Cerebral oxygenation in major pediatric trauma: its relevance to trauma severity and outcome.
BACKGROUND
Trauma is the commonest cause of death in the pediatric population, which is prone to diffuse primary brain injury aggravated by secondary insults (eg, hypoxia, hypotension). Standard monitoring involves intracranial pressure (ICP) and cerebral perfusion pressure, which do not reflect true cerebral oxygenation (oxygen delivery [Do(2)]). We explore the merits of a brain tissue oxygen-directed critical care guide.


METHODS
Sixteen patients with major trauma (Injury Severity Score, >16/Pediatric Trauma Score [PTS], <7) had partial pressure of brain tissue oxygen (Pbto(2)) monitor (Licox; Integra Neurosciences, Plainsboro, NJ) placed under local anesthesia using twist-drill craniostomy and definitive management of associated injuries. Pbto(2) levels directed therapy intensity level (ventilator management, inotrops, blood transfusion, and others). Patient demographics, short-term physiological parameters, Pbto(2), ICP, Glasgow Coma Score, trauma scores, and outcomes were analyzed to identify the patients at risk for low Do(2).


RESULTS
There were 10 males and 6 females (mean age, 14 years) sustaining motor vehicle accident (14), falls (1), and assault (1), with a mean Injury Severity Score of 36 (16-59); PTS, 3 (0-7); and Revised Trauma Score, 5.5 (4-11). Eleven patients (70%) had low Do(2) (Pbto(2), <20 mm Hg) on admission despite undergoing standard resuscitation affected by fraction of inspired oxygen, Pao(2), and cerebral perfusion pressure (P = .001). Eubaric hyperoxia improved cerebral oxygenation in the low-Do(2) group (P = .044). The Revised Trauma Score (r = 0.65) showed moderate correlation with Pbto(2) and was a significant predictor for low Do(2) (P = .001). In patients with Pbto(2) of less than 20 mm Hg, PTS correlated with cerebral oxygenation (r = 0.671, P = .033). The mean 2-hour Pbto(2) and the final Pbto(2) in survivors were significantly higher than deaths (21.6 vs 7.2 mm Hg [P = .009] and 25 vs 11 mm Hg [P = .01]). Although 4 of 6 deaths were from uncontrolled high ICP, PTS and 2-hour low Do(2) were significant for roots for mortality.


CONCLUSIONS
Pbto(2) monitoring allows for early recognition of low-Do(2) situations, enabling appropriate therapeutic intervention.
Narotam
Pradeep K
PK
Division of Neurosurgery and Trauma, Creighton University Medical Center, Omaha, NE 68131, USA. narotam@creighton.edu
Burjonrappa
Sathyaprasad C
SC
Raynor
Stephen C
SC
Rao
Malini
M
Taylon
Charles
C
D000293:Adolescent; D001921:Brain / Q000378:metabolism*; D001930:Brain Injuries / Q000145:classification* / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016887:Cardiopulmonary Resuscitation; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D006931:Hyperbaric Oxygenation; D002534:Hypoxia, Brain / Q000209:etiology* / Q000628:therapy*; D007223:Infant; D007427:Intracranial Pressure; D008297:Male; D010100:Oxygen / Q000032:analysis*; D010347:Patient Care Planning; D011237:Predictive Value of Tests; D011379:Prognosis; D012121:Respiration, Artificial; D012307:Risk Factors; D013534:Survival; D015599:Trauma Severity Indices; D016896:Treatment Outcome
D010100:Oxygen