Muhterem DUYU, Selin YILDIZ, Zeynep KARAKAYA

Nontraumatic coma in the pediatric intensive care unit: etiology, clinical characteristics and outcome

Background/aim: The purpose of this study was to evaluate the etiology, clinical characteristics, and outcome of nontraumatic coma (NTC) among children admitted to a pediatric intensive care unit (PICU). Materials and methods: A total of 159 children with NTC were included in the study. The modified Glasgow coma scale (GCS) was used to assess consciousness. Patients were classified with regard to etiology. For each patient, demographic and clinical characteristics, survival and degree of disability at PICU discharge were recorded. Results: Median age was 55 months (IQR: 17.0 - 109.0). The most common cause of NTC was neuroinfection (31.4%) followed by toxicmetabolic conditions (25.8%) and epileptic disorder (15.1%). There was no significant relationship between the level of encephalopathy at admission and NTC etiology. A total of 13 patients died (8.2%). Among the survivors, 61.6% were discharged without any neurologic deficit, 2.8% had severe neurologic disability, and 3.4% were in a vegetative state. Complete neurological recovery was significantly more common in patients with toxic metabolic disease, whereas neurological deficits were more frequent in patients with tuberculous meningo-encephalitis (P = 0.01 and P = 0.04, respectively). Higher pediatric risk of mortality III (PRISM III) score at PICU admission (Odds ratio: 1.51, 95% CI: 1.19 - 1.92; P < 0.001) was the only variable that was independently associated with mortality. The length of stay (LOS) at hospital (Odds ratio: 0.73, 95% CI: 0.58-0.91; P = 0.006) was associated with improved odds of survival. Conclusions: Although results obtained from this single-center study cannot be generalized to the pediatric population, the contribution to the literature in terms of the relationships between NTC etiology, and outcome can be crucial for clinical decision-making. We report neuroinfection as the most common cause of NTC, and the only factor that was closely associated with mortality was PRISM III score. Length of hospital stay was inversely correlated to patient mortality.Key words: Coma, nontraumatic, children, pediatric critical care, etiology, outcome

PDF

___

1. Abend NS, Kessler SK, Helfaer MA, Licht DJ. Evaluation of the comatose child. In: Nichols DG (editor). Rogers Textbook of Pediatric Intensive Care: Evaluation of the comatose child. 4th ed. Philadelphia, USA: Lippincott, Williams & Wilkins; 2008. pp. 846-861.
2. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. The Lancet 1974; 304 (7872): 81-84. doi: 10.1016/s0140-6736(74)91639-0
3. Kirschen MP, Snyder M, Smith K, Lourie K, Agarwal K et al. Inter-rater reliability between critical care nurses performing a pediatric modification to the Glasgow Coma Scale. Pediatric Critical Care Medicine 2019; 20 (7): 660-666. doi: 10.1097/ PCC.0000000000001938
4. Wong C, Forsyth R, Kelly T, Eyre J. Incidence, aetiology, and outcome of non-traumatic coma: a population based study. Archives of Disesase Childhood 2001; 84 (3): 193-199. doi: 10.1136/adc.84.3.193
5. Stevens RD, Bhardwaj A. Approach to the comatose patient. Critical Care Medicine 2006; 34 (1): 31-41. doi: 10.1097/01. ccm.0000194534.42661.9f
6. Edlow JA, Rabinstein A, Traub SJ, Wijdicks EF. Diagnosis of reversible causes of coma. The Lancet 2014; 384 (9959): 2064- 2076. doi: 10.1016/S0140-6736(13)62184-4
7. Wijdicks EF. The bare essentials: coma. Practical Neurology 2010; 10 (1): 51-60. doi: 10.1136/jnnp.2009.200097
8. Dewan MC, Mummareddy N, Wellons III JC, Bonfield CM. Epidemiology of global pediatric traumatic brain injury: qualitative review. World Neurosurgery 2016; 9: 497-509. doi: 10.1016/j.wneu.2016.03.045
9. Sarnaik A, Ferguson NM, O’Meara AI, Agrawal S, Deep A et al. Age and mortality in pediatric severe traumatic brain injury: results from an international study. Neurocritical Care 2018; 2 (3): 302-313. doi: 10.1007/s12028-017-0480-x
10. Lu W-Y, Weng W-C, Wong L-C, Lee W-T. The etiology and prognosis of super-refractory convulsive status epilepticus in children. Epilepsy & Behavior 2018; 86: 66-71. doi: 10.1016/j. yebeh.2018.06.029
11. Fisler G, Monty MA, Kohn N, Assaad P, Trope R et al. Characteristics and outcomes of critically ill pediatric patients with posterior reversible encephalopathy syndrome. Neurocritical Care 2020; 32 (1): 145-151. doi: 10.1007/s12028-019-00720-9
12. Mastrolia MV, Rubino C, Resti M, Trapani S, Galli L. Characteristics and outcome of influenza-associated encephalopathy/encephalitis among children in a tertiary pediatric hospital in Italy, 2017–2019. BMC Infectious Disease 2019; 19 (1): 1012. doi: 10.1186/s12879-019-4636-5
13. Bansal A, Singhi SC, Singhi PD, Khandelwal N, Ramesh S. Non traumatic coma. The Indian Journal of Pediatrics 2005; 72 (6): 467-473. doi: 10.1007/BF02724422
14. Gowda VK, Bannigidad NB, Kumar P, Srikanteswara P-K, Vykuntaraju SH et al. Predictors of non-traumatic coma in a pediatric cohort from a South Indian tertiary care center: Results of a multivariate analysis. J Pediatric Neurology 2014; 12 (1): 35-43. doi: 10.3233/JPN-140636
15. Sacco RL, VanGool R, Mohr J, Hauser W. Nontraumatic coma: Glasgow coma score and coma etiology as predictors of 2-week outcome. Archives of Neurology 1990; 47 (11): 1181-1184. doi: 10.1001/archneur.1990.00530110035013
16. Forsberg S, Höjer J, Ludwigs U. Prognosis in patients presenting with nontraumatic coma. The Journal of Emergency Medicine 2012; 42 (3): 249-253. doi: 10.1016/j.jemermed.2010.04.021
17. Fiser DH, Long N, Roberson PK, Hefley G, Zolten K et al. Relationship of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1-and 6-month follow-up assessments. Critical Care Medicine 2000; 28 (7): 2616-2620. doi: 10.1097/00003246-200007000-00072
18. Ibekwe R, Ibekwe M, Onwe E, Nnebe-Agumadu U, Ibe B. Nontraumatic childhood coma in Ebonyi State University Teaching Hospital, Abakaliki, South Eastern Nigeria. Nigerian Journal of Clinical Practice 2011; 14 (1): 43-46. doi: 10.4103/1119- 3077.79239
19. Ali A, Al Abdul Gader A, Kamal H, Al Wehedy A. Traumatic and non-traumatic coma in children in the referral hospital, Al-Hasa, Saudi Arabia. Eastern Mediterranean Health Journal 2007; 13 (3): 608-614.
20. Khajeh A, Miri-Aliabad G, Fayyazi A. Non-traumatic coma in children in south-east of Iran. Journal of Comprehensive Pediatrics 2015; 6 (1): e25049. doi: 10.17795/compreped-25049
21. Goto S, Nosaka N, Yorifuji T, Wada T, Fujii Y et al. Epidemiology of pediatric acute encephalitis/encephalopathy in Japan. Acta Medica Okayama 2018; 72 (4): 351-357. doi: 10.18926/ AMO/56170
22. Anık A, Tekgül H, Yılmaz S, Karapınar B, Kitiş Ö et al. The prognostic role of clinical, electroencephalographic and neuroradiological parameters in predicting outcome in pediatric non-traumatic coma. Pamukkale Medical Journal 2020. doi: https://doi.org/10.31362/patd.685215
23. Ahmed S, Ejaz K, Shamim MS, Salim MA, Khans MU. Nontraumatic coma in pediatric patients: etiology and predictors of outcome. Journal of the Pakistan Medical Association. 2011; 61 (7): 671-675.
24. Ogunmekan AO. Non-traumatic coma in childhood: etiology, clinical findings, morbidity, prognosis and mortality. Journal of Tropical Pediatrics 1983; 29 (4): 230-232. doi: 10.1093/ tropej/29.4.230
25. Sofiah A, Hussain I. Childhood non-traumatic coma in Kuala Lumpur, Malaysia. Annals of Tropical Paediatrics 1997; 17 (4): 327-331. doi: 10.1080/02724936.1997.11747906
26. Matuja W, Matekere N. Causes and early prognosis of nontraumatic coma in Tanzania. Muhimbili Medical Centre experience. Tropical and Geographic Medicine 1987; 39 (4): 330-335.
27. Hoshino A, Saitoh M, Oka A, Okumura A, Kubota M et al. Epidemiology of acute encephalopathy in Japan, with emphasis on the association of viruses and syndromes. Brain & Development 2012; 34 (5): 337-343. doi: 10.1016/j. braindev.2011.07.012
28. Ceyhan M, Ozsurekci Y, Tanır Basaranoglu S, Gurler N, Sali E et al. Multicenter hospital-based prospective surveillance study of bacterial agents causing meningitis and seroprevalence of different serogroups of neisseria meningitidis, Haemophilus Influenzae Type B, and Streptococcus Pneumoniae During 2015 to 2018 in Turkey. mSphere 2020; 5 (2): e00060-20. doi: 10.1128/mSphere.00060-20
29. Seshia SS, Seshia MMK, Sachdeva RK. Coma in childhood. Development Medicine and Child Neurology 1977; 9: 614-628. doi: 10.1111/j.1469-8749.1977.tb07995.x
30. Kraus JF, Black MA, Hessol N, Ley P, Rokaw W et al. The incidence of acute brain injury and serious impairement in a defined population. American Journal Epidemiology 1984; 119 (2): 186-201. doi: 10.1093/oxfordjournals.aje.a113737
31. Forsberg S, Höjer J, Luswigs U. Prognosis in patients presenting with non-traumatic coma. The Journal of Emergency Medicine 2012; 42 (3): 249-253. doi: 10.1016/j.jemermed.2010.04.021.
32. Catenaccio E, Riggs BJ, Sun LR, Urrutia VC, Johnson B et al. Performance of a pediatric stroke alert team within a comprehensive stroke center. Journal of Child Neurology 2020; 883073820920111. doi: 10.1177/0883073820920111
33. Forsyth RJ, Wong CP, Kelly TP, Borril H, Stilgoe S et al. Cognitive and adaptive outcomes and age at insult effects after non-traumatic coma. Archives of Disease in Childhood 2001; 84 (3): 200-204. doi: 10.1136/adc.84.3.200
34. Nayana PP, Serane TV, Nalini P, Mahadevan S. Long-term outcome in coma. The Indian Journal of Pediatrics 2005; 7 (4): 293-295. doi: 10.1007/BF02724006
35. Chaturvedi P, Kishore M. Modified Glasgow Coma Scale to predict mortality in febrile unconscious children. The Indian Journal of Pediatrics 2001; 68 (4): 311-314. doi: 10.1007/ BF02721834