Pediatric Patients With Traumatic Brain Injury
Like many areas of pediatric critical care, the majority of evidence for using HTS to treat severe TBI in children is extrapolated from the adult literature. There have been few rigorous prospective studies examining the effect of HTS for severe TBI in children. Fisher et al performed a randomized controlled crossover study of 18 children with severe TBI and compared bolus dosing of 3% HTS with normal saline.20 They reported that HTS was associated with a lower ICP and a reduced need for additional interventions (thiopental and hyperventilation) to control ICP. Simma et al prospectively randomized 35 consecutive pediatric patients with severe TBI to receive either lactated Ringer’s solution or 1.7% HTS for 72 hours.21 All patients subsequently received ICP monitors, and their ICU courses were compared. While there was no significant difference in survival rate, patients treated with HTS had a shorter length of ICU stay and required fewer interventions to maintain ICP control. These studies suggest that HTS is promising for the treatment of severe TBI in children, but the strength of their conclusions is limited due to small sample sizes.
The pediatric section of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies published guidelines in 2012 for the treatment of the pediatric patient with severe TBI.70 They cited 2 pediatric studies20,21 as evidence for the use of HTS and adapted adult severe TBI guidelines. They recommended that HTS be considered for the treatment of pediatric TBI associated with elevated ICP (Level II evidence). While they recognized that there was insufficient evidence to recommend specific concentrations or doses, they recommended bolus dosing between 6.5 and 10 mL/kg of 3% HTS.
Jeffrey A. Holmes, MD
February 4, 2013