Brain tissue oxygen tension monitoring in pediatric severe traumatic brain injury : PPPart 1: Relationship with outcome
Divisions of Neurosurgery, University of Cape Town, Red Cross Children's Hospital, Cape Town, South Africa; Infectious Disease Epidemiology Unit (Biostatistics), School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Pediatric Critical Care, University of Cape Town, Red Cross Children's Hospital, Cape Town, South Africa; Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19107, United States
Introduction: Intracranial pressure (ICP) monitoring and cerebral perfusion pressure (CPP) management are the current standards to guide care of severe traumatic brain injury (TBI). However, brain hypoxia and secondary brain injury can occur despite optimal ICP and CPP. In this study, we used brain tissue oxygen tension (PbtO2) monitoring to examine the association between multiple patient factors, including PbtO2, and outcome in pediatric severe TBI. Materials and methods: In this prospective observational study, 52 children (less than 15 years) with severe TBI were managed with continuous PbtO2 and ICP monitoring. The relationships between outcome [Glasgow Outcome Score (GOS) and Pediatric Cerebral Performance Category Scale] and clinical, radiologic, treatment, and physiological variables, including PbtO2, were examined using multiple logistic regression analysis. Results: Outcome was favorable in 40 patients (77%) and unfavorable (mortality, 9.6%; n∈=∈5) in 12 (23%). In univariate analysis, the following variables had a significant association with unfavorable outcome: initial GCS, computed tomography classification, ICPpeak, mICP24, mICP, CPPlow, CPP<40, pupil reactivity, PbtO2low, PbtO2<5 mmHg, PbtO2< 10 mmHg, mPbtO224, and time-severity product. PbtO2 parameters had the strongest independent association with poor outcome in multiple regression analysis. In particular, when PbtO2 was <5 mmHg for >1 h, the adjusted OR for poor outcome was 27.4 (95% confidence interval, 1.9-391). No variables apart from PbtO2 were independently associated with mortality when controlled for PbtO2. Conclusion: Reduced PbtO2 is shown to be an independent factor associated with poor outcome in pediatric severe TBI in the largest study to date. It appears to have a stronger association with outcome than conventionally evaluated measures. © 2009 Springer-Verlag.
thiopental; adolescent; article; brain decompression; brain oxygen tension; brain perfusion; brain tissue; child; childhood mortality; computer assisted tomography; confidence interval; controlled study; craniectomy; female; hospital admission; hospital discharge; human; intensive care unit; intracranial pressure; major clinical study; male; multiple regression; multivariate logistic regression analysis; preschool child; priority journal; school child; scoring system; traumatic brain injury; univariate analysis; Adolescent; Analysis of Variance; Brain; Brain Injuries; Child; Child, Preschool; Female; Follow-Up Studies; Humans; Infant; Logistic Models; Male; Monitoring, Physiologic; Oxygen; Prospective Studies; Severity of Illness Index; Treatment Outcome