Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury.
Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury.
复制标题
DOI：
10.1097/ccm.0000000000000507
复制
发表时间：
2014-10
影响因子：
8.8
通讯作者：
Pediatric Guideline Adherence and Outcomes Study
中科院分区：
文献类型：
--
作者：
Vavilala MS;Kernic MA;Wang J;Kannan N;Mink RB;Wainwright MS;Groner JI;Bell MJ;Giza CC;Zatzick DF;Ellenbogen RG;Boyle LN;Mitchell PH;Rivara FP;Pediatric Guideline Adherence and Outcomes Study
第一个严重的小儿创伤性脑损伤（TBI）指南中的急性护理临床指标与结局之间的关系尚未得到研究。我们的目的是开发一套急性护理指南影响的临床依从性指标，并在入院后的前72小时内测试这些指标与出院结局之间的关系。回顾性多中心队列研究五个附属于学术医疗中心的地区儿科创伤中心。17岁以下严重TBI儿童（入院时格拉斯哥昏迷量表（GCS）评分≤ 8分，ICD-9诊断代码为800.0-801.9、803.0-804.9、850.0-854.1、959.01、950.1-950.3、995.55，对2007 - 2011年间在重症监护室（ICU）接受气管插管至少48小时的患者进行了检查。确定了所有治疗地点（院前[PH]、急诊科[艾德]、手术室[OR]和重症监护室[ICU]）在入住研究中心后前72小时内对临床指标的总依从性百分比。主要结局是出院生存率和格拉斯哥结局量表（GOS）评分。所有地点和所有中心的总依从率范围为68- 78%。依从性的临床指标与生存率相关（aHR 0.94; 95% CI 0.91，0.96）。三个指标与生存率相关：无PH缺氧（aHR 0.20; 95% CI 0.08，0.46），ICU早期开始营养（aHR 0.06; 95% CI 0.01，0.26），ICU PaCO 2>30 mmHg，无脑疝的影像学或临床体征（aHR 0.22; 95% CI 0.06，0.8）。在存活者中，依从性的临床指标与良好的GOS相关（aHR 0.99; 95% CI 0.98，0.99）。3项指标与良好的出院GOS相关：所有OR CPP >40 mm Hg（aRR 0.64; 95% CI 0.55，0.75），所有ICU CPP > 40 mm Hg（aRR 0.74; 95% CI 0.63，0.87），无手术（任何类型; aRR 0.72; 95% CI 0.53，0.97）。急性护理临床指标的遵守儿科指南与出院生存率显着提高和改善出院GOS。一些指标是保护性的，无论治疗地点，这表明需要一个跨学科的方法来照顾严重的TBI儿童。
The relationship between acute care clinical indicators in the first severe Pediatric traumatic brain injury (TBI) Guidelines and outcomes have not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. Retrospective multicenter cohort study Five regional pediatric trauma centers affiliated with academic medical centers. Children under 17 years with severe TBI (admission Glasgow coma scale (GCS) score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated injury severity score ≥ 3) who received tracheal intubation for at-least 48 hours in the intensive care unit (ICU) between 2007 -2011 were examined. None Total percent adherence to the clinical indicators across all treatment locations (pre-hospital [PH], emergency department [ED], operating room [OR], and intensive care unit [ICU]) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow outcome scale (GOS) score. Total adherence rate across all locations and all centers ranged from 68-78%. Clinical indicators of adherence were associated with survival (aHR 0.94; 95 % CI 0.91, 0.96). Three indicators were associated with survival: absence of PH hypoxia (aHR 0.20; 95% CI 0.08, 0.46), early ICU start of nutrition (aHR 0.06; 95% CI 0.01, 0.26), and ICU PaCO2 >30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (aHR 0.22; 95% CI 0.06, 0.8). Clinical indicators of adherence were associated with favorable GOS among survivors, (aHR 0.99; 95% CI 0.98, 0.99). Three indicators were associated with favorable discharge GOS: all OR CPP >40 mm Hg (aRR 0.64; 95% CI 0.55, 0.75), all ICU CPP > 40mm Hg (aRR 0.74; 95% CI 0.63, 0.87), and no surgery (any type; aRR 0.72; 95% CI 0.53, 0.97). Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge GOS. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe TBI.