Monitoring of intracranial pressure in patients with severe traumatic brain injury: an Austrian prospective multicenter study

Testing the Impact of Protocolized Care of Patients With Severe Traumatic Brain Injury Without Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol

BACKGROUND

Most patients with severe traumatic brain injury (sTBI) in low- or-middle-income countries and surprisingly many in high-income countries are managed without intracranial pressure (ICP) monitoring. The impact of the first published protocol (Imaging and Clinical Examination [ICE] protocol) is untested against nonprotocol management.

OBJECTIVE

To determine whether patients treated in intensive care units (ICUs) using the ICE protocol have lower mortality and better neurobehavioral functioning than those treated in ICUs using no protocol.

METHODS

This study involved nineteen mostly public South American hospitals. This is a prospective cohort study, enrolling patients older than 13 years with sTBI presenting within 24 h of injury (January 2014-July 2015) with 6-mo postinjury follow-up. Five hospitals treated all sTBI cases using the ICE protocol; 14 used no protocol. Primary outcome was prespecified composite of mortality, orientation, functional outcome, and neuropsychological measures.

RESULTS

A total of 414 patients (89% male, mean age 34.8 years) enrolled; 81% had 6 months of follow-up. All participants included in composite outcome analysis: average percentile (SD) = 46.8 (24.0) nonprotocol, 56.9 (24.5) protocol. Generalized estimating equation (GEE) used to account for center effects (confounder-adjusted difference [95% CI] = 12.2 [4.6, 19.8], P = .002). Kaplan-Meier 6-month mortality (95% CI) = 36% (30%, 43%) nonprotocol, 25% (19%, 31%) protocol (GEE and confounder-adjusted hazard ratio [95% CI] = .69 [.43, 1.10], P = .118). Six-month Extended Glasgow Outcome Scale for 332 participants: average Extended Glasgow Outcome Scale score (SD) = 3.6 (2.6) nonprotocol, 4.7 (2.8) protocol (GEE and confounder-adjusted and lost to follow-up-adjusted difference [95% CI] = 1.36 [.55, 2.17], P = .001).

CONCLUSION

ICUs managing patients with sTBI using the ICE protocol had better functional outcome than those not using a protocol. ICUs treating patients with sTBI without ICP monitoring should consider protocolization. The ICE protocol, tested here and previously, is 1 option.

The Significance of Intracranial Pressure Monitoring for Reducing Mortality in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Background

Despite guidelines provided by the Brain Trauma Foundation (BTF) for treating patients with TBI, including advice to monitor intracranial pressure (ICP), the clinical application of ICP monitoring is far from universal. This laxity has been attributed to the relationship between mortality in TBI patients and ICP monitoring.

Objective

This systematic review and meta-analysis was aimed at determining the effect of intracranial pressure (ICP) monitoring on the mortality of patients with traumatic brain injury (TBI).

Method

A systematic search for articles was conducted on PubMed, Scopus, Cochrane Central Register of Control Trials (CENTRAL), and APA PsycNet for articles published from 1 January 2000 to 1 August 2022. Manager 5.4 was used to carry out statistical analysis.

Results

Article search yielded 1421 articles, but only 23 cohort studies were included in the systematic review and meta-analysis. The total number of study participants is 80,058. Seventeen studies reported unadjusted odds ratios (OR), and only 8 reported the adjusted odds ratio (OR). Nine out of seventeen studies reported an unadjusted OR of less than 1, and five out of eight studies reported an adjusted OR of less than 1. From this paper's analysis, the OR for in-hospital mortality was 1.01 [95% CI, 0.80, 1.28], with a p value of 0.92. OR for ICU mortality was 0.84 [95% CI, 0.52, 1.35], with a p value of 0.47.

Conclusion

But due to conflicting results, as evident above, it is unsatisfyingly challenging to draw any substantial conclusions from them. This paper thus calls for more research on this particular paper.

Intracranial Pressure Monitoring in the Intensive Care Unit for Patients with Severe Traumatic Brain Injury: Analysis of the CENTER-TBI China Registry

BACKGROUND

Although the current guidelines recommend the use of intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (sTBI), the evidence indicating benefit is limited. The present study aims to evaluate the impact of ICP monitoring on patients with sTBI in the intensive care unit (ICU).

METHODS

The patient data were obtained from the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury China Registry, a prospective, multicenter, longitudinal, observational, cohort study. Patients with sTBI who were admitted to 52 ICUs across China, managed with ICP monitoring or without, were analyzed in this study. Patients with missing information on discharge survival status, Glasgow Coma Scale score on admission to hospital, and record of ICP monitoring application were excluded from the analysis. Data on demographic characteristics, injury, clinical features, treatments, survival at discharge, discharge destination, and length of stay were collected and assessed. The primary end point was survival state at discharge, and death from any cause was considered the event of interest.

RESULTS

A total of 2029 patients with sTBI were admitted to the ICU; 737 patients (36.32%) underwent ICP monitoring, and 1292 (63.68%) were managed without ICP monitoring. There was a difference between management with and without ICP monitoring on in-hospital mortality in the unmatched cohort (18.86% vs. 26.63%, p < 0.001) and the propensity-score-matched cohort (19.82% vs. 26.83%, p = 0.003). Multivariate logistic regressions also indicated that increasing age, higher injury severity score, lower Glasgow Coma Scale score, unilateral and bilateral pupillary abnormalities, systemic hypotension (SBP ≤ 90 mm Hg), hypoxia (SpO2 < 95%) on arrival at the hospital, and management without ICP monitoring were associated with higher in-hospital mortality. However, the patients without ICP monitoring had a lower length of stay in the ICU (11.79 vs. 7.95 days, p < 0.001) and hospital (25.96 vs. 21.71 days, p < 0.001), and a higher proportion of survivors were discharged to the home with better recovery in self-care.

CONCLUSIONS

Although ICP monitoring was not widely used by all of the centers participating in this study, patients with sTBI managed with ICP monitoring show a better outcome in overall survival. Nevertheless, the use of ICP monitoring makes the management of sTBI more complex and increases the costs of medical care by prolonging the patient's stay in the ICU or hospital.

Factors associated with receipt of intracranial pressure monitoring in older adults with traumatic brain injury

BACKGROUND

The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines.

METHODS

We analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression.

RESULTS

Our sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of <9 (OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2).

DISCUSSION

Worsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

A population study on the epidemiology and outcome of brain injuries in intensive care

BACKGROUND

Traumatic Brain Injury (TBI) is characterized by a highly heterogenous profile in terms of pathophysiology, clinical presentation and outcome.

OBJECTIVE

This is the first population study investigating the epidemiology and outcomes of moderate-to-severe TBI in Cyprus. Patients treated in the Intensive Care Unit (ICU) of Nicosia General Hospital, the only Level 1 Trauma Centre in the country, were recruited between January 2013 and December 2016.

METHODS

This was an observational cohort study, using longitudinal methods and six-month follow-up. Patients (N = 203) diagnosed with TBI were classified by the Glasgow Coma Scale at the Emergency Department as moderate or severe.

RESULTS

Compared to international multicentre studies, the current cohort demonstrates a different case mix that includes older age, more motor vehicle collisions and lower mortality rates. There was a significantly higher proportion of injured males. Females were significantly older than males. There were no sex differences in the type, severity or place of injury. Sex did not yield differences in mortality or outcomes or on injury indices predicting outcomes. In contrast, older age was a predictor of higher mortality rates and worse outcomes.

CONCLUSION

Trends as described in the study emphasize the importance of continuous evaluation of TBI epidemiology and outcome in different countries.

Intracranial pressure monitoring following traumatic brain injury: evaluation of indications, complications, and significance of follow-up imaging-an exploratory, retrospective study of consecutive patients at a level I trauma center

Background

Measurement of intracranial pressure (ICP) is an essential part of clinical management of severe traumatic brain injury (TBI). However, clinical utility and impact on clinical outcome of ICP monitoring remain controversial. Follow-up imaging using cranial computed tomography (CCT) is commonly performed in these patients. This retrospective cohort study reports on complication rates of ICP measurement in severe TBI patients, as well as on findings and clinical consequences of follow-up CCT.

Methods

We performed a retrospective clinical chart review of severe TBI patients with invasive ICP measurement treated at an urban level I trauma center between January 2007 and September 2017.

Results

Clinical records of 213 patients were analyzed. The mean Glasgow Coma Scale (GCS) on admission was 6 with an intra-hospital mortality of 20.7%. Overall, complications in 12 patients (5.6%) related to the invasive ICP-measurement were recorded of which 5 necessitated surgical intervention. Follow-up CCT scans were performed in 192 patients (89.7%). Indications for follow-up CCTs included routine imaging without clinical deterioration (n = 137, 64.3%), and increased ICP values and/or clinical deterioration (n = 55, 25.8%). Follow-up imaging based on clinical deterioration and increased ICP values were associated with significantly increased likelihoods of worsening of CCT findings compared to routinely performed CCT scans with an odds ratio of 5.524 (95% CI 1.625–18.773) and 6.977 (95% CI 3.262–14.926), respectively. Readings of follow-up CCT imaging resulted in subsequent surgical intervention in six patients (3.1%).

Conclusions

Invasive ICP-monitoring in severe TBI patients was safe in our study population with an acceptable complication rate. We found a high number of follow-up CCT. Our results indicate that CCT imaging in patients with invasive ICP monitoring should only be considered in patients with elevated ICP values and/or clinical deterioration.

Adherence to brain trauma foundation guidelines for intracranial pressure monitoring in severe traumatic brain injury and the effect on outcome: A population-based study

Background:

Severe traumatic brain injury (TBI) is a significant cause of death and disability. The objective of this study was to provide an overview of whether adherence to brain trauma foundation (BTF) guidelines improved outcomes following TBI utilizing intracranial pressure (ICP) monitoring.

Methods:

This cohort study between 2000 and 2013 involved 1848 patients who sustained severe blunt TBI. Outcomes were correlated with whether or not ICP monitoring was utilized based on BTF guidelines.

Results:

The BTF guideline adherence rate for utilizing ICP monitoring in patients with TBI was 30% in 1848 patients. Adherence rates positively correlated with younger age, high injury severity scores, lower Glasgow Coma Scores, abnormal computed tomography scans of the head, performance of a craniotomy, neurocritical care unit admission, the lack of alcohol intoxication, and the absence of a cardiac arrest. Greater adherence to BTF guidelines was associated with higher mortality rates (OR 2.01, 95% CI: 1.56–2.59, P < 0.001), and increase ICU and hospital lengths of stay (P < 0.001).

Conclusion:

Adherence rates to BTF guidelines for ICP monitoring in patients with severe TBI were low. Further, these rates varied across centers and were correlated with higher mortality and morbidity rates. Although ICP insertion may be an indicator of TBI severity, the current BTF criteria for insertion of ICP monitors may fail to identify patients likely to benefit.

The Value of Managing Severe Traumatic Brain Injury During the Perioperative Period Using Intracranial Pressure Monitoring

This study aimed to investigate the clinical efficacy of intracranial pressure (ICP) monitoring regarding the perioperative management of patients with severe traumatic brain injury (sTBI). This was a cohort study performed between Jan 2013 and Jan 2016 and included all patients with sTBI. All patients were split into ICP monitoring and non-ICP monitoring groups. The primary outcomes were in-hospital mortality and Glasgow Outcome Scale (GOS) scores 6 months after injury, whereas the secondary outcomes include rate of successful nonsurgical treatment, rate of decompression craniotomy (DC), the length of stay in the ICU, and the hospital and medical expenses. This retrospective analysis included 246 ICP monitoring sTBI patients and 695 without ICP monitoring sTBI patients. No significant difference between groups regarding patient demographics. All patients underwent a GOS assessment 6 months after surgery. Compared to the non-ICP monitoring group, a lower in-hospital mortality (20.3% vs 30.2%, P < 0.01) and better GOS scores after 6 months (3.3 ± 1.6 vs 2.9 ± 1.6, P < 0.05) with ICP monitoring. In addition, patients in the ICP monitoring group had a lower craniotomy rate (41.1% vs 50.9%, P < 0.01) and a lower DC rate (41.6% vs 55.9%, P < 0.05) than those in the non-ICP monitoring group. ICU length of stay (12.4 ± 4.0 days vs 10.2 ± 4.8 days, P < 0.01) was shorter in the non-ICP monitoring group, but it had no difference between 2 groups on total length of hospital stay (22.9 ± 13.6 days vs 24.6 ± 13.6 days, P = 0.108); Furthermore, the medical expenses were significantly higher in the non-ICP monitoring group than the ICP monitoring group (11.5 ± 7.2 vs 13.3 ± 9.1, P < 0.01). Intracranial pressure monitoring has beneficial effects for sTBI during the perioperative period. It can reduce the in-hospital mortality and DC rate and also can improve the 6-month outcomes. However, this was a single institution and observational study, well-designed, multicenter, randomized control trials are needed to evaluate the effects of ICP monitoring for perioperative sTBI patients.

Statewide Trends in Intracranial Pressure Monitor Use in 36,915 Patients with Severe Traumatic Brain Injury in a Mature Trauma System over the Past 18 Years

OBJECTIVE

Intracranial pressure (ICP)-guided therapy has been the mainstay of treatment of patients with severe traumatic brain injury (TBI), but recent data have questioned its efficacy. The aim of this study was to demonstrate trends in compliance to TBI guidelines and use of ICP-guided care in a mature trauma system.

METHODS

A retrospective analysis was conducted of 36,915 patients with severe TBI collected by the Pennsylvania Trauma Systems Foundation. The registry includes all patients >18 years old with a diagnosis of TBI with a Glasgow Coma Scale score ≤8 who were admitted from January 2000 to December 2017.

RESULTS

Of 36,915 patients, 73.6% were men with a median age of 43.0 ± 21.3 years. An ICP monitor was placed in 16.3% of all patients. The rate of ICP monitoring ranged from 17.8% of patients in 2000-2004 to 16.7% in 2005-2009, 16.4% in 2010-2014, and 12.8% in 2015-2017 (P < 0.001). The most statistically significant decrease was noted from 2014 (16.4%) to 2015 (14.1%, P = 0.042). The percent decrease in ICP monitoring from 2000-2014 to 2015-2017 was equivalent for patients with Glasgow Coma Scale scores of 3-5 (-4.0%) and 6-8 (-4.5%).

CONCLUSIONS

As studies emerged that demonstrated unclear benefit of ICP monitoring in improving care in patients with severe TBI, there was a significant statewide decline in the use of ICP monitoring after 2014 among all TBI subpopulations despite noteworthy limitations in the aforementioned studies and clear recommendations from the Brain Trauma Foundation guidelines.

Value of Ventricular Intracranial Pressure Monitoring for Traumatic Bifrontal Contusions

OBJECTIVE

To investigate clinical efficacy of and optimal therapeutic strategy for ventricular intracranial pressure monitoring (V-ICPM) in patients with traumatic bifrontal contusions (TBCs).

METHODS

From 8760 patients with traumatic brain injury treated between January 2010 and January 2016, a retrospective analysis was performed on 105 patients with TBCs who underwent V-ICPM and 282 patients with TBCs who did not. All patients underwent treatment at the 101st Hospital of PLA, Wuxi, China. Rates of successful conservative treatment, decompressive craniectomy, and bifrontal craniotomy; incidence of neurologic dysfunction; length of stay; and medical expenses were compared between groups.

RESULTS

Glasgow Outcome Scale was used to assess all patients during follow-up (range, 6 months to 5.5 years). There were no significant differences in prognosis between the 2 groups (P = 0.100). Compared with the patients who did not undergo V-ICPM, the V-ICPM group had a significantly better successful conservative treatment rate (64.8% vs. 47.2%, P = 0.002), decompressive craniectomy rate (8.1% vs. 22.1%, P = 0.008), and bifrontal craniotomy rate (5.7% vs. 15.6%, P = 0.01); shorter length of stay (P = 0.000); and lower medical expenses (P = 0.004).

CONCLUSIONS

Patients with TBCs should be strictly, closely, and dynamically observed by neurosurgery intensive care unit physicians and nurses. Patients should undergo ventricular intracranial pressure probe implantation in a timely manner. V-ICPM can help optimize treatment. Although V-ICPM did not significantly improve the prognosis of patients, it had many other advantages. V-ICPM warrants further clinical research and may be beneficial for patients with TBCs.

A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol

The imaging and clinical examination (ICE) algorithm used in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) randomized controlled trial is the only prospectively investigated clinical protocol for traumatic brain injury management without intracranial pressure (ICP) monitoring. As the default literature standard, it warrants careful evaluation. We present the ICE protocol in detail and analyze the demographics, outcome, treatment intensity, frequency of intervention usage, and related adverse events in the ICE-protocol cohort. The 167 ICE protocol patients were young (median 29 years) with a median Glasgow Coma Scale motor score of 4 but with anisocoria or abnormal pupillary reactivity in 40%. This protocol produced outcomes not significantly different from those randomized to the monitor-based protocol (favorable 6-month extended Glasgow Outcome Score in 39%; 41% mortality rate). Agents commonly employed to treat suspected intracranial hypertension included low-/moderate-dose hypertonic saline (72%) and mannitol (57%), mild hyperventilation (adjusted partial pressure of carbon dioxide 30-35 mm Hg in 73%), and pressors to maintain cerebral perfusion (62%). High-dose hyperosmotics or barbiturates were uncommonly used. Adverse event incidence was low and comparable to the BEST TRIP monitored group. Although this protocol should produce similar/acceptable results under circumstances comparable to those in the trial, influences such as longer pre-hospital times and non-specialist transport personnel, plus an intensive care unit model of aggressive physician-intensive care by small groups of neurotrauma-focused intensivists, which differs from most high-resource models, support caution in expecting the same results in dissimilar settings. Finally, this protocol's ICP-titration approach to suspected intracranial hypertension (vs. crisis management for monitored ICP) warrants further study.

Impact of extended monitoring-guided intensive care on outcome after severe traumatic brain injury: A prospective multicentre cohort study (PariS-TBI study)

OBJECTIVE

We evaluated whether an integrated monitoring with systemic and specific monitoring affect mortality and disability in adults with severe traumatic brain injury (sTBI).

METHODS

Adults with severeTBI (Glasgow Coma Scale [GCS] ≤ 8) admitted alive in intensive care units (ICUs) were prospectively included. Primary endpoints were in-hospital 30-day mortality and extended Glasgow outcome score (GOSE) at 3 years. Association with the intensity of monitoring and outcome was studied by comparing a high level of monitoring (HLM) (systemic and ≥3 specific monitoring) and low level of monitoring (LLM) (systemic and 0-2 specific monitoring) and using inverse probability weighting procedure.

RESULTS

476 patients were included and IPW was used to improve the balance between the two groups of treatments (HLM/LMM). Overall hospital mortality (at 30 days) was 43%, being significantly lower in HLM than LLM group (27% vs. 53%: RR, 1.63: 95% CI: 1.23-2.15). The 14-day hospital mortality was also lower in the HLM group than expected, based upon the CRASH prediction model (35%). At 3 years, disability was not significantly different between the monitoring groups.

CONCLUSIONS

After adjustment, HLM group improved short-term mortality but did not show any improvement in the 3-year outcome compared with LLM.

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition

The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.

Effects of Intracranial Pressure Monitoring on Mortality in Patients with Severe Traumatic Brain Injury: A Meta-Analysis

BACKGROUND

The Brain Trauma Foundation (BTF) guidelines published in 2007 suggest some indications for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). However, some studies had not shown clinical benefit in patients with severe TBI; several studies had even reported that ICP monitoring was associated with an increased mortality rate. The effect of ICP monitoring has remained controversial, regardless of the ICP monitoring guidelines. Here we performed a meta-analysis of published studies to assess the effects of ICP monitoring in patients with severe TBI.

METHODS

We searched three comprehensive databases, the Cochrane Library, PUBMED, and EMBASE, for studies without limitations published up to September 2015. Mortality, ICU LOS, and hospital LOS were analyzed with Review Manager software according to data from the included studies.

RESULTS

Eighteen eligible studies involving 25229 patients with severe TBI were included in our meta-analysis. The results indicated no significant reduction in the ICP monitored group in mortality (hospitalized before 2007), hospital mortality (hospitalized before 2007), mortality in randomized controlled trials. However, overall mortality, mortality (hospitalized after 2007), hospital mortality (hospitalized after 2007), mortality in observational studies (hospitalized after 2007), 2-week mortality, 6-month mortality, were reduced in ICP monitored group. Patients with an increased ICP were more likely to require ICP monitoring.

CONCLUSION

Superior survival was observed in severe TBI patients with ICP monitoring since the third edition of "Guidelines for the Management of Severe Traumatic Brain Injury," which included "Indications for intracranial pressure monitoring," was published in 2007.

Measurement of intracranial pressure and short-term outcomes of patients with traumatic brain injury: a propensity-matched analysis

Objective

To assess the impact of intracranial pressure monitoring on the short-term outcomes of traumatic brain injury patients.

Methods

Retrospective observational study including 299 consecutive patients admitted due to traumatic brain injury from January 2011 through July 2012 at a Level 1 trauma center in São Paulo, Brazil. Patients were categorized in two groups according to the measurement of intracranial pressure (measured intracranial pressure and non-measured intracranial pressure groups). We applied a propensity-matched analysis to adjust for possible confounders (variables contained in the Crash Score prognostic algorithm).

Results

Global mortality at 14 days (16%) was equal to that observed in high-income countries in the CRASH Study and was better than expected based on the CRASH calculator score (20.6%), with a standardized mortality ratio of 0.77. A total of 28 patients received intracranial pressure monitoring (measured intracranial pressure group), of whom 26 were paired in a 1:1 fashion with patients from the non-measured intracranial pressure group. There was no improvement in the measured intracranial pressure group compared to the non-measured intracranial pressure group regarding hospital mortality, 14-day mortality, or combined hospital and chronic care facility mortality. Survival up to 14 days was also similar between groups.

Conclusion

Patients receiving intracranial pressure monitoring tend to have more severe traumatic brain injuries. However, after adjusting for multiple confounders using propensity scoring, no benefits in terms of survival were observed among intracranial pressure-monitored patients and those managed with a systematic clinical protocol.

Is Intracranial Pressure Monitoring of Patients With Diffuse Traumatic Brain Injury Valuable? An Observational Multicenter Study

BACKGROUND

Although intracranial pressure (ICP) monitoring of patients with severe traumatic brain injury (TBI) is recommended by the Brain Trauma Foundation, any benefits remain controversial.

OBJECTIVE

To evaluate the effects of ICP monitoring on the mortality of and functional outcomes in patients with severe diffuse TBI.

METHODS

Data were collected on patients with severe diffuse TBI (Glasgow Coma Scale [GCS] score on admission <9 and Marshall Class II-IV) treated from January 2012 to December 2013 in 24 hospitals (17 level I trauma centers and 7 level II trauma centers) in 9 Chinese provinces. We evaluated the impact of ICP monitoring on 6-month mortality and favorable outcome using propensity score-matched analysis after controlling for independent predictors of these outcomes.

RESULTS

ICP monitors were inserted into 287 patients (59.5%). After propensity score matching, ICP monitoring significantly decreased 6-month mortality. ICP monitoring also had a greater impact on the most severely injured patients on the basis of head computed tomography data (Marshall computed tomography classification IV) and on patients with the lowest level of consciousness (GCS scores 3-5). After propensity score matching, monitoring remained nonassociated with a 6-month favorable outcome for the overall sample. However, monitoring had a significant impact on the 6-month favorable outcomes of patients with the lowest level of consciousness (GCS scores 3-5).

CONCLUSION

ICP monitor placement was associated with a significant decrease in 6-month mortality after adjustment for the baseline risk profile and the monitoring propensity of patients with diffuse severe TBI, especially those with GCS scores of 3 to 5 or of Marshall computed tomography classification IV.

[Monitoring intracranial pressure in severe traumatic brain injury]

INTRODUCTION

Severe traumatic brain injury (TBI) is a serious condition. Intracranial pressure (ICP) monitoring can be used to direct treatment, which is of limited access in developing countries.

OBJECTIVE

To describe the clinical experience of pediatric patients with severe TBI.

PATIENTS AND METHOD

A clinical experience in patients with severe TBI was conducted. Age was 1-17 years, exclusion criteria were chronic illness and psicomotor retardation. Informed consent was obtained in each case. Two groups were formed based on the criterion of neurosurgeons: with and without intracraneal pressure (ICP) monitoring. PIC monitoring was performed through a 3PN Spiegelberg catheter and a Spiegelberg HDM 26 monitor. Patients were treated according international pediatric guides. The characteristics of both groups are described at 6 months of follow-up.

RESULTS

Forty-two patients (CM=14 and SM=28). Those in the CM Group had lower Glasgow coma scale score and Marshall classification with poorer prognosis. Among them survival rate was lower, although the outcome was from moderate to good. No complications were reported with the use of the ICP catheter.

CONCLUSION

Patients with ICP monitoring had greater severity at admission and an increased mortality; however, the outcome for the survivors was from moderate to good. It is necessary to conduct randomized clinical trials to define the impact of ICP monitoring on survival and quality of life in severe TBI patients.

Tracheostomy is associated with decreased hospital mortality after moderate or severe isolated traumatic brain injury

Background

Data regarding the impact and timing of tracheostomy in patients with isolated traumatic brain injury (TBI) are ambiguous. Our goal was to evaluate the impact of tracheostomy on hospital mortality in patients with moderate or severe isolated TBI.

Materials and Methods

We performed a retrospective cohort analysis of data prospectively collected at 87 Austrian intensive care units (ICUs). All patients continuously admitted between 1998 and 2010 were evaluated for the study. In total, 4,735 patients were admitted to ICUs with isolated TBI. Of these patients, 2,156 had a moderate or severe TBI (1,603 patients were endotracheally intubated only, 553 patients underwent tracheostomy). Epidemiological data (trauma severity, treatment, and outcome) of the two groups were compared.

Results

Patients with moderate or severe isolated TBI undergoing tracheostomy had a similar Glasgow Coma Scale score, median (interquartile range): 6 (3–8) vs 6 (3–8); p = 0.90, and Simplified Acute Physiology Score II, 45 (37–54) vs 45 (35–56); p = 0.86, compared with intubated patients not undergoing tracheostomy. Furthermore, patients undergoing tracheostomy exhibited higher Abbreviated Injury Scale Head scores and had a longer ICU stay for survivors, 30 (22–42) vs 9 (3–17) days; p < 0.0001). In contrast, risk-adjusted mortality was lower in patients undergoing tracheostomy compared with patients who remained intubated, observed-to-expected mortality ratio (95 % confidence interval): 0.62 (0.53–0.72) vs 1.00 (0.95–1.05) respectively.

Conclusions

Despite the greater severity of head injury, patients with isolated TBI who underwent tracheostomy had a lower risk-adjusted mortality than patients who remained intubated. Reasons for this difference in outcome may be multifactorial and require further investigation.

Intracranial pressure monitoring during adult spinal deformity correction in a patient with critical venous occlusive disease and superior vena cava syndrome: A technical note

Background:

Intracranial pressure (ICP) monitoring is not routinely used during complex spinal deformity correction surgery. The authors report a 66-year-old male who during thoracolumbar deformity surgery required the placement of an ICP monitor due to the underlying history of a superior vena cava syndrome (e.g., s/p right jugular stent).

Case Description:

A 66-year-old male with multiple prior lumbar spinal procedures presented with lower back and bilateral lower extremity pain, paresthesias, and weakness. He had a history of chronic left internal jugular and brachiocephalic venous occlusion (e.g., he had a right internal jugular stent). During deformity surgery, a frontal intraparenchymal ICP monitor was placed. During the early portion of the operation, bed adjustments (increasing reverse trendelenburg position) were required to compensate for ICP elevations as high as 30 mm Hg. A subsequent inadvertent durotomy during decompression lowered the ICP to <5 mm Hg; no further ICP spikes occurred. His postoperative course was uneventful, and 14-month later, he was dramatically improved.

Conclusion:

ICP monitoring may be a useful adjunct for patient safety in selected patients who are at risk for developing intracranial hypertension during extensive spinal deformity surgery.

Impact of Intracranial Pressure Monitoring on Prognosis of Patients With Severe Traumatic Brain Injury: A PRISMA Systematic Review and Meta-Analysis

To evaluate the influences of using intracranial pressure (ICP) monitoring on the prognosis of patients with severe traumatic brain injury. Systematic search were conducted in PubMed, Embase, Cochrane Library, Wanfang, and CNKI. The eligible studies were identified for pooling analysis under fixed- or random effects model. Hospital mortality, functional outcomes, length of hospital stay, and the related complications in patients were extracted. Six randomized controlled trials with 880 cases and 12 cohort studies with 12,606 cases were included. Combined analysis found that ICP monitoring was effective for reducing the risk rate of electrolyte disturbances (RR = 0.47, 95% confidence interval (CI): 0.63-0.90), rate of renal failure (RR = 0.50, 95% CI: 0.30-0.83), and for improving favorable prognosis (RR = 1.15, 95% CI: 1.00-1.35). However, ICP monitoring was not significant for hospital mortality (RR = 0.91, 95% CI: 0.77-0.1.06), decreasing rate of pulmonary infection (RR = 0.93, 95% CI: 0.76-1.14), rate of mechanical ventilation (RR = 1.02, 95% CI: 0.86-1.09), and duration of hospital stays (weighted mean difference (WMD) = 0.06, 95% CI: -0.03, 0.16). ICP monitoring may not reduce the risk of hospital mortality, but plays a role in decreasing the rate of electrolyte disturbances, rate of renal failure, and increasing favorable functional outcome. However, effect of other outcomes need to be further confirmed in the future randomized controlled trials (RCTs) with larger sample size.

Multimodal neuromonitoring for traumatic brain injury: A shift towards individualized therapy

Multimodal neuromonitoring in the management of traumatic brain injury (TBI) enables clinicians to make individualized management decisions to prevent secondary ischemic brain injury. Traditionally, neuromonitoring in TBI patients has consisted of a combination of clinical examination, neuroimaging and intracranial pressure monitoring. Unfortunately, each of these modalities has its limitations and although pragmatic, this simplistic approach has failed to demonstrate improved outcomes, likely owing to an inability to consider the underlying heterogeneity of various injury patterns. As neurocritical care has evolved, so has our understanding of underlying disease pathophysiology and patient specific considerations. Recent additions to the multimodal neuromonitoring platform include measures of cerebrovascular autoregulation, brain tissue oxygenation, microdialysis and continuous electroencephalography. The implementation of neurocritical care teams to manage patients with advanced brain injury has led to improved outcomes. Herein, we present a narrative review of the recent advances in multimodal neuromonitoring and highlight the utility of dedicated neurocritical care.

Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge

OBJECT The goal of critical care in treating traumatic brain injury (TBI) is to reduce secondary brain injury by limiting cerebral ischemia and optimizing cerebral blood flow. The authors compared short-term outcomes as defined by discharge disposition and Glasgow Outcome Scale scores in children with TBI before and after the implementation of a protocol that standardized decision-making and interventions among neurosurgeons and pediatric intensivists. METHODS The authors performed a retrospective pre- and postprotocol study of 128 pediatric patients with severe TBI, as defined by Glasgow Coma Scale (GCS) scores < 8, admitted to a tertiary care center pediatric critical care unit between April 1, 2008, and May 31, 2014. The preprotocol group included 99 patients, and the postprotocol group included 29 patients. The primary outcome of interest was discharge disposition before and after protocol implementation, which took place on April 1, 2013. Ordered logistic regression was used to assess outcomes while accounting for injury severity and clinical parameters. Favorable discharge disposition included discharge home. Unfavorable discharge disposition included discharge to an inpatient facility or death. RESULTS Demographics were similar between the treatment periods, as was injury severity as assessed by GCS score (mean 5.43 preprotocol, mean 5.28 postprotocol; p = 0.67). The ordered logistic regression model demonstrated an odds ratio of 4.0 of increasingly favorable outcome in the postprotocol cohort (p = 0.007). Prior to protocol implementation, 63 patients (64%) had unfavorable discharge disposition and 36 patients (36%) had favorable discharge disposition. After protocol implementation, 9 patients (31%) had unfavorable disposition, while 20 patients (69%) had favorable disposition (p = 0.002). In the preprotocol group, 31 patients (31%) died while 6 patients (21%) died after protocol implementation (p = 0.04). CONCLUSIONS Discharge disposition and mortality rates in pediatric patients with severe TBI improved after implementation of a standardized protocol among caregivers based on best-practice guidelines.

Intracranial pressure monitoring: fundamental considerations and rationale for monitoring

Traumatic brain injury (TBI) is a major cause of death and disability worldwide. In large part critical care for TBI is focused on the identification and management of secondary brain injury. This requires effective neuromonitoring that traditionally has centered on intracranial pressure (ICP). The purpose of this paper is to review the fundamental literature relative to the clinical application of ICP monitoring in TBI critical care and to provide recommendations on how the technique maybe applied to help patient management and enhance outcome. A PubMed search between 1980 and September 2013 identified 2,253 articles; 244 of which were reviewed in detail to prepare this report and the evidentiary tables. Several important concepts emerge from this review. ICP monitoring is safe and is best performed using a parenchymal monitor or ventricular catheter. While the indications for ICP monitoring are well established, there remains great variability in its use. Increased ICP, particularly the pattern of the increase and ICP refractory to treatment is associated with increased mortality. Class I evidence is lacking on how monitoring and management of ICP influences outcome. However, a large body of observational data suggests that ICP management has the potential to influence outcome, particularly when care is targeted and individualized and supplemented with data from other monitors including the clinical examination and imaging.

Effects and Clinical Characteristics of Intracranial Pressure Monitoring-Targeted Management for Subsets of Traumatic Brain Injury: An Observational Multicenter Study

OBJECTIVES

To evaluate the efficacy of traumatic brain injury management guided by intracranial pressure monitoring and to explore the specific subgroups for which intracranial pressure monitoring might be significantly associated with improved outcomes based on a classification of the various traumatic brain injury pathophysiologies using the clinical features and CT scans.

DESIGN

Retrospective observational multicenter study.

SETTING

Twenty-two hospitals (16 level I trauma centers and six level II trauma centers) in nine provinces in China.

PATIENTS

Moderate or severe traumatic brain injury patients who were more than 14 years old.

INTERVENTIONS

Intracranial pressure monitoring.

MEASUREMENTS AND MAIN RESULTS

All data were collected by physicians from medical records. The 6-month mortality and favorable outcome were assessed with the Glasgow Outcome Scale Extended score. An intracranial pressure monitor was inserted into 838 patients (58.1%). The mean duration of intracranial pressure monitoring was 4.44 ± 3.65 days. The significant predictors of intracranial pressure monitoring included the mechanism of injury, a Glasgow Coma Scale score of 9-12 at admission that dropped to a score of 3-8 within 24 hours after injury, a Marshall CT classification of III-IV, the presence of a major extracranial injury, subdural hematoma, intraparenchymal lesions, trauma center level, and intracranial pressure monitoring utilization of hospital. The intracranial pressure monitoring and no intracranial pressure monitoring groups did not significantly differ in terms of complications. For the total sample, the placement of intracranial pressure monitoring was not associated with either 6-month mortality (16.9% vs 20.5%; p = 0.086) or 6-month unfavorable outcome (49.4% vs 45.8%; p = 0.175). For patients with a Glasgow Coma Scale score of 3-8 at admission, intracranial pressure monitoring was also not significantly associated with 6-month mortality (20.9% vs 26.0%; p = 0.053) or an unfavorable outcome (56.9% vs 55.5%; p = 0.646). Multivariate logistic regression analyses showed that intracranial pressure monitoring resulted in a significantly lower 6-month mortality for patients who had a Glasgow Coma Scale score of 3-5 at admission (adjusted odds ratio, 0.57; 95% CI, 0.36-0.90; adjusted p = 0.016), those who had a Glasgow Coma Scale score of 9-12 at admission that dropped to 3-8 within 24 hours after injury (adjusted odds ratio, 0.28; 95% CI, 0.08-0.96; adjusted p = 0.043), and those who had a probability of death at 6 months greater than 0.6 (adjusted odds ratio, 0.55; 95% CI, 0.32-0.94; adjusted p = 0.029).

CONCLUSIONS

There were multiple differences between the intracranial pressure monitoring and no intracranial pressure monitoring groups regarding patient characteristics, injury severity, characteristics of CT scan, and hospital type. Intracranial pressure monitoring in conjunction with intracranial pressure-targeted therapies is significantly associated with lower mortality in some special traumatic brain injury subgroups. The prospective randomized controlled trials specifically investigating these subgroups will be required to further characterize the effects of intracranial pressure monitoring on behavioral outcomes in patients with traumatic brain injury.

Intracranial pressure monitoring and inpatient mortality in severe traumatic brain injury: A propensity score-matched analysis

BACKGROUND

Although intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI) is recommended by the Brain Trauma Foundation, the benefits remain controversial. We sought to determine the impact of ICP monitor placement on inpatient mortality within a regional trauma system after correcting for selection bias through propensity score matching.

METHODS

Data were collected on all severe TBI cases presenting to 14 trauma centers during the 2-year study period (2009-2010). Inclusion criteria were as follows: blunt injury, Glasgow Coma Scale (GCS) score of 8 or lower in the emergency department, and abnormal intracranial findings on head computed tomography (CT). Two separate multivariate logistic regression models were used to predict ICP monitor placement and inpatient mortality after controlling for demographics, severity of injury, comorbidities, and TBI-specific variables (GCS score, pupil reactivity, international normalized ratio, and nine specific head CT findings). To account for selection bias, we developed a propensity score-matched model to estimate the "true" effect of ICP monitoring on in-hospital mortality.

RESULT

A total of 844 patients met inclusion criteria; 22 died on arrival to the emergency department. Inpatient mortality was 38.8%; 46.0% of the patients underwent ICP monitor placement. Unadjusted mortality rates were significantly lower in the ICP monitoring group (30.7% vs. 45.7%, p < 0.001). ICP monitor placement was positively associated with CT findings of subdural hematoma, intraparenchymal contusion, and mass effect and negatively associated with age, alcoholism, and elevated international normalized ratio. After adjusting for selection bias via propensity score matching, ICP monitor placement was associated with an 8.3 percentage point reduction in the risk-adjusted mortality rate.

CONCLUSION

ICP monitor placement occurred in only 46% of eligible patients but was associated with significantly decreased mortality after adjusting for baseline risk profile and the propensity to undergo monitoring. As the individual impact of ICP monitoring may vary, future efforts must determine who stands to benefit from invasive monitoring techniques.

LEVEL OF EVIDENCE

Therapeutic/care management study, level III.

More fateful than fruitful? Intracranial pressure monitoring in elderly patients with traumatic brain injury is associated with worse outcomes

BACKGROUND

In an expanding elderly population, traumatic brain injury (TBI) remains a significant cause of death and disability. Guidelines for management of TBI, according to the Brain Trauma Foundation (BTF), include intracranial pressure (ICP) monitoring. Whether ICP monitoring contributes to outcomes in the elderly patients with TBI has not been explored.

METHODS

This is a retrospective study extracted from the National Trauma Database 2007-2008 research datasets. Patients were included if aged >55 y and they met BTF indications for ICP monitoring. Patients that had nonsurvivable injuries (any body region, abbreviated injury score = 6), were dead on arrival, had withdrawal of care, or length of stay <48 h were excluded. Outcomes were then stratified based on ICP monitoring. The primary outcomes were inhospital mortality and favorable discharge. Logistic regression was used to analyze the effect of ICP monitoring on outcomes.

RESULTS

A total of 4437 patients were included with 11.2% having an ICP monitor placed. Patients requiring an ICP monitor were younger overall, more likely to present hypertensive, had higher injury severity, and more likely to require operative intervention. Median initial Glasgow coma scale (3) was similar between groups. Of those patients with ICP monitoring, overall mortality was significantly higher, and they were less likely to have favorable discharge status. Craniotomy itself was not associated with increased mortality (P = 0.450).

CONCLUSIONS

Our findings suggest that the use of ICP monitoring according to BTF guidelines in elderly TBI patients does not provide outcomes superior to treatment without monitoring. The ideal group to benefit from ICP monitor placement remains to be elucidated.

Low-dose mannitol (0.3 g kg(-1)) improves the pulsatility index and minimum diastolic blood flow velocity in traumatic brain injury

OBJECTIVE

The aim of the study was to investigate the effects of using low-dose mannitol (0.3 g kg(-1)) on the pulsatility index (PI) and minimum diastolic blood flow velocity (FV-min) of the middle cerebral artery in a traumatic brain injury (TBI).

METHODS

Low-dose mannitol (0.3 g kg(-1)) was administered to a group of 20 patients with a TBI. Transcranial Doppler (TCD) ultrasonography was used to monitor the PI and FV-min. The study included patients with a diffuse traumatic brain injury and Glasgow coma score < 8. The initial TCD ultrasonography values were pathological (PI > 1.4 and FV-min < 20 cm s(-1)). TCD ultrasonography examinations were carried out before mannitol administration, immediately after administration and 1, 2 and 3 hours after the administration of mannitol.

RESULTS

A one-way analysis of variance revealed significant changes in the PI (F = 8.392; p < 0.001) and FV-min (F = 8.291; p = 0.001) after the use of mannitol.

CONCLUSIONS

Low-dose mannitol administration appears to be efficacious for improving the indicators of disturbed circulation in a TBI (FV-min increase, PI decrease). The maximum decrease in the PI was recorded 1 hour after the administration of mannitol and was 10.9% of the initial value. The maximum increase in the FV-min was recorded 1 hour after administration and was 29.7% of the initial value. These changes were significant ∼ 2 hours later.

External Ventricular Drains versus Intraparenchymal Intracranial Pressure Monitors in Traumatic Brain Injury: A Prospective Observational Study

BACKGROUND

Intracranial pressure (ICP) monitoring is the standard of care for patients with traumatic brain injury (TBI) and is used frequently. However, the efficacy of treatment based on the type of ICP monitor used for improving patient outcome has not been assessed prospectively. This study explores whether the type of ICP monitoring device used affects the neurologic outcomes of patients with TBI.

METHODS

A prospective, observational study was conducted in 122 patients with TBI ≥13 years old with indications for monitoring who were being treated in neurosurgical intensive care units between January 2009 and December 2012. All enrolled patients required monitoring randomly using an external ventricular drain (EVD) or intraparenchymal fiberoptic monitor (IPM). Patients were placed into 2 groups depending on the type of monitoring device. Clinically relevant outcomes, refractory intracranial hypertension, survival rates, and device-related complications were compared between the 2 groups.

RESULTS

There was a significant between-group difference in the Glasgow Outcome Scale score 6 months after injury, which was the primary outcome. Refractory intracranial hypertension was diagnosed in 44 of 122 patients, and patients monitored using IPM had a higher percentage of refractory intracranial hypertension (51.7% vs. 21.0%, P < 0.001). The 1-month survival rate was 90.3% in the EVD group and 76.7% in the IPM group (log-rank test, P = 0.04), and patients managed with EVDs had a significantly higher 6-month postinjury survival rate compared with patients treated with IPMs (88.7% vs. 68.3%, log-rank test, P = 0.006). There was no statistically significant difference between the groups in device-related complications (P = 0.448).

CONCLUSIONS

Device selection for ICP monitoring provides prognostic discrimination, and use of EVDs may have a bigger advantage in controlling refractory intracranial hypertension. Based on our findings, we recommend routine placement of an EVD in patients with TBI, unless only parenchymal-type monitoring is available.

Impact of intracranial pressure monitoring on mortality in patients with traumatic brain injury: a systematic review and meta-analysis

OBJECT

Some studies have demonstrated that intracranial pressure (ICP) monitoring reduces the mortality of traumatic brain injury (TBI). But other studies have shown that ICP monitoring is associated with increased mortality. Thus, the authors performed a meta-analysis of studies comparing ICP monitoring with no ICP monitoring in patients who have suffered a TBI to determine if differences exist between these strategies with respect to mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS.

METHODS

The authors systematically searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (Central) from their inception to October 2013 for relevant studies. Randomized clinical trials and prospective cohort, retrospective observational cohort, and case-control studies that compared ICP monitoring with no ICP monitoring for the treatment of TBI were included in the analysis. Studies included had to report at least one point of mortality in an ICP monitoring group and a no-ICP monitoring group. Data were extracted for study characteristics, patient demographics, baseline characteristics, treatment details, and study outcomes.

RESULTS

A total of 14 studies including 24,792 patients were analyzed. The meta-analysis provides no evidence that ICP monitoring decreased the risk of death (pooled OR 0.93 [95% CI 0.77-1.11], p = 0.40). However, 7 of the studies including 12,944 patients were published after 2012 (January 2012 to October 2013), and they revealed that ICP monitoring was significantly associated with a greater decrease in mortality than no ICP monitoring (pooled OR 0.56 [95% CI 0.41-0.78], p = 0.0006). In addition, 7 of the studies conducted in North America showed no evidence that ICP monitoring decreased the risk of death, similar to the studies conducted in other regions. ICU LOSs were significantly longer for the group subjected to ICP monitoring (mean difference [MD] 0.29 [95% CI 0.21-0.37]; p < 0.00001). In the pooled data, the hospital LOS with ICP monitoring was also significantly longer than with no ICP monitoring (MD 0.21 [95% CI 0.04-0.37]; p = 0.01).

CONCLUSIONS

In this systematic review and meta-analysis of ICP monitoring studies, the authors found that the current clinical evidence does not indicate that ICP monitoring overall is significantly superior to no ICP monitoring in terms of the mortality of TBI patients. However, studies published after 2012 indicated a lower mortality in patients who underwent ICP monitoring.

External Ventricular Drains and Mortality in Patients with Severe Traumatic Brain Injury

Purpose:

To determine our institutional adherence to the Brain Trauma Foundation guidelines with respect to intracranial pressure (ICP) monitoring, and examine the relationship between external ventricular drain (EVD) use and mortality.

Materials & Methods:

Retrospective cohort study of 171 patients with severe traumatic brain injury (TBI). Propensity score adjusted logistic regression was used to model the association between EVD use and mortality.

Results:

EVDs were inserted in 98 of 171 patients. Of the 73 patients without an EVD, 63 (86%) would have qualified for ICP monitoring under the current guidelines. EVDs werein situfor a median of 8 days (SD 6). In adjusted analyses, EVD use was associated with hospital mortality (OR 2.8, 95% CI: 1.1 - 7.1, p=0.04) and 28-day mortality (OR 2.1, 95% CI: 0.80 - 5.6, p=0.13). We observed significant modification of the association between EVD and 28-day mortality by GCS within 12 hours (p-interaction = 0.04), indicating strong association only among those patients with GCS score of at least 6 (OR 5.0, 95% CI: 1.5 - 16.7, p<0.01).

Conclusions:

The association of EVD with 28-day mortality was only apparent among patients with GCS score of ≥ 6. Further research is warranted to further refine which patients may benefit from ICP monitoring.

Neurocritical care: why does it make a difference?

PURPOSE OF REVIEW

The care of critically ill brain-injured patients is complex and requires careful balancing of cerebral and systemic treatment priorities. A growing number of studies have reported improved outcomes when patients are admitted to dedicated neurocritical care units (NCCUs). The reasons for this observation have not been definitively clarified.

RECENT FINDINGS

When recently published articles are combined with older literature, there have been more than 40 000 patients assessed in observational studies that compare neurological and general ICUs. Although results are heterogeneous, admission to NCCUs is associated with lower mortality and a greater chance of favorable recovery. These findings are remarkable considering that there are few interventions in neurocritical care that have been demonstrated to be efficacious in randomized trials. Whether the relationship is causal is still being elucidated but potential explanations include higher patient volume and, in turn, greater clinician experience; more emphasis on and adherence to protocols to avoid secondary brain injury; practice differences related to prognostication and withdrawal of life-sustaining interventions; and differences in the use and interpretation of neuroimaging and neuromonitoring data.

SUMMARY

Neurocritical care is an evolving field that is associated with improvements in outcomes over the past decade. Further research is required to determine how monitoring and treatment protocols can be optimized.

The effects of intracranial pressure monitoring in patients with traumatic brain injury

Background

Although international guideline recommended routine intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury(TBI), there were conflicting outcomes attributable to ICP monitoring according to the published studies. Hence, we conducted a meta-analysis to evaluate the efficacy and safety of ICP monitoring in patients with TBI.

Methods

Based on previous reviews, PubMed and two Chinese databases (Wangfang and VIP) were further searched to identify eligible studies. The primary outcome was mortality. Secondary outcomes included unfavourable outcome, adverse events, length of ICU stay and length of hospital stay. Weighted mean difference (WMD), odds ratio (OR) and 95% confidence intervals (CIs) were calculated and pooled using fixed-effects or random-effects model.

Results

two randomized controlled trials (RCTs) and seven cohort studies involving 11,038 patients met the inclusion criteria. ICP monitoring was not associated with a significant reduction in mortality (OR, 1.16; 95% CI, 0.87–1.54), with substantial heterogeneity (I² = 80%, P<0.00001), which was verified by the sensitivity analyses. No significant difference was found in the occurrence of unfavourable outcome (OR, 1.40; 95% CI, 0.99–1.98; I² = 4%, P = 0.35) and advese events (OR, 1.04; 95% CI, 0.64–1.70; I² = 78%, P = 0.03). However, we should be cautious to the result of adverse events because of the substantial heterogeneity in the comparison. Furthermore, longer ICU and hospital stay were the consistent tendency according to the pooled studies.

Conclusions

No benefit was found in patients with TBI who underwent ICP monitoring. Considering substantial clinical heterogeneity, further large sample size RCTs are needed to confirm the current findings.

Decreased risk of acute kidney injury with intracranial pressure monitoring in patients with moderate or severe brain injury

OBJECT

The authors undertook this study to evaluate the effects of continuous intracranial pressure (ICP) monitoring-directed mannitol treatment on kidney function in patients with moderate or severe traumatic brain injury (TBI).

METHODS

One hundred sixty-eight patients with TBI were prospectively assigned to an ICP monitoring group or a conventional treatment control group based on the Brain Trauma Foundation guidelines. Clinical data included the dynamic changes of patients' blood concentrations of cystatin C, creatinine (Cr), and blood urea nitrogen (BUN); mannitol use; and 6-month Glasgow Outcome Scale (GOS) scores.

RESULTS

There were no statistically significant differences with respect to hospitalized injury, age, or sex distribution between the 2 groups. The incidence of acute kidney injury (AKI) was higher in the control group than in the ICP monitoring group (p < 0.05). The mean mannitol dosage in the ICP monitoring group (443 ± 133 g) was significantly lower than in the control group (820 ± 412 g) (p < 0.01), and the period of mannitol use in the ICP monitoring group (3 ± 3.8 days) was significantly shorter than in the control group (7 ± 2.3 days) (p < 0.01). The 6-month GOS scores in the ICP monitoring group were significantly better than in the control group (p < 0.05). On the 7th, 14th, and 21st days after injury, the plasma cystatin C and Cr concentrations in the ICP-monitoring group were significantly higher than the control group (p < 0.05).

CONCLUSIONS

In patients with moderate and severe TBI, ICP-directed mannitol treatment demonstrated a beneficial effect on reducing the incidence of AKI compared with treatment directed by neurological signs and physiological indicators.

Intracranial pressure monitoring in severe traumatic brain injury: results from the American College of Surgeons Trauma Quality Improvement Program

Although existing guidelines support the utilization of intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI), the evidence suggesting benefit is limited. To evaluate the impact on outcome, we determined the relationship between ICP monitoring and mortality in centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP). Data on 10,628 adults with severe TBI were derived from 155 TQIP centers over 2009-2011. Random-intercept multilevel modeling was used to evaluate the association between ICP monitoring and mortality after adjusting for important confounders. We evaluated this relationship at the patient level and at the institutional level. Overall mortality (n=3769) was 35%. Only 1874 (17.6%) patients underwent ICP monitoring, with a mortality of 32%. The adjusted odds ratio (OR) for mortality was 0.44 [95% confidence interval (CI), 0.31-0.63], when comparing patients with ICP monitoring to those without. It is plausible that patients receiving ICP monitoring were selected because of an anticipated favorable outcome. To overcome this limitation, we stratified hospitals into quartiles based on ICP monitoring utilization. Hospitals with higher rates of ICP monitoring use were associated with lower mortality: The adjusted OR of death was 0.52 (95% CI, 0.35-0.78) in the quartile of hospitals with highest use, compared to the lowest. ICP monitoring utilization rates explained only 9.9% of variation in mortality across centers. Results were comparable irrespective of the method of case-mix adjustment. In this observational study, ICP monitoring utilization was associated with lower mortality. However, variability in ICP monitoring rates contributed only modestly to variability in institutional mortality rates. Identifying other institutional practices that impact on mortality is an important area for future research.

Impact of concomitant injuries on outcomes after traumatic brain injury

BACKGROUND

Patients with traumatic brain injury (TBI) frequently have concomitant injuries; we aimed to investigate their impact on outcomes.

METHODS

Between February 2002 and April 2010, 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data on accident, treatment, and outcomes were collected. Patients who survived until intensive care unit (ICU) admission and had survivable TBI were selected, and were assigned to "isolated TBI" or "TBI + injury" groups. Six-month outcomes were classified as "favorable" if Glasgow Outcome Scale (GOS) scores were five or four, and were classified as "unfavorable" if GOS scores were three or less. Univariate statistics (Fisher's exact test, t test, χ(2)-test) and logistic regression were used to identify factors associated with hospital mortality and unfavorable outcome.

RESULTS

Of the 767 patients, 403 (52.5 %) had isolated TBI, 364 (47.5 %) had concomitant injuries. Patients with isolated TBI had higher mean age (53 vs. 44 years, P = 0.001); hospital mortality (30.0 vs. 27.2 %, P = 0.42) and rate of unfavorable outcome (50.4 vs. 41.8 %, P = 0.02) were higher, too. There were no significant mortality differences for factors like age groups, trauma mechanisms, neurologic status, CT findings, or treatment factors. Concomitant injuries were associated with higher mortality (33.3 vs. 12.5 %, P = 0.05) in patients with moderate TBI, and were significantly associated with more ventilation, ICU, and hospitals days. Logistic regression revealed that age, Glasgow Coma Scale score, pupillary reactivity, severity of TBI and CT score were the main factors that influenced outcomes.

CONCLUSIONS

Concomitant injuries have a significant effect upon the mortality of patients with moderate TBI. They do not affect the mortality in patients with severe TBI.

Intensive care for pediatric traumatic brain injury

PURPOSES

The aims of this study are to describe a cohort of head-injured pediatric patients, focusing on current practice for intracranial pressure (ICP) monitoring and treatment and to verify the relationship between clinical and radiological parameters and the six-month outcome in a multivariable statistical model.

METHODS

A retrospective review was done of a prospectively collected database considering patients younger than 19 years admitted to three neuro-intensive care units (ICU). Patients were divided into four age groups: 0-5 (infant), 6-12 (children), 13-16 (pre-adolescent) and 17-18 years (adolescent). The ICP and cerebral perfusion pressure (CPP) were analyzed calculating average data and values exceeding thresholds for more than 5 min. Outcome was assessed 6 months after trauma using the Glasgow Outcome Score.

RESULTS

There were 199 patients, 155 male, included. Sixty percent had extracranial injuries. Pupils were abnormal in 38 %. Emergency evacuation of intracranial hematomas was necessary in 81 cases. The ICP was monitored in 117 patients; in 87 cases ICP was higher than 20 mmHg, with no differences among age groups. All but six patients received therapy to prevent raised ICP; barbiturates, deep hyperventilation or surgical decompression were used in 31 cases. At 6 months, mortality was 21 % and favorable outcome was achieved by 72 %. Significant predictors of outcome in the multivariable model were the Glasgow Coma Scale (GCS) motor score, pupils and ICP.

CONCLUSIONS

Pediatric head injury is associated with a high incidence of intracranial hypertension. Early surgical treatment and intensive care may achieve favorable outcome in the majority of cases.

Intracranial pressure monitors in traumatic brain injury: a systematic review

We conducted a systematic review to examine the relationship between intracranial pressure monitors (ICP) monitors and mortality in traumatic brain injury (TBI). We systematically searched for articles that met the following criteria: (1) adults patients, (2) TBI, (3) use of an ICP monitor, (4) point estimate for mortality with ICP monitoring (5) adjustment for potential confounders. Six observational studies were identified with 11,371 patients. There was marked between-study heterogeneity that precluded a pooled analysis. Patients with ICP monitors had different clinical characteristics and received more ICP targeted therapy in the ICU. Four studies found no significant relationship between ICP monitoring and survival, while the other two studies demonstrated conflicting results. Significant confounding by indication in observational studies limits the examination of isolated TBI interventions. More research should focus on interventions that affect TBI careplan systems. Further research is needed to identify which subset of severe TBI patients may benefit from ICP monitoring.

Factors influencing intracranial pressure monitoring guideline compliance and outcome after severe traumatic brain injury

OBJECTIVE

To determine adherence to Brain Trauma Foundation guidelines for intracranial pressure monitoring after severe traumatic brain injury, to investigate if characteristics of patients treated according to guidelines (ICP+) differ from those who were not (ICP-), and whether guideline compliance is related to 6-month outcome.

DESIGN

Observational multicenter study.

PATIENTS

Consecutive severe traumatic brain injury patients (≥16 yrs, n = 265) meeting criteria for intracranial pressure monitoring.

MEASUREMENTS AND MAIN RESULTS

Data on demographics, injury severity, computed tomography findings, and patient management were registered. The Glasgow Outcome Scale Extended was dichotomized into death (Glasgow Outcome Scale Extended = 1) and unfavorable outcome (Glasgow Outcome Scale Extended 1-4). Guideline compliance was 46%. Differences between the monitored and nonmonitored patients included a younger age (median 44 vs. 53 yrs), more abnormal pupillary reactions (52% vs. 32%), and more intracranial pathology (subarachnoid hemorrhage 62% vs. 44%; intraparenchymal lesions 65% vs. 46%) in the ICP+ group. Patients with a total intracranial lesion volume of ~150 mL and a midline shift of ~12 mm were most likely to receive an intracranial pressure monitor and probabilities decreased with smaller and larger lesions and shifts. Furthermore, compliance was low in patients with no (Traumatic Coma Databank score I -10%) visible intracranial pathology. Differences in case-mix resulted in higher a priori probabilities of dying (median 0.51 vs. 0.35, p < .001) and unfavorable outcome (median 0.79 vs. 0.63, p < .001) in the ICP+ group. After correction for baseline and clinical characteristics with a propensity score, intracranial pressure monitoring guideline compliance was not associated with mortality (odds ratio 0.93, 95% confidence interval 0.47-1.85, p = .83) nor with unfavorable outcome (odds ratio 1.81, 95% confidence interval 0.88-3.73, p = .11).

CONCLUSIONS

Guideline noncompliance was most prominent in patients with minor or very large computed tomography abnormalities. Intracranial pressure monitoring was not associated with 6-month outcome, but multiple baseline differences between monitored and nonmonitored patients underline the complex nature of examining the effect of intracranial pressure monitoring in observational studies.

Intraparenchymal vs extracranial ventricular drain intracranial pressure monitors in traumatic brain injury: less is more?

BACKGROUND

Management of severe traumatic brain injury has centered on continuous intracranial pressure (ICP) monitoring with intraparenchymal ICP monitors (IPM) or extracranial ventricular drains (EVD). Our hypothesis was that neurologic outcomes are unaffected by the type of ICP monitoring device.

STUDY DESIGN

We reviewed 377 adult patients with traumatic brain injury requiring ICP monitoring. Primary outcome was Glasgow Outcome Score (GOS) 1 month after injury. Secondary outcomes included mortality, monitoring-related complications, and length of ICU and hospital stay.

RESULTS

There were 253 patients managed with an IPM and 124 with an EVD. There was no difference in Glasgow Outcome Score (2.7 ± 1.3 vs 2.5 ± 1.3, p = 0.45), mortality (30.9% vs 32.2%, p = 0.82), and hospital length of stay (LOS) (15.6 ± 12.4 days vs 16.4 ± 10.7 days, p = 0.57). Device-related complications (11.9% vs 31.1%, p < 0.001), duration of ICP monitoring (3.8 ± 2.6 days vs 7.3 ± 5.6 days, p < 0.001), and ICU LOS (7.6 ± 5.6 days vs 9.5 ± 6.2 days, p = 0.004) were longer in the EVD group. Age, opening ICP, and size of midline shift were independent predictors for neurologic outcomes and mortality, when type and severity of brain injury, as well as overall injury severity were controlled for. Duration of ICP monitoring and opening ICP were independent predictors for hospital LOS and the former predicted prolonged ICU stay. Device-related complications were affected by type of device.

CONCLUSIONS

Use of EVDs in adult traumatic brain injury patients is associated with prolonged ICP monitoring, ICU LOS, and more frequent device-related complications.

Neurocritical care nursing research priorities

The science of nursing has long been discussed as a blending of the art and science of caring, and nursing research builds the evidence of support for nursing practice. Nurses and nursing care are key to successful neurocritical care research endeavors. Ideally nursing care should be evidence based and supported by solid research. The goal of nursing research is to expand the knowledge of caring for patients. Within the scope of nursing research, the priorities for research in neurocritical care should support this goal. In this manuscript, we discuss what we believe are the priorities of neurocritical care nursing research, the obstacles, and some possible solutions.

Critical care management of severe traumatic brain injury in adults

Traumatic brain injury (TBI) is a major medical and socio-economic problem, and is the leading cause of death in children and young adults. The critical care management of severe TBI is largely derived from the "Guidelines for the Management of Severe Traumatic Brain Injury" that have been published by the Brain Trauma Foundation. The main objectives are prevention and treatment of intracranial hypertension and secondary brain insults, preservation of cerebral perfusion pressure (CPP), and optimization of cerebral oxygenation. In this review, the critical care management of severe TBI will be discussed with focus on monitoring, avoidance and minimization of secondary brain insults, and optimization of cerebral oxygenation and CPP.

Relationship between intracranial pressure monitoring and outcomes in severe traumatic brain injury patients

Intracranial pressure (ICP) monitoring is recommended in patients with a severe traumatic brain injury (TBI) and an abnormal computed tomography (CT) scan. However, there is contradicting evidence about whether ICP monitoring improves outcome. The purpose of this study was to examine the relationship between ICP monitoring and outcomes in patients with severe TBI. From February 2001 to December 2008, a total of 477 consecutive adult (> or =18 years) patients with severe TBI were included retrospectively in the study. Patients who underwent ICP monitoring (n=52) were compared with those who did not (n=425). The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, mechanical ventilation duration, the need for tracheostomy, and ICU and hospital length of stay (LOS). After adjustment for multiple potential confounding factors, ICP monitoring was not associated with significant difference in hospital or ICU mortality (odds ratio [OR] = 1.71, 95% confidence interval [CI] = 0.79 to 3.70, P = 0.17; OR = 1.01, 95% CI = 0.41 to 2.45, P = 0.99, respectively). ICP monitoring was associated with a significant increase in mechanical ventilation duration (coefficient = 5.66, 95% CI = 3.45 to 7.88, P < 0.0001), need for tracheostomy (OR = 2.02, 95% CI = 1.02 to 4.03, P = 0.04), and ICU LOS (coefficient = 5.62, 95% CI = 3.27 to 7.98, P < 0.0001), with no significant difference in hospital LOS (coefficient = 8.32, 95% CI = -82.6 to 99.25, P = 0.86). Stratified by the Glasgow Coma Scale score, ICP monitoring was associated with a significant increase in hospital mortality in the group of patients with Glasgow Coma Scale 7 to 8 (adjusted OR = 12.89, 95% CI = 3.14 to 52.95, P = 0.0004). In patients with severe TBI, ICP monitoring was not associated with reduced hospital mortality, however with a significant increase in mechanical ventilation duration, need for tracheostomy, and ICU LOS.

Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study

Changes in the demographics, approach, and treatment of traumatic brain injury (TBI) patients require regular evaluation of epidemiological profiles, injury severity classification, and outcomes. This prospective multicenter study provides detailed information on TBI-related variables of 508 moderate-to-severe TBI patients. Variability in epidemiology and outcome is examined by comparing our cohort with previous multicenter studies. Additionally, the relation between outcome and injury severity classification assessed at different time points is studied. Based on the emergency department Glasgow Coma Scale (GCS), 339 patients were classified as having severe and 129 as having moderate TBI. In 15%, the diagnosis differed when the accident scene GCS was used for classification. In-hospital mortality was higher if severe TBI was diagnosed at both time points (44%) compared to moderate TBI at one or both time points (7-15%, p<0.001). Furthermore, 14% changed diagnosis when a threshold (≥6 h) for impaired consciousness was used as a criterion for severe TBI: In-hospital mortality was<5% when impaired consciousness lasted for<6 h. This suggests that combining multiple clinical assessments and using a threshold for impaired consciousness may improve the classification of injury severity and prediction of outcome. Compared to earlier multicenter studies, our cohort demonstrates a different case mix that includes a higher age (mean=47.3 years), more diffuse (Traumatic Coma Databank [TCDB] I-II) injuries (58%), and more major extracranial injuries (40%), with relatively high 6 month mortality rates for both severe (46%) and moderate (21%) TBI. Our results confirm that TBI epidemiology and injury patterns have changed in recent years whereas case fatality rates remain high.

Multimodal Cerebral Monitoring in Traumatic Brain Injury

Traumatic brain injury presents a significant impact on patients in terms of morbidity and mortality. Pathology is heterogeneous and is often associated with secondary deterioration. This paper reviews both clinical and research modes of monitoring to detect deterioration and compares what is available to the ideal. Intracranial pressure measurement, jugular venous oxygen saturation, microdialysis and cerebral oxygen monitoring are among the variables described and future research-based modalities are explored.