Treatment of severe traumatic brain injury in German pediatric intensive care units—a survey of current practice
German pediatric guidelines for severe traumatic brain injury (TBI) management expired in 2011. Thus, divergent evidence-based institutional protocols are predominantly being followed. We performed a survey of current Pediatric Intensive Care Unit (PICU) management of isolated severe TBI in Germany to reveal potential varying practices.
Seventy German PICUs were invited to join an anonymous online survey from February to May 2017. Twenty-nine participants (41.4%) successfully completed the survey (17 university hospitals and 12 district hospitals). The majority of items were polar (yes/no) or scaled (e.g., never - always). Main topics were imaging, neurosurgery, neuromonitoring, adjuvant therapy, and medication. Severity of TBI was defined via Glasgow Coma Scale.
The majority of respondents (93.1%) had internal TBI standards, and patients were mainly administered to interdisciplinary trauma units. The use of advanced neuromonitoring techniques, intracranial hypertension management, and drug treatment differed between PICUs. Routine administration of hypertonic saline in TBI-associated cerebral edema was performed by 3.4%, while it was never an option for 31.0% of the participants. Prophylactic anticonvulsive therapy was restrictively performed. If indicated, the main anticonvulsive drugs used were phenobarbital and levetiracetam. Neuroendocrine follow-up was recommended/performed by 58.6% of the PICUs.
This survey provides an overview of the current PICU practices of isolated severe TBI management in Germany and demonstrates a wide instrumental and therapeutical range, revealing an unmet need for the revised national guideline and further (international) clinical trials for the treatment of severe TBI in pediatrics.
KeywordsICP Neuromonitoring Neuroimaging Adjuvant therapy
We thank all participants who committed their time and effort. We thank Prof. Dr. Dr. h.c. Wolfgang Rascher for supporting this study. Data acquisition was performed by Valerie Konrad in fulfillment of the requirements for obtaining the degree “Dr. med.” at the Friedrich-Alexander-University of Erlangen-Nuremberg, Dept. of Pediatrics and Adolescent Medicine, Germany.
Departmental funds only.
Compliance with ethical standards
Conflict of interest
We declare no competing interests.
- 2.Coronado VG, Xu L, Basavaraju SV, McGuire LC, Wald MM, Faul MD et al (2011) Surveillance for traumatic brain injury-related deaths—United States, 1997-2007. MMWR Surveill Summ 60:1–32Google Scholar
- 3.Kipfmueller F, Wyen H, Borgman MA, Spinella PC, Wirth S, Maegele M (2013) Epidemiology, risk stratification and outcome of severe pediatric trauma. Klin Padiatr 225:34–40Google Scholar
- 4.Elsässer G (2011) Unfälle, Gewalt, Selbstverletzung bei Kindern und Jugendlichen. Ergebnisse der amtlichen Statistik zum Verletzungsgeschehen 2009. Statistisches Bundesamt, Wiesbaden (https://www.destatis.de/)
- 8.Vavilala MS, Kernic MA, Wang J, Kannan N, Mink RB, Wainwright MS, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Boyle LN, Mitchell PH, Rivara FP, Pediatric Guideline Adherence and Outcomes Study (2014) Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury. Crit Care Med 42:2258–2266CrossRefGoogle Scholar
- 9.AWMF Guideline (13.02.2011) Register-ID: 024/018 – Schädel-Hirn-Trauma im Kindesalter (https://www.awmf.org)
- 11.Roberts I, Yates D, Sandercock P, Farrell B, Wasserberg J, Lomas G, Cottingham R, Svoboda P, Brayley N, Mazairac G, Laloë V, Muñoz-Sánchez A, Arango M, Hartzenberg B, Khamis H, Yutthakasemsunt S, Komolafe E, Olldashi F, Yadav Y, Murillo-Cabezas F, Shakur H, Edwards P, CRASH trial collaborators (2004) Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 364:1321–1328CrossRefGoogle Scholar
- 12.Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S et al (2012) Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition. Pediatric Crit Care Med : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 13(Suppl 1):S1–S82Google Scholar
- 13.Bell MJ, Adelson PD, Wisniewski SR, Investigators of the AS (2017) Challenges and opportunities for pediatric severe TBI-review of the evidence and exploring a way forward. Child’s Nerv Syst: ChNS : official journal of the International Society for Pediatric Neurosurgery 33:1663–1667CrossRefGoogle Scholar
- 15.Kurz JE, Poloyac SM, Abend NS, Fabio A, Bell MJ, Wainwright MS, Investigators for the Approaches and Decisions in Acute Pediatric TBI Trial (2016) Variation in anticonvulsant selection and electroencephalographic monitoring following severe traumatic brain injury in children-understanding resource availability in sites participating in a comparative effectiveness study. Pediatric Crit Care Med : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 17:649–657CrossRefGoogle Scholar
- 16.Kruer RM, Harris LH, Goodwin H, Kornbluth J, Thomas KP, Slater LA et al (2013) Changing trends in the use of seizure prophylaxis after traumatic brain injury: a shift from phenytoin to levetiracetam. J Crit Care 28(883):e889–e813Google Scholar
- 20.Miglioretti DL, Johnson E, Williams A, Greenlee RT, Weinmann S, Solberg LI, Feigelson HS, Roblin D, Flynn MJ, Vanneman N, Smith-Bindman R (2013) The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr 167:700–707CrossRefGoogle Scholar
- 25.Stowe CD, Lee KR, Storgion SA, Phelps SJ (2000) Altered phenytoin pharmacokinetics in children with severe, acute traumatic brain injury. J Clin Pharmacol 40:1452–1461Google Scholar
- 30.Adelson PD, Wisniewski SR, Beca J, Brown SD, Bell M, Muizelaar JP, Okada P, Beers SR, Balasubramani GK, Hirtz D, Paediatric Traumatic Brain Injury Consortium (2013) Comparison of hypothermia and normothermia after severe traumatic brain injury in children (cool kids): a phase 3, randomised controlled trial. The Lancet Neurology 12:546–553CrossRefGoogle Scholar
- 31.Mellion SA, Bennett KS, Ellsworth GL, Moore K, Riva-Cambrin J, Metzger RR, Bratton SL (2013) High-dose barbiturates for refractory intracranial hypertension in children with severe traumatic brain injury. Pediatric Crit Care Med : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 14:239–247CrossRefGoogle Scholar
- 32.Weintraub D, Williams BJ, Jane J Jr (2012) Decompressive craniectomy in pediatric traumatic brain injury: a review of the literature. NeuroRehabilitation 30:219–223Google Scholar