Background

The 2012 Brain Trauma Foundation (BTF) guidelines for severe traumatic brain injury (TBI) in infants, children and adolescents (2^nd edition) provided recommendations for management in paediatric intensive care units (PICU). However, weak recommendations based on low quality evidence can lead to variability in clinical practice.

Objectives

Describe the variability of individual UK PICU TBI guidelines compared to BTF guidelines and/or each other.

Methods

Current TBI guidelines were requested from 17 UK PICUs. Guidelines were anonymised and analysed for consistency in 12 key areas of clinical practice.

Results

12/17 (71%) UK PICU TBI guidelines were received. None of the guidelines were entirely consistent with the BTF. Widespread variability was observed in all analysed areas of clinical practice including intracranial, cerebral perfusion pressure thresholds and intracranial hypertension management strategies (Figure 1). Of note, none of the analysed guidelines recommended the choice of 6.5-10mL/kg 3% hypertonic saline suggested by BTF for bolus dose of hyperosmotic therapy. Most of the guidelines (83%) recommended decompressive craniectomy as a rescue option in refractory intracranial hypertension, consistent with BTF. However, lack of clarity about exact timing, indication and surgical technique were widely observed.

Conclusion

Current UK PICUs TBI guidelines differ significantly with BTF recommendations and amongst each other. There is potential for significant differences in clinical practice and the need for higher quality data to inform recommendations.

Background

Determination of neurologic death (DND) in children is a clinical diagnosis requiring absence of neurologic function with co-existence of irreversible coma and apnea. Apnea testing (AT) assesses spontaneous respiration when arterial carbon dioxide (PaCO₂) increases to ≥ 60mmHg and ≥ 20mmHg above baseline. CO2 measurement during AT for DND in children using transcutaneous carbon dioxide monitoring (TcCO₂) is unknown.

Objectives

To assess correlation between paired TcCO₂ and PaCO₂ values during AT for DND.

Methods

Retrospective case series of children 0-18 years of age undergoing DND between May 2017–December 2018. Location was a 28 bed Pediatric Intensive Care Unit in a 259-bed tertiary care pediatric referral center. Primary outcomes were paired TcCO₂ and PaCO₂ values obtained during AT. Radiometer TOSCA Monitor (Radiometer America©. Brea, California) was used for all trials.

Results

Eight children (5 male), mean age 2 years (range 0.1-8.1 years) met criteria for DND. 31 paired TcCO₂ and PaCO₂ values were obtained from 15 DND encounters. TcCO₂ and PaCO₂ correlated well (r=0.94, p < 0.01). TcCO₂ and PaCO₂ median difference was 5 mmHg (IQR:3-7) with no correlation to vasoactive inotropic score (r=0.2) or patient temperature (r=0.11). ROC curve of TcCO2 after 3-6 minutes of apnea to discriminate PaCO₂ consistent with DND yielded AUC of 0.91 and cut-off value of ≥ 64 mmHg (sensitivity 91.67%, specificity 100%).

Conclusion

TcCO₂ demonstrated high accuracy and reliability compared with PaCO₂ by blood gas analysis during AT for DND in children. TcCO₂ monitoring may reduce redundant arterial gas sampling by identifying appropriate timing to achieve target PaCO₂.

Background

Early diagnosis of acute intracranial hypertension is essential for the optimal treatment. Opthalmic ultrasound measurement of optic nerve sheath diameter (ONSD) is an easy, portabl, noninvasive and a radiation free technique to determine increased intracranial pressure.

Objectives

The aim was to establish the normal values for ONSD in premature and mature newborns.

Methods

Newborns without intracranial pathology in NICUs and Obstetrics/ Gynecology Departments were included. ONSD were measured at a distance 2, 2.5 and 3 mm beyond the right optic nerve head in preterms and at 3 mm in term infants. Measurements were done by a pediatric intensive care fellow who expertise with point-of-care ultrasound.

Results

554 newborn infants (premature:253, mature:301) were included in the study. The mean ONSD of premature babies from 2, 2.5 and 3 mm were 0.32±0.03 cm (range 0.20-0.42 cm), 0.33±0.03 cm (range 0.22-0.45 cm) and 0.36±0.02 cm (range 0.29-0.45 cm), respectively. The mean ONSD from 3 mm behind the optic disc of mature babies was 0.40±0.027 cm (range 0.33-0.36 cm). There was no significant difference in ONSD between males and females. In the correlation analysis, a significant, strong and positive correlation was found between ONSD measurements from 2, 2.5 and 3 mm behind the optic disc and gestational age, actual weight, birth height and birth head circumference.

Conclusion

Our study is important in terms of being the largest series in the literatu defining the normal range of ONSD in newborns. The normal values reported by present study may be used for evaluating the ONSD of newborns with and without increased incracranial pressure.

Background

HIE occurs in 1.5 to 4 per 1,000 births in developed countries, and in as many as 26 per 1,000 live births in resource-limited settings. Therapeutic hypothermia significantly reduces the combined outcome of death or severe neurodevelopmental impairment from 65% to 40-50%, but additional treatments to further improve outcomes are needed.

Objectives

To evaluate possible neuroprotective effect of dexmedetomidine in term neonates with HIE.

Methods

Prospective single-center randomized clinical study in 205 term neonates with HIE was performed in NICU Level III in 2009-2019. Babies in control group received morphine sedation 10-20 mcg/kg/hour vs. dexmedetomidine 0.1-0.5 mcg/kg/hour in study group. End-points included aEEG, transfontanel Doppler, serum neuronal biomarkers (NSE, protein S-100) and cerebral leukomalacia morbidity.

Results

Table 1. Comparative analysis of dexmedetomidine vs. control group.

No significant differences in Doppler cerebral blood flow indexes, NSE and S-100 were found. A significant differences between two groups were revealed in seizers detection, mean blood pressure, time to extubation and cerebral leukomalacia morbidity.

Conclusion

Dexmedetomidine is a safe sedative agent with stable hemodynamics profile and possible neuroprotective effect in HIE, additional to therapeutic hypothermia.