Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA.
Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA.
Lancet Child Adolesc Health. 2019 Jan;3(1):23-34. doi: 10.1016/S2352-4642(18)30341-9. Epub 2018 Nov 23.
As far as we know, there are no tested in-hospital care programmes for paediatric traumatic brain injury. We aimed to assess implementation and effectiveness of the Pediatric Guideline Adherence and Outcomes (PEGASUS) programme in children with severe traumatic brain injury.
We did a prospective hybrid implementation and effectiveness study at the Harborview Medical Center (Seattle, WA, USA). We included children (aged <18 years) with traumatic brain injury (trauma mechanism and image findings). We assessed service provision, adherence to three key performance indicators, and discharge outcomes associated with the PEGASUS programme. The three key performance indicators were early initiation of enteral (oral or tube feeds) or parenteral nutrition; avoidance of any unwanted hypocarbia (PaCO <30 mm Hg) without brain herniation; and maintenance of cerebral perfusion pressure (>40 mm Hg) for 72 h after the diagnosis of severe traumatic brain injury. Poisson regression with robust standard errors was used to estimate the association between adhering to key performance indicators and discharge outcomes.
Between May 1, 2011, and July 1, 2017, 199 children (median age 11·9 years [IQR 3·4-16·1]) participated in the PEGASUS programme, of whom 193 (97%) had severe traumatic brain injury and six (3%) had moderate traumatic brain injury. 105 patients contributed data for all three key performance indicators. Adherence to at least one key performance indicator was achieved by 101 (96%) of 105 participants, and 44 (42%) achieved adherence to all three key performance indicators. Programme participants achieved adherence to the key performance indicators of hypocarbia (76 of 105 [72%]), nutrition (162 of 199 [81%]), and cerebral perfusion pressure (128 of 199 [64%]). Adherence to the nutrition key performance indicator was associated with higher discharge survival (relative risk [RR] 2·70, 95% CI 1·54-4·73) and a more favourable discharge disposition (3·05, 1·52-6·11). Adherence to the cerebral perfusion pressure key performance indicator was also associated with higher discharge survival (RR 1·33, 95% CI 1·12-1·59) and favourable disposition (1·53, 1·19-1·96). Adherence to each additional key performance indicator was associated with higher survival (RR 1·27, 1·12-1·44) and a more favourable discharge disposition (1·46, 1·23-1·72), in a dose-response manner.
The multilevel, hospital-wide, high-fidelity PEGASUS programme might benefit children and adolescents admitted to the emergency department with severe traumatic brain injury. Cerebral perfusion pressure, nutrition, and hypocarbia targets are essential components of the PEGASUS programme and are associated with favourable discharge outcomes.
National Institutes of Health.
据我们所知，目前尚无针对儿科创伤性脑损伤的经检验的院内护理方案。我们旨在评估在严重创伤性脑损伤儿童中实施和评估儿科指南依从性和结果（PEGASUS）方案的效果。
我们在 Harborview 医疗中心（西雅图，WA，美国）进行了一项前瞻性混合实施和有效性研究。我们纳入了（<18 岁）患有创伤性脑损伤（创伤机制和影像结果）的儿童。我们评估了服务提供情况、对三个关键绩效指标的依从性以及与 PEGASUS 方案相关的出院结果。三个关键绩效指标是早期开始肠内（口服或管饲）或肠外营养；避免出现无脑疝的任何不必要低碳酸血症（PaCO <30mmHg）；以及在严重创伤性脑损伤诊断后 72 小时内维持脑灌注压（>40mmHg）。使用具有稳健标准误差的泊松回归来估计关键绩效指标的依从性与出院结果之间的关联。
在 2011 年 5 月 1 日至 2017 年 7 月 1 日期间，199 名儿童（中位数年龄为 11.9 岁[IQR 3.4-16.1]）参与了 PEGASUS 方案，其中 193 名（97%）患有严重创伤性脑损伤，6 名（3%）患有中度创伤性脑损伤。105 名患者提供了所有三个关键绩效指标的数据。105 名参与者中有 101 名（96%）至少遵守了一个关键绩效指标，44 名（42%）遵守了所有三个关键绩效指标。方案参与者遵守了低碳酸血症（76/105[72%]）、营养（162/199[81%]）和脑灌注压（128/199[64%]）的关键绩效指标。对营养关键绩效指标的依从性与更高的出院存活率（相对风险[RR]2.70，95%CI 1.54-4.73）和更有利的出院处置（3.05，1.52-6.11）相关。对脑灌注压关键绩效指标的依从性也与更高的出院存活率（RR 1.33，95%CI 1.12-1.59）和有利的处置（1.53，1.19-1.96）相关。依从性每增加一个关键绩效指标与更高的存活率（RR 1.27，1.12-1.44）和更有利的出院处置（1.46，1.23-1.72）相关，呈剂量反应关系。
多水平、全院范围、高保真度的 PEGASUS 方案可能使因严重创伤性脑损伤而入住急诊科的儿童和青少年受益。脑灌注压、营养和低碳酸血症目标是 PEGASUS 方案的重要组成部分，与有利的出院结果相关。
美国国立卫生研究院。
