Brain tissue oxygen monitoring after severe traumatic brain injury in children: relationship to outcome and association with other clinical parameters

Clinical article

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Object

Minimizing secondary brain injuries after traumatic brain injury (TBI) in children is critical to maximizing neurological outcome. Brain tissue oxygenation monitoring (as measured by interstitial partial pressure of O2 [PbO2]) is a new tool that may aid in guiding therapies, yet experience in children is limited. This study aims to describe the authors' experience of PbO2 monitoring after TBI. It was hypothesized that PbO2 thresholds could be established that were associated with favorable neurological outcome, and it was determined whether any relationships between PbO2 and other important clinical variables existed.

Methods

Forty-six children with severe TBI (Glasgow Coma Scale score ≤ 8 after resuscitation) who underwent PbO2 and brain temperature monitoring between September 2004 and June 2008 were studied. All patients received standard neurocritical care, and 24 were concurrently enrolled in a trial of therapeutic early hypothermia (n = 12/group). The PbO2 was measured in the uninjured frontal cortex. Hourly recordings and calculated daily means of various variables including PbO2, intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial blood pressure, partial pressure of arterial O2, and fraction of inspired O2 were compared using several statistical approaches. Glasgow Outcome Scale scores were determined at 6 months after injury.

Results

The mean patient age was 9.4 years (range 0.1–16.5 years; 13 girls) and 8554 hours of monitoring were analyzed (PbO2 range 0.0–97.2 mm Hg). A PbO2 of 30 mm Hg was associated with the highest sensitivity/specificity for favorable neurological outcome at 6 months after TBI, yet CPP was the only factor that was independently associated with favorable outcome. Surprisingly, instances of preserved PbO2 with altered ICP and CPP were observed in some children with unfavorable outcomes.

Conclusions

Monitoring of PbO2 demonstrated complex interactions with clinical variables reflecting intracranial dynamics using this protocol. A higher threshold than reported in studies in adults was suggested as a potential therapeutic target, but this threshold was not associated with improved outcomes. Additional studies to assess the utility of PbO2 monitoring after TBI in children are needed.

Abbreviations used in this paper:CPP = cerebral perfusion pressure; FiO2 = fraction of inspired O2; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; MAP = mean arterial pressure; PaCO2 = partial pressure of carbon dioxide in the blood; PaO2 = partial pressure of arterial O2; PbO2 = partial pressure of O2; TBI = traumatic brain injury.

Article Information

* Drs. Stippler and Ortiz contributed equally to this work.

Address correspondence to: Michael J. Bell, M.D., Safar Center for Resuscitation Research, 3434 5th Avenue, Pittsburgh, Pennsylvania 15260. email: bellmj4@upmc.edu.

Please include this information when citing this paper: published online September 14, 2012; DOI: 10.3171/2012.8.PEDS12165.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Distribution of paired hourly PbO2 and ICP values in children with favorable (left; GOS score 1–2, n = 5701 time points) and unfavorable outcome (right; GOS score 3–5, n = 2853 time points). Quadrants can be identified based on arbitrary clinical goals (ICP = 20 mm Hg, PbO2 = 30 mm Hg, gray lines). Quadrant I (upper left) = normal ICP and preserved oxygenation (ICP < 20, PbO2 > 30); Quadrant II (lower left) = cerebral hypoxia without intracranial hypertension (ICP < 20, PbO2 < 3 0); Quadrant III (upper r ight) = intracranial hypertension with preserved cerebral oxygenation (ICP > 20, PbO2 > 30); and Quadrant IV (lower right) = combined intracranial hypertension and cerebral hypoxia (ICP > 20, PbO2 < 30). Note that there are instances of intracranial hypertension with preserved cerebral oxygenation in children with unfavorable outcome (arrow, right panel).

  • View in gallery

    Distribution of paired hourly PbO2 and CPP values in children with favorable (left; GOS score 1–2, n = 5701 time points) and unfavorable outcome (right; GOS score 3–5, n = 2853 time points). Quadrants can be identified based on arbitrary clinical goals (CPP = 60 mm Hg, PbO2 = 30 mm Hg, gray lines). Quadrant I (upper left) = decreased cerebral perfusion with preserved cerebral oxygenation (CPP < 60, PbO2 > 30); Quadrant II (lower left) = decreased cerebral perfusion combined with cerebral hypoxia (CPP < 60, PbO2 < 30); Quadrant III (upper right) = normal cerebral perfusion and preserved oxygenation (CPP > 60, PbO2 > 30); and Quadrant IV (lower right) = cerebral hypoxia with preserved cerebral perfusion (CPP > 60, PbO2 < 30). Note that there are instances of decreased cerebral perfusion with preserved cerebral oxygenation in the children with unfavorable neurological outcome (arrow, right panel).

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