Predicting one year clinical outcome in traumatic brain injury (TBI) at the beginning of rehabilitation

Effects of propofol on intracranial pressure and prognosis in patients with severe brain diseases undergoing endotracheal suctioning

BACKGROUND

To investigate whether the administration of intravenous propofol before endotracheal suctioning (ES) in patients with severe brain disease can reduce the sputum suction response, improve prognosis, and accelerate recovery.

METHODS

A total of 208 severe brain disease patients after craniocerebral surgery were enrolled in the study. The subjects were randomly assigned to the experimental group (n = 104) and the control group (n = 104). The experimental group was given intravenous propofol (10 ml propofol with 1 ml 2% lidocaine), 0.5-1 mg/kg, before ES, while the control group was subjected to ES only. Changes in vital signs, sputum suction effect, the fluctuation range of intracranial pressure (ICP) before and after ES, choking cough response, short-term complications, length of stay, and hospitalization cost were evaluated. Additionally, the Glasgow Outcome Scale (GOS) prognosis score was obtained at 6 months after the operation.

RESULTS

At the baseline, the characteristics of the two groups were comparable (P > 0.05). The increase of systolic blood pressure after ES was higher in the control group than in the experimental group (P < 0.05). The average peak value of ICP in the experimental group during the suctioning (15.57 ± 12.31 mmHg) was lower than in the control group (18.24 ± 8.99 mmHg; P < 0.05). The percentage of patients experiencing cough reaction- during suctioning in the experimental group was lower than in the control group (P < 0.05), and the fluctuation range of ICP was increased (P < 0.0001). The effect of ES was achieved in both groups. The incidence of short-term complications in the two groups was comparable (P > 0.05). At 6 months after the surgery, the GOS scores were significantly higher in the experimental than in the control group (4-5 points, 51.54% vs. 32.64%; 1-3 points, 48.46% vs. 67.36%; P < 0.05). There was no significant difference in the length of stay and hospitalization cost between the two groups.

CONCLUSIONS

Propofol sedation before ES could reduce choking cough response and intracranial hypertension response. The use of propofol was safe and improved the long-term prognosis. The study was registered in the Chinese Clinical Trial Registry on May 16, 2015 (ChiCTR-IOR-15006441).

Usefulness of serum glucose and potassium ratio as a predictor for 30-day death among patients with severe traumatic brain injury

BACKGROUND

Serum glucose and potassium ratio (GPR) was recently found to be related to outcome of aneurysmal subarachnoid hemorrhage. This retrospectively study was to investigate the association of serum GPR with mortality in severe traumatic brain injury (sTBI).

METHODS

Clinical data were retrospectively reviewed of isolated sTBI patients admitted within 12 h after trauma between January 2014 and January 2019. We analyzed relationships between admission serum GPR and post-traumatic 30-day mortality in addition to admission Glasgow coma scale (GCS) scores. Discriminative ability was evaluated using area under receiver operating characteristic curve (AUC).

RESULTS

A total of 146 patients, of whom 37 (25.3%) died within 30 days following trauma, were included. Admission serum GPR emerged as an independent predictor for 30-day mortality (odds ratio, 5.256; 95% confidence interval (CI), 1.111-14.856) and overall survival (hazard ratio, 4.822; 95% CI, 1.157-12.870), with an AUC of 0.777 (95% CI, 0.693-0.835), which was equivalent to that of GCS scores (AUC, 0.831; 95% CI, 0.760-0.888; P = 0.179). There was a significant correlation between admission serum GPR and GCS scores (r² = 0.293).

CONCLUSIONS

Serum GPR in cases of sTBI is substantially associated with trauma severity and 30-day mortality. Therefore, the potential value of serum GPR for predicting short-term mortality of sTBI patients is favorable.

A new hybrid classification system for traumatic brain injury which helps predict long-term consciousness: a single-center retrospective study

BACKGROUND

To develop and validate a refined traumatic brain injury (TBI) classification system to supplement the existing systems which have limited accuracy for predicting long-term consciousness recovery.

METHODS

The refined classification system was developed using medical records of 527 patients according to clinical presentations within 12-24 hrs after injury. Multiple linear regression was applied to identify protective and risk factors for Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) score at 12-month follow-up. The TBI severity was moved to a less or more severe level when more than half of the protective or risk factors were present. The capability and reliability of each system for predicting 12 month GCS and GOS scores, and mortality were assessed using ROC curve analysis and Cronbach's Alpha reliability coefficient.

RESULTS

One protective factor and four risk factors were identified for predicting long-term outcomes. The refined system had higher sensitivity and specificity in predicting 12-month GCS and GOS scores, and mortality than the other two systems. The refined system had lower reliability than the GCS system and higher reliability than the Chinese system.

CONCLUSIONS

The refined system incorporates the advantages of both GCS and Chinese systems and provides a better prediction of long-term consciousness outcome.

Prediction of occupational disability from psychological and neuropsychological evidence in forensic context

Within the fields of psychiatry, psychology, and neuropsychology, medical examiners are often tasked with providing an opinion about an injured individual's health prognosis and likelihood of returning to work. Traditionally, examiners have conducted such assessments by employing clinical intuition, expert knowledge, and judgment. More recently, however, an accumulation of research on factors predictive of disability has allowed examiners to provide prognostications using specific empirically supported evidence. This paper integrates current evidence for four common clinical issues encountered in forensic assessments-musculoskeletal pain, depression, Posttraumatic Stress Disorder, and traumatic brain injury. It discusses an evidence-informed, cross-diagnostic and multifactorial model of predicting disability that is emerging from the literature synthesis, along with recommendations for best forensic assessment practice.

Age-related carbon dioxide reactivity in children after moderate and severe traumatic brain injury

OBJECTIVE The objective of this study is to assess carbon dioxide reactivity (CO2R) in children following traumatic brain injury (TBI). METHODS This prospective observational study enrolled children younger than 18 years old following moderate and severe TBI. Thirty-eight mechanically ventilated children had daily CO2R testing performed by measuring changes in their bilateral middle cerebral artery flow velocities using transcranial Doppler ultrasonography (TCD) after a transient increase in minute ventilation. The cohort was divided into 3 age groups: younger than 2 years (n = 12); 2 to 5 years old (n = 9); and older than 5 years (n = 17). RESULTS Children younger than 2 years old had a lower mean CO2R over time. The 2-5-year-old age group had higher mean CO2R than younger patients (p = 0.01), and the highest CO2R values compared with either of the other age groups (vs > 5 years old, p = 0.046; vs < 2 years old, p = 0.002). Having a lower minimum CO2R had a statistically significant negative effect on outcome at discharge (p = 0.0413). Impaired CO2R beyond Postinjury Day 4 trended toward having an effect on outcome at discharge (p = 0.0855). CONCLUSIONS Abnormal CO2R is prevalent in children following TBI, and the degree of impairment varies by age. No clinical or laboratory parameters were identified as risk factors for impaired CO2R. Lower minimum CO2R values are associated with worse outcome at discharge.

Prognostic value of FOUR and GCS scores in determining mortality in patients with traumatic brain injury

BACKGROUND

The Glasgow Coma Scale (GCS) is considered the gold standard for assessment of unconsciousness in patients with traumatic brain injury (TBI) against which other scales are compared. To overcome the disadvantages of GCS, the Full Outline Of Unresponsiveness (FOUR) score was proposed. We aimed to compare the predictability of FOUR score and GCS for early mortality, after moderate and severe TBI.

METHODS

This is a prospective observational study of patients with moderate and severe TBI. Both FOUR and GCS scores were determined at admission. The primary outcome was mortality at the end of 2 weeks of injury.

RESULTS

A total of 138 (117 males) patients were included in the study. Out of these, 17 (12.3 %) patients died within 2 weeks of injury. The mean GCS and FOUR scores were 9.5 (range, 3-13) and 11 (0-16), respectively. The total GCS and FOUR scores were significantly lower in patients who did not survive. At a cut-off score of 7 for FOUR score, the AUC was 0.97, with sensitivity of 97.5 and specificity of 88.2 % (p < 0.0001). For GCS score, AUC was 0.95, with sensitivity of 98.3 % and specificity of 82.4 % with cut-off score of 6 (p < 0.0001). The correlation coefficient was 0.753 (p < 0.001) between the GCS and FOUR scores.

CONCLUSIONS

The predictive value of the FOUR score on admission of patients with TBI is no better than the GCS score.

[Urgency of neurosurgical interventions for severe traumatic brain injury]

BACKGROUND

The aim of this study was to assess whether the time interval between accident and neurosurgical intervention has an influence on functional neurological outcome and mortality in severe traumatic brain injury (sTBI) or whether the further clinical course has already been determined by the initial severity of the injury.

METHODS

Data were derived from the Trauma Registry of the German Society of Trauma Surgery. A total of 770 patients were identified who had undergone decompressive surgery, had an ISS ≥ 9 and for whom time of accident and start of surgery had been documented. To evaluate the possible influence of the time factor on outcome and mortality, these patients were subdivided into five groups according to time until decompression (I: < 2 h, II: 2-3 h, III: 3-6 h, IV: 6-24 h and V: > 24 h). Aside from mortality we analysed AIS, GCS, age and ISS in survivors and non-survivors.

RESULTS

Complete data were available for 770 patients with sTBI (AIS skull ≥3). The average age was 39.9 years and 71.6% were male. The average overall injury severity was reflected by an ISS score of 31.3 and the average AIS head score was 4.51. Of the 570 who underwent surgery in less than 6 h (groups 1-III), 33% died (188/570). Of the remaining 200 patients 40 died (20%). Mortality decreased throughout the groups (49 to 14%), as did the severity of the head injury (AIS 4.66 to 4.23); GCS on the other hand increased with the time between accident and surgery (5.9 to 8.8).

CONCLUSION

We could not substantiate that reducing the time between accident and neurosurgical decompression could decrease mortality. It rather seems that the initial magnitude of brain damage determines prognosis and outcome after sTBI. The interval between the appearance of neurological symptoms (e.g. anisocoria) and neurosurgical intervention plays an important role and should be kept as short as possible.

Outcome trends post discharge from inpatient rehabilitation to the community

PURPOSE

This study provides evidence of the outcome trends following inpatient rehabilitation services.

METHODS

The methodology of this study design uses descriptive statistical analysis, paired t-tests, and analysis of variance (ANOVA) to examine multiple variables. This quantitative, non-experimental study describes the research population and the data collection instrument, the inpatient rehabilitation facility patient assessment instrument (IRF PAI), including the Functional Independence Measure (FIM).

FINDINGS

Identified trends provide evidence that functional gains of the disabled population were maintained post discharge from an inpatient rehabilitation facility. Demographics, medical information, and discharge information were studied to describe relationships between the discharge information (discharge living setting, discharge with home health services, discharge to the person living with) and maintained functional performance.

CONCLUSIONS

This evidence provides essential information for healthcare providers, including nurses, policy makers, and governments regarding functional gains following inpatient rehabilitation, and community discharge trends of people receiving inpatient rehabilitation services.

CLINICAL RELEVANCE

The evidence in this study supports that inpatient rehabilitation services should be provided to all persons with disabilities to increase functioning to the greatest level of independence possible. Further evidence-based knowledge regarding the proposed 75% Rule of the Prospective Payment System (PPS) is needed and required, affecting the access and delivery of rehabilitation services. All patients have a right to quality, cost-effective care without restrictions to certain populations to encourage return to community dwelling.

Time to follow commands remains the most useful injury severity variable for predicting WeeFIM® scores 1 year after paediatric TBI

OBJECTIVE

To investigate the relationship between injury severity variables, particularly time to follow commands (TFC) and long-term functional outcomes in paediatric traumatic brain injury (TBI).

METHODS AND PROCEDURE

Participants included 40 children with moderate-to-severe TBI discharged from inpatient rehabilitation. Measures of severity were initial Glasgow Coma Scale score, TFC, duration of Post Traumatic Amnesia (PTA) and total duration of impaired consciousness (TFC + PTA). Functional outcome was measured by age-corrected Functional Independence Measure for Children (WeeFIM®) scores at 1-year after discharge.

RESULTS

Correlations indicated that injury severity variables (TFC, PTA and TFC + PTA) were all associated with functional outcome. Regression analyses revealed that TFC and TFC + PTA similarly accounted for 49% or 47% of the variance, respectively, in total WeeFIM® score. Thirty-seven of 40 children had good outcome; of the three children with TFC >26 days, two had poor outcome.

CONCLUSION

PTA and TFC + PTA do not provide a benefit over TFC alone for prediction of long-term outcome and TFC is identified earlier in the recovery course. TFC remains an important predictor of functional outcome 1-year after discharge from inpatient rehabilitation after paediatric TBI.

Functional survival after acute care for severe head injury at a designated trauma center in Hong Kong

BACKGROUND

Severe head injury is known to be a major cause of early mortalities and morbidities. Patients' long-term outcome after acute care, however, has not been widely studied. We aim to review the outcome of severely head-injured patients after discharge from acute care at a designated trauma center in Hong Kong.

MATERIALS AND METHODS

This is a retrospective study of prospectively collected data of patients admitted with severe head injuries between 2004 and 2008. Patients' functional status post-discharge was assessed using the Extended Glasgow Outcome Score (GOSE).

RESULTS

Of a total of 1565 trauma patients, 116 had severe head injuries and 41 of them survived acute hospital care. Upon the last follow-up, 23 (56.1%) of the acute-care survivors had improvements in their GOSE, six (11.8%) experienced deteriorations, and 12 (23.5%) did not exhibit any change. The greatest improvement was observed in patients with GOSE of 5 and 6 upon discharge, but two of the 16 patients with GOSE 2 or 3 also had a good recovery. On logistic regression analysis, old age and prolonged acute hospital stay were found to be independent predictors of poor functional outcome after a mean follow-up duration of 42 months.

CONCLUSION

Multidisciplinary neurorehabilitation service is an important component of comprehensive trauma care. Despite significant early mortalities, a proportion of severely head-injured patients who survive acute care may achieve good long-term functional recovery.

Neurological outcomes of neurosurgical operations for multiple trauma elderly patients in Hong Kong

Background:

We aimed to investigate neurological outcomes in elderly patients with multiple trauma, and to review their clinical outcomes following neurosurgical operations.

Patients and Methods:

The study was conducted in a regional trauma center in Hong Kong. We collected prospective data on consecutive trauma patients from January 2001 to December 2008. Patients with multiple trauma (as defined by Injury Severity Score of 15 or more), with both head injury and extracranial injury, were included for analysis.

Results:

Age over 65 years, admission Glasgow Coma Scale (GCS), and Injury Severity Score were significantly poor prognostic factors in logistic regression analysis. Eleven (32%) of the 34 patients aged over 65 who underwent neurosurgical operations attained favorable neurological outcomes (GCS 4-5) at 6 months.

Conclusions:

Age was an important prognostic factor in multiple trauma patients requiring neurosurgical operations. Future randomized controlled clinical trials should be designed to recruit elderly patients (such as age between 65 and 75 years) at clinical equipoise for traumatic hematoma (such as subdural hematoma or traumatic intracerebral hematoma) evacuation and assess the quality of life, neurological, and cognitive outcomes.

A systematic review of factors contributing to outcomes in patients with traumatic brain injury

AIM AND OBJECTIVE

To review, systematically, factors contributing to outcomes in patients with traumatic brain injury.

BACKGROUND

Traumatic brain injury is a leading cause of death and disability. Several studies have determined the significant predictors of outcomes after traumatic brain injury. The comprehensive identification of these reliable factors for traumatic brain injury is critical to both clinical practice and research.

DESIGN

Systematic literature review.

METHODS

Eligible studies that combined at least two variables to predict outcomes in patient with traumatic brain injury were identified via electronic database searches, footnote chasing and contact with clinical experts. Quality of selected studies was assessed in terms of internal and external validity using 15 questions. Two reviewers independently examined titles, abstracts and whether each met the predefined inclusion criteria.

RESULTS

A total of 46 studies which met review criteria were finally selected. Most studies satisfied internal validity in terms of validity of research variables and multivariate analysis, but few were validated externally. The following factors were significantly associated with unfavourable outcomes: sociodemographic factors such as older age, male gender, lower level of education; clinical factors such as lower Glasgow Coma Scale score, injury caused by motor vehicle crash, hypotension, hypoxia, increased intracranial pressure, no pupil reaction, hypo- or hyperglycaemia, anaemia, coagulopathy, hypo- or hyperthermia, abnormal level of electrolytes, duration of coma; higher level of computed tomography classification by Marshall category; type of intracerebral lesions.

CONCLUSION

Further studies on integrating the sociodemographic factors, the course of the clinical condition and a unified CT scoring system, are recommended for the evaluation and improvement of the prognosis of traumatic brain injury.

RELEVANCE TO CLINICAL PRACTICE

A systematic review of factors contributing to outcome for patients with traumatic brain injury will be invaluable in triage criteria, injury prognostication, care and discharge planning, resource use and patient and family counselling.

Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial

BACKGROUND

Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care.

METHODS

Sedated adults (>/=18 years of age) in the ICU who had been on mechanical ventilation for less than 72 h, were expected to continue for at least 24 h, and who met criteria for baseline functional independence were eligible for enrolment in this randomised controlled trial at two university hospitals. We randomly assigned 104 patients by computer-generated, permuted block randomisation to early exercise and mobilisation (physical and occupational therapy) during periods of daily interruption of sedation (intervention; n=49) or to daily interruption of sedation with therapy as ordered by the primary care team (control; n=55). The primary endpoint-the number of patients returning to independent functional status at hospital discharge-was defined as the ability to perform six activities of daily living and the ability to walk independently. Therapists who undertook patient assessments were blinded to treatment assignment. Secondary endpoints included duration of delirium and ventilator-free days during the first 28 days of hospital stay. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00322010.

FINDINGS

All 104 patients were included in the analysis. Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p=0.02; odds ratio 2.7 [95% CI 1.2-6.1]). Patients in the intervention group had shorter duration of delirium (median 2.0 days, IQR 0.0-6.0 vs 4.0 days, 2.0-8.0; p=0.02), and more ventilator-free days (23.5 days, 7.4-25.6 vs 21.1 days, 0.0-23.8; p=0.05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony.

INTERPRETATION

A strategy for whole-body rehabilitation-consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness-was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care.

FUNDING

None.

[The effect of age on executive functioning after acquired brain injury in adults]

INTRODUCTION

Executive functioning deficits have often been described in normal aging. They are also known to be a frequent sequel of traumatic brain injury, where patients may exhibit severe long-standing impairments in instrumental activities of daily living. One could therefore expect that cerebral lesions affecting executive functioning would result in more severe impairments in older patients. We previously developed an ecological assessment of executive functions, consisting of a cooking task, requiring multitasking abilities and known to be sensitive to a dysexecutive syndrome [Cortex 36 (2000) 649-669]. The aim of this study was to analyze the effect of age on the cognitive and ecological assessments of executive functions in a group of patients with acquired brain injury (ABI) resulting in a dysexecutive syndrome. Studies in this area usually focus on patients older than 60 or 65, but we chose to analyze the effect of age in a younger population. We hypothesized that older patients would have poorer performances on the cognitive and ecological tests of executive functioning, when compared to younger patients.

METHODS

Forty-five patients with ABI resulting in frontal lesions and a dysexecutive syndrome participated in this study. Patients underwent a comprehensive battery of cognitive tests assessing executive functioning, as well as the cooking task. We also studied a group of 12 control subjects who performed the cooking task.

RESULTS

No effect of age was found on performance in the cooking task in the control group. Age was not related to demographic parameters or injury severity in the ABI group. Although the ABI group was relatively young (mean age: 40.3 years (S.D.=12.5), ranging from 17 to 63), results indicated a significant deleterious effect of age on the cognitive tests of executive functioning in the ABI group. We also highlighted a significant worsening of patients' performance in the cooking task with age, and this effect was found on several variables of task analysis: the number of errors and occurrence of dangerous behaviors.

CONCLUSION

Our study demonstrates the deleterious effect of aging on cognitive and ecological assessment of executive functioning after ABI. The strength of this study is that it deviated from the traditional age considered in studies of elderly populations and focused on younger patients. It is therefore important to consider the implication that this may have on a patient's rehabilitation program and postinjury discharge.

Being restricted in participation after a traumatic brain injury is negatively associated by passive coping style of the caregiver

PURPOSE

To examine whether the caregivers' coping style is associated with the functional outcome of the traumatic brain injury (TBI) patient 1 year post-injury.

METHOD

A cross-sectional study among patients with a TBI, including their primary caregivers. The study included 51 patients aged 17-64 years with a moderate-to-severe TBI and 51 caregivers (23 parents and 28 partners) aged 23-67 years. The coping preferences of the caregivers were assessed at minimum 6 and maximum 12 months post-injury, by filling out the Utrecht Coping List (UCL) and were related to limitations in activity, as measured with the Frenchay Activities Index and with restrictions in participation as measured with the Sickness Impact Profile-68 of TBI patients 1 year post-injury. The patients were interviewed at their homes; the caregivers received and returned the UCL by mail.

RESULTS

The patients' age and the caregivers' coping style are independently associated with restrictions in participation 1 year post-injury.

CONCLUSIONS

A passive coping style of the primary caregiver is negatively associated with the patient's functional outcome in terms of participation in society.

Use of hinge craniotomy for cerebral decompression

✓Decompressive craniectomy to relieve cerebral edema and intracranial hypertension due to traumatic brain injury is a generally accepted practice; however, the procedure remains controversial because of its uncertain effects on outcome, specific complications such as the syndrome of the sinking skin flap, and the need for subsequent cranioplasty. The authors developed a novel craniotomy technique using titanium bone plates in a hinged fashion, which maintains cerebral protection while reducing postoperative complications and eliminating subsequent cranioplasty procedures.

The authors conducted a retrospective review of data obtained in all consecutive patients who had undergone post-traumatic cerebral decompression craniotomy using the hinge technique at a Level I trauma facility between 1990 and 2004.

Twenty-five patients, most of whom were male (88%) and Caucasian (88%) with a mean age of 38.2 ± 16.1 years, underwent the hinge craniotomy. The in-hospital mortality rate was 48%, and good cerebral decompression was achieved. None of the patients required surgery for flap replacement. Long-term follow-up data showed that one patient required subsequent cranioplasty due to infection and one patient presented with cranial deformities. None of the patients presented with bone resorption or sinking flap syndrome.

The hinge technique effectively prevents procedure-related morbidity and the need for subsequent surgical bone replacement otherwise introduced by traditional decompressive craniectomy. A randomized controlled trial is required to substantiate these findings.

Reliability, responsiveness, and validity of the Kansas University Standing Balance Scale

PURPOSE

The purpose of this research was to investigate the reliability, responsiveness, and concurrent validity of the Kansas University Standing Balance Scale (KUSBS).

METHODS

For the reliability study, the KUSBS was used twice on 2 separate days with 23 inpatient rehabilitation patients. To assess responsiveness and concurrent validity, a retrospective chart review of 25 patients was performed to examine changes in KUSBS scores and changes in FIM transfer and walking scores from admission to discharge.

RESULTS

In the reliability study, the KUSBS was found to have good intra-rater reliability (intraclass correlation coefficient, ICC = 0.893 for novice physical therapists, ICC = 0.765 for experienced physical therapists), and moderate inter-rater reliability (ICC = 0.728). In comparing scores at admission and discharge to determine responsiveness, KUSBS scores were significantly different at these 2 times (p = 0.001), and the effect size was 0.58. In the concurrent validity study, changes in KUSBS scores were significantly correlated with changes in the FIM mark transfer score (rs = 0.486, p = 0.014) but correlation with changes in the FIM walking score did not reach significance (rs = 0.383, p = 0.06).

CONCLUSION

The reliability, responsiveness, and concurrent validity of the KUSBS are promising, although further study is needed to examine this scale in different therapy settings with a larger sample.