Childs Nerv Syst DOI 10.1007/s00381-016-3298-5
LETTER TO THE EDITOR
Pediatric traumatic brain injury: discussion about hyperosmolar therapy Marcia Mitie Nagumo 1 & Manoel Jacobsen Teixeira 2 & Wellingson Silva Paiva 2
Received: 25 October 2016 / Accepted: 11 November 2016 # Springer-Verlag Berlin Heidelberg 2016
Dear Editor: We read with great interest the recent study by Roumeliotis et al. [1] published in the Child’s Nervous System, concerning the hyperosmolar therapy in pediatric traumatic brain injury (TBI). Secondary injuries associated with traumatic brain injury are the result of processes that contribute to cell death after the initial trauma, including hypoxia, metabolic disorders, and electrolyte disturbances. However, intracranial hypertension is the leading cause of death related to TBI [2]. Thus, the adequate control of intracranial pressure and cerebral perfusion pressure is essential in the treatment of patients with TBI [3]. Hyperosmolar solutions are strategic to control intracranial hypertension [1, 3]. Given this, the authors conducted a retrospective review of 16 patients admitted between 2007 and 2014 in a pediatric intensive care unit of a pediatric and maternal tertiary care center and a trauma center. They focused their study on the use of hyperosmolar therapy and its effect on intracranial pressure and cerebral perfusion pressure. Indeed, as pointed out by the authors, it is still a controversy the use of hypertonic solutions in adults and children, and clear therapeutic guidelines are not consistent. Therefore, we would like to thank the authors for their contribution to bring this subject up and for sharing their experience in the treatment of their patients. * Wellingson Silva Paiva
[email protected] 1
Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
2
Division of Neurosurgery at University of São Paulo Medical School, 255 Eneas Aguiar, São Paulo 05403-000, Brazil
Overall, a retrospective study has its negative limitations especially in this case that were obtained from patient’s chart, and the reports were not standardized with quality criteria information. We believe that the lack of a standard protocol for hyperosmolar management after traumatic brain injury in place was also negative, as each doctor would prescribe the therapy based upon his/her own criteria and patient’s status. We believe that special attention should be focused on the age population of the study that has been pretty diverse (from 1 month old to 18 years old), and the data analysis was not separated by age for comparison. We believe that the trauma pathophysiology and the response to the hyperosmolar therapy could differ between all those ages. Huh and Raghupathi [4] point out interesting concepts in treatment of pediatric traumatic brain injury. In the study flowchart, we did not understand the first box of exclusions as it mentions about ten patients that were excluded by being non-severe traumatic brain injury. If the eligibility of patients was severe traumatic brain injury, then those non-severe cases would not even part of inclusion criteria of the study. Regarding the statistical analysis, the authors did not explain their sample size calculation, and if the sample achieved a normal distribution, we could better understand the use of parametric or non-parametric tests. Also, as each patient has several measures (pre-bolus; 1, 2, 3, and 4 h), we were in doubt if ANOVA was indeed the most ideal test, or if cluster analysis would have been more appropriate. Unfortunately, the confounding variables in the study, as mentioned by the authors, were a real limitation for better consistent results. Overall, this study will help to better understand the use of hyperosmolar therapy in pediatric traumatic brain injury, and the authors suggest a controlled prospective study that we agree and also encourage.
Childs Nerv Syst Compliance with ethical standards Conflict of interest There is no conflict of interest.
References 1.
Roumeliotis N, Dong C, Pettersen G, Crevier L, Emeriaud G (2016) Hyperosmolar therapy in pediatric traumatic brain injury: a retrospective study. Childs Nerv Syst. doi:10.1007/s00381-016-3231-y
2.
Andrade AF, Paiva WS, Amorim RL, Figueiredo EG, Rusafa Neto E, Teixeira MJ (2009) The pathophysiological mechanisms following traumatic brain injury. Rev Assoc Med Bras 55(1):75–81 3. Kochanek PM, Carney N, Adelson PD et al (2012) Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition. Pediatric Critical Care Medicine: a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 13(Suppl 1): S1–82 4. Huh JW, Raghupathi R (2009) New concepts in treatment of pediatric traumatic brain injury. Anesthesiol Clin 27(2):213– 240. doi:10.1016/j.anclin.2009.05.006
