Does adherence to treatment targets in children with severe traumatic brain injury avoid brain hypoxia? A brain tissue oxygenation study.
OBJECTIVE
Most physicians rely on conventional treatment targets for intracranial pressure, cerebral perfusion pressure, systemic oxygenation, and hemoglobin to direct management of traumatic brain injury (TBI) in children. In this study, we used brain tissue oxygen tension (PbtO2) monitoring to examine the association between PbtO2 values and outcome in pediatric severe TBI and to determine the incidence of compromised PbtO2 in patients for whom acceptable treatment targets had been achieved.


METHODS
In this prospective observational study, 26 children with severe TBI and a median postresuscitation Glasgow Coma Scale score of 5 were managed with continuous PbtO2 monitoring. The relationships between outcome and the 6-hour period of lowest PbtO2 values and the length of time that PbtO2 was less than 20, 15, 10, and 5 mmHg were examined. The incidence of reduced PbtO2 for each threshold was evaluated where the following targets were met: intracranial pressure less than 20 mmHg, cerebral perfusion pressure greater than 50 mmHg, arterial oxygen tension greater than 60 mmHg (and peripheral oxygen saturation > 90%), and hemoglobin greater than 8 g/dl.


RESULTS
There was a significant association between poor outcome and the 6-hour period of lowest PbtO2 and length of time that PbtO2 was less than 15 and 10 mmHg. Multiple logistic regression analysis showed that low PbtO2 had an independent association with poor outcome. Despite achieving the management targets described above, 80% of patients experienced one or more episodes of compromised PbtO2 (< 20 mmHg), and almost one-third experienced episodes of brain hypoxia (PbtO2 < 10 mmHg).


CONCLUSIONS
Reduced PbtO2 is associated with poor outcome in pediatric severe TBI. In addition, many patients experience episodes of compromised PbtO2 despite achieving acceptable treatment targets.
Figaji
Anthony A
AA
Division of Neurosurgery, School of Child and Adolescent Health, University of Cape Town, Red Cross Children's Hospital, Cape Town, South Africa. anthony.figaji@uct.ac.za
Fieggen
A Graham
AG
Argent
Andrew C
AC
Leroux
Peter D
PD
Peter
Jonathan C
JC
D000293:Adolescent; D001921:Brain / Q000378:metabolism*; D001930:Brain Injuries / Q000150:complications / Q000378:metabolism* / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D002534:Hypoxia, Brain / Q000209:etiology / Q000378:metabolism* / Q000628:therapy*; D007223:Infant; D008297:Male; D010101:Oxygen Consumption / Q000502:physiology*; D011446:Prospective Studies; D016896:Treatment Outcome