Prospective evaluation of the safety of ultrasound-guided cervical medial branch blocks using the in-plane technique.

BACKGROUND: While fluoroscopic guidance is currently the imaging standard for cervical medial branch blocks (CMBBs), ultrasound guidance (USG) offers several potential safety advantages such as real-time needle visualization and the ability to detect and avoid critical soft tissue vascular or neural structures. However, no large-scale trials have examined the safety of USG for CMBB. METHODS: Five hundred patients undergoing 2308 individual block levels were recruited using a prospective cohort design, and blocks were performed in an outpatient office setting using an in-plane USG technique. Primary outcomes included immediate block-related complication, as well as delayed occurrences, in the following 2 weeks. Vascular structures adjacent to the target area, as well as the occurrence of vascular breach, were recorded. RESULTS: Three minor immediate complications were noted (two subcutaneous hematomas, one vasovagal reaction) comprising 0.13% of blocks (0.03% to 0.38%; 95% two-sided CI), and no delayed events were recorded (0% to 0.16%; 97.5% one-sided CI). Blood vessels were detected and avoided in 8.2% of blocks, and vascular breach was noted in 0.52% of blocks (0.27% to 0.91%; 95% two-sided CI). CONCLUSION: When performed using an in-plane technique by experienced operators, USG CMBB was found to be safe, with rare minor immediate complications and no further adverse event reported in the following 2 weeks. TRIAL REGISTRATION NUMBER: NCT04852393.

A Pilot Prospective Observational Study of Cerebral Autoregulation and 12-Month Outcomes in Children With Complex Mild Traumatic Brain Injury: The Argument for Sufficiency Conditions Affecting TBI Outcomes.

BACKGROUND: The relationship between cerebral autoregulation and outcomes in pediatric complex mild traumatic brain injury (TBI) is unknown, and explored in this study. METHODS: We conducted a prospective observational study of patients aged 0 to 18 years hospitalized with complex mild TBI (admission Glasgow Coma Scale score 13 to 15 with either abnormal computerized tomogram of the head or history of loss of consciousness). Cerebral autoregulation was tested using transcranial Doppler ultrasonography, and impaired autoregulation defined as autoregulation index<0.4. We collected Glasgow Outcome Scale Extended-Pediatrics score and health-related quality of life data at 3, 6, and 12 months after discharge. RESULTS: Twenty-four patients aged 1.8 to 16.6 years (58.3% male) with complete 12-month outcome data were included in the analysis. Median admission Glasgow Coma Scale score was 15 (range: 13 to 15), median injury severity score was 12 (range: 4 to 29) and 23 patients (96%) had isolated TBI. Overall, 10 (41.7%) patients had impaired cerebral autoregulation. Complete recovery was observed in 6 of 21 (28.6%) children at 3 months, in 4 of 16 (25%) children at 6 months, and in 8 of 24 (33.3%) children at 12 months. There was no difference in median (interquartile range) Glasgow Outcome Scale Extended-Pediatrics score (2 [2.3] vs. 2 [interquartile range 1.3]) or health-related quality of life scores (91.5 [21.1] vs. 90.8 [21.6]) at 12 months between those with intact and impaired autoregulation, respectively. Age-adjusted hypotension occurred in 2/24 (8.3%) patients. CONCLUSION: Two-thirds of children with complex mild TBI experienced incomplete functional recovery at 1 year. The co-occurrence of hypotension and cerebral autoregulation may be a sufficiency condition needed to affect TBI outcomes.

Cardiac-cerebral-renal associations in pediatric traumatic brain injury: Preliminary findings.

OBJECTIVE: The clinical epidemiology of organ outcomes in pediatric traumatic brain injury (TBI) has not been examined. We describe associated markers of cerebral, cardiac and renal injury after pediatric TBI. DESIGN: Prospective observational study. PATIENTS: Children 0-18 years who were hospitalized with TBI. MEASUREMENTS: Measures of myocardial (at least one elevated plasma troponin [cTnI] ≥ 0.4 ng/ml) and multiorgan (hemodynamic variables, cerebral perfusion, and renal) function were examined within the first ten days of hospital admission and within 24 h of each other. MAIN RESULTS: Data from 28 children who were 11[IQR 10.3] years, male (64.3%), with isolated TBI (67.9%), injury severity score (ISS) 25[10], and admission Glasgow coma score (GCS) 11[9] were examined. Overall, 50% (14 children) had elevated cTnI, including those with isolated TBI (57.9%; 11/19), polytrauma (33.3%; 3/9), mild TBI (57.1% 8/14), and severe TBI (42.9%; 6/11). Elevated cTnI occurred within the first six days of admission and across all age groups, in both sexes, and regardless of TBI lesion type, GCS, and ISS. Age-adjusted admission tachycardia was associated with cTnI elevation (AUC 0.82; p < 0.001). Reduced urine output occurred more commonly in patients with isolated TBI (27.3% elevated cTnI vs. 0% normal cTnI). CONCLUSIONS: Myocardial injury commonly occurs during the first six days after pediatric TBI irrespective of injury severity, age, sex, TBI lesion type, or polytrauma. Age-adjusted tachycardia may be a clinical indicator of myocardial injury, and elevated troponin may be associated with cardio-cerebro-renal dysfunction.

Plasma Levels, Temporal Trends and Clinical Associations between Biomarkers of Inflammation and Vascular Homeostasis after Pediatric Traumatic Brain Injury.

Expression of inflammatory (interleukin-6 [IL-6]) and vascular homeostatic (angiopoietin-2 [AP-2], endothelin-1 [ET-1], endocan-2 [EC-2]) biomarkers in pediatric traumatic brain injury (TBI) was examined in this prospective, observational cohort study of 28 children hospitalized with mild, moderate, and severe TBI by clinical measures (age, sex, Glasgow Coma Scale score [GCS], Injury Severity Score [ISS], and cerebral autoregulation status). Biomarker patterns suggest an inverse relationship between GCS and AP-2, GCS and IL-6, ISS and ET-1, but a direct relationship between GCS and ET-1 and ISS and AP-2. Biomarker patterns suggest an inverse relationship between AP-2 and ET-1, AP-2 and EC-2, but a direct relationship between AP-2 and IL-6, IL-6 and EC-2, and IL-6 and ET-1. Plasma concentrations of inflammatory and vascular homeostatic biomarkers suggest a role for inflammation and disruption of vascular homeostasis during the first 10 days across the severity spectrum of pediatric TBI. Although not statistically significant, without impact on cerebral autoregulation, biomarker patterns suggest a relationship between inflammation and alterations in vascular homeostasis. The large variation in biomarker levels within TBI severity and age groups, and by sex suggests other contributory factors to biomarker expression.

A multicenter, randomized comparison between 2, 5, and 8 mg of perineural dexamethasone for ultrasound-guided infraclavicular block.

BACKGROUND AND OBJECTIVES: This multicenter, randomized trial compared 2, 5, and 8 mg of perineural dexamethasone for ultrasound-guided infraclavicular brachial plexus block. Our research hypothesis was that all three doses of dexamethasone would result in equivalent durations of motor block (equivalence margin=3.0 hours). METHODS: Three hundred and sixty patients undergoing upper limb surgery with ultrasound-guided infraclavicular block were randomly allocated to receive 2, 5, or 8 mg of preservative-free perineural dexamethasone. The local anesthetic agent (35 mL of lidocaine 1%-bupivacaine 0.25% with epinephrine 5 µg/mL) was identical in all subjects. Patients and operators were blinded to the dose of dexamethasone. During the performance of the block, the performance time, number of needle passes, procedural pain, and complications (vascular puncture, paresthesia) were recorded. Subsequently a blinded observer assessed the success rate (defined as a minimal sensorimotor composite score of 14 out of 16 points at 30 min), onset time as well as the incidence of surgical anesthesia (defined as the ability to complete surgery without local infiltration, supplemental blocks, intravenous opioids, or general anesthesia). Postoperatively, the blinded observer contacted patients with successful blocks to inquire about the duration of motor block, sensory block, and postoperative analgesia. The main outcome variable was the duration of motor block. RESULTS: No intergroup differences were observed in terms of technical execution (performance time/number of needle passes/procedural pain complications), onset time, success rate, and surgical anesthesia. Furthermore, all three doses of dexamethasone provided similar durations of motor block (14.9-16.1 hours) and sensory block. Although 5 mg provided a longer analgesic duration than 2 mg, the difference (2.7 hours) fell within our pre-established equivalence margin (3.0 hours). CONCLUSIONS: 2, 5, and 8 mg of dexamethasone provide clinically equivalent sensorimotor and analgesic durations for ultrasound-guided infraclavicular block. Further trials are required to compare low (ie, 2 mg) and ultra-low (eg, 0.5-1 mg) doses of perineural dexamethasone for brachial plexus blocks. TRIAL REGISTRATION NUMBER: TCTR20150624001.

Prevalence, Evolution, and Extent of Impaired Cerebral Autoregulation in Children Hospitalized With Complex Mild Traumatic Brain Injury.

OBJECTIVES: To examine cerebral autoregulation in children with complex mild traumatic brain injury. DESIGN: Prospective observational convenience sample. SETTING: PICU at a level I trauma center. PATIENTS: Children with complex mild traumatic brain injury (trauma, admission Glasgow Coma Scale score 13-15 with either abnormal head CT, or history of loss of consciousness). INTERVENTIONS: Cerebral autoregulation was tested using transcranial Doppler ultrasound between admission day 1 and 8. MEASUREMENTS AND MAIN RESULTS: The primary outcome was prevalence of impaired cerebral autoregulation (autoregulation index < 0.4),determined using transcranial Doppler ultrasonography and tilt testing. Secondary outcomes examined factors associated with and evolution and extent of impairment. Cerebral autoregulation testing occurred in 31 children 10 years (SD, 5.2 yr), mostly male (59%) with isolated traumatic brain injury (91%), median admission Glasgow Coma Scale 15, Injury Severity Scores 14.2 (SD, 7.7), traumatic brain injury due to fall (50%), preadmission loss of consciousness (48%), and abnormal head CT scan (97%). Thirty-one children underwent 56 autoregulation tests. Impaired cerebral autoregulation occurred in 15 children (48.4%) who underwent 19 tests; 68% and 32% of tests demonstrated unilateral and bilateral impairment, respectively. Compared with children on median day 6 of admission after traumatic brain injury, impaired autoregulation was most common in the first 5 days after traumatic brain injury (day 1: relative risk, 3.7; 95% CI, 1.9-7.3 vs day 2: relative risk, 2.7; 95% CI, 1.1-6.5 vs day 5: relative risk, 1.33; 95% CI, 0.7-2.3). Children with impaired autoregulation were older (12.3 yr [SD, 1.3 yr] vs 8.7 yr [SD, 1.1 yr]; p = 0.04) and tended to have subdural hematoma (64% vs 44%), epidural hematoma (29% vs 17%), and subarachnoid hemorrhage (36% vs 28%). Eight children (53%) were discharged home with ongoing impaired cerebral autoregulation. CONCLUSIONS: Impaired cerebral autoregulation is common in children with complex mild traumatic brain injury, despite reassuring admission Glasgow Coma Scale 13-15. Children with complex mild traumatic brain injury have abnormal cerebrovascular hemodynamics, mostly during the first 5 days. Impairment commonly extends to the contralateral hemisphere and discharge of children with ongoing impaired cerebral autoregulation is common.

Blood Pressure Thresholds and Mortality in Pediatric Traumatic Brain Injury.

BACKGROUND: Hypotension after pediatric traumatic brain injury (TBI) is associated with poor outcomes, but definitions of low systolic blood pressure (SBP) vary. Age- and sex-specific, percentile-based definitions of hypotension may help to better identify children at risk for poor outcomes compared with traditional thresholds recommended in pediatric trauma care. METHODS: Using the National Trauma Data Bank between 2007 and 2014, we conducted a retrospective cohort study of children with isolated severe TBI. We classified admission SBP into 5 percentile categories according to population-based values: (1) SBP less than the fifth percentile, (2) SBP in the fifth to 24th percentile, (3) SBP in the 25th to 74th percentile, (4) SBP in the 75th to 94th percentile, and (5) SBP ≥95th percentile. These definitions were compared with the American College of Surgeons (ACS) hypotension definition. The association between SBP percentiles and in-hospital mortality was analyzed by using multivariable Poisson regression models. RESULTS: There were 10 473 children with severe TBI included in this study. There were 2388 (22.8%) patients who died while in the hospital. Compared with SBP in the 75th to 94th percentile, mortality was higher with SBP less than the fifth percentile (relative risk [RR] 3.2; 95% confidence interval [CI] 2.9-3.6), SBP in the fifth to 24th percentile (RR 2.3; 95% CI 2.0-2.7), and SBP in the 25th to 74th percentile (RR 1.4; 95% CI 1.2-1.6). An increased risk of mortality with SBP <75th percentile was present across all age subgroups. SBP targets using the ACS hypotension definition were higher than the fifth percentile hypotension definition, but were lower than the 75th percentile hypotension definition. CONCLUSIONS: Admission SBP <75th percentile was associated with a higher risk of in-hospital mortality after isolated severe TBI in children. SBP targets based on the 75th percentile were higher compared with traditional ACS targets. Percentile-based SBP targets should be considered in defining hypotension in pediatric TBI.

Clinical Epidemiology of Adults With Moderate Traumatic Brain Injury.

OBJECTIVES: To characterize admission patterns, treatments, and outcomes among patients with moderate traumatic brain injury. DESIGN: Retrospective cohort study. SETTING: National Trauma Data Bank. PATIENTS: Adults (age > 18 yr) with moderate traumatic brain injury (International Classification of Diseases, Ninth revision codes and admission Glasgow Coma Scale score of 9-13) in the National Trauma Data Bank between 2007 and 2014. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Demographics, mechanism of injury, hospital course, and facility characteristics were examined. Admission characteristics associated with discharge outcomes were analyzed using multivariable Poisson regression models. Of 114,066 patients, most were white (62%), male (69%), and had median admission Glasgow Coma Scale score of 12 (interquartile range, 10-13). Seventy-seven percent had isolated traumatic brain injury. Concussion, which accounted for 25% of moderate traumatic brain injury, was the most frequent traumatic brain injury diagnosis. Fourteen percent received mechanical ventilation, and 66% were admitted to ICU. Over 50% received care at a community hospital. Seven percent died, and 32% had a poor outcome, including those with Glasgow Coma Scale score of 13. Compared with patients 18-44 years, patients 45-64 years were twice as likely (adjusted relative risk, 1.97; 95% CI, 1.92-2.02) and patients over 80 years were five times as likely (adjusted relative risk, 4.66; 95% CI, 4.55-4.76) to have a poor outcome. Patients with a poor discharge outcome were more likely to have had hypotension at admission (adjusted relative risk, 1.10; 95% CI, 1.06-1.14), lower admission Glasgow Coma Scale (adjusted relative risk, 1.37; 95% CI, 1.34-1.40), higher Injury Severity Score (adjusted relative risk, 2.97; 95% CI, 2.86-3.09), and polytrauma (adjusted relative risk, 1.05; 95% CI, 1.02-1.07), compared with those without poor discharge outcomes. CONCLUSIONS: Many patients with moderate traumatic brain injury deteriorate, require neurocritical care, and experience poor outcomes. Optimization of care and outcomes for this vulnerable group of patients are urgently needed.

Early changes in cerebral autoregulation among youth hospitalized after sports-related traumatic brain injury.

OBJECTIVE: To examine early cerebral haemodynamic changes among youth hospitalized with sports-related traumatic brain injury (TBI). STUDY DESIGN: Youth 0-18 years admitted to a level one trauma centre with sports-related TBI were enrolled. Daily measures included clinical symptoms and Glasgow Coma Scale (GCS) score. Using Transcranial Doppler (TCD) ultrasonography and tilt testing, we measured middle cerebral artery flow velocity (Vmca) and cerebral autoregulation index (ARI). RESULTS: Six previously healthy males age 14 (IQR 12-16) years with headache and abnormal head CT were admitted with median admission GCS 15. Six patients underwent 12 TCD examinations between hospital days 0-9. Low Vmca occurred in 3/6 patients and on the side of TBI, whereas high Vmca occurred in 2/6 patients. Five patients had at least one measurement of impaired and five patients had absent cerebral autoregulation of at least one hemisphere; all these five patients had GCS 15 and headache during TCD examinations. Three patients were discharged with absent cerebral autoregulation. Five (83%) patients were discharged to home and one patient was discharged to a rehabilitation facility. CONCLUSION: Headache, abnormal Vmca and impaired cerebral autoregulation occur after sports-related TBI, despite normal GCS. Headache may signal underlying neurovascular abnormality in sports-related TBI.

Critical Care Resource Utilization and Outcomes of Children With Moderate Traumatic Brain Injury.

OBJECTIVES: To characterize admission patterns, critical care resource utilization, and outcomes in moderate pediatric traumatic brain injury. DESIGN: Retrospective cohort study. SETTING: National Trauma Data Bank. PATIENTS: Children under 18 years old with a diagnosis of moderate traumatic brain injury (admission Glasgow Coma Scale score of 9-13) in the National Trauma Data Bank between 2007 and 2014. MEASUREMENT AND MAIN RESULTS: We examined clinical characteristics, critical care resource utilization, and discharge outcomes. Poor outcomes were defined as discharge to hospice, skilled nursing facility, long-term acute care, or death. We examined 20,010 patient records. Patients were 9 years old (interquartile range, 2-15 yr), male (64%) with isolated traumatic brain injury (81%), Glasgow Coma Scale score of 12, head Abbreviated Injury Scale score of 3, and Injury Severity Score of 10. Majority (34%) were admitted to nontrauma hospitals. Critical care utilization was 58.7% including 11.5% mechanical ventilation and 3.2% intracranial pressure monitoring. Compared to patients with Glasgow Coma Scale score of 13, admission Glasgow Coma Scale score of 9 was associated with greater critical care resource utilization, such as ICU admission (72% vs 50%), intracranial pressure monitoring (7% vs 1.8%), mechanical ventilation (21% vs 6%), and intracranial surgery (10% vs 5%). Most patients (70%) were discharged to home, but up to one third had poor outcomes. Older age group had a higher risk of poor outcomes (10-14 yr; adjusted relative risk, 1.32; 95% CI, 1.13-1.54; 15-17 yr; adjusted relative risk, 2.39; 95% CI, 2.12-2.70). Poor outcomes occurred with lower Glasgow Coma Scale (Glasgow Coma Scale score of 9 vs Glasgow Coma Scale score of 13: adjusted relative risk, 2.89; 95% CI, 2.47-3.38), higher Injury Severity Score (Injury Severity Score of ≥ 16 vs Injury Severity Score of < 9: adjusted relative risk, 8.10; 95% CI 6.27-10.45), and polytrauma (adjusted relative risk, 1.40; 95% CI, 1.22-1.61). CONCLUSIONS: Critical care resources are used in more than half of all moderate pediatric traumatic brain injury, and many receive care at nontrauma hospitals. Up to one third of moderate pediatric traumatic brain injury have poor outcomes, risk factors for which include age greater than 10 years, lower admission Glasgow Coma Scale, higher Injury Severity Score, and polytrauma. There is urgent need to optimize triage, care, and outcomes in this vulnerable population.

Oral rehydration with 10% carbohydrate drink for preventing postoperative nausea and vomiting (PONV) after low dose of spinal morphine.

BACKGROUND: Preoperative oral carbohydrate (CHO) drink may improve patients' comfort. However, whether it prevents or reduces postoperative nausea and vomiting (PONV) is questionable. OBJECTIVE: Evaluate the effect of oral rehydration with 10% CHO drink before anesthesia on incidence and severity of postoperative nausea and vomiting (PONV) after spinal morphine injection. MATERIAL AND METHOD: One hundred patients scheduled for unilateral total knee replacement (TKR) were randomly divided into two equal groups (n = 50 each). Group I patients received 400 ml 10% CHO drink the preoperative night and 2-hour before anesthesia, whereas Group II patients served as control. Spinal anesthesia for all patients contained 0.5% bupivacaine 2.0 to 3.5 ml plus morphine 0.2 mg. Pain therapy was standardized with femoral nerve block, local infiltration, intravenous parecoxib, and oral paracetamol. Incidence and severity of PONV within 24 hours were recorded In addition, preoperative intensity of thirst and hunger, dry lips and throat, and anxiety was also recorded RESULTS: Incidence and severity of PONV (81.2% vs. 72.0%, p = 0.536) as well as preoperative thirst, hunger dry lips, and throat were not different between the groups. CONCLUSION: Preoperative oral rehydration with carbohydrate drinks had no positive effect on PONV nor patients' comfort.