title: Which paediatric head injured patients might benefit from decompression? Thresholds of ICP and CPP in the first six hours.
abstract: Severe head injury in childhood continues to be associated with considerable mortality and morbidity. Early surgical decompression may be beneficial and the objective of this study was to examine the relationship between age-related thresholds of mean intracranial pressure (ICP) and cerebral perfusion pressure (CPP) over the first 6 hours and age outcome in paediatric head injury patients. A total of 209 head injured children admitted to five UK hospitals were studied. Patients aged 2 to 16 years were included if they had a minimum of six hours of invasive pressure monitoring. Mean values of ICP and CPP over this period were calculated and compared to those with independent (good recovery and moderate disability) and poor outcome (severe disability, and death) for different age groups. There were 148 children with independent outcome (92 good recovery, 56 moderately disabled), and 61 with poor outcome (30 severely disabled, 31 deaths). There was a significant difference between those with independent compared to poor outcome in relation to ICP (p < 0.001) and CPP (p < 0.001). Patients were divided into three groups according to age. The sensitivity of ICP and CPP in predicting outcome was similar for all groups but the specificity differed between groups. At a CPP of 50 mmHg the specificity varied between the age groups (2 to 6 years: 0.47, 7 to 10 years: 0.28 and 11 to 16 years: 0.10) and similarly for an ICP of 25 mmHg (2 to 6 years: 0.53, 7 to 10 years: 0.44 and 11 to 16 years: 0.38). Younger children may be able to tolerate lower perfusion pressures and still have an independent outcome. Our threshold values for young children are likely to be important in the identification of patients who might benefit from new treatments such as surgical decompression.
authors.affiliation: Regional Medical Physics Department, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK. i.r.chambers@ncl.ac.uk
authors.forename: I R
authors.initials: IR
authors.lastname: Chambers
authors.forename: P A
authors.initials: PA
authors.lastname: Jones
authors.forename: R A
authors.initials: RA
authors.lastname: Minns
authors.forename: L
authors.initials: L
authors.lastname: Stobbart
authors.forename: A D
authors.initials: AD
authors.lastname: Mendelow
authors.forename: R C
authors.initials: RC
authors.lastname: Tasker
authors.forename: F
authors.initials: F
authors.lastname: Kirkham
mesh_terms: D000293:Adolescent; D001794:Blood Pressure; D001930:Brain Injuries / Q000175:diagnosis* / Q000401:mortality* / Q000601:surgery; D002560:Cerebrovascular Circulation; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D003399:Craniotomy / Q000706:statistics & numerical data; D003422:Critical Care / Q000379:methods / Q000706:statistics & numerical data; D019299:Decompression, Surgical / Q000706:statistics & numerical data; D004056:Differential Threshold; D005260:Female; D006801:Humans; D015994:Incidence; D019586:Intracranial Hypertension / Q000175:diagnosis* / Q000401:mortality* / Q000601:surgery; D007427:Intracranial Pressure; D008297:Male; D008991:Monitoring, Physiologic / Q000379:methods* / Q000706:statistics & numerical data; D018579:Patient Selection; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate; D006113:United Kingdom / Q000453:epidemiology