Department of Neurological Surgery, University of Washington, Seattle , Washington , USA.
Department of Orthopaedic Surgery, University of Washington, Seattle , Washington , USA.
Neurosurgery. 2024 Jan 1;94(1):72-79. doi: 10.1227/neu.0000000000002760. Epub 2023 Nov 13.
The efficacy of our current approach to incorporating intracranial pressure (ICP) data into pediatric severe traumatic brain injury (sTBI) management is incompletely understood, lacking data from multicenter, prospective, randomized studies. The National Institutes of Health-supported Benchmark Evidence from Latin America-Treatment of Raised Intracranial Pressure-Pediatrics trial will compare outcomes from pediatric sTBI of a management protocol based on ICP monitoring vs 1 based on imaging and clinical examination without monitoring. Because no applicable comprehensive management algorithms for either cohort are available, it was necessary to develop them.
A consensus conference involving the 21 intensivists and neurosurgeons from the 8 trial sites used Delphi-based methodology to formulate management algorithms for both study cohorts. We included recommendations from the latest Brain Trauma Foundation pediatric sTBI guidelines and the consensus-based adult algorithms (Seattle International Brain Injury Consensus Conference/Consensus Revised Imaging and Clinical Examination) wherever relevant. We used a consensus threshold of 80%.
We developed comprehensive management algorithms for monitored and nonmonitored cohort children with sTBI. We defined suspected intracranial hypertension for the nonmonitored group, set minimum number and timing of computed tomography scans, specified minimal age-adjusted mean arterial pressure and cerebral perfusion pressure targets, defined clinical neuroworsening, described minimal requisites for intensive care unit management, produced tiered management algorithms for both groups, and listed treatments not routinely used.
We will study these protocols in the Benchmark Evidence from Latin America-Treatment of Raised Intracranial Pressure-Pediatrics trial in low- and middle-income countries. Second, we present them here for consideration as prototype pediatric sTBI management algorithms in the absence of published alternatives, acknowledging their limited evidentiary status. Therefore, herein, we describe our study design only, not recommended treatment protocols.
目前将颅内压（ICP）数据纳入小儿严重创伤性脑损伤（sTBI）管理的方法的疗效尚不完全清楚，缺乏多中心、前瞻性、随机研究的数据。美国国立卫生研究院支持的拉丁美洲基准证据——颅内压升高治疗-儿科试验将比较基于 ICP 监测的管理方案与不进行监测的基于影像学和临床检查的管理方案治疗小儿 sTBI 的结果。由于对于这两个队列都没有适用的综合管理算法，因此有必要制定这些算法。
由来自 8 个试验站点的 21 名重症监护医师和神经外科医师组成的共识会议使用基于德尔菲法的方法为两个研究队列制定了管理算法。我们纳入了最新的脑外伤基金会小儿 sTBI 指南中的建议以及基于共识的成人算法（西雅图国际脑损伤共识会议/共识修订影像学和临床检查），只要相关。我们使用 80%的共识阈值。
我们为接受监测和未接受监测的 sTBI 患儿制定了全面的管理算法。我们为未接受监测组定义了疑似颅内高压，设定了计算机断层扫描的最小次数和时间，规定了最小年龄调整后的平均动脉压和脑灌注压目标，定义了临床神经恶化，描述了重症监护病房管理的最低要求，为两组制定了分层管理算法，并列出了不常规使用的治疗方法。
我们将在中低收入国家的拉丁美洲基准证据——颅内压升高治疗-儿科试验中研究这些方案。其次，我们在这里提出这些方案，作为在缺乏已发表替代方案的情况下的小儿 sTBI 管理算法原型，承认其有限的证据地位。因此，本文仅描述了我们的研究设计，而不是推荐的治疗方案。
