From the Department of Pediatrics, University of Arkansas for Medical Sciences.
University of Arkansas for Medical Sciences, Little Rock, AR.
Pediatr Emerg Care. 2021 Dec 1;37(12):e791-e804. doi: 10.1097/PEC.0000000000001959.
Intubated pediatric patients with isolated traumatic brain injury (TBI) are a diagnostic challenge for early detection of altered cerebral physiology instigated by trauma-induced increased intracranial pressure (ICP) while preventing secondary neuronal damage (secondary insult detection) and assessing the effects of increased ICP therapeutic interventions (3% hypertonic saline [HTS]). Invasive brain tissue oxygen monitoring is guiding new intensive care unit TBI management but is not pediatric emergency department (PED) readily accessible. Objective measurements on pediatric isolated TBI-altered bihemispheric cerebral physiology and treatment effects of 3% HTS are currently lacking. Cerebral oximetry can assess increased ICP-induced abnormal bihemispheric cerebral physiology by measuring regional tissue oxygenation (rcSO2) and cerebral blood volume index (CBVI) and the mechanical cerebrospinal fluid removal effects on the increased ICP-induced abnormal bihemispheric cerebral physiology.In the PED intubated patients with isolated TBI, assessing the 3% HTS therapeutic response is solely by vital signs and limited clinical assessment skills. Objective measurements of the 3% HTS hyperosmolar effects on the PED isolated TBI patients' altered bihemispheric cerebral physiology are lacking. We believe that bihemispheric rcSO2 and CBVI could elucidate similar data on 3% HTS impact and influence in the intubated isolated TBI patients.
This study aimed to analyze the effects of 3% HTS on bihemispheric rcSO2 and CBVI in intubated patients with isolated TBI.
An observational, retrospective analysis of bihemispheric rcSO2 and CBVI readings in intubated pediatric patients with isolated TBI receiving 3% HTS infusions, was performed.
From 2010 to 2017, 207 intubated patients with isolated TBI received 3% HTS infusions (median age, 2.9 [1.1-6.9 years]; preintubation Glasgow Coma Scale score, 7 [6-8]). The results were as follows: initial pre-3% HTS, 43% (39.5% to 47.5%; left) and 38% (35% to 42%; right) for rcSO2 < 60%, and 8 (-28 to 21; left) and -15 (-34 to 22; right) for CBVI; post-3% HTS, 68.5% (59.3% to 76%, P < 0.0001; left) and 62.5% (56.0% to 74.8%, P < 0.0001; right) for rcSO2 < 60%, and 12 (-7 to 24, P = 0.04; left) and 14 (-21 to 22, P < 0.0001; right) for CBVI; initial pre-3% HTS, 90% (83% to 91%; left) and 87% (82% to 92%; right) for rcSO2 > 80%, and 16.5 (6 to 33, P < 0.0001; left) and 16.8 (-2.5 to 27.5, P = 0.005; right) for CBVI; and post-3% HTS, 69% (62% to 72.5%, P < 0.0001; left) and 63% (59% to 72%, P < 0.0001; right) for rcSO2 > 80%, and 16.5 (6 to 33, P < 0.0001; left) and 16.8 (-2.5 to 27.5, P = 0.005; right) for CBVI. The following results for cerebral pathology pre-3% HTS were as follows: epidural: 85% (58% to 88.5%) for left rcSO2 and -9.25 (-34 to 19) for left CBVI, and 85.5% (57.5% to 89%) for right rcSO2 and -12.5 (-21 to 27) for CBVI; subdural: 45% (38% to 54%) for left rcSO2 and -9.5 (-25 to 19) for left CBVI, and 40% (33% to 49%) for right rcSO2 and -15 (-30.5 to 5) for CBVI. The following results for cerebral pathology post-3% HTS were as follows: epidural: 66% (58% to 69%, P = 0.03) for left rcSO2 and 15 (-1 to 21, P = 0.0004) for left CBVI, and 63% (52% to 72%, P = 0.009) for right rcSO2, and 15.5 (-22 to 24, P = 0.02) for CBVI; subdural: 63% (56% to 72%, P < 0.0001) for left rcSO2 and 9 (-20 to 22, P < 0.0001) for left CBVI, and 62.5% (48% to 73%, P < 0.0001) for right rcSO2, and 3 (-26 to 22, P < 0.0001) for CBVI. Overall, heart rate showed no significant change. Three percent HTS effect on interhemispheric rcSO2 difference >10 showed rcSO2 < 60%, and subdural hematomas had the greatest reduction (P < 0.001). The greatest positive changes occurred in bihemispheric or one-hemispheric rcSO2 < 60% with an interhemispheric discordance rcSO2 > 10 and required the greatest number of 3% HTS infusions. For 3% HTS 15% rcSO2 change time effect, all patients achieved positive change with subdural hematomas and hemispheric rcSO2 readings <60% with the shortest achievement time of 1.2 minutes (0.59-1.75; P < 0.001).
In intubated pediatric patients with isolated TBI who received 3% HTS infusions, bihemispheric rcSO2 and CBVI readings immediately detected and trended the 3% HTS effects on the trauma-induced cerebral pathophysiology. The 3% HTS infusion produced a significant improvement in rcSO2 and CBVI readings and a reduction in interhemispheric rcSO2 discordance differences. In patients with bihemispheric or one-hemispheric rcSO2 readings <60% with or without an interhemispheric discordance, rcSO2 > 10 demonstrated the greatest significant positive delta change and required the greatest numbers of 3% HTS infusions. Overall, 3% HTS produced a significant positive 15% change within 2.1 minutes of infusion, whereas heart rate showed no significant change. During trauma neuroresuscitation, especially in intubated isolated TBI patients requiring 3% HTS, cerebral oximetry has shown its functionality as a rapid adjunct neurological, therapeutic assessment tool and should be considered in the initial emergency department pediatric trauma neurological assessment and neuroresuscitation regimen.
创伤性颅内压（ICP）升高导致的脑生理改变是伴有孤立性创伤性脑损伤（TBI）的插管儿科患者的诊断挑战，同时需要预防继发性神经元损伤（继发性损伤检测）和评估增加 ICP 的治疗干预措施（3%高渗盐水[HTS]）的效果。侵入性脑组织氧监测正在指导新的重症监护病房 TBI 管理，但儿科急诊部门（PED）无法获得。目前缺乏儿科孤立性 TBI 改变的大脑半球生理学和 3% HTS 治疗效果的客观测量。脑氧饱和度可以通过测量区域组织氧合（rcSO2）和脑血容量指数（CBVI）来评估由 ICP 升高引起的异常大脑半球生理学，并通过机械性脑脊液去除对由 ICP 升高引起的异常大脑半球生理学的影响。在 PED 中，插管伴有孤立性 TBI 的患者仅通过生命体征和有限的临床评估技能来评估 3% HTS 的治疗反应。缺乏客观测量 3% HTS 对 PED 孤立性 TBI 患者改变的大脑半球生理学的高渗作用。我们认为，双半球 rcSO2 和 CBVI 可以阐明 3% HTS 对插管孤立性 TBI 患者的影响和影响的类似数据。
本研究旨在分析 3% HTS 对插管伴孤立性 TBI 患者双半球 rcSO2 和 CBVI 的影响。
对接受 3% HTS 输注的插管伴孤立性 TBI 的儿科患者的双半球 rcSO2 和 CBVI 读数进行了观察性、回顾性分析。
2010 年至 2017 年，207 例插管伴孤立性 TBI 的患者接受了 3% HTS 输注（中位年龄 2.9 [1.1-6.9 岁]；插管前格拉斯哥昏迷量表评分为 7 [6-8]）。结果如下：初始 3% HTS 前，rcSO2<60%的左半球和右半球分别为 43%（39.5%-47.5%）和 38%（35%-42%），CBVI 为-28 至 21 和-34 至 22；3% HTS 后，rcSO2<60%的左半球和右半球分别为 68.5%（59.3%-76%，P<0.0001）和 62.5%（56.0%-74.8%，P<0.0001），CBVI 为 12 至 24 和-21 至 22；初始 3% HTS 前，rcSO2>80%的左半球和右半球分别为 90%（83%-91%）和 87%（82%-92%），CBVI 为 16.5（6 至 33，P<0.0001）和 16.8（-2.5 至 27.5，P=0.005）；3% HTS 后，rcSO2>80%的左半球和右半球分别为 69%（62%-72.5%，P<0.0001）和 63%（59%-72%，P<0.0001），CBVI 为 16.5（6 至 33，P<0.0001）和 16.8（-2.5 至 27.5，P=0.005）。3% HTS 前脑病理的以下结果如下：硬膜外：左 rcSO2 为 85%（58%-88.5%）和左 CBVI 为-9.25（-34 至 19），右 rcSO2 为 85.5%（57.5%-89%）和右 CBVI 为-12.5（-21 至 27）；硬膜下：左 rcSO2 为 45%（38%-54%）和左 CBVI 为-9.5（-25 至 19），右 rcSO2 为 40%（33%-49%）和右 CBVI 为-15（-30.5 至 5）。3% HTS 后脑病理的以下结果如下：硬膜外：左 rcSO2 为 66%（58%-69%，P=0.03）和左 CBVI 为 15（1 至 21，P=0.0004），右 rcSO2 为 63%（52%-72%，P=0.009）和右 CBVI 为 15.5（-22 至 24，P=0.02）；硬膜下：左 rcSO2 为 63%（56%-72%，P<0.0001）和左 CBVI 为 9（-20 至 22，P<0.0001），右 rcSO2 为 62.5%（48%-73%，P<0.0001）和右 CBVI 为 3（-26 至 22，P<0.0001）。总的来说，心率没有明显变化。3% HTS 对双半球 rcSO2 差值>10 的影响表现为 rcSO2<60%，硬膜下血肿的降幅最大（P<0.001）。最大的正变化发生在双半球或单半球 rcSO2<60%且半球间 rcSO2 差异>10 的患者中，需要输注最多的 3% HTS。对于 3% HTS 15% rcSO2 变化时间效应，所有患者均实现了正变化，硬膜下血肿和 rcSO2 读数<60%的最短实现时间为 1.2 分钟（0.59-1.75；P<0.001）。
在接受 3% HTS 输注的插管伴孤立性 TBI 的儿科患者中，双半球 rcSO2 和 CBVI 读数立即检测到 3% HTS 对创伤性脑病理生理学的影响，并呈现出趋势。3% HTS 输注显著改善了 rcSO2 和 CBVI 读数，并减少了半球间 rcSO2 差异的差异。在伴有或不伴有半球间 rcSO2 读数<60%的双半球或单半球 rcSO2 读数的患者中，rcSO2>10 显示出最大的显著阳性 delta 变化，并且需要输注最多的 3% HTS。总的来说，3% HTS 在输注后 2.1 分钟内产生了显著的 15%变化，而心率没有明显变化。在创伤性神经复苏期间，特别是在需要 3% HTS 的插管孤立性 TBI 患者中，脑氧饱和度已经显示出其作为快速辅助神经学、治疗评估工具的功能，并且应该在初始急诊儿科创伤神经评估和神经复苏方案中考虑。
