Age-specific cerebral perfusion pressure thresholds and survival in children and adolescents with severe traumatic brain injury*

Abstract

Objectives: Evidence-based traumatic brain injury guidelines support cerebral perfusion pressure thresholds for adults at a class 2 level, but evidence is lacking in younger patients. The purpose of this study is to identify the impact of age-specific cerebral perfusion pressure thresholds on short-term survival among patients with severe traumatic brain injury.

Design: Institutional review board-approved, prospective, observational cohort study.

Setting: Level I or II trauma centers in New York State.

Patients: Data on all patients with a postresuscitation Glasgow Coma Score less than 9 were added in the Brain Trauma Foundation prospective New York State TBI-trac database.

Measurements and main results: We calculated the survival rates and relative risks of mortality for patients with severe traumatic brain injury based on predefined age-specific cerebral perfusion pressure thresholds. A higher threshold and a lower threshold were defined for each age group: 60 and 50 mm Hg for 12 years old or older, 50 and 35 mm Hg for 6-11 years, and 40 and 30 mm Hg for 0-5 years. Patients were stratified into age groups of 0-11, 12-17, and 18 years old or older. Three exclusive groups of CPP-L (events below low cerebral perfusion pressure threshold), CPP-B (events between high and low cerebral perfusion pressure thresholds), and CPP-H (events above high cerebral perfusion pressure threshold) were defined. As an internal control, we evaluated the associations between cerebral perfusion pressure events and events of hypotension and elevated intracranial pressure. Survival was significantly higher in 0-11 and 18 years old or older age groups for patients with CPP-H events compared with those with CPP-L events. There was a significant decrease in survival with prolonged exposure to CPP-B events for the 0-11 and 18 years old and older age groups when compared with the patients with CPP-H events (p = 0.0001 and p = 0.042, respectively). There was also a significant decrease in survival with prolonged exposure to CPP-L events in all age groups compared with the patients with CPP-H events (p< 0.0001 for 0- to 11-yr olds, p = 0.0240 for 12- to 17-yr olds, and p < 0.0001 for 18-yr old and older age groups). The 12- to 17-year olds had a significantly higher likelihood of survival compared with adults with prolonged exposure to CPP-L events (< 50 mm Hg). CPP-L events were significantly related to systemic hypotension for the 12- to 17-year-old group (p = 0.004) and the 18-year-old and older group (p < 0.0001). CPP-B events were significantly related to systemic hypotension in the 0- to 11-year-old group (p = 0.014). CPP-B and CPP-L events were significantly related to elevated intracranial pressure in all age groups.

Conclusions: Our data provide new evidence that cerebral perfusion pressure targets should be age specific. Furthermore, cerebral perfusion pressure goals above 50 or 60 mm Hg in adults, above 50 mm Hg in 6- to 17-year olds, and above 40 mm Hg in 0- to 5-year olds seem to be appropriate targets for treatment-based studies. Systemic hypotension had an inconsistent relationship to events of low cerebral perfusion pressure, whereas elevated intracranial pressure was significantly related to all low cerebral perfusion pressure events across all age groups. This may impart a clinically important difference in care, highlighting the necessity of controlling intracranial pressure at all times, while targeting systolic blood pressure in specific instances.

Figure 1

Database screening. ¹Not pharmacologically paralyzed. ²Included in sensitivity analysis; data missing for arrival time at trauma center, time of trauma, or arrival time recorded as before trauma time. ³Of 2,074 patients, 14 patients do not have outcome data; included in sensitivity analysis. GCS = Glasgow Coma Score.

Figure 2

A–C, Kaplan-Meier survival plots for total monitored time above the high cerebral perfusion pressure (CPP) threshold (CPP-H, continuous line), total time between CPP thresholds (CPP-B, dotted line), and total time below the low CPP threshold (CPP-L, dashed line) at each age group. CPP-H = above 40 mm Hg for 0- to 5-yr olds, above 50 mm Hg for 6- to 11-yr olds, and above 60 mm Hg for 12-yr olds and older. CPP-B = between 30 and 40 mm Hg for 0- to 5-yr olds, between 35 and 50 mm Hg for 6- to 11-yr olds, and between 50 and 60 mm Hg for 12-yr olds and older. CPP-L = below 30 mm Hg for 0- to 5-yr olds, below 35 mm Hg for 6- to 11-yr olds, and below 50 mm Hg for 12-yr olds and older. D, Kaplan-Meier survival plot for time below 50 mm Hg for the 12- to 17-yr-old age group (continuous line) and the 18-yr-old and older age group (dashed line).