First 3-Day Severe Pediatric Traumatic Brain Injury Guideline Adherence Rates in South American Intensive Care Units by Guideline, Patient, and Clinical Care Characteristics

Severe traumatic brain injury (TBI) is a leading cause of pediatric mortality. Evidence-based Brain Trauma Foundation (BTF) guidelines promote best practices for severe TBI in the intensive care unit (ICU). We examined guideline, patient, and clinical care characteristics associated with early ICU guideline adherence. We used prospectively collected data from September 2019 to July 2020 from Argentina, Paraguay, and Chile. Patients ≤18 years with computed tomography evidence of TBI and Glasgow Coma Scale (GCS) score ≤ 8 or GCS motor score ≤ 5 at admission or at deterioration after admission were included. Cumulative ICU guideline adherence achieved during the first 3 days after TBI was analyzed by guideline recommendation ( n = 15), recommendation category ( n = 3), and patient and clinical care characteristics. Intergroup differences were compared using multivariate logistic regression with site-cluster adjustment. Among 116 patients, children were 1–4 years (38; 32.7%), male (74; 63.8%), and had extracranial injuries (77; 66.4%). Overall cumulative 3-day ICU guideline adherence rate was 81.3% (standard deviation: 13.0). Among the three guideline categories, adherence to the threshold category was higher than monitoring or treatment categories ( p < 0.001). Adherence to the threshold category was lower in patients 1–4 years than 10–14 years ( p = 0.02). Adherence to the monitoring category was lowest in minor/moderate Abbreviated Injury Scale and Injury Severity Score groups ( p = 0.012 and 0.03, respectively). Ninety-five (81%) patients had nonadherence (0% adherence) to 1–3 recommendations across applicable BTF guideline recommendations. Overall, daily adherence rate was highest on ICU day 3 ( p < 0.01). Early overall ICU guideline adherence rate was high but varied by recommendation, recommendation category, and patient characteristics. Nonadherence to a few recommendations was common, highlighting key targets for improvement and strategies to optimize guideline adherence in severe pediatric TBI.