Guidelines for the Management of Pediatric Severe TBI, 3rd Edition
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Recommendations
Strength of Recommendations: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
To Improve Overall Outcomes. III.1. Use of ICP monitoring is suggested.
-
Recommendations
Strength of Recommendation: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
To Improve Overall Outcomes.
III.1. If brain tissue oxygenation (PbrO2) monitoring is used, maintaining a level greater than 10 mm Hg is suggested.
Note 1. There was insufficient evidence to support a recommendation for the use of a monitor of PbrO2to improve outcomes.
Note 2. Use of advanced neuromonitoring (brain oxygenation) should only be for patients with no contraindications to invasive neuromonitoring such as coagulopathy and for patients who do not have a diagnosis of brain death.
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Recommendations
Strength of Recommendation: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
To Improve Overall Outcomes.
III.1. Excluding the possibility of elevated ICP on the basis of a normal initial (0–6 hr after injury) CT examination of the brain is not suggested in comatose pediatric patients.
III.2. Routinely obtaining a repeat CT scan greater than 24 hours after the admission and initial follow-up is not suggested for decisions about neurosurgical intervention, unless there is either evidence of neurologic deterioration or increasing ICP.
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Recommendations
Strength of Recommendation: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
To Improve Overall Outcomes
III.1. Treatment of ICP targeting a threshold of less than 20 mmHg is suggested.
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Recommendations
Strength of Recommendations: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
To Improve Overall Outcomes.
III.1. Treatment to maintain a CPP at a minimum of 40 mm Hg is suggested.
III.2. A CPP target between 40 and 50 mm Hg is suggested to ensure that the minimum value of 40 mm Hg is not breached. There may be age-specific thresholds with infants at the lower end and adolescents at or above the upper end of this range.
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Recommendations
Strength of Recommendations: Weak
Level I
There was insufficient evidence to support a level I recommendation for this topic.
Level II
For ICP Control.
II.1. Bolus HTS (3%) is recommended in patients with intracranial hypertension. Recommended effective doses for acute use range between 2 and 5 mL/kg over 10–20 minutes.
Level III
For ICP Control.
III.1. Continuous infusion HTS is suggested in patients with intracranial hypertension. Suggested effective doses as a continuous infusion of 3% saline range between 0.1 and 1.0 mL/kg of body weight per hour, administered on a sliding scale. The minimum dose needed to maintain ICP less than 20 mm Hg is suggested.
III.2. Bolus of 23.4% HTS is suggested for refractory ICP. The suggested dose is 0.5 mL/kg with a maximum of 30 mL.
Safety Recommendation (applies to all recommendations for this topic). In the context of multiple ICP-related therapies, avoiding sustained (> 72 hr) serum sodium greater than 170 mEq/L is suggested to avoid complications of thrombocytopenia and anemia, whereas avoiding a sustained serum sodium greater than 160 mEq/L is suggested to avoid the complication of deep vein thrombosis (DVT).
Note. Although mannitol is commonly used in the management of raised ICP in pediatric TBI, no studies meeting inclusion criteria were identified for use as evidence for this topic.
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Recommendations
Strength of Recommendations: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
For ICP Control.
III.1. With use of multiple ICP-related therapies, as well as appropriate use of analgesia and sedation in routine ICU care, avoiding bolus administration of midazolam and/or fentanyl during ICP crises is suggested due to risks of cerebral hypoperfusion.
Note 1. In the absence of outcome data, the specific indications, choice, and dosing of analgesics, sedatives, and neuromuscular blocking agents should be left to the treating physician.
Note 2. Based on guidance from the U.S. Food and Drug Administration, prolonged continuous infusion of propofol for either sedation or the management of refractory intracranial hypertension is not recommended.
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Recommendations
Strength of Recommendation: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
For ICP Control.
III.1. CSF drainage through an EVD is suggested to manage increased ICP.
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Recommendations
Strength of Recommendation: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
For Seizure Prevention (Clinical and Subclinical).
III.1. Prophylactic treatment is suggested to reduce the occurrence of early (within 7 d) PTSs.
Note. At the present time, there is insufficient evidence to recommend levetiracetam over phenytoin based on either efficacy in preventing early PTS (EPTS) or toxicity.
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Recommendations
Strength of Recommendations: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
To Improve Overall Outcomes.
III.1. Prophylactic severe hyperventilation to a Paco2 less than 30 mm Hg in the initial 48 hours after injury is not suggested.
III.2. If hyperventilation is used in the management of refractory intracranial hypertension, advanced for evaluation of cerebral ischemia is suggested.
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Recommendations
Strength of Recommendation: Moderate
Level I
There was insufficient evidence to support a level I recommendation for this topic.
Level II
To Improve Overall Outcomes.
II.1. Prophylactic moderate (32–33°C) hypothermia is not recommended over normothermia to improve overall outcomes.
Level III
For ICP Control.
III.1. Moderate (32–33°C) hypothermia is suggested for ICP control.
Safety Recommendation 1. If hypothermia is used and rewarming is initiated, it should be carried out at a rate of 0.5–1.0°C every 12–24 hours or slower to avoid complications.
Safety Recommendation 2. If phenytoin is used during hypothermia, monitoring and dosing adjusted to minimize toxicity, especially during the rewarming period, are suggested.
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Recommendations
Strength of Recommendations: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
For ICP Control.
III.1. High-dose barbiturate therapy is suggested in hemodynamically stable patients with refractory intracranial hypertension despite maximal medical and surgical management.
Safety Recommendation. When high-dose barbiturate therapy is used to treat refractory intracranial hypertension, continuous arterial blood pressure monitoring and cardiovascular support to maintain adequate CPP are required because cardiorespiratory instability is common among patients treated with barbiturate coma.
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Recommendations
Strength of Recommendation: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
For ICP Control.
III.1. Decompressive craniectomy (DC) is suggested to treat neurologic deterioration, herniation, or intracranial hypertension refractory to medical management.
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Recommendations
Strength of Recommendations: Weak
Level I
There was insufficient evidence to support a level I recommendation for this topic.
Level II
To Improve Overall Outcomes.
II.1. Use of an immune-modulating diet is not recommended.
Level III
To Improve Overall Outcomes.
III.1. Initiation of early enteral nutritional support (within 72 hr from injury) is suggested to decrease mortality and improve outcomes.
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Recommendations
Strength of the Recommendation: Weak
Levels I and II
There was insufficient evidence to support a level I or II recommendation for this topic.
Level III
To Improve Overall Outcomes
III.1.The use of corticosteroids is not suggested to improve outcome or reduce ICP.
Note: Recommendation III.1. is not intended to circumvent use of replacement corticosteroids for patients needing chronic steroid replacement therapy, those with adrenal suppression, and those with injury to the hypothalamic-pituitary steroid axis.