LAUSR

88 www.pccmjournal.org January 2017 • Volume 18 • Number 1 AEDs, presumably prophylactically, whereas 88% with seizures were treated with one or more AEDs, but it is not known when they received them, which medication(s) or whether therapeutic concentrations were achieved. The same is true for neuromuscular blocking agents. Had AEDs and paralytics not been used, the incidence of early PTS may have been higher. Similarly, hypotension was documented to occur about one fourth as frequently as has been reported previously, and there were so many missing oxygen saturation data points that the effect of hypoxia on PTS could not be assessed. Intraparenchymal hemorrhage, depressed skull fracture, and cerebral edema could not be assessed. PTS had a negative effect on outcome measured by the LOS in the ICU and hospital but had a positive effect on survival. As we all know, using mortality as an endpoint is fraught with problems. In my opinion, there should be a moratorium on using mortality as an endpoint unless timing, cause, and mode of death are explicitly reported and analyzed, none of which was done here. This is the era of big data, lowhanging fruit, sadly moving away from expensive randomized controlled trials. However, big data projects can easily and often fail to capture important details as is the case here. Nevertheless, the investigators did an extraordinary job and made a significant contribution to the literature on pediatric TBI, documenting that PTS after severe pediatric TBI have a very high prevalence with and a still high prevalence without certain risk factors. Many questions remain. Can we identify which children with severe TBI have a low enough risk of PTS to warrant withholding prophylactic AEDs? Probably not. Should we withhold AEDs until there is a documented seizure either witnessed or by electroencephalographic monitoring? We have a long way to go before this approach can be safely adopted. Hopefully, this excellent research team will continue to mine these data for more insights into the complex challenges of caring for children with severe TBI.