Differences in medical therapy goals for children with severe traumatic brain injury-an international study

Abstract

Objectives: To describe the differences in goals for their usual practice for various medical therapies from a number of international centers for children with severe traumatic brain injury.

Design: A survey of the goals from representatives of the international centers.

Setting: Thirty-two pediatric traumatic brain injury centers in the United States, United Kingdom, France, and Spain.

Patients: None.

Interventions: None.

Measurements and main results: A survey instrument was developed that required free-form responses from the centers regarding their usual practice goals for topics of intracranial hypertension therapies, hypoxia/ischemia prevention and detection, and metabolic support. Cerebrospinal fluid diversion strategies varied both across centers and within centers, with roughly equal proportion of centers adopting a strategy of continuous cerebrospinal fluid diversion and a strategy of no cerebrospinal fluid diversion. Use of mannitol and hypertonic saline for hyperosmolar therapies was widespread among centers (90.1% and 96.9%, respectively). Of centers using hypertonic saline, 3% saline preparations were the most common but many other concentrations were in common use. Routine hyperventilation was not reported as a standard goal and 31.3% of centers currently use PbO(2) monitoring for cerebral hypoxia. The time to start nutritional support and glucose administration varied widely, with nutritional support beginning before 96 hours and glucose administration being started earlier in most centers.

Conclusions: There were marked differences in medical goals for children with severe traumatic brain injury across our international consortium, and these differences seemed to be greatest in areas with the weakest evidence in the literature. Future studies that determine the superiority of the various medical therapies outlined within our survey would be a significant advance for the pediatric neurotrauma field and may lead to new standards of care and improved study designs for clinical trials.

Figure 1

Summary of the goals for starting of nutritional support from an international pediatric neurotrauma consortium consisting of 32 centers from the United States and Europe. Centers were asked, “When do you start nutritional support to patients?” and were able to respond in freeform text. Centers responded with discrete time points (“X” in the figure) or by describing a range of time periods where nutritional support was intended to be started (“line” in the figure). All times are expressed as time after traumatic brain injury (TBI).

Figure 2

Summary of the goals for starting of glucose from an international pediatric neurotrauma consortium consisting of 32 centers from the United States and Europe. Centers were asked, “When do you start to administer glucose to patients?” and were able to respond in freeform text. Centers responded with discrete time points (“X” in the figure) or by describing a range of time periods where nutritional support was intended to be started (“line” in the figure). Three centers responded with goals that were not time-based (when intracranial pressure < 20, when hypoglycemic, based on the age of patient) and are excluded from this figure. All times are expressed as time after traumatic brain injury (TBI).