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Abstract Body

Background & Aims

Data visualisation techniques are useful to better understand the impact of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) dose-responses on brain trauma outcome in adults. We aim to better understand how ICP and CPP dose-responses impact on childhood brain trauma outcome.

Methods

Prospectively collected minute-by-minute physiological data of 199 paediatric brain trauma patients from KidsBrainIT, an EU grant funded multi-national multi-centre paediatric brain trauma research initiative, were analysed. The relationships between the 6 months post-injury global outcome and episodes of elevated ICP and low CPP were visualised in respectively 3D colour-coded plots (i.e. the ICP and CPP dose-response visualisation plots).

Results

The ICP dose-response plot confirmed a transitional curve delineating the duration and intensity of those higher ICP episodes associated with worse outcome from episodes of lower degree of intracranial hypertension associated with better outcome. Transition to worse outcomes above ICP of 18 mmHg occurred at 4 minutes, but ICP of 20 mmHg or more was not tolerated at all. Paediatric CPP dose-response visualisation plots confirmed for the first time, like adults, an almost exponential transition curve separating the episodes of CPP associated with better outcomes from episode of low CPP associated with worse outcome.

Conclusions

Dose-response visualisation plots for ICP and CPP are respectively useful in better understand their impact on childhood brain trauma outcome. To improve outcome after childhood brain trauma, ICP of 20 mmHg or more must be avoided. The relationships between CPP tolerance thresholds, different ages, and cerebrovascular reactivity warrant further investigations.

Background and Aims

Mortality rates in childhood are lower in females than males. However, for children admitted to Paediatric Intensive Care Units (PICU), mortality is reported to be lower in males, although males have higher admission rates into PICU.

Our primary aim is to estimate the difference in mortality rates between males and females aged 0-18 years, who die in PICU.

Methods

Any study that reported the rates of mortality in children admitted to intensive care by sex were eligible for inclusion. Our peer reviewed search strategy was described in our previously published protocol.

Results

We identified 124 eligible studies (Figure 1) of which, 114 reported counts of deaths by sex which give a population of 278,274 children; 121,800 (44%) females and 156,474 males (56%). The mortality rate for females was 5,614/121,800 (4.61%), and for males 6,828/156,474 (4.36%). Females had higher OR of mortality, see Table1. Only five studies reported sex as the primary exposure, thus meeting our criteria for quality assessment (Figure 2).

Table 1. Summary of pooled analyses

Conclusions

Our review shows that whilst more male children are admitted to PICU, female children are more likely to die in PICU. Pooled analyses whether fixed or random effects, show higher female mortality in PICU relative to male mortality.

Background and Aims

Thanks to continuing medical developments, children are thriving with diagnoses previously felt to be unsurvivable. There will always be children who reach a critical juncture where consideration should be given as to whether continuing life-sustaining treatment (LST) is in their best interest. These are complex, ethically challenging decisions, yet within Nottingham Children’s Hospital (NCH) there is a lack of guidance to support this process. We aimed to design and implement an inclusive guideline to support exemplary decision making and palliative care during withdrawal of life-sustaining treatment on PCCU.

Methods

Key professionals, including palliative care nurses, intensivists, pharmacists, hospice teams, chaplaincy, and parents were identified and consulted. Authors met with stakeholders to collate guidance and produce a document to support healthcare professionals to fulfil the needs of children and families approaching the end of life (EOL).

Results

A comprehensive, patient centred guideline has been produced. Users are supported to recognise and communicate the need for re-orientation of care and a framework is provided to create a unique, holistic EOL plan. Alongside pharmacy approved drug formularies designed to optimise symptom management at the EOL, there is clear guidance for clinicians regarding proceedings and support after a child’s death.

Conclusions

By consulting and collaborating with the wider multi-disciplinary team a comprehensive, holistic, patient-centred guideline has been produced which promotes sensitive, compassionate and dignified withdrawal of LSTs within PCCU. This has been well received within NCH and further evaluation will be undertaken to understand the impact of this guideline on both families and staff.

Background and Aims

In developed countries, severe trauma injury is one of the main causes of morbimortality in children. Its prognosis is highly variable and its development difficult to predict.

Our aim is to identify eventual predicting risk factors of poor outcome [brain death (BD) and moderate-severe neurological sequelae (NS)].

Methods

Observational restrospective study of patients addmitted to PICU for TBI between 2009 and 2021.

Epidemiological, clinical and radiological variables were analyzed using multivariate and bivariate analysis

Results

89 patients (77.5% male); 75 months (RIC:21-133.5). 33.7% had severe brain injury according to GSC (<8). 42.7% required evacuating surgery and 19.1% urgent craniectomy.

The most common NS were altered consciousness (44.9%), aphasia (9%), hemiparesis (7.9%), limb paresis (6.4%) and visual disturbance (5.6%). Intraparenchymatous hemorrhage (25.8%) OR 3.7 (95% CI 1.2-11.4); bradycardia (16.9%) OR 4.1 (95% CI 1.1-14.9); and brain swelling (30.3%) OR 4.2 (95% CI 1.4-12.4) had an increased risk of severe NS.

7 patients evolved to BD. At greater risk were those with pupillary alterations [(OR 21.6; 95% CI 1.42 -328.69); and no trunk reflexes (OR 19.3; 95% CI 1.01 -367.24)].

30.7% had signs of cerebral edema (CD) (loss of gray-white matter differentiation, effacement of sulci and/or basal cisterns) and this was related to both NS (55.7% vs 18% p < 0.0001 ) and BD (25.9% vs 0% p< 0,001).

Conclusions

Early brain swelling is a predicting risk factor of both BD and NS, while focal lesions such as intraparenchymal hemorrhage increase the risk of severe neurological sequelae. Severe clinical onset may progress to brain death.