Minimum serum cholinesterase levels as a prognostic marker for 6-month outcomes in pediatric traumatic brain injury: a retrospective cohort study.

Abstract

Objective: Although cholinesterase levels have been linked to disease severity in critically ill patients, their prognostic significance in pediatric traumatic brain injury (TBI) remains uncertain. In this study, the authors investigate the association between minimum cholinesterase levels during hospitalization and 6-month outcomes in children with TBI, as well as the potential dose-response relationship between these factors.

Methods: This retrospective cohort study included children with TBI who were admitted to Jiangsu Children's Medical Center between June 2017 and June 2024. Inverse probability of treatment weighting was used to adjust for confounding, fitting weighted outcome regression models and using restricted cubic spline (RCS) regression to evaluate both the association and the dose-response relationship between minimum cholinesterase levels and 6-month Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds) scores. Robustness was assessed through a bootstrap sensitivity analysis with 1000 resamples, and extreme weights were truncated at the 5th and 95th percentiles to minimize the influence of outliers. Stratified analysis by Glasgow Coma Scale (GCS) score (≤ 8 vs > 8) was conducted to assess effect modification.

Results: The primary analysis included 370 pediatric patients. Adequate balance was achieved across baseline covariates. Lower minimum cholinesterase levels were significantly associated with higher odds of an unfavorable 6-month GOS-E Peds outcome, even after adjusting for all potential confounders (OR per 1000-unit increase 0.61, 95% CI 0.402-0.912, p = 0.002). RCS analysis showed no evidence of nonlinearity. The association remained robust in the sensitivity analysis. In a stratified analysis by baseline GCS score, the association was stronger in patients with severe TBI (GCS score ≤ 8: OR 0.33, 95% CI 0.18-0.58, p < 0.001) than in those with moderate TBI (GCS > 8: OR 0.68, 95% CI 0.52-0.89, p = 0.004).

Conclusions: Lower minimum cholinesterase levels were significantly associated with worse 6-month outcomes in pediatric TBI. Routine monitoring of cholinesterase levels may help identify high-risk pediatric patients with TBI, but further studies are needed to validate its prognostic value.