Severe head injury management in a general surgical department

Emergency Neurosurgery Performed by General Surgeons: A Systematic Review

BACKGROUND

In under-resourced settings, general surgeons may be called upon to perform emergency operations within other specialties. Accordingly, we aimed to characterise patient outcomes after emergency neurosurgery performed by a general surgeon or general surgery trainee.

METHODS

PubMed, Embase and the Cochrane Library were searched to 30 May 2021 for observational studies reporting outcomes after emergency neurosurgery performed by a general surgeon. Study screening, data extraction, and risk of bias using the Downs and Black checklist were performed in duplicate. Data on setting, operation undertaken, mortality rates and complications were extracted. Meta-analysis was planned but not possible due to heterogeneity. This study is registered with PROSPERO, CRD42021258097.

RESULTS

From 632 records, 14 retrospective observational studies were included, covering a total sample of 1,988 operations. Four studies were from Australia, and the remaining 10 were, respectively, from 10 other countries. Most common operations performed were decompressive surgery with burr holes or craniectomy for head trauma and insertion of intracranial pressure monitors. Rural hospitals were the most common settings. Mortality rates for procedures performed by general surgeons at latest follow-up were heterogenous, ranging from 5% for evacuation of chronic subdural haematoma in Kenya to 81% in head injured patients in a Hong Kong study.

CONCLUSIONS

This is the first systematic review that synthesises the literature to characterise patient outcomes after neurosurgical operations performed by a general surgeon. Findings from this study may benefit global surgery performed in rural, remote, military or humanitarian settings.

Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen-directed therapy

OBJECT

Cerebral ischemia is the leading cause of preventable death in cases of major trauma with severe traumatic brain injury (TBI). Intracranial pressure (ICP) control and cerebral perfusion pressure (CPP) manipulation have significantly reduced the mortality but not the morbidity rate in these patients. In this study, the authors describe their 5-year experience with brain tissue oxygen (PbtO(2)) monitoring, and the effect of a brain tissue oxygen-directed critical care guide (PbtO(2)-CCG) on the 6-month clinical outcome (based on the 6-month Glasgow Outcome Scale score) in patients with TBIs.

METHODS

One hundred thirty-nine patients admitted to Creighton University Medical Center with major traumatic injuries (Injury Severity Scale [ISS] scores >or= 16) and TBI underwent prospective evaluation. All patients were treated with a PbtO(2)-CCG to maintain a brain oxygen level > 20 mm Hg, and control ICP < 20 mm Hg. The role of demographic, clinical, and imaging parameters in the identification of patients at risk for cerebral hypooxygenation and the influence of hypooxygenation on clinical outcome were recorded. Outcomes were compared with those in a historical ICP/CPP patient cohort. Subgroup analysis of severe TBI was performed and compared to data reported in the Traumatic Coma Data Bank.

RESULTS

The majority of injuries were sustained in motor vehicle crashes (63%), and diffuse brain injury was the most common abnormality (58%). Mechanism of injury, severity of TBI, pathological entity, neuroimaging results, and trauma indices were not predictive of ischemia. Factors affecting death included gunshot injury, poor trauma indices, subarachnoid hemorrhage, and coma. After standard resuscitation, 65% of patients had an initially low PbtO(2). Data are presented as means +/- SDs. Treatment with the PbtO(2)-CCG resulted in a 44% improvement in mean PbtO(2) (16.21 +/- 12.30 vs 23.65 +/- 14.40 mm Hg; p < 0.001), control of ICP (mean 12.76 +/- 6.42 mm Hg), and the maintenance of CPP (mean 76.13 +/- 15.37 mm Hg). Persistently low cerebral oxygenation was seen in 37% of patients at 2 hours, 31% at 24 hours, and 18% at 48 hours of treatment. Thus elevated ICP and a persistent low PbtO(2) after 2 hours represented increasing odds of death (OR 14.3 at 48 hours). Survivors and patients with good outcomes generally had significantly higher mean daily PbtO(2) and CPP values compared to nonsurvivors. Polytrauma, associated with higher ISS scores, presented an increased risk of vegetative outcome (OR 9.0). Compared to the ICP/CPP cohort, the mean Glasgow Outcome Scale score at 6 months in patients treated with PbtO(2)-CCG was higher (3.55 +/- 1.75 vs 2.71 +/- 1.65, p < 0.01; OR for good outcome 2.09, 95% CI 1.031-4.24) as was the reduction in mortality rate (25.9 vs 41.50%; relative risk reduction 37%), despite higher ISS scores in the PbtO(2) group (31.6 +/- 13.4 vs 27.1 +/- 8.9; p < 0.05). Subgroup analysis of severe closed TBI revealed a significant relative risk reduction in mortality rate of 37-51% compared with the Traumatic Coma Data Bank data, and an increased OR for good outcome especially in patients with diffuse brain injury without mass lesions (OR 4.9, 95% CI 2.9-8.4).

CONCLUSIONS

The prevention and aggressive treatment of cerebral hypooxygenation and control of ICP with a PbtO(2)-directed protocol reduced the mortality rate after TBI in major trauma, but more importantly, resulted in improved 6-month clinical outcomes over the standard ICP/CPP-directed therapy at the authors' institution.

Availability of trauma specialists in level I and II trauma centers: a national survey

BACKGROUND

Despite American College of Surgeons Committee on Trauma's criteria, little data exists about the variability of practices in both the composition of trauma teams and timing of specialist availability across trauma centers. The purpose of the study was to determine the availability of trauma team personnel in Level I and II trauma centers across the United States.

METHODS

Two surveys were developed and mailed to trauma directors and coordinators in 450 centers. Responses were received from 254 directors (56%) and 218 coordinators (48%). The director survey was designed to collect data on trauma team composition and timeliness in response to a hypothetical scenario. The coordinator survey was designed to collect data on trauma center characteristics and general availability of trauma specialists.

RESULTS

Eighty-two percent of Level I and II centers had trauma surgeons available within 15 minutes of and 37% at patient admission. The in-house (IH) centers (60%) had a trauma surgeon at patient admission significantly more than on-call centers did (22%). The specialty surgeons, such as neurosurgeons (73%) and orthopedic surgeons (75%), were mostly available through the on-call system. An IH system, high volumes of trauma patients, and designation by American College of Surgeons were significantly associated with higher likelihood of trauma surgeons physically present at the bedside within 15 minutes.

CONCLUSIONS

There was a large variation in the availability of expertise at or shortly after a trauma admission. For centers with low patient volume, early triage, better notification systems based on advanced telecommunication technology, and compensation for IH call may be a solution to better use the trauma surgical specialties.

Outcome of children with traumatic brain injury in rural Malaysia

Malaysia had the second highest crude accident rate in the world until 1998. Most children who were involved in these road traffic accidents required intensive neurosurgical care management. We report a prospective study on 36 paediatric neurotrauma patients in rural North East West Malaysia who underwent uniform intensive therapy and were subsequently followed up over a period of 2 years. The modified paediatric Glasgow Coma Scale with support of the revised Wechlser Intelligence Scale for children was used to test the outcome of these children over a period of two years. All patients were managed aggressively in our intensive care as well as our high dependency units. Our results indicate that improvement in outcome is seen after a six month period. Midline shift, duration of coma and duration of transport were found to be significant variables associated with bad outcome. Other variables i.e. age, sex, Glasgow Coma Scale on admission and on site, and lesions of the dominant lobe were not found to be associated with good outcome in these patients.

Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage

OBJECTIVE

To determine whether mortality rate after intracerebral hemorrhage (ICH) is lower in patients admitted to a neurologic or neurosurgical (neuro) intensive care unit (ICU) compared to those admitted to general ICUs.

BACKGROUND

The utility of specialty ICUs is debated. From a cost perspective, having fewer larger ICUs is preferred. Alternatively, the impact of specialty ICUs on patient outcome is unknown. Patients with ICH are admitted routinely to both general and neuro ICUs and provide an opportunity to address this question.

SETTING

Forty-two neuro, medical, surgical, and medical-surgical ICUs.

MEASUREMENTS AND MAIN RESULTS

The study was an analysis of data prospectively collected by Project Impact over 3 yrs from 42 participating ICUs (including one neuro ICU) across the country. The records of 36,986 patients were merged with records of 3,298 patients from a second neuro ICU that collected the same data over the same period. The impact of clinical (age, race, gender, Glasgow Coma Scale score, reason for admission, insurance), ICU (size, number of ICH patients, full-time intensivist, clinical service, American College for Graduate Medical Education or Critical Care Medicine fellowship), and institutional (size, location, medical school affiliation) characteristics on hospital mortality rate of ICH patients was assessed by using a forward-enter multivariate analysis. Data from 1,038 patients were included. The 13 ICUs that admitted >20 patients accounted for 83% of the admissions with a mortality rate that ranged from 25% to 64%. Multivariate analysis adjusted for patient demographics, severity of ICH, and ICU and institutional characteristics indicated that not being in a neuro ICU was associated with an increase in hospital mortality rate (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.65-7.6). Other factors associated with higher mortality rate were greater age (OR, 1.03/year; 95% CI, 1.01-1.04), lower Glasgow Coma Scale score (OR, 0.6/point; 95% CI, 0.58-0.65), fewer ICH patients (OR, 1.01/patient; 95% CI, 1.00-1.01), and smaller ICU (OR, 1.1/bed; 95% CI, 1.02-1.13). Having a full time intensivist was associated with lower mortality rate (OR, 0.388; 95% CI, 0.22-0.67).

CONCLUSIONS

For patients with acute ICH, admission to a neuro vs. general ICU is associated with reduced mortality rate.

How well do neurosurgeons care for trauma patients? A survey of the membership of the American Association for the Surgery of Trauma

OBJECTIVE

To quantify the trauma community's perceptions about neurosurgeons' involvement in trauma.

METHODS

Mail survey of the membership of the American Association for the Surgery of Trauma.

RESULTS

The response rate was 33.6% (280 of 833 mailings). Eighty-four percent of respondents practiced in an academic setting, and 51% reported that neurosurgery residents were available in their hospitals at night and on weekends. Approximately 60% reported that neurosurgeons were in charge of the care of adults with isolated head injuries (HIs) who had been operated on. A similar percentage thought that neurosurgeons should be in charge of such patients' care. Only 31.5% indicated that neurosurgeons were in charge if no operation had been performed (P < 0.001 versus patients who had been operated on), but 42.1% thought that neurosurgeons should be in charge of patients who had not been operated on (P < 0.001 versus neurosurgeons who actually were in charge of such patients). The same question was asked with regard to adults with both HIs and systemic injuries and with regard to children with HIs with and without systemic injuries. In general, the actuality of a leadership role for neurosurgeons depended on whether a craniotomy had been performed, and it was believed that more neurosurgeons should be in charge than actually were in charge of patients with HIs. Reluctance to insert intracranial pressure monitors was the most commonly reported problem (44.8% of respondents) with regard to neurosurgeons' care of patients with HIs. All problems were reported to be significantly more common when in-house neurosurgery residents were not available. More than 40% of respondents indicated that non-neurosurgeons should be allowed to insert intracranial pressure monitors, and 14% thought that non-neurosurgeons should be allowed to perform trauma craniotomies. These opinions were strongly associated with the reporting of problems in neurosurgeons' performance in these areas (P < 0.001 and P = 0.001, respectively).

CONCLUSION

Neurosurgeons frequently yield responsibility for managing patients with HIs to other specialists, but more frequent leadership of neurosurgeons in this area would be welcome. Reported problems with neurosurgical care of trauma patients may be related to a lack of immediate availability of neurosurgeons, such as the absence of in-house neurosurgery residents at night. Failure of neurosurgeons to address perceived deficiencies in their care of trauma patients may lead to serious erosion of the central role of neurosurgeons in managing patients with HIs.

Neurosurgery in Papua New Guinea

BACKGROUND

An audit of neurosurgery in Papua New Guinea (PNG) based on the experience of a visiting neurosurgeon is presented. The objectives of the study were to determine the type and frequency of neurosurgical conditions in PNG, whether major neurosurgery can be performed successfully in PNG, and to develop a strategy for the development of neurosurgical services in PNG.

METHODS

The audit was carried out over two periods of 2 weeks duration in 1992 and 1993 in Port Moresby and Goroka. Instrumentation and equipment were limited and no additional equipment was used. Myelography and angiography were available in Port Moresby.

RESULTS

There were 82 patients in total, 55 (67.1%) were consultations, 23 (28%) had elective surgery, four (4.8%) had emergency surgery and 16 (19.5%) await surgery. Cases were subdivided into nine major groupings: neurotrauma 18 (seven severe); spine 18; congenital 13; hydrancephaly four; scalp, skull and orbit six; vascular three; peripheral nerve three; and neurology five. Seventy-two (87.8%) patients required CT/MRI which were unavailable. Four ventriculograms were performed in lieu of CT/MRI. Fifteen (18.3%) cases could not be treated in PNG.

CONCLUSIONS

Neurosurgical problems in PNG can often be adequately managed with limited resources. Complex procedures were performed with gratifying results and acceptable morbidity. There is sufficient pathology in a country of four million people to justify training a small number of neurosurgeons by the end of the decade. CT scanning will be a necessary adjunct.