Singhi Sunit, Kumar Ramesh, Singhi Pratibha, Jayashree Muralidharan, Bansal Arun
Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Pediatr Crit Care Med. 2015 Jun;16(5):453-60. doi: 10.1097/PCC.0000000000000353.
Intracranial pressure monitoring can help in early identification of raised intracranial pressure and in setting more informed goals for treatment. We describe our 10-year experience of bedside burr holes performed by pediatric intensivists to establish intracranial pressure monitoring in children with CNS infections in a resource-limited setting and the technical difficulties and complications encountered.
Descriptive study of prospectively recorded data.
PICU of a tertiary care academic institute.
Consecutive comatose patients with raised intracranial pressure who underwent intracranial pressure monitoring from 2004 to 2013.
An intraparenchymal (1.2 mm) or an intraventricular transducer (3.4 mm) (Codman) was placed by a pediatric intensivist through a micro burr hole using a standard protocol. Technical difficulties during the procedure and complications were recorded.
Over 10 years, 265 intracranial pressure catheters were placed in 259 patients, mainly for acute CNS infections (n = 242, 93.4%). Median age of patients was 4.8 years, youngest being 6 weeks; 21 patients (8.1%) were younger than 1 year. Intraparenchymal transducer was used in 252 patients (97.3%). Median (interquartile range) duration of intracranial pressure monitoring was 96 hours (72-144 hr). Complications were seen in 3.5% of patients (n = 9/259); the incidence was 0.28 per 1,000 hours of intracranial pressure monitoring. Procedure-related ventriculitis occurred in three of seven patients (42.8%) with intraventricular catheter, in contrast to none in patients with intraparenchymal transducer. Overall mortality was 32.8% (n = 85). On Cox-regression analysis, "blood component therapy" was an independent predictor of poor outcome defined as death or severe neurodisability (adjusted hazard ratio, 1.58; 95% CI, 1.16-2.16; p = 0.004).
In a resource-limited setting, pediatric intensivists can safely and successfully perform burr holes at bedside for establishing intraparenchymal intracranial pressure monitoring in children with acute CNS infections. However, our data do not support placement of ventriculostomy catheters by pediatric intensivists in similar settings.
颅内压监测有助于早期识别颅内压升高，并为制定更明智的治疗目标提供依据。我们描述了在资源有限的情况下，儿科重症监护医生进行床边颅骨钻孔以建立中枢神经系统感染患儿颅内压监测的10年经验，以及所遇到的技术困难和并发症。
对前瞻性记录数据的描述性研究。
一家三级医疗学术机构的儿科重症监护病房。
2004年至2013年期间接受颅内压监测的连续昏迷且颅内压升高的患者。
儿科重症监护医生按照标准方案，通过微小颅骨钻孔置入脑实质内（1.2毫米）或脑室内传感器（3.4毫米）（Codman）。记录手术过程中的技术困难和并发症。
在10年期间，259例患者共置入265根颅内压导管，主要用于急性中枢神经系统感染（n = 242，93.4%）。患者中位年龄为4.8岁，最小为6周；21例患者（8.1%）年龄小于1岁。252例患者（97.3%）使用了脑实质内传感器。颅内压监测的中位（四分位间距）持续时间为96小时（72 - 144小时）。3.5%的患者（n = 9/259）出现并发症；颅内压监测每1000小时的发生率为0.28。7例脑室内置管患者中有3例（42.8%）发生了与手术相关的脑室炎，而脑实质内传感器置入患者无一例发生。总体死亡率为32.8%（n = 85）。Cox回归分析显示，“血液成分治疗”是定义为死亡或严重神经功能障碍的不良结局的独立预测因素（调整后风险比，1.58；95%置信区间，1.16 - 2.16；p = 0.004）。
在资源有限的情况下，儿科重症监护医生可以在床边安全、成功地进行颅骨钻孔，为急性中枢神经系统感染患儿建立脑实质内颅内压监测。然而，我们的数据不支持儿科重症监护医生在类似情况下放置脑室造瘘管。
