Any closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand

Transcription

1 Any closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand

2 Evidence Pathophysiology Why? Management

3 Non-degenerative, Non-congenital insult External mechanical force Permanent or temporary impairment of functionscognitive, physical, and psychosocial Associated with a diminished or altered state of consciousness

4 J Head Trauma Rehabil Vol. 21, No. 5, pp AT RISK: Males > Females 2:1 Individuals who have suffered a previous TBI Peak Ages: 0-4 yr & years Percentage of average annual traumatic brain injuryrelated emergency department visits, hospitalizations, and deaths by external cause, United States, Age dependant injury patterns NB: NON ACCIDENTAL INJURY

5 Annually, in the US: 1.4 million people sustain a TBI (57 million) 50,000 people die from a TBI (10 million) 475,000 TBIs - occur among infants, children, and adolescents. (0-14 years) 80,000-90,000 people experience the onset of a long-term disability due to a TBI.

6 No variance in annual admissions Peak age- 6 years Boys > Girls Main MOI: Pedestrian Vehicle Accidents Most injuries on weekends Mortality 14.6%

7 Children <5 years Causes: RTA Falls Intentional injury Peak age- 1 year M>F Deaths- 91% accidental 6% homicides

8 The severity of TBI according to the GCS score (within 48 h) is as follows: Mild TBI = Modrt TBI = 9-12 Severe TBI = 3-8

9 PRIMARY SECONDARY FOCAL DIFFUSE EXTRACRANIAL INTRACRANIAL Hypoxemia, Hypotension Elevated ICP Hypercarbia or hypocarbia Hyperglycemia or hypoglycemia Electrolyte abnormalities Coagulopathy Hyperthermia

10 Inclusions: Severe TBI (GCS 3-8) In hospital management >25 subjects Children < 18 years Exclusions: >15% with other pathologies and TBI data not separated Wrong variables

11 Intracranial Pressure Monitoring Circulatory Support Advanced Neuro-monitoring & Imaging Glucose, Nutrition & Fluids Hyperosmolar Therapy Hyperventilation Sedation & Analgesia Seizure Management Temperature Regulation Surgical Considerations

12 BRAIN 80% BLOOD 12% CSF 8%

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14 Copied from: Rogers (1996) Textbook of Pediatric Intensive Care p. 646

15 CPP = MAP - ICP Cerebral Perfusion Pressure Mean Arterial Pressure Intracranial Pressure

16 1. Better outcomes in children who had ICP monitoring Tilford, et al, Crit Care Med 2005; 33: Tilford, et al,crit Care Med 2001;29: Children with severe TBI are at risk for ICH 8 small studies Total 0f 476 patients 0-18 years of age Survivors had lower ICP s than non survivors Barzilay Z, Augarten A, Sagy M, et al:intensive Care Med 1988;14: Bruce DA, Raphaely RC, Goldberg AI, et al: Childs Brain 1979; 5: Esparza J, M-Portillo J, Sarabia M, et al: Childs Nerv Syst 1985; 1: Kasoff SS, Lansen TA, Holder D, et al: Pediatr Neurosci 1988; 14: Shapiro K, Marmarou A J Neurosurg 1982; 56: Cruz J, Nakayama P, Imamura JH, et al Neurosurgery 2002; 50: Pfenninger J, Santi A: Swiss Med Wkly 2002; 132: White JR, Farukhi Z, Bull C, et al, Crit Care Med 2001; 29:

17 3. ICP Monitoring and directed treatments improve outcomes Study n Outcome Effect Alberico,et al yrs Neurological outcome at 3 months & 1 year Reducible ICH was significantly associated with better outcomes than Non-reducible ICH Jagannathan, et al yrs Neurological Outcome at 2 years Mortality 1. Death assoc with Refractory ICP 2. QOL related to medical management of ICP 3. Long-term outcomes not correlated with peak ICP

18 Treatment of ICP may be considered at a level of 20 mmhg (Level III) Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.) Unanswered Questions: 1. Are values age-dependant? 2. Does MOI or CT findings change treatment thresholds? 3. Correlation between biochemical & physiological surrogates and ICP 4. Duration of targeting ICP post injury or post hypertensive episode 5. Value of ICP vs CPP targeted thresholds

19 A Minimum CPP of 40mmHg should be considered in children with TBI (Level III) Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.) A CPP threshold 40-50mmHg may be considered. There appears to be age-specific thresholds with infants being lower, and adolescents higher Further studies needed

20 Maintain mean arterial blood pressure and maintain CPP 6 Number of Hypotensive Episodes in the first 24 hours after TBI Good Moderate Severe Vegetative Dead 0 Patient Outcome Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

21 Cerebral Microdialysis Jugular venous oxygen saturation Monitors Thermal diffusion probes Transcranial doppler Near Infrared spectroscopy If brain oxygenation monitoring is used, maintenance of a partial pressure of brain-tissue oxygen (Pbto2 ) 10 mm Hg may be considered (Level III) Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.)

22 Early neuroimaging mainstay in evaluating the extent and severity of injury Can also be used as triage tool In the absence of neurologic deterioration routine repeat CT scan may not be indicated

23 Glucose: Hyperglycemia -high brain lactate levels and possibly greater cerebral cellular injury, particularly in the early phases of brain injury Post traumatic hyperglycaemia is associated with poor outcome Avoid glucose containing fluids Nutrition: No difference in outcomes immune enhancing vs regular feeds Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.)

24 Brain cell Fluid Increases blood osmolality Blood vessel Movement of fluid out of cell reduces oedema Decreased Intracranial Pressure: Osmosis: Fluid will move from area of lower osmolarity to an area of higher osmolarity T. Trimarchi, 2000

25 Use of hypertonic (3%) saline/acetate infusion in the treatment of cerebral edema: Effect on intracranial pressure and lateral displacement of the brain. Qureshi, Critical Care Medicine. 26(3): , March 1998.

26 Hypertonic saline should be considered for intracranial hypertension effective doses range between 6.5 and 10 ml/kg (Level II) Hypertonic saline should be considered effective doses as a continuous infusion of 3% saline range between 0.1 and 1.0 ml/kg/h administered on a sliding scale (Level III) No evidence for the use of Mannitol despite its common use Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.)

27 PaO2 PaCO2

28 Effect of hyperventilation on regional cerebral blood flow in head-injured children. Skippen, et al Critical Care Medicine. 25(8): , August 1997

29 Avoidance of prophylactic severe hyperventilation (PaC02 <30mmHg) may be considered in initial 48 hrs after injury (Level III) If hyperventilation is used in the management of refractory intracranial hypertension, advanced neuromonitoring for evaluation of cerebral ischaemia may be considered. (Level III) Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.)

30 In the absence of outcome data, the choice of and dosing of sedatives, analgesia, and NMB should be left to the treating physician (Level III) Etomidate may be considered to control severe intracranial hypertension. Risks for adrenal suppression should be considered (Level III) Thiopentone may be considered to control intracranial hypertension (Level III) High-dose barbiturate therapy may be considered in refractory intracranial hypertension despite maximal medical and surgical management (Level III) CONTINOUS INFUSION OF PROPOFOL FOR SEDATION/TRATMENT OF ICP IN INFANTS AND CHILDREN IS CONTRAINDICATED Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.)

31 Prophylactic treatment with PHENYTOIN may be considered to reduce the incidence of EARLY posttraumatic seizures in paediatric patients with severe TBI (Level III) Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.) EEG monitoring Prompt Treatment

32 Hyperthermia >38C must be avoided Hypothermia - cooling reduces the cerebral metabolic rate & oxygen consumption Published data are rather controversial

33 Moderate hypothermia (32 33 C) early after severe traumatic brain injury (TBI) for only 24 hrs duration should be avoided (Level II) Moderate hypothermia (32 33 C) beginning within 8 hrs after severe TBI for up to 48 hrs duration should be considered (Level II) If hypothermia is induced for any indication, rewarming at a rate of > 0.5 C/hr should be avoided Moderate hypothermia (32 33 C) beginning early after severe TBI for 48 hrs,duration may be considered (Level III) Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.)

34 CSF drainage through an external ventricular drain may be considered in the management of increased ICP (Level III) Decompressive craniectomy with duraplasty, leaving the bone flap out, may be considered when: showing early signs of neurologic deterioration or herniation refractory intracranial hypertension during the early stages of their treatment. Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.)

35 The use of corticosteroids is not recommended to improve outcome or reduce ICP for children with severe traumatic brain injury (Level II) Pediatr Crit Care Med 2012 Vol. 13, No. 1 (Suppl.)

36 Traumatic Brain Injury GCS< 8 Intubated ICP Monitor Sedation & Analgesia ICP Threshold mmhg Temperature <37.5 o C PaCO 2 Target < 30mmHg Electrolytes Glucose CPP Target Seizure Control 2 nd tier Hyperosmolar DC Hypothermia

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