Table 2.
Summary of evidence generated from the 2012 pediatric TBI guidelines
| Topic | Level of Evidence | Recommendation |
|---|---|---|
| Indications for ICP monitoring | Level III | “Use of ICP monitoring may be considered…” |
| Threshold for treatment of intracranial hypertension | Level III | “Treatment of ICP may be considered at a threshold of 20 mm Hg” |
| Cerebral perfusion pressure thresholds | Level III | “A minimum CPP of 40 mm Hg may be considered … A CPP threshold of 40–50 mm Hg may be considered…” |
| Advanced neuromonitoring | Level III | “If brain oxygenation monitoring is used, maintenance of a partial pressure of brain-tissue oxygen (Pbto2) ≥10 mm Hg may be considered” |
| Neuroimaging | Level III | “In the absence of neurologic deterioration … routine repeat CT scan … may not be indicated…” |
| Hyperosmolar therapy | Level II | “Hypertonic saline should be considered … for intracranial hypertension … effective doses … range between 6.5 and 10 mL/kg” |
| Level III | “Hypertonic saline should be considered … effective doses as a continuous infusion of 3% saline range between 0.1 and 1.0 mL/kg/h administered on a sliding scale…” | |
| Temperature control | Level II | “Moderate hypothermia … for only 24 h duration should be avoided … moderate hypothermia starting within 8 h after injury and lasting for 48 h duration should be considered to reduce ICP … rewarming at a rate of 0.5°C/h should be avoided” |
| Level III | “Moderate hypothermia … for 48 h duration may be considered” | |
| Cerebrospinal fluid drainage | Level III | “CSF drainage through an externalized ventricular drain … may be considered … The addition of a lumbar drain may be considered…” |
| Barbiturates | Level III | “High-dose barbiturate therapy may be considered in hemodynamically stable patients with refractory intracranial hypertension … continuous arterial blood pressure monitoring and cardiovascular support to maintain adequate CPP are required” |
| Decompressive craniectomy for the treatment of intracranial hypertension | Level III | “Decompressive craniectomy with duraplasty … may be considered for pediatric patients … showing early signs of neurologic deterioration or herniation or are developing intracranial hypertension refractory to medical management…” |
| Hyperventilation | Level III | “Avoidance of prophylactic severe hyperventilation to a Paco2 <30 mm Hg may be considered within the first 48 h … If hyperventilation is used … advanced neuromonitoring for evaluation of cerebral ischemia may be considered” |
| Corticosteroids | Level II | “The use of corticosteroids is not recommended to improve outcome or lower ICP…” |
| Glucose and nutrition | Level II | “The evidence does not support the use of an immune-modulating diet … to improve outcome” |
| Level III | “…glycemic control … should be left to the treating physician” | |
| Antiseizure prophylaxis | Level III | “Prophylactic treatment with phenytoin may be considered to reduce the incidence of early posttraumatic seizures…” |
Abbreviations: CPP, cerebral perfusion pressure (mean arterial blood pressure minus intracranial pressure); CSF, cerebrospinal fluid; CT, computed tomography; ICP, intracranial pressure.
Data from Kochanek PK, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents: second edition. Pediatr Crit Care Med 2012;13(Suppl 1):S1–82.