Tensing Maa

The epidemiology of vasospasm in children with moderate-to-severe traumatic brain injury

Objective:To gain a description of the prevalence and time course of vasospasm in children suffering moderate-to-severe traumatic brain injury. Design:A prospective, observational study was performed. Children with a diagnosis of traumatic brain injury, a Glasgow Coma Score less than or equal to 12, and abnormal head imaging were enrolled. Transcranial Doppler ultrasound was performed to identify and follow vasospasm. Diagnostic criteria included flow velocity elevation more than or equal to 2 sd above age and gender normal values for the middle cerebral and basilar arteries. Additional criteria required for vasospasm diagnosis in the middle cerebral artery was a ratio of flow in the middle cerebral artery to extracranial internal carotid artery more than or equal to 3. Interventions:None. Measurements and Main Results:Sixty-nine children were included. The prevalence of middle cerebral artery vasospasm in children with moderate traumatic brain injury (Glasgow Coma Score, 9–12) was 8.5% and was 33.5% in those with severe traumatic brain injury (Glasgow Coma Score, ⩽ 8). The prevalence of basilar artery vasospasm in children with moderate traumatic brain injury was 3% and with severe traumatic brain injury was 21%. Mean time to onset of vasospasm was 4 days (± 2 d) in the middle cerebral arteries and 5 days (± 2.5 d) in the basilar artery. Mean duration of vasospasm in the middle cerebral artery was 2 days (± 2 d) and 1.5 days (± 1 d) in the basilar artery. Children in whom vasospasm developed were more likely to have been involved in motor vehicle accidents, had higher Injury Severity Scores, had fever at admission, and had lower Glasgow Coma Score scores. Good neurologic outcome (Glasgow Outcome Score Extended Pediatric version of ≥ 4) at 1 month from injury was seen in 76% of those with moderate traumatic brain injury without vasospasm and in 40% of those with vasospasm. In those with severe traumatic brain injury, good neurologic outcome was seen in 29% of those children without vasospasm and in 15% of those with vasospasm. Conclusions:Vasospasm occurs in a sizeable number of children with moderate and severe traumatic brain injury. Children in whom vasospasm developed were more likely to have been involved in a motor vehicle accident, had higher Injury Severity Scores, had fever at admission, and had lower Glasgow Coma scores than in those whom vasospasm did not develop. Based on these findings, we recommend aggressive screening for posttraumatic vasospasm in these patients. Future studies should establish the relationship between vasospasm and long-term functional outcomes and should also evaluate potential preventative or therapeutic options for vasospasm in these children.

Age-related carbon dioxide reactivity in children after moderate and severe traumatic brain injury.

OBJECTIVE The objective of this study is to assess carbon dioxide reactivity (CO2R) in children following traumatic brain injury (TBI). METHODS This prospective observational study enrolled children younger than 18 years old following moderate and severe TBI. Thirty-eight mechanically ventilated children had daily CO2R testing performed by measuring changes in their bilateral middle cerebral artery flow velocities using transcranial Doppler ultrasonography (TCD) after a transient increase in minute ventilation. The cohort was divided into 3 age groups: younger than 2 years (n = 12); 2 to 5 years old (n = 9); and older than 5 years (n = 17). RESULTS Children younger than 2 years old had a lower mean CO2R over time. The 2-5-year-old age group had higher mean CO2R than younger patients (p = 0.01), and the highest CO2R values compared with either of the other age groups (vs > 5 years old, p = 0.046; vs < 2 years old, p = 0.002). Having a lower minimum CO2R had a statistically significant negative effect on outcome at discharge (p = 0.0413). Impaired CO2R beyond Postinjury Day 4 trended toward having an effect on outcome at discharge (p = 0.0855). CONCLUSIONS Abnormal CO2R is prevalent in children following TBI, and the degree of impairment varies by age. No clinical or laboratory parameters were identified as risk factors for impaired CO2R. Lower minimum CO2R values are associated with worse outcome at discharge.

Defining leadership competencies for pediatric critical care fellows: Results of a national needs assessment

Abstract Introduction: Physicians in training, including those in Pediatric Critical Care Medicine, must develop clinical leadership skills in preparation to lead multidisciplinary teams during their careers. This study seeks to identify multidisciplinary perceptions of leadership skills important for Pediatric Critical Care Medicine fellows to attain prior to fellowship completion. Methods: We performed a multi-institutional survey of Pediatric Critical Care Medicine attendings, fellows, and nurses. Subjects were asked to rate importance of 59 leadership skills, behaviors, and attitudes for Pediatric Critical Care practitioners and to identify whether these skills should be achieved before completing fellowship. Skills with the highest ratings by respondents were deemed essential. Results: Five hundred and eighteen subjects completed the survey. Of 59 items, only one item (“displays honesty and integrity”) was considered essential by all respondents. When analyzed by discipline, nurses identified 21 behaviors essential, fellows 3, and attendings 1 (p < 0.05). Nurses differed (p < 0.05) from attendings in their opinion of importance in 64% (38/59) of skills. Conclusions: Despite significant variability among Pediatric Critical Care attendings, fellows, and nurses in identifying which clinical leadership competencies are important for graduating Pediatric Critical Care fellows, they place the highest importance on skills in self-management and self-awareness. Leadership skills identified as most important may guide the development of interventions to improve trainee education and interprofessional care.

In Situ Simulation

In situ simulation describes training that occurs in real patient care environments, rather than in a simulation center or off-site training area. Mobile simulation, taking simulation to hospitals or clinics in the community, can make in situ simulation methodologies accessible across institutions and international boundaries.

Cerebral blood flow velocity and autoregulation in paediatric patients following a global hypoxic-ischaemic insult

AIM To describe the cerebral blood flow velocity pattern and investigate cerebral autoregulation using transcranial Doppler ultrasonography (TCD) following a global hypoxic-ischaemic (HI) event in children. METHODS This was a prospective, observational study in a quaternary-level paediatric intensive care unit. Intubated children, newborn to 17 years admitted to the PICU following HI injury (asphyxia, drowning, cardiac arrest) were eligible for inclusion. TCD was performed daily until post-injury day 8, discharge, or death, whichever occurred earliest. RESULTS Twenty-six patients were enrolled. Median age was 3 years (0.33, 11.75), initial pH 6.95, and initial lactate 5.4. Median post-resuscitation Glasgow Coma Score was 3T. Across the entire cohort, cerebral blood flow velocity (CBFV) was near normal on day 1. Flow velocity increased to a maximum median value of 1.4 standard deviations above normal on day 3 and slowly downtrended back to baseline by the end of the study period. Median Paediatric Extended Version of the Glasgow Outcome Score was 4 at three months. No patient in the favourable outcome group had extreme CBFV on day one, and only one patient in the favourable group had extreme CBFV on PID 2. In contrast, 38% of patients in the unfavourable group had extreme CBFV on PID 1 (p=.039 compared to frequency in favourable group), and 55% had extreme CBFV on PID 2 (p = .023 compared to frequency in favourable group). No patient had consistently intact cerebral autoregulation throughout the study period. CONCLUSIONS Following a HI event, patients with favourable neurologic outcomes had flow velocity near normal whereas unfavourable outcomes had more extreme flow velocity. Intermittently intact cerebral autoregulation was more frequently seen in those with favourable neurologic outcomes though return to the autoregulatory baseline appears delayed.

735: CEREBRAL BLOOD FLOW VELOCITY AND AUTOREGULATION IN CHILDREN AFTER A GLOBAL HYPOXIC-ISCHEMIC EVENT.

Learning Objectives: Global hypoxic-ischemic (GHI) events are a common cause of morbidity and mortality. There is a paucity of literature on the cerebrovascular response following GHI; thus, no evidence-based, goal directed therapies exist. Understanding the basic response is necessary to inform trials aimed at therapeutic options. Methods: This is a single-center, prospective, observational study of children (0–18 years) admitted to our PICU following a GHI. Those with prior pathology that would alter cerebral blood flow velocity (CBFV) were excluded. Patients underwent daily transcranial Doppler ultrasonography for 8 days, during which the bilateral middle cerebral arteries (MCA) were insonated and cerebral autoregulation was tested using the transient hyperemic response ratio. 3 month follow-up was performed using the Glasgow Outcome Score– Pediatric Extended Version (PE-GOS). Results: 18 patients met inclusion criteria, 3 declined for a sample size of 15. Median age was 3 years (0.33, 9.5), 67% male. GHI etiology included: drowning+cardiac arrest–2, asphyxia without arrest–1, asphyxia+cardiac arrest–4, and cardiopulmonary arrest–8. Median GCS 3T (3,3), initial pH 6.88 (6.66,6.99), and initial lactate 5.9 (3.9,11.3). Mean MCA CBFV was near normal for critically ill children on post-injury day (PID) 1. Hyperemia occurred on PID 2–3 with return to normal by day 8 in survivors (n=7). Non-survivors (n=8, 53%) did not follow this pattern as their CBFV was abnormal until the end of the study period. 91% of those with a bad outcome (n = 11, PE-GOS 5–8) compared to 50% in the good outcome group (n=4, PEGOS 1–4) had at least one episode of extreme CBFV (+/2 standard deviations), p=0.1538 (Fisher’s exact). Autoregulation was not reliably intact in any child. Median PE-GOS score was 8 (6,8). Conclusions: Following a GHI, survivors had a hyperemic response on PID 2–3 with normalization thereafter. Non-survivors and those with poor neurologic outcome had persistently abnormal CBFV. Abnormal cerebral autoregulation was noted in all cases. These findings may aid prognostication and encourage the use of neuroprotective measures.

167: IDENTIFYING ESSENTIAL LEADERSHIP SKILLS IN PEDIATRIC CRITICAL CARE MEDICINE

Introduction: Leadership is vitally important to the delivery of high quality health care and is especially important in the critical care environment. Intensivists must develop leadership skills during training, but a validated methodology for teaching and assessment of leadership does not exist. M