Michael F. Stiefel, Joshua D. Udoetuk, Phillip B. Storm, Leslie N. Sutton, Heakyung Kim, Troy E. Dominguez, Mark A. Helfaer and Jimmy W. Huh
Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring are fundamental to the management of severe traumatic brain injury (TBI). In adults, brain tissue oxygen monitoring (specifically PO2) and treatment have been shown to be safe additions to conventional neurocritical care and are associated with improved outcome. Brain tissue oxygen monitoring, however, has not been described in pediatric patients with TBI. In this report, the authors present preliminary experience with the use of ICP and PO2 monitoring in this population.
Pediatric patients (age <18 years) with severe TBI (Glasgow Coma Scale score <8) admitted to a Level 1 trauma center who underwent ICP and PO2 monitoring were evaluated. Therapy was directed at maintaining ICP below 20 mm Hg and age-appropriate CPP (≥ 40 mm Hg).
Data obtained in six patients (two girls and four boys ranging in age from 6–16 years) were analyzed. Brain tissue oxygen levels were significantly higher (p <0.01) at an ICP of less than 20 mm Hg (PO2 29.29 ± 7.17 mm Hg) than at an ICP of greater than or equal to 20 mm Hg (PO2 22.83 ± 13.85 mm Hg). Significant differences (p <0.01) were also measured when CPP was less than 40 mm Hg (PO2 2.53 ± 7.98 mm Hg) and greater than or equal to 40 mm Hg (PO2 28.97 ± 7.85 mm Hg).
Brain tissue oxygen monitoring may be a safe and useful addition to ICP monitoring in the treatment of pediatric patients with severe TBI.
Shih-Shan Lang, Bingqing Zhang, Hugues Yver, Judy Palma, Matthew P. Kirschen, Alexis A. Topjian, Benjamin Kennedy, Phillip B. Storm, Gregory G. Heuer, Janell L. Mensinger and Jimmy W. Huh
External ventricular drains (EVDs) are commonly used in the neurosurgical population. However, very few pediatric neurosurgery studies are available regarding EVD-associated infection rates with antibiotic-impregnated EVD catheters. The authors previously published a large pediatric cohort study analyzing nonantibiotic-impregnated EVD catheters and risk factors associated with infections. In this study, they aimed to analyze the EVD-associated infection rate after implementation of antibiotic-impregnated EVD catheters.
A retrospective observational cohort of pediatric patients (younger than 18 years of age) who underwent a burr hole for antibiotic-impregnated EVD placement and who were admitted to a quaternary care ICU between January 2011 and January 2019 were reviewed. The ventriculostomy-associated infection rate in patients with antibiotic-impregnated EVD catheters was compared to the authors’ historical control of patients with nonantibiotic-impregnated EVD catheters.
Two hundred twenty-nine patients with antibiotic-impregnated EVD catheters were identified. Neurological diagnostic categories included externalization of an existing shunt (externalized shunt) in 34 patients (14.9%); brain tumor (tumor) in 77 patients (33.6%); intracranial hemorrhage (ICH) in 27 patients (11.8%); traumatic brain injury (TBI) in 6 patients (2.6%); and 85 patients (37.1%) were captured in an “other” category. Two of 229 patients (0.9% of all patients) had CSF infections associated with EVD management, totaling an infection rate of 0.99 per 1000 catheter days. This is a significantly lower infection rate than was reported in the authors’ previously published analysis of the use of nonantibiotic-impregnated EVD catheters (0.9% vs 6%, p = 0.00128).
In their large pediatric cohort, the authors demonstrated a significant decline in ventriculostomy-associated CSF infection rate after implementation of antibiotic-impregnated EVD catheters at their institution.
Shih-Shan Lang, Omaditya Khanna, Natalie J. Atkin, Judy E. Palma, Ian Yuan, Phillip B. Storm, Gregory G. Heuer, Benjamin Kennedy, Angela J. Waanders, Yimei Li and Jimmy W. Huh
The lack of a continuous, noninvasive modality for monitoring intracranial pressure (ICP) is a major obstacle in the care of pediatric patients with hydrocephalus who are at risk for intracranial hypertension. Intracranial hypertension can lead to cerebral ischemia and brain tissue hypoxia. In this study, the authors evaluated the use of near-infrared spectroscopy (NIRS) to measure regional cerebral oxygen saturation (rSO2) in symptomatic pediatric patients with hydrocephalus concerning for elevated ICP.
The authors evaluated the NIRS rSO2 trends in pediatric patients presenting with acute hydrocephalus and clinical symptoms of intracranial hypertension. NIRS rSO2 values were recorded hourly before and after neurosurgical intervention. To test for significance between preoperative and postoperative values, the authors constructed a linear regression model with the rSO2 values as the outcome and pre- and postsurgery cohorts as the independent variable, adjusted for age and sex, and used the generalized estimating equation method to account for within-subject correlation.
Twenty-two pediatric patients underwent NIRS rSO2 monitoring before and after CSF diversion surgery. The mean durations of NIRS rSO2 recording pre- and postoperatively were 13.95 and 26.82 hours, respectively. The mean pre- and postoperative rSO2 values were 73.84% and 80.65%, respectively, and the adjusted mean difference estimated from the regression model was 5.98% (adjusted p < 0.0001), suggestive of improved cerebral oxygenation after definitive neurosurgical CSF diversion treatment. Postoperatively, all patients returned to baseline neurological status with no clinical symptoms of elevated ICP.
Cerebral oxygenation trends measured by NIRS in symptomatic pediatric hydrocephalus patients with intracranial hypertension generally improve after CSF diversion surgery.