title: Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury.
abstract: OBJECTIVE
  Data on intraoperative secondary insults in pediatric traumatic brain injury (TBI) are limited.
  
  
  METHODS
  We examined intraoperative secondary insults during extracranial surgery in children with moderate-severe TBI and polytrauma and their association with postoperative head computed tomography (CT) scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores 24 h after surgery. After IRB approval, we reviewed the records of children <18 years with a Glasgow Coma Scale score <13 who underwent extracranial surgery within 72 h of TBI. Definitions of secondary insults were as follows: systemic hypotension (SBP <70 + 2 × age or 90 mmHg), cerebral hypotension (cerebral perfusion pressure <40 mmHg), intracranial hypertension (ICP >20 mmHg), hypoxia (oxygen saturation <90 %), hypercarbia (end-tidal CO2 >45 mmHg), hypocarbia (end-tidal CO2 <30 mmHg without hypotension and in the absence of intracranial hypertension), hyperglycemia (blood glucose >200 mg/dL), hyperthermia (temperature >38 °C), and hypothermia (temperature <35 °C).
  
  
  RESULTS
  Data from 50 surgeries in 42 patients (median age 15.5 years, 25 males) revealed systemic hypotension during 78 %, hypocarbia during 46 %, and hypercarbia during 25 % surgeries. Intracranial hypertension occurred in 64 % and cerebral hypotension in 18 % surgeries with ICP monitoring (11/50). Hyperglycemia occurred during 17 % of the 29 surgeries with glucose monitoring. Cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension (p = 0.02 and 0.03, respectively). We did not observe an association between intraoperative secondary insults and postoperative worsening of head CT scan or TIL score.
  
  
  CONCLUSIONS
  Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.
authors.affiliation: Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
authors.forename: Yasuki
authors.initials: Y
authors.lastname: Fujita
authors.forename: Nelson N
authors.initials: NN
authors.lastname: Algarra
authors.forename: Monica S
authors.initials: MS
authors.lastname: Vavilala
authors.forename: Sumidtra
authors.initials: S
authors.lastname: Prathep
authors.forename: Suchada
authors.initials: S
authors.lastname: Prapruettham
authors.forename: Deepak
authors.initials: D
authors.lastname: Sharma
mesh_terms: D000293:Adolescent; D000768:Anesthesia, General / Q000009:adverse effects; D001930:Brain Injuries / Q000150:complications*; D002245:Carbon Dioxide / Q000097:blood; D002648:Child; D002675:Child, Preschool; D005260:Female; D005334:Fever / Q000209:etiology; D015600:Glasgow Coma Scale; D006801:Humans; D006943:Hyperglycemia / Q000209:etiology; D007022:Hypotension / Q000209:etiology; D007035:Hypothermia / Q000209:etiology; D000860:Hypoxia / Q000209:etiology*; D007223:Infant; D019586:Intracranial Hypertension / Q000209:etiology*; D019585:Intracranial Hypotension / Q000150:complications*; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D013514:Surgical Procedures, Operative / Q000009:adverse effects*
chemical_list: D002245:Carbon Dioxide