Svedung Wettervik Teodor, Smith Claudia Ann, Hånell Anders, Bögli Stefan Yu, Hutchinson Peter, Agrawal Shruti, Smielewski Peter
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden.
Crit Care. 2025 Aug 4;29(1):344. doi: 10.1186/s13054-025-05568-4.
Paediatric traumatic brain injury (TBI) is a heterogeneous condition with age-dependent differences in systemic and cerebral physiology, making cerebral perfusion pressure (CPP) challenging to target. Monitoring cerebral autoregulation using the pressure reactivity index (PRx) and deriving an autoregulatory optimal CPP (CPPopt) may personalize treatment, but evidence in children remains limited. In this multicentre paediatric TBI study, we aimed to explore and visualize PRx and CPPopt in relation to outcome.
In this secondary analysis of the prospective, multicentre study (STARSHIP), 98 paediatric TBI patients (1-16 years) from 10 paediatric intensive care units, in the UK, between 2018 and 2023, with high-frequency physiological data and 12-month GOS-E Peds outcomes, not treated with decompressive craniectomy, were included. Intracranial pressure (ICP), PRx, CPP, and ΔCPPopt were correlated with outcome using insult intensity/duration heatmaps across the full monitoring period. Two-variable heatmaps incorporating PRx were also used to assess how autoregulation modified the relationship between ICP, CPP, and ΔCPPopt with outcome.
There was a transition from favourable to unfavourable outcome when PRx exceeded + 0.00 for longer episodes. Furthermore, there was a transition towards worse outcome when CPP went below 40 mmHg and above 100 mmHg for sustained durations. For ΔCPPopt, the transition towards poor prognosis occurred for values below - 20 mmHg, but positive ΔCPPopt was tolerated. In the two-variable heatmaps, PRx above + 0.50 together with ICP above 20 mmHg, CPP below 60 mmHg, or negative ΔCPPopt were particularly associated with unfavourable outcome.
This novel study visualized the safe and dangerous intervals for PRx and CPPopt as well as the interaction effect between the autoregulatory status and ICP, CPP, and ΔCPPopt in relation to outcome in paediatric TBI. Future prospective trials are needed to evaluate the safety, feasibility, and efficacy of PRx/CPPopt guided management.
小儿创伤性脑损伤（TBI）是一种异质性疾病，其全身和脑生理存在年龄依赖性差异，使得脑灌注压（CPP）的目标设定具有挑战性。使用压力反应性指数（PRx）监测脑自动调节并得出自动调节最佳CPP（CPPopt）可能使治疗个体化，但儿童中的证据仍然有限。在这项多中心小儿TBI研究中，我们旨在探讨并可视化PRx和CPPopt与预后的关系。
在这项对前瞻性多中心研究（STARSHIP）的二次分析中，纳入了2018年至2023年间来自英国10个儿科重症监护病房的98例小儿TBI患者（1至16岁），这些患者有高频生理数据和12个月的GOS-E Peds预后，且未接受减压颅骨切除术。在整个监测期内，使用损伤强度/持续时间热图将颅内压（ICP）、PRx、CPP和ΔCPPopt与预后进行关联。还使用包含PRx的双变量热图来评估自动调节如何改变ICP、CPP和ΔCPPopt与预后之间的关系。
当PRx在较长时间段内超过+0.00时，预后从良好转变为不良。此外，当CPP持续低于40 mmHg和高于100 mmHg时，预后向更差转变。对于ΔCPPopt，当值低于-20 mmHg时，预后向不良转变，但正的ΔCPPopt是可耐受的。在双变量热图中，PRx高于+0.50，同时ICP高于20 mmHg、CPP低于60 mmHg或ΔCPPopt为负，这些情况尤其与不良预后相关。
这项新研究可视化了PRx和CPPopt的安全和危险区间，以及自动调节状态与ICP、CPP和ΔCPPopt之间关于小儿TBI预后的相互作用效应。未来需要进行前瞻性试验来评估PRx/CPPopt指导管理的安全性、可行性和有效性。
