Crystalloid Volume is Associated with Short Term Morbidity in Children with Severe Traumatic Brain Injury: An Eastern Association for the Surgery of Trauma Multicenter Trial Post-Hoc Analysis
Authors: MacArthur Taleen A. , Vogel Adam M. , Glasgow Amy E. , Moody Suzanne , Kotagal Meera , Williams Regan F. , Kayton Mark L. , Alberto Emily C. , Burd Randall S. , Schroeppel Thomas J. , Baerg Joanne E. , Munoz Amanda , Rothstein William B. , Boomer Laura A. , Campion Eric M. , Robinson Caitlin , Nygaard Rachel M. , Richardson Chad J. , Garcia Denise I. , Streck Christian J. , Gaffley Michaela , Petty John K. , Ryan Mark , Pandya Samir , Russell Robert T. , Yorkgitis Brian K. , Mull Jennifer , Pence Jeffrey , Santore Matthew T. , Klinkner Denise B. , Safford Shawn D. , Trevilian Tanya , Jensen Aaron R. , Mooney David P. , Ketha Bavana , Dassinger Melvin S. , Goldenberg-Sandau Anna , Falcone Richard A. , Polites Stephanie F. 
Published: April 2023

ABSTRACT

Objective
This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI.

Methods
This is a post-hoc analysis of a prospective, observational study of injured children <18 years old (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale (AIS) score ≥ 3. Timing and volume of resuscitation products were assessed using Chi-squared t-test, Fisher's exact t-test, Kruskal-Wallis, and multivariable logistic regression analyses.

Results
There were 142 patients with sTBI and 547 with non-sTBI injuries. sTBI patients had lower initial hemoglobin (11.3 vs. 12.4, p < .001), greater initial INR (1.4 vs. 1.1, p < .001), greater ISS (25 vs. 5, p < .001), greater rates of ventilator (59% vs. 11%, p < .001) and ICU requirement (79% vs. 27%, p < .001), and more inpatient complications (18% vs. 3.3%, p < .001). sTBI patients received more pre-hospital crystalloid (25% vs. 15 %, p = .008), ≥1 crystalloid boluses (52% vs.24%, p < .001), and blood transfusion (44 % vs.12%, p < .001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs.64%, p < .001), longer median ICU (6 vs.4 days, p = 0.027) and hospital stay (9 vs.4 days, p < .001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for injury severity score (OR 3.4-4.4, all p < .010).

Conclusion
Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater INR at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed.

Level of Evidence
IV

Study Type

Retrospective post-hoc analysis of a prospective observational cohort study