ICP monitoring in children: why are we not adhering to guidelines?

BACKGROUND: Despite pediatric guidelines, variability exists in the management of severe traumatic brain injury (TBI), as somewhere between 7 and 60% of children undergo intracranial pressure (ICP) monitoring. Reasons for this low adherence to TBI management guidelines remain unclear. The objective of this study was to evaluate the current practices at CHU Sainte-Justine with regards to ICP monitoring in severe TBI and explore the reasons why ICP monitoring is not undertaken.

METHODS: A retrospective review was conducted of all patients age 1 month to 18 years, with severe TBI (Glasgow Coma Scale (GCS) ≤8) from 2007 to 2014. Presence of ICP monitoring, head imaging reports, and reasons for lack of monitoring were recorded.

RESULTS: Sixty-four patients with severe TBI were admitted. Twenty (31%) patients had invasive ICP monitoring in the first 6 h and 5 in the following 24 h. Improvement of the GCS on arrival to tertiary care center (20%, n = 13) and moribund status (20%, n = 13) were the two main reasons ICP monitoring was not undertaken. Fourteen patients (21%) with reassuring cerebral tomography (Rotterdam scores 1-3) and median GCS 7 (IQR 6-8) were initially followed with clinical surveillance, five of which ended up with an ICP monitor (>6 h).

CONCLUSION: Our study confirms that many children with severe TBI do not undergo ICP monitoring, mainly due to rapid improvement or moribund status. A subgroup of patients, with reassuring cerebral CT scan, was not monitored. Further research is necessary to assess if imaging should be considered in ICP indication, as in adult guidelines.