Recommendations for Thresholds for Treatment of Intracranial Hypertension
Clinicians recommend a threshold of less than 20 mm Hg for treatment of ICP in pediatric patients and an even lower threshold for infants and young children. Due to the heterogenous pathophysiology associated with pediatric TBI, management of ICP in some cases may need to be individualized.
This recommendation is unchanged from the Second Edition, and though there was insufficient evidence supporting a level I or II recommendation, 2 new class 3 studies were added to the evidence base for this topic.
Recommendations for Thresholds for Cerebral Perfusion Pressure
To improve overall pediatric TBI outcomes, cerebral perfusion pressure treatment targeting a threshold between 40 and 50 mm Hg is recommended to ensure treatment does not breach a minimum value of 40 mm Hg. Age specific thresholds may apply for infants on the lower end and adolescents on the upper end of the range.
This recommendation is unchanged from the Second Edition. Although 4 new studies were added to this edition, the lack of level I or II evidence make this recommendation weak.
Recommendations for Hyperosmolar Therapy
To control intracranial hypertension, clinicians suggest bolus of 3% hypertonic saline with recommended effective doses ranging between 2 and 5 mL/kg of body weight administered over 10 to 20 minutes.
For continuous infusion, suggested effective doses range between 0.1 and 1.0 mL/kg per hour administered on a sliding scale. A bolus of 23.4% hypertonic saline is recommended for refractory ICP using a dose of 0.5 mL/kg with a maximum of 30 mL.
Safety recommendations for hyperosmolar therapy suggest avoiding sustained (>72 hours) serum sodium greater than 160 mEq/L when multiple ICP-related therapies are being used. These safety recommendations are indicated to avoid complications of deep vein thrombosis, thrombocytopenia, and anemia.
These recommendations have been updated from the Second Edition, and the safety recommendations are new. Six new studies and a treatment series were added to the evidence base for this topic; however, the strength of the recommendations is weak.
Recommendations for Analgesics, Sedatives, and Neuromuscular Blocking Agents
The appropriate use of analgesics, sedatives, and neuromuscular blocking agents should be left up to the treating physician. However, when using multiple ICP-related therapies, researchers recommend against bolus administration of midazolam and/or fentanyl due to risk for cerebral hypoperfusion. Based on FDA guidelines, prolonged infusion of propofol is not suggested for sedation or to manage refractory ICP.
Although 5 class 3 studies and a treatment series were added to the evidence base for this topic, insufficient evidence was available to support a level I or II recommendation.
Recommendations for CSF Drainage
The therapeutic benefit of cerebrospinal fluid (CSF) drainage using an external ventricular drain is suggested for the management of elevated ICP following TBI in pediatric patients. It should be noted that the technique and route of CSF drainage is potentially associated with risk for complications from hemorrhage and malposition.
Though a single new class 3 treatment series was added to the evidence base for this topic and a recommendation regarding the use of lumbar drain was eliminated, the strength of these recommendations remains weak.
Recommendations for Seizure Prophylaxis
Clinicians suggest prophylactic treatment may be effective to reduce the occurrence of early posttraumatic seizures in children, which are defined as occurring within 7 days of injury. However, there is insufficient evidence to recommend levetiracetam over phenytoin, an addition to the recommendation from the Second Edition.
Three new studies have been added to the evidence base, but overall do not support a level I or level II recommendation for this topic.
Recommendations for Ventilation Therapies
To improve outcomes in pediatric TBI, prophylactic severe hyperventilation to a partial pressure of carbon dioxide (PaCO2) <30 mm Hg administered within 48 hours of injury is not recommended. Hyperventilation used to manage refractory ICP should be accompanied by advanced neuromonitoring to evaluate for possible cerebral ischemia.
These recommendations are unchanged from the Second Edition, and the low-quality studies included in the evidence limit the recommendation strength for this topic.