Researchers are calling for a re-evaluation of guidelines used in the care of children with traumatic head injuries following the first multi-centre study of its kind in the UK.
The paper, published in the international peer-reviewed journal JAMA Pediatrics, “Intracranial Pressure Treatment Thresholds in Pediatric Traumatic Brain Injury”, suggests that the existing brain pressure (Intracranial Pressure, ICP) thresholds used for treatment should be lower in children than in adults, marking a potentially significant shift from current clinical practice.
The results come from a UK wide multicentre prospective study in paediatric traumatic brain injury (pTBI), called STARSHIP (Status of Cerebrovascular AutoRegulation relates to outcome in Severe Paediatric Head Injury).
Key findings
In this secondary analysis of high-resolution physiological data from the STARSHIP research database, patients with brain pressures below 14-15 mmHg were more likely to have improved long-term functional outcomes. Importantly, this association persisted even after accounting for how severe the original injury was and how intensively patients were treated. In other words, the benefit was not simply because the patients had less severe injury or received more aggressive care, lower brain pressure itself appeared to matter in the long-term outcome.
The study concludes: “Sustained ICP elevations above 14-15 mmHg are strongly associated with poor long-term functional outcomes in paediatric traumatic brain injury (pTBI), which warrant prospective evaluation.”
Dr Shruti Agrawal, a paediatric intensivist and paediatric trauma lead at Cambridge University Hospitals NHS Foundation Trust (CUH), who led the study said: “Our findings suggest that clinically relevant treatment thresholds in children with TBI may be lower than the current 20 mmHg benchmark. Together with prior studies, this evidence supports re-evaluating guideline targets for ICP management in paediatric TBI and highlights the need for prospective, age-specific validation to optimise neuroprotective strategies.”
STARSHIP Study Background
The first phase of STARSHIP was published in February last year, exploring how “continuous assessment of cerebrovascular autoregulation (CA) using pressure reactivity index (PRx)” with the potential to improve outcomes by individualising targets by real-time analysis of routinely collected data.
STARSHIP was conducted across ten UK Paediatric Intensive Care Units (PICUs) over five years recruiting 135 children under 16-years. The study has created a high-resolution research database containing detailed clinical and treatment information. This resource is helping researchers understand and identify the factors associated with better recovery and functional outcomes in children with TBI. In the near future, the database will be made available to external researchers, encouraging wider collaboration and further studies aimed at improving understanding and outcomes for children affected by head injury.
Dr Agrawal said: “Our study has many strengths, the most important being the prospective multicentre design with a predefined sample size and protocol. Given the paucity of such evidence and data, STARSHIP database offers a unique opportunity of ongoing research and data collection.”
The study was funded by Addenbrooke’s Charitable Trust (opens in a new tab) (ACT) and Action Medical Research for Children (opens in a new tab), sponsored by Cambridge University Hospitals NHS Foundation Trust, and supported by the National Institute of Health and Care Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Clinical Research Network. Helping were departments within the University of Cambridge; Cambridge and Peterborough NHS Foundation Trust; Birmingham Children’s Hospital; Great Ormond Street Hospital; Leeds Children’s Hospital; Manchester Children’s Hospital; Nottingham Children’s Hospital; Oxford University Hospitals; Royal London Hospital; Sheffield Children’s Hospital and Southampton Children’s Hospital.
The study comes as CUH presses ahead to build a dedicated children’s hospital for the eastern region, combining physical and mental healthcare under one roof. Learn more about it here (opens in a new tab).