Invasive brain tissue oxygen and intracranial pressure (ICP) monitoring versus ICP-only monitoring in pediatric severe traumatic brain injury.

OBJECTIVE: Severe traumatic brain injury (TBI) is a leading cause of disability and death in the pediatric population. While intracranial pressure (ICP) monitoring is the gold standard in acute neurocritical care following pediatric severe TBI, brain tissue oxygen tension (PbtO2) monitoring may also help limit secondary brain injury and improve outcomes. The authors hypothesized that pediatric patients with severe TBI and ICP + PbtO2 monitoring and treatment would have better outcomes than those who underwent ICP-only monitoring and treatment. METHODS: Patients ≤ 18 years of age with severe TBI who received ICP ± PbtO2 monitoring at a quaternary children's hospital between 1998 and 2021 were retrospectively reviewed. The relationships between conventional measurements of TBI were evaluated, i.e., ICP, cerebral perfusion pressure (CPP), and PbtO2. Differences were analyzed between patients with ICP + PbtO2 versus ICP-only monitoring on hospital and pediatric intensive care unit (PICU) length of stay (LOS), length of intubation, Pediatric Intensity Level of Therapy scale score, and functional outcome using the Glasgow Outcome Score-Extended (GOS-E) scale at 6 months postinjury. RESULTS: Forty-nine patients, including 19 with ICP + PbtO2 and 30 with ICP only, were analyzed. There was a weak negative association between ICP and PbtO2 (ß = -0.04). Conversely, there was a strong positive correlation between CPP ≥ 40 mm Hg and PbtO2 ≥ 15 and ≥ 20 mm Hg (ß = 0.30 and ß = 0.29, p < 0.001, respectively). An increased number of events of cerebral PbtO2 < 15 mm Hg or < 20 mm Hg were associated with longer hospital (p = 0.01 and p = 0.022, respectively) and PICU (p = 0.015 and p = 0.007, respectively) LOS, increased duration of mechanical ventilation (p = 0.015 when PbtO2 < 15 mm Hg), and an unfavorable 6-month GOS-E score (p = 0.045 and p = 0.022, respectively). An increased number of intracranial hypertension episodes (ICP ≥ 20 mm Hg) were associated with longer hospital (p = 0.007) and PICU (p < 0.001) LOS and longer duration of mechanical ventilation (p < 0.001). Lower minimum hourly and average daily ICP values predicted favorable GOS-E scores (p < 0.001 for both). Patients with ICP + PbtO2 monitoring experienced longer PICU LOS (p = 0.018) compared to patients with ICP-only monitoring, with no significant GOS-E score difference between groups (p = 0.733). CONCLUSIONS: An increased number of cerebral hypoxic episodes and an increased number of intracranial hypertension episodes resulted in longer hospital LOS and longer duration of mechanical ventilator support. An increased number of cerebral hypoxic episodes also correlated with less favorable functional outcomes. In contrast, lower minimum hourly and average daily ICP values, but not the number of intracranial hypertension episodes, were associated with more favorable functional outcomes. There was a weak correlation between ICP and PbtO2, supporting the importance of multimodal invasive neuromonitoring in pediatric severe TBI.

Trajectory of Long-Term Outcome in Severe Pediatric Diffuse Axonal Injury: An Exploratory Study.

Introduction: Pediatric severe traumatic brain injury (TBI) is one of the leading causes of disability and death. One of the classic pathoanatomic brain injury lesions following severe pediatric TBI is diffuse (multifocal) axonal injury (DAI). In this single institution study, our overarching goal was to describe the clinical characteristics and long-term outcome trajectory of severe pediatric TBI patients with DAI. Methods: Pediatric patients (<18 years of age) with severe TBI who had DAI were retrospectively reviewed. We evaluated the effect of age, sex, Glasgow Coma Scale (GCS) score, early fever ≥ 38.5°C during the first day post-injury, the extent of ICP-directed therapy needed with the Pediatric Intensity Level of Therapy (PILOT) score, and MRI within the first week following trauma and analyzed their association with outcome using the Glasgow Outcome Score-Extended (GOS-E) scale at discharge, 6 months, 1, 5, and 10 years following injury. Results: Fifty-six pediatric patients with severe traumatic DAI were analyzed. The majority of the patients were >5 years of age and male. There were 2 mortalities. At discharge, 56% (30/54) of the surviving patients had unfavorable outcome. Sixty five percent (35/54) of surviving children were followed up to 10 years post-injury, and 71% (25/35) of them made a favorable recovery. Early fever and extensive DAI on MRI were associated with worse long-term outcomes. Conclusion: We describe the long-term trajectory outcome of severe pediatric TBI patients with pure DAI. While this was a single institution study with a small sample size, the majority of the children survived. Over one-third of our surviving children were lost to follow-up. Of the surviving children who had follow-up for 10 years after injury, the majority of these children made a favorable recovery.

Head of bed elevation in pediatric patients with severe traumatic brain injury.

OBJECTIVE: Head of bed (HOB) elevation to 30° after severe traumatic brain injury (TBI) has become standard positioning across all age groups. This maneuver is thought to minimize the risk of elevated ICP in the hopes of decreasing cerebral blood and fluid volume and increasing cerebral venous outflow with improvement in jugular venous drainage. However, HOB elevation is based on adult population data due to a current paucity of pediatric TBI studies regarding HOB management. In this prospective study of pediatric patients with severe TBI, the authors investigated the role of different head positions on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral venous outflow through the internal jugular veins (IJVs) on postinjury days 2 and 3 because these time periods are considered the peak risk for intracranial hypertension. METHODS: Patients younger than 18 years with a Glasgow Coma Scale score ≤ 8 after severe TBI were prospectively recruited at a single quaternary pediatric intensive care unit. All patients had an ICP monitor placed, and no other neurosurgical procedure was performed. On the 2nd and 3rd days postinjury, the degree of HOB elevation was varied between 0° (head-flat or horizontal), 10°, 20°, 30°, 40°, and 50° while ICP, CPP, and bilateral IJV blood flows were recorded. RESULTS: Eighteen pediatric patients with severe TBI were analyzed. On each postinjury day, 13 of the 18 patients had at least 1 optimal HOB position (the position that simultaneously demonstrated the lowest ICP and the highest CPP). Six patients on each postinjury day had 30° as the optimal HOB position, with only 2 being the same patient on both postinjury days. On postinjury day 2, 3 patients had more than 1 optimal HOB position, while 5 patients did not have an optimal position. On postinjury day 3, 2 patients had more than 1 optimal HOB position while 5 patients did not have an optimal position. Interestingly, 0° (head-flat or horizontal) was the optimal HOB position in 2 patients on postinjury day 2 and 3 patients on postinjury day 3. The optimal HOB position demonstrated lower right IJV blood flow than a nonoptimal position on both postinjury days 2 (p = 0.0023) and 3 (p = 0.0033). There was no significant difference between optimal and nonoptimal HOB positions in the left IJV blood flow. CONCLUSIONS: In pediatric patients with severe TBI, the authors demonstrated that the optimal HOB position (which decreases ICP and improves CPP) is not always at 30°. Instead, the optimal HOB should be individualized for each pediatric TBI patient on a daily basis.

Pediatric rehabilitation: trends in length of stay.

Length of stay (LOS) is one of the most important pieces of data used to measure clinical rehabilitation outcomes, but there is a paucity of LOS data regarding pediatric acute rehabilitation. The purpose of this study was to predict LOS based on admission diagnosis to an acute pediatric inpatient rehabilitation unit. The hypothesis was that LOS will vary according to admission diagnosis. One thousand one hundred forty-five patients were admitted to our acute inpatient rehabilitation unit from January 1, 2000 to December 31, 2007. Common admission impairment groups were orthopedic conditions (29.3%), brain injury (17.9%), brain tumor (7.9%), pain syndrome (7.5%), complex medical conditions (7.4%), stroke (7.2%), meningoencephalitis (7.2%), and spinal cord injury (4.4%). The distribution of LOS data was significantly skewed to the right (for example, mean 40.6 days and median 26 days, respectively, in brain injury group). The median LOS of patients admitted with orthopedic conditions was the shortest (13 days), compared to patients admitted with spinal cord lesions, which was the longest (32 days). Logarithm-transformed mean LOS was different among the admission impairment groups (F=28.7, p < 0.01). However Tukey's Honestly Significance Difference test further showed that: 1) LOS data was not always statistically different across admission impairment groups, and 2) LOS of patients with orthopedic conditions and spinal cord lesions was the shortest and longest, respectively, compared to other admission impairment groups. No proportional decrease in median LOS was observed across the impairment groups from 2000 to 2007. LOS for pediatric acute inpatient rehabilitation varied according to admission diagnosis. When considering future comprehensive pediatric rehabilitation outcome studies, focusing on a uniform impairment group is suggested. In addition, attention to other factors such as functional status changes, severity of illness, payment types, and psychosocioeconomic status should be considered.

Pediatric rehabilitation: 2. Environmental factors affecting participation.

OBJECTIVE: This self-directed learning module highlights the environmental factors that influence the participation of children and youth with disabilities in life situations, including activities of self-care, mobility, socialization, education, recreation, and community life. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. This module emphasizes the participation of children with disabilities in adapted sports and reviews mobility devices to promote function, in the context of the International Classification of Functioning and in reference to the Americans with Disabilities Act. It provides the physiatrist with strategies to promote community participation, functional independence and healthcare transitions for children with disabilities as they approach adulthood. The goal of this article is to improve the learner's treatment strategies to maximize the participation of children and youth with disabilities in all settings, particularly schools and communities.

Pediatric rehabilitation: 3. Facilitating family-centered treatment decisions.

OBJECTIVE: This self-directed learning module focuses on the role of accurate diagnosis, psychological support, and family integration of children who have chronic impairments such as pain, spasticity, or cognitive disability. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The role of therapeutic, medical (traditional and nontraditional) and psychological interventions that improve family and individual function are emphasized. The goal of this article is to refine a learner's knowledge of the impact family-centered care can have on the medical, psychological, financial, and functional capabilities of families to improve treatment decisions in the context of children with disability.

Pediatric rehabilitation: 4. Prescribing assistive technology to promote community integration.

OBJECTIVE: This self-directed learning module highlights the equipment and assistive technology needs of children and youth with disabilities. This article specifically focuses on preparing families and patients for equipment transitions that occur over the course of childhood and adolescence including progressing from stroller to wheelchair to powerchair, as well as job training and use of augmentative communication. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to modify the learner's current practice techniques to ensure that assistive technology is used to promote community integration from early childhood through transition and into adulthood.

Pediatric rehabilitation: 1. Common medical conditions in children with disabilities.

OBJECTIVE: This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.

Pediatric rehabilitation: 5. Transitioning teens with disabilities into adulthood.

OBJECTIVE: This self-directed learning module focuses on preparing adolescent patients with special health care needs for adulthood by promoting their independence in their own self-care; helping them to navigate issues of sexuality, marriage, and parenting; preparing the patient and family to make guardianship decisions during the transition between childhood and adulthood; and planning for higher education or vocation. Emphasis will be on the role of the physiatrist in providing this guidance and its importance in improving the patient's quality of life. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to refine the learner's knowledge of preparing adolescent patients with special health care needs for adulthood to improve their quality of life.

Pediatric stroke recovery: a descriptive analysis.

OBJECTIVE: To investigate recovery patterns and potential prognostic factors of pediatric stroke. DESIGN: Retrospective study. SETTING: Acute rehabilitation at a university-based children's hospital. PARTICIPANTS: Children (N=44; 25 boys, 19 girls; age range, 8mo-17y) with diagnosis of first-ever stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional outcomes at discharge and 1-year follow-up. Modified Brunnstrom stages, Gross Motor Function Classification System, activities of daily living (ADLs), swallowing, speech, and sphincter function were measured. RESULTS: Recovery of swallowing function occurred earlier than other functions in the first 2 to 3 months poststroke. Less than half of the patients were able to use the affected arms and legs without assistive devices. Eleven of 32 patients who initially had poor body control became ambulatory without assistive devices. A total of 18 of 44 patients were able to walk without assistive devices. Bilateral hemisphere lesions and flaccid muscle tone of the affected extremity at stroke onset had a less favorable prognosis in terms of ambulation and ADLs. Hemorrhagic strokes without surgical complications had a better prognosis than nonhemorrhagic strokes. CONCLUSIONS: Similar to the adult stroke population, most of the functional recovery in pediatric stroke occurs within the first 2 to 3 months after stroke, but the quality of functional recovery was better in the pediatric population. The lesion size of the stroke was found to be related to prognosis. Additional large cohort studies are suggested to understand the complex similarities and differences in recovery between pediatric and adult stroke.

Neuromuscular rehabilitation and electrodiagnosis. 1. Mononeuropathy.

UNLABELLED: This self-directed learning module highlights mononeuropathies. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on diagnostic criteria and classifications of mononeuropathies, including carpal tunnel, brachial neuritis, and lumbosacral plexopathy. The timeline status post nerve injury is discussed in relation to findings on electrodiagnostic studies. The differential diagnosis and electrodiagnostic design and interpretation is detailed in the chapter. Treatment options are reviewed. OVERALL ARTICLE OBJECTIVE: To summarize the diagnosis, classification, and treatment of mononeuropathies, from an electrodiagnostic perspective.

Neuromuscular rehabilitation and electrodiagnosis. 2. Peripheral neuropathy.

UNLABELLED: This self-directed learning module highlights peripheral neuropathies. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on diagnostic criteria and classifications of peripheral neuropathy, including diabetic, alcoholic, carcinomatous, human immunodeficiency virus-associated, and critical illness polyneuropathies. Treatment options are reviewed. The causes for difficult to obtain nerve conduction studies are highlighted. OVERALL ARTICLE OBJECTIVE: To summarize the diagnosis, classification, and treatment of peripheral neuropathies.

Neuromuscular rehabilitation and electrodiagnosis. 3. Diseases of muscles and neuromuscular junction.

UNLABELLED: This self-directed learning module highlights formation of a differential diagnosis as well as electrodiagnostic evaluation for those patients who present with the common complaint of weakness. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the common symptoms and typical clinical findings that allow the clinician to narrow the differential diagnosis. This is followed by the diagnostic evaluation, with emphasis on the technical aspects and interpretation of electrodiagnostic studies. OVERALL ARTICLE OBJECTIVE: To summarize the clinical presentation and electrodiagnostic findings in persons with disorders of muscle or disorders of the neuromuscular junction.

Neuromuscular rehabilitation and electrodiagnosis. 4. Pediatric issues.

UNLABELLED: This self-directed learning module highlights the physician's role in the diagnosis and treatment of neuromuscular disorders in pediatric populations. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses both clinical and electrodiagnostic features of common neuromuscular disorders in pediatric populations. The diagnostic value of somatosensory evoked potential is reviewed in a case of traumatic spinal cord injury without radiographic abnormality. Therapeutic interventions of progressive muscular dystrophy are discussed, as well as the differential diagnosis of floppy infant syndrome, the most common pediatric electrodiagnostic referral. OVERALL ARTICLE OBJECTIVES: (a) To become familiar with electrodiagnosis and rehabilitation for common neuromuscular disorders in the pediatric population, (b) to undrstand electrodiagnostic findings of Guillain-Barre syndrome corresponding to pathophysiology, (c) to become familiar with somatosensory evoked potentials, and (d) to be able to make differential diagnosis of floppy infant syndrome based on clinical findings as well as electrodiagnosis.

The rehabilitation of causalgia (complex regional pain syndrome-type II).

CRPS-type I or causalgia is a challenging pain syndrome and its pathogenesis remains controversial. Although its incidence is relatively low, the pain and suffering it causes can be severe and functionally debilitating. Early, accurate diagnosis permits initiation of appropriate therapeutic interventions and enhances the potential for successful treatment.