Predictors of outcome in severely head-injured children

Objective: Determine variables in the acute care period associated with survival and pediatric intensive care unit (PICU) length of stay (LOS) for children 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 traumatic brain injury and admission Glasgow Coma Scale score of ≤8. Interventions: None. Measurements and Main Results: The first 72 hrs of hospitalization were analyzed in detail for 136 patients. The primary end point was survival; secondary end points were PICU LOS, cost, and day at which Glasgow Coma Scale score was ≥14. Predictors of outcome were abstracted, including Pediatric Trauma Score, Glasgow Coma Scale score, Pediatric Risk of Mortality, physiologic variables, computed tomography evidence of brain injury, and neuroresuscitative medications. The fatality rate was 24%. Age and gender were similar between groups (p ≥ .1). Survival was independently predicted by 6-hr Glasgow Coma Scale score (odds ratio [OR] 4.6; 95% confidence interval [Cl] 2.06-11.9; p < .001) and maximum systolic blood pressure (OR 1.05; 95% Cl 1.01-1.09; p < .02). Odds of survival increased 19-fold when maximum systolic blood pressure was ≥135 mm Hg (OR 18.8; 95% Cl 2.0-178.0; p < .01). By discharge, 67% of patients had an age-appropriate Glasgow Coma Scale score. Median hospital costs were $8,798 for survivors: only mannitol use independently predicted high cost (odds ratio 4.9; 95% Cl 1.2-19.1; p < .01). For survivors, median PICU LOS was 2 days, although 25% had LOS >6 days. Six-hour Glasgow Coma Scale score (OR 0.62; 95% Cl 0.48-0.80; p < .001) and mannitol (OR 7.9; 95% Cl 2.3-27.3; p < .001) were each independently associated with a prolonged 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 associated with maximum systolic blood pressure ≥135 mm Hg, suggesting that supranormal blood pressures are associated with improved outcome. Mannitol administration was associated with prolonged LOS, yet conferred no survival advantage. We suggest reevaluation of blood pressure targets and mannitol use in children with severe traumatic brain injury.