Background In 2003, the Brain Trauma Foundation (BTF) issued guidelines that severe hyperventilation (SHV, PaCO2 < 30 mm Hg) should be avoided in severe pediatric traumatic brain injury (pTBI) when intracranial pressure (ICP) is < 20 mm Hg. The effectiveness of the BTF guidelines in decreasing the incidence of unnecessary SHV in severe pTBI has not been studied. Our objective was to examine the incidence of SHV in severe pTBI before and after publication of 2003 BTF guidelines.
Methods Electronic medical records at the Harborview Medical Center at University of Washington were reviewed retrospectively for all severe pTBI injuries in children < 15 years of age from January 1, 1995, to December 31, 2005. The cutoff for pre-BTF was designated July 31, 2003. Patients with no PaCO2 records in the first 48 hours were excluded. Differences in PaCO2 sampling and incidence between the pre- and post-BTF periods were examined. Trends in SHV over time and predictors for mortality were also examined. Student's t-test and logistic regression analysis were used.
Results The pre-BTF group included 375 patients and the post-BTF group included 89 patients. There was no difference in the PaCO2 sampling frequency (7.1 vs 8.4 PaCO2 samples in 48 hours). SHV was common during both periods, and no difference was found between pre- and post-BTF (59.7% vs 51.7%). However, SHV incidence decreased over successive years (1995-2005). The majority of SHV occurred during the first 2 hours after hospital admission. In SHV episodes with preceding recorded ICP measurements, the majority (62/81) occurred with ICP < 20 mm Hg. In patients with correcting ventilator settings recorded following an SHV episode, the majority (100/126) led to an increase in PaCO2. SHV predicted mortality (2.815, 95% CI [1.328-5.964]) independent of emergency department (ED) Glasgow Coma Scale score, lowest ED systolic blood pressure, and injury severity score.
Conclusions SHV was common during the first 48 hours after hospital admission. There was no decrease in SHV pre- and post-BTF. SHV predicted mortality.
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