Predictors of outcome in severely head-injured children

Objective: Determine variables in the acute care period associated with sur vival and pediatric intensive care unit (PICU) length of stay (LOS) for chi ldren with severe traumatic brain injury. Design: Retrospective cohort. Setting: Level 1 pediatric trauma center. Patients: Children (0-17 yrs) admitted 1991 to 1995 with nonpenetrating tra umatic brain injury and admission Glasgow Coma Scale score of less than or equal to8. Interventions: None. Measurements and Main Result's: The first 72 hrs of hospitalization were an alyzed in detail for 136 patients. The primary end point was survival; seco ndary end points were PICU LOS, cost, and day at which Glasgow Coma Scale s core was greater than or equal to 14. Predictors of outcome were abstracted , including Pediatric Trauma Score, Glasgow Coma Scale score, Pediatric Ris k of Mortality, physiologic variables, computed tomography evidence of brai n injury, and neuroresuscitative medications. The fatality rate was 24%. Ag e and gender were similar between groups (p greater than or equal to .1). S urvival was independently predicted by 6-hr Glasgow Coma Scale score (odds ratio [OR] 4.6; 95% confidence interval [CI] 2.06-11.9; p < .001) and maxim um systolic blood pressure (OR 1.05; 95% CI 1.01-1.09; p < .02). Odds of su rvival increased 19-fold when maximum systolic blood pressure was greater t han or equal to 135 mm Hg (OR 18.8; 95% CI 2.0-178.0; p < .01). By discharg e, 67% of patients had an age-appropriate Glasgow Coma Scale score. Median hospital costs were $8,798 for survivors: only mannitol use independently p redicted high cost (odds ratio 4.9; 95% CI 1.2-19.1; p < .01). For survivor s, median PICU LOS was 2 days, although 25% had LOS >6 days. Six-hour Glasg ow Coma Scale score (OR 0.62; 95% GI 0.48-0.80; p < .001) and mannitol (OR 7.9; 95% CI 2.3-27.3; p < .001) were each independently associated with a p rolonged LOS among survivors. Conclusions: Patients with higher 6-hr Glasgow Coma Scale scores were more likely to survive. Adjusting for severity of injury, survival was associate d with maximum systolic blood pressure greater than or equal to 135 mm Hg, suggesting that supranormal blood pressures are associated with improved ou tcome, Mannitol administration was associated with prolonged LOS, yet confe rred no survival advantage. We suggest reevaluation of blood pressure targe ts and mannitol use in children with severe traumatic brain injury.