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      Traumatismo craneoencefálico pediátrico grave (II): factores relacionados con la morbilidad y mortalidad Translated title: Severe pediatric head injuries (II): factors associated to morbidity-mortality

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          Abstract

          Objetivo: Describir los factores asociados a la morbilidad y mortalidad de los pacientes pediátricos con traumatismo craneoencefálico grave (TCEG). Material y método: Revisión de los pacientes ingresados en una unidad de medicina intensiva pediátrica (UMIP) con TCEG en el periodo comprendido entre julio de 1983 y diciembre de 2009. Resultados: De los 389 pacientes con TCE ingresados en nuestra unidad durante el periodo de estudio, presentaron TCEG 174 (45%). La edad media de este grupo fue de 67±9 meses, con una puntuación media en la escala de Glasgow (GCS) de 5,5±1,8 y una puntuación PRISM media de 10,6±6,7. El 39% de los pacientes presentaron lesión encefálica difusa (LED) grave en la TAC. Un 79% de los pacientes en los que se monitorizó la presión intracraneal (PIC) presentaron hipertensión intracraneal (HIC). Estos pacientes tuvieron una mayor incidencia de secuelas graves que aquellos que no desarrollaron HIC (66,7 vs 23,1%; p=0,01). Las secuelas de relevancia clínica se encontraron en 59 pacientes (34%), y fueron graves en el 64% de los mismos. La mortalidad de los pacientes con TCEG fue de un 25% y se asoció de forma significativa a una menor puntuación del GCS, a la existencia de hiperglucemia o HIC, a la presencia de midriasis o shock y a la necesidad de ventilación mecánica. La mortalidad de la LED grave fue significativamente más elevada que la LED leve-moderada (87,5 vs 7,2%; p<0,001) y que la lesión focal (87,5 vs 36,1%; p<0,001). Los factores responsables de la mortalidad de forma independiente en los pacientes pediátricos con TCEG fueron la existencia de midriasis (OR: 31,27), HIC (OR: 13,23) e hiperglucemia (OR: 3,10). Conclusiones: a) Los TCEG en edad pediátrica asocian una alta morbilidad y mortalidad; b) la existencia de HIC se asoció al desarrollo de secuelas graves; c) los factores de riesgo de mortalidad de forma independiente fueron la existencia de midriasis, HIC e hiperglucemia.

          Translated abstract

          Objective: To describe the factors associated to morbidity-mortality in pediatric patients with severe head injury (SHI). Material and method: A review was made of the patients admitted to the Pediatric Intensive Care Unit (PICU) with SHI between July 1983 and December 2009. Results: Of the 389 patients with head injuries, 174 (45%) presented SHI. The mean age of these subjects was 67 (9) months, with a Glasgow Coma Score (GCS) of 5.5 (1.8) and a PRISM score of 10.6 (6.7). Thirty-nine percent of the patients showed diffuse encephalic injury (DEI) in the computed tomography (CT) study. Seventy-nine percent of the patients subjected to intracranial pressure monitoring (ICP) presented intracranial hypertension. These patients had a greater incidence of serious sequelae (66.7 vs. 23.1%; p=0.01). Sequelae of clinical relevance were recorded in 59 patients (34%), and proved serious in 64% of the cases. The mortality rate among the patients with SHI was 24.7%, and mortality was significantly associated with a lower GCS score, hyperglycemia, intracranial hypertension and the presence of mydriasis or shock. The mortality rate associated to severe DEI was significantly higher than in the case of mild-moderate DEI (87.5 vs. 7.2%; p<0.001). The independent mortality risk factors in the pediatric patients with SHI were found to be the presence of mydriasis (OR: 31.27), intracranial hypertension (OR: 13.23) and hyperglycemia (OR: 3.10). Conclusions: a) SHI in pediatric patients was associated with high morbidity-mortality; b) intracranial hypertension was associated to the development of serious sequelae; c) independent mortality risk factors were the existence of mydriasis, intracranial hypertension and hyperglycemia.

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          A population-based study of inflicted traumatic brain injury in young children.

          Physical abuse is a leading cause of serious head injury and death in children aged 2 years or younger. The incidence of inflicted traumatic brain injury (TBI) in US children is unknown. To determine the incidence of serious or fatal inflicted TBI in a defined US population of approximately 230 000 children aged 2 years or younger. All North Carolina children aged 2 years or younger who were admitted to a pediatric intensive care unit or who died with a TBI in 2000 and 2001 were identified prospectively. Injuries were considered inflicted if accompanied by a confession or a medical and social service agency determination of abuse. Incidence of inflicted TBI. Multivariate logistic regression models were used to compare children with inflicted injuries with those with noninflicted injuries and with the general state population aged 2 years or younger. A total of 152 cases of serious or fatal TBI were identified, with 80 (53%) incurring inflicted TBI. The incidence of inflicted traumatic brain injury in the first 2 years of life was 17.0 (95% confidence interval [CI], 13.3-20.7) per 100 000 person-years. Infants had a higher incidence than children in the second year of life (29.7 [95% CI, 22.9-36.7] vs 3.8 [95% CI, 1.3-6.4] per 100 000 person-years). Boys had a higher incidence than girls (21.0 [95% CI, 15.1-26.6] vs 13.0 [95% CI, 8.4-17.7] per 100 000 person-years). Relative to the general population, children who incurred an increased risk of inflicted injury were born to young mothers (< or =21 years), non-European American, or products of multiple births. In this population of North Carolina children, the incidence of inflicted TBI varied by characteristics of the injured children and their mothers. These data may be helpful for informing preventive interventions.
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            Intensive insulin therapy reduces microdialysis glucose values without altering glucose utilization or improving the lactate/pyruvate ratio after traumatic brain injury.

            To determine that intensive glycemic control does not reduce microdialysis glucose concentration brain metabolism of glucose. Prospective monitoring followed by retrospective data analysis of cerebral microdialysis and global brain metabolism. Single center, academic neurointensive care unit. Forty-seven moderate to severe traumatic brain injury patients. A nonrandomized, consecutive design was used for glycemic control with loose insulin (n=33) for the initial 2 yrs or intensive insulin therapy (n=14) for the last year. In 14 patients treated with intensive insulin therapy, there was a reduction in microdialysis glucose by 70% of baseline concentration compared with a 15% reduction in 33 patients treated with a loose insulin protocol. Despite this reduction in microdialysis glucose, the global metabolic rate of glucose did not change. However, intensive insulin therapy was associated with increased incidence of microdialysis markers of cellular distress, namely elevated glutamate (38+/-37% vs. 10+/-17%, p<.01), elevated lactate/pyruvate ratio (38+/-37% vs. 19+/-26%, p<.03) and low glucose (26+/-17% vs. 11+/-15%, p<.05, and increased global oxygen extraction fraction. Mortality was similar in the intensive and loose insulin treatment groups (14% vs. 15%, p=.9), as was 6-month clinical outcome (p=.3). Intensive insulin therapy results in a net reduction in microdialysis glucose and an increase in microdialysis glutamate and lactate/pyruvate without conveying a functional outcome advantage.
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              The influence of hyperglycemia on neurological outcome in patients with severe head injury.

              Traumatic brain injury is associated with a stress response that includes hyperglycemia, which has been shown to worsen neurological outcome during cerebral ischemia and hypoxia. To better examine the relationship between hyperglycemia and outcome after head injury, we studied the clinical course of 267 head-injured patients who were admitted for treatment in the neurosurgical department of Asclepeion Hospital of Athens between January 1993 and November 1997. We prospectively studied 267 patients with moderate or severe craniocerebral injury (Glasgow Coma Scale scores, 3-12) who were treated surgically for evacuation of an intracranial hematoma and/or placement of a device for intracranial pressure monitoring under general anesthesia to determine the relationship between serum glucose levels, severity of injury, and neurological outcome. Patients with severe head injury had significantly higher serum glucose levels than did those with moderate injury. Patients who subsequently had an unfavorable outcome had significantly higher glucose levels than did those with a better prognosis. Among the patients with more severe head injury, a glucose level greater than 200 mg/dl was associated with a worse outcome. In the same group of patients, a significant relationship was found between postoperative glucose levels, pupillary reaction, and maximum intracranial pressure during the first 24 hours. Multivariate analysis showed that postoperative glucose levels were an independent predictor of outcome. Early hyperglycemia is a frequent component of the stress response to head injury, a significant indicator of its severity, and a reliable predictor of outcome.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                medinte
                Medicina Intensiva
                Med. Intensiva
                Elsevier España, S.L. (, , Spain )
                0210-5691
                September 2011
                : 35
                : 6
                : 337-343
                Affiliations
                [01] Las Palmas de Gran Canaria orgnameComplejo Hospitalario Universitario Insular Materno-Infantil de Canarias orgdiv1Unidad de Medicina Intensiva Pediátrica España
                [02] Las Palmas de Gran Canaria orgnameUniversidad de Las Palmas de Gran Canaria orgdiv1Facultad de Medicina orgdiv2Departamento de Bioestadística España
                Article
                S0210-56912011000600004
                10.1016/j.medin.2011.02.006
                2c28e9b3-0b58-4a3a-ae20-fee8a5558f71

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 21 September 2010
                : 01 February 2011
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 43, Pages: 7
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                SciELO Spain


                Traumatismo craneoencefálico pediátrico,Factores pronósticos,Morbilidad,Mortalidad,Severe head injury pediatric patients,Risk factors,Morbidity,Mortality

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