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Intensive care treatments associated with favorable discharge outcomes in Argentine children with severe traumatic brain injury: For the South American Guideline Adherence Group.

Intensive care treatments associated with favorable discharge outcomes in Argentine children with severe traumatic brain injury: For the South American Guideline Adherence Group.
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Vavilala MS, Lujan SB, Qiu Q, Bell MJ, Ballarini NM, Guadagnoli N, Depetris MA, Faguaga GA, Baggio GM, Busso LO, García ME, González Carrillo OR, Medici PL, Sáenz SS, Vanella EE, Farr CK, Petroni GJ,


Vavilala MS, Lujan SB, Qiu Q, Bell MJ, Ballarini NM, Guadagnoli N, Depetris MA, Faguaga GA, Baggio GM, Busso LO, García ME, González Carrillo OR, Medici PL, Sáenz SS, Vanella EE, Farr CK, Petroni GJ, (click to view)

Vavilala MS, Lujan SB, Qiu Q, Bell MJ, Ballarini NM, Guadagnoli N, Depetris MA, Faguaga GA, Baggio GM, Busso LO, García ME, González Carrillo OR, Medici PL, Sáenz SS, Vanella EE, Farr CK, Petroni GJ,

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PloS one 2017 12 1512(12) e0189296 doi 10.1371/journal.pone.0189296
Abstract
OBJECTIVE
Little is known about the critical care management of children with traumatic brain injury (TBI) in low middle income countries. We aimed to identify indicators of intensive care unit (ICU) treatments associated with favorable outcomes in Argentine children with severe TBI.

METHODS
We conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with severe TBI who were admitted to an ICU in one of the seven study centers. Severe TBI was defined by head AIS ≥ 3, head CT with traumatic lesion, and admission GCS < 9. Seven indicators of best practice TBI care were examined. The primary outcome was discharge Pediatric Cerebral Performance Category Scale [PCPC] and Pediatric Overall Performance category Scale [POPC]. We also examined variation in ICU care and in-patient mortality. RESULTS
Of the 117 children, 67% were male and 7.5 (4.3) years on average, 92% had isolated TBI. Hypotension (54%) was more common than hypoxia (28%) and clinical or radiographic signs of high intracranial pressure (ICP) were observed in 92%. Yet, ICP monitoring occurred in 60% and hyperosmolar therapy was used in only 36%. Adherence to indicators of best TBI practice ranged from 55.6% to 83.7% across the seven centers and adherence was associated with favorable discharge PCPC (aRR 0.98; 95% CI [0.96, 0.99]), and POPC (aRR 0.98; 95% CI [0.96, 0.99]). Compared to patients whose adherence rates were below 65%, patients whose adherence rates were higher between 75%-100% had better discharge PCPC (aRR 0.28; 95% CI [0.10, 0.83]) and POPC (aRR 0.32; 95% CI [0.15, 0.73]. Two indicators were associated with favorable discharge PCPC: Avoidance of hypoxia (aRR 0.46; 95% CI [0.23, 0.93]), and Nutrition started in 72 hours (aRR 0.45; 95% CI [0.21, 0.99]). Avoiding hypoxia was also associated with favorable discharge POPC (aRR 0.47; 95% CI [0.22, 0.99]).

CONCLUSION
There is variation in Argentine ICU practice in the care of children with severe TBI. Second insults are common and hyperosmolar therapy use is uncommon. Adherence to best practice TBI care by avoiding hypoxia and providing timely nutrition were associated with significantly favorable discharge outcomes. Implementing strategies that prevent hypoxia and facilitate early nutrition in the ICUs are urgently needed to improve pediatric TBI outcomes.

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