Neuroprognostication in critically ill pediatric patients with moderate to severe traumatic brain injury: a prospective study

Traumatic brain injury (TBI) is the leading cause of death and disability in critically ill pediatric patients, affecting up to 500,000 children per year in the United States. It is estimated that as many as 62% of these patients with moderate to severe TBI experience disability. Although TBI associated death rates have decreased over last few decades, disabilities for children who survive TBI continue to have significant impact on the society.  Current treatment guidelines for pediatric patients with TBI are largely adopted from guidelines for adult patients  and to improve the neurological outcome for pediatric TBI, there is an unmet need to understand factors affecting outcome after pediatric TBI. Neurocritical care society have recently published the guidelines for neuroprognostication in critically ill adult patients with moderate to severe TBI. By Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, they conducted a systematic narrative review of the ten clinically relevant predictors and nine prediction models cited in the literature. In clinical variables, only the presence of bilateral pupillary nonreactivity on admission was deemed moderately reliable predictor for functional outcomes at 6 months or beyond. In terms of prediction models, the Corticosteroid Randomization After Significant Head Injury (CRASH)-basic, CRASH-CT (CRASH-basic extended by computed tomography features), International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT)-core, IMPACT-extended, and IMPACT-lab models were recommended as moderately reliable in predicting mortality at discharge and beyond and functional outcomes at 6 months and beyond. The advances in prognosticating outcome after the injury in critically ill pediatric patients with TBI have been limited despite of extensive research in randomized controlled trials. Neuroprognosticating predictors for pediatric patients with moderate to severe TBI are still lacking. Although several studies demonstrated that various demographic or clinical variables (age, sex, GCS, GCS P, lactate, PT, APTT, INR) as well as other parameters (diffuse axonal injury, inclusion of MRI) which can influence the outcome in pediatric TBI patients, these factors have not been rigorously evaluated in the development of prognostic indicators. Analysis of existing trauma databases in critically ill pediatric patients may elucidate factors associated with worse outcomes after TBI and, in turn, provide discussion regarding neuroprognostication and anticipated resources needed after injury.