediatric Surgeons is Perter Skippen's from 1997 summarized in this slide In the middle of the slide there are two charts and look at the chart above There were 23 children with a single brain injury, Glasgow coma <8

These data were collected at the time we ventilated the patient with PaCO2 <25 mmHg Peter Skippen took advantage of this opportunity to take xenon-CT to measure cerebral blood flow while performing aeration They also assessed whether there was cerebral hemorrhage when the CO2 concentration changed In the middle of the slide below, you can see that ischemia is defined as blood flow <18 mL / 100 g / min At each concentration level of CO2 <25, 25-35 or> 35, there are several cases of partial ischemia Targeting 30 mmHg can not rule out the possibility that a child has ischemic stroke

If you want to see a very impressive image of the problem, look at the two images on the left This is a xenon-CT image The above picture is when the ventilation is not increased After viewing this picture, you do not need to perform augmentation In the figure below, blood flow has decreased significantly with increased ventilation So in my opinion, this is probably the article that changed our approach to CO2 on this subject

So what should we do in our unit? I can tell you what happens at my will but this is what really happens What I am describing here is that of a child with severe brain injury that is monitored by ICP After 168 hours, we have redrawn all EtCO2 values ​​(final carbon dioxide exhalation) with red dots and all the value of carbon dioxide in arterial blood with blue dots Most of the time, the measurements are usually 30-40, but there are also less than 30 Assuming the target is 40 mmHg, it is possible to see the measured concentration for most of the time is less than 40

This certainly shows something is going on And we need better servo control mechanisms At the moment all are handcrafted by respiratory therapists who are changing the ventilation This can cause progressive brain damage that we can not continue to cure In practice and when he read the evidence, control ventilation with a target pCO2 of about 40 and avoid increased airflow due to concerns about ischemia due to increased ventilation Unless there is a major impact due to hernia and may interfere with neurosurgery So in which case would you recommend increased ventilation to a pCO2 target less than 30? In my case, the hernia can not be avoided if it is below 30 Of course, there are now many new technologies that can change this, It also has the ability to monitor and measure organ perfusion, tissue, blood flow and oxygen saturation

Of course, CO2 concentration is just a guide, which allows us to predict what is going on If we can really keep track of what is going on On the distribution and consumption of oxygen, it will change everything However, this is now the best thing we have in most medical institutions around the world As we have shared with Dr Tasker in Boston, the practice is to target PCM2 40 mmHg

Now I would like to stop here and ask your friends around the world for your practice First, tell your local pediatric intensive care unit, Then let us know what your target pCO2 is Concurrently gather opinions from around the world and ask any questions for Dr Tasker at this time Robert, do not know if we can move on to the second theme: hypothermia? What is the evidence for hypothermia? What is your method of practice in Boston? When to do it? What is the time and temperature range? Thank you, Jeff

Go back to the diagram, in the bottom row on the right, This is where second line treatments are done The abstract of the tutorial looks out of place, but it only has two options Basically, early moderate hypothermia (32-33 ° C) should be avoided after serious TBI in only 24 hours Consider initiating moderate hypothermia (32-33 ° C) within 8 hours after severe TBI up to 48 hours to relieve increased intracranial pressure If hypothermia is taken, the rate of re-warming should be below 0

5 ° C per hour Finally, level C evidence should consider early initiation of moderate hypothermia after severe TBI for 48 hours Here's why these seemingly ambiguous things really come from the evidence Let's look at the next slide, Here are 3 studies on cooling in children This is a study by David Adelson in 2005, This is a preliminary study in 75 children with results measured in 3 and 6 months that showed no effect

Then came Jamie Hutchison's study in 2008 Over 225 children with results after 12 months are certainly not effective Some people point out that hypothermia almost brings about more adverse outcomes Finally, a study by David Adelson 340 patients were expected but stopped in 77 patients This study was presented at the World Conference in Sydney Results are evaluated within 12 months and also ineffective

The evidence I have given above demonstrates that hypothermia does not indicate potential adverse effects or effects In general, our goal is to target normal body temperature Here is the data in the same table that I showed you earlier, but now look at the picture on the left, This is all the central temperature measured in this child Can be seen, in 168 hours, generally the temperature is about 35-375 ° C

At the first 24 hours, the temperature was higher than we expected And of course, near the end of the hospitalization, the temperature rose higher than we expected In summary, avoiding hyperthermia and hypothermia in most patients is what we do Is technically important, between peripheral cooling versus central cooling? Can you tell me about your practice in Boston? We conduct warming and cooling blankets We do not inject cold solution into a vein or into the bladder or change the humidity temperature

In my opinion, these measures can help maintain the patient's normal body temperature If we use hypothermia therapy for traumatic brain injury I think the question arises would be "How fast should we be?" "How long should we do?" "What do we need to do during the warm up?" As far as we know from the evidence up to this point it is unclear And I will return to this topic at the end of the discussion today Thank you Now we can pause and ask the international audience about your practice

Again, if you answer the question first, tell your emergency resuscitation unit in which city Secondly, do you have hypothyroidism for children with traumatic brain injury? If so, hypothermia will occur within hours of entry into the ICU, How long does it take and what is the central temperature target? Also, can you elaborate on some of the concerns about reheating? Dr Tasker, can we move on to the third theme – intracranial pressure monitoring (ICP)? Last year, some of the literature suggested and questioned the value of intracranial pressure monitoring devices for these patients Given these evidence, the reports in these articles have suggested Should not we use intracranial pressure monitoring devices in children with brain injury? To date we have confirmed the fact that we actually have ICP tracking And we set the target PaCO2 or temperature with ICP criteria If you look at the guides to date, this slide summarizes both adult and children data

In the upper row were retrospective observational studies, including five adult studies and one pediatric study reviewing ICP monitoring and whether it improves outcomes Lower ICP was associated with better outcomes In the prospective study, five studies were conducted in adults and one in children and also showed better outcomes when ICP was lower There is also a new study that you mentioned, It is a randomized controlled trial of children and adults over 13 years of age These regulations relate to therapy directed at ICP or therapeutic approaches to imaging and examination

The authors looked at the composite outcome of survival and function 6 months after injury They found more interventions in the ICP group than those without ICP In the past, we learned from pediatric research, from the Cochrane report that Patients who were monitored for ICP in the event of head injury should stay ICU longer Now let's look at these data more closely This data was released in late 2012 in the New England Journal of Medicine

The number of patients in the study was 324 As I said, for ICP tracking the goal is <20mm Hg compared to other groups with image-based procedures and clinical examination The outcome of the two groups was similar: 39% versus 41% To date, there are a number of posts appearing on the New England Journal regarding this article The bottom part of this slide is what I draw from both the original and related articles

The first thing to point out is that this study was conducted in six centers in Bolivia and Ecuador Pre-admission care on this population is very noticeable 45% of the patients were referred to the first hospital by ambulance We do not know what happened to the other 55% of the patients I did not know about the interventions that were performed prior to admission

44% of patients with one or both pupils are inactive You should compare that number with 25% in other TBI studies conducted in North America and Europe 85% of patients had cerebral palsy or lack of fluid around the brain space You should compare that number to 22% in other studies conducted in North America and Europe So before admission, this is a particularly serious group It's heavier than the group we've seen in North America or Europe

The patient recovered within 48 hours and half of them had neurosurgery The bottom line is that the overall outcome is nearly 40% Look at all the research published in the New England Journal The overall mortality rate should not exceed 28% Therefore, in the context of this study, with pre-hospital status and severity of the patient, You can conclude that ICP monitoring does not bring much benefit in managing these patients compared with regular clinical visits and CT scans

In my opinion, where I work, the mortality rate is 10% -20% I do not believe that it is a good idea to check the issue to see if the ICP monitoring is beneficial To use these data from places where the mortality rate is close to 40% I think it would be a mistake to transfer those data to a place where the mortality rate is less than 20% So, at this moment, we have engaged in the use of ICP track And these data are not enough for us to change the practice

Although there are many who argue about this data Can you tell us about the equipment you use in Boston and the preferred location for combining intracranial pressure? Again, different centers differ We used a combination of intracranial pressure instruments in the brain parenchyma or intraventricular device with drainage of the ventricles That is the 2 devices we use Thank you

Can we move on to the question of clinical practice of international audiences Again, if yes, indicate which city you are in your active care unit Do you use an ICU for children with traumatic brain injury? If you do not use an intracranial pressure monitor, Do you use follow-up procedures to guide treatment? We look forward to hearing from you about these issues Dr Tasker, thank you very much for the wonderful presentation today

What are your thoughts on sharing with us? Yes, thank you Jeff Another part is more relevant to this discussion As we saw in the last slide, there were some system and system performance issues that we worked on This is a chart from the center in England, caring for children with severe brain injury In the middle of the diagram on the right hand side, You will see the mortality risk adjusted in many instances of each center over a five year period

The number of patients is almost 2500 cases of severe brain injury In all cases under the age of 16, the risk-adjusted model is the PIM model As you can see, there is a central shift in risk-adjusted mortality, from 4% to 20% The obvious question is why inter-center performance is not the same? Is it because large centers have better outcomes, and small centers have worse outcomes? Or the problem of the system somewhere? How do they do it? We have talked about the issue of CO2 How do we make hypothermia, whether we should watch and keep the temperature at 35, 37 degrees or not It is possible that these details make a difference in the centers

Or because some centers have CT scans and conduct ICP procedures We do not know and all are unknown In the next five years, the goal will be to try to understand what happens between the centers The American Academy of Medicine has called for a whole approach to comparative research Consider carefully and create a large database of patients with similar conditions Patients with the same condition are treated with different therapies and centers have different outcomes

Great Thank you very much for the presentation above We look forward to hearing the questions raised through this conversation He also wants to listen to his presentation at the next World Practice Sharing Forum Thanks very much

Thank you Goodbye

Source: Youtube

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