TY - JOUR
T1 - Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury
T2 - An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis
AU - Macarthur, Taleen A.
AU - Vogel, Adam M.
AU - Glasgow, Amy E.
AU - Moody, Suzanne
AU - Kotagal, Meera
AU - Williams, Regan F.
AU - Kayton, Mark L.
AU - Alberto, Emily C.
AU - Burd, Randall S.
AU - Schroeppel, Thomas J.
AU - Baerg, Joanne E.
AU - Munoz, Amanda
AU - Rothstein, William B.
AU - Boomer, Laura A.
AU - Campion, Eric M.
AU - Robinson, Caitlin
AU - Nygaard, Rachel M.
AU - Richardson, Chad J.
AU - Garcia, Denise I.
AU - Streck, Christian J.
AU - Gaffley, Michaela
AU - Petty, John K.
AU - Ryan, Mark
AU - Pandya, Samir
AU - Russell, Robert T.
AU - Yorkgitis, Brian K.
AU - Mull, Jennifer
AU - Pence, Jeffrey
AU - Santore, Matthew T.
AU - Klinkner, Denise B.
AU - Safford, Shawn D.
AU - Trevilian, Tanya
AU - Jensen, Aaron R.
AU - Mooney, David P.
AU - Ketha, Bavana
AU - Dassinger, Melvin S.
AU - Goldenberg-Sandau, Anna
AU - Falcone, Richard A.
AU - Polites, Stephanie F.
N1 - Publisher Copyright:
© Wolters Kluwer Health, Inc. All rights reserved.
PY - 2023/7/1
Y1 - 2023/7/1
N2 - OBJECTIVE This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ2 t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
AB - OBJECTIVE This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ2 t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
KW - TBI
KW - Trauma
KW - pediatric
KW - resuscitation
KW - surgery
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U2 - 10.1097/TA.0000000000004013
DO - 10.1097/TA.0000000000004013
M3 - Article
C2 - 37072882
AN - SCOPUS:85163868363
SN - 2163-0755
VL - 95
SP - 78
EP - 86
JO - Journal of Trauma and Acute Care Surgery
JF - Journal of Trauma and Acute Care Surgery
IS - 1
ER -