title: Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge.
abstract: OBJECT The goal of critical care in treating traumatic brain injury (TBI) is to reduce secondary brain injury by limiting cerebral ischemia and optimizing cerebral blood flow. The authors compared short-term outcomes as defined by discharge disposition and Glasgow Outcome Scale scores in children with TBI before and after the implementation of a protocol that standardized decision-making and interventions among neurosurgeons and pediatric intensivists. METHODS The authors performed a retrospective pre- and postprotocol study of 128 pediatric patients with severe TBI, as defined by Glasgow Coma Scale (GCS) scores < 8, admitted to a tertiary care center pediatric critical care unit between April 1, 2008, and May 31, 2014. The preprotocol group included 99 patients, and the postprotocol group included 29 patients. The primary outcome of interest was discharge disposition before and after protocol implementation, which took place on April 1, 2013. Ordered logistic regression was used to assess outcomes while accounting for injury severity and clinical parameters. Favorable discharge disposition included discharge home. Unfavorable discharge disposition included discharge to an inpatient facility or death. RESULTS Demographics were similar between the treatment periods, as was injury severity as assessed by GCS score (mean 5.43 preprotocol, mean 5.28 postprotocol; p = 0.67). The ordered logistic regression model demonstrated an odds ratio of 4.0 of increasingly favorable outcome in the postprotocol cohort (p = 0.007). Prior to protocol implementation, 63 patients (64%) had unfavorable discharge disposition and 36 patients (36%) had favorable discharge disposition. After protocol implementation, 9 patients (31%) had unfavorable disposition, while 20 patients (69%) had favorable disposition (p = 0.002). In the preprotocol group, 31 patients (31%) died while 6 patients (21%) died after protocol implementation (p = 0.04). CONCLUSIONS Discharge disposition and mortality rates in pediatric patients with severe TBI improved after implementation of a standardized protocol among caregivers based on best-practice guidelines.
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: O'Lynnger
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Chevis N
authors.initials: CN
authors.lastname: Shannon
authors.affiliation: Pediatrics, Division of Pediatric Critical Care Medicine, and.
authors.forename: Truc M
authors.initials: TM
authors.lastname: Le
authors.affiliation: Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Amber
authors.initials: A
authors.lastname: Greeno
authors.affiliation: Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Dai
authors.initials: D
authors.lastname: Chung
authors.affiliation: Pediatrics, Division of Pediatric Critical Care Medicine, and.
authors.forename: Fred S
authors.initials: FS
authors.lastname: Lamb
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: John C
authors.initials: JC
authors.lastname: Wellons
mesh_terms: D000293:Adolescent; D001930:Brain Injuries / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D003422:Critical Care / Q000379:methods / Q000592:standards*; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D008297:Male; D017063:Outcome Assessment, Health Care; D010351:Patient Discharge; D017410:Practice Guidelines as Topic / Q000592:standards*; D012189:Retrospective Studies
keywords: CPP = cerebral perfusion pressure; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; OR = odds ratio; PICU = pediatric intensive care unit; TBI = traumatic brain injury; critical care; discharge; protocol; trauma; traumatic brain injury