R3-Survey of traumatic brain injury management in European Brain IT centres year 2001

Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study

Background

No definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI). It is therefore likely that centers and practitioners individually balance potential benefits and risks of different intracranial pressure (ICP) management strategies, resulting in practice variation. The aim of this study was to examine variation in monitoring and treatment policies for intracranial hypertension in patients with TBI.

Methods

A 29-item survey on ICP monitoring and treatment was developed on the basis of literature and expert opinion, and it was pilot-tested in 16 centers. The questionnaire was sent to 68 neurotrauma centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study.

Results

The survey was completed by 66 centers (97% response rate). Centers were mainly academic hospitals (n = 60, 91%) and designated level I trauma centers (n = 44, 67%). The Brain Trauma Foundation guidelines were used in 49 (74%) centers. Approximately 90% of the participants (n = 58) indicated placing an ICP monitor in patients with severe TBI and computed tomographic abnormalities. There was no consensus on other indications or on peri-insertion precautions. We found wide variation in the use of first- and second-tier treatments for elevated ICP. Approximately half of the centers were classified as using a relatively aggressive approach to ICP monitoring and treatment (n = 32, 48%), whereas the others were considered more conservative (n = 34, 52%).

Conclusions

Substantial variation was found regarding monitoring and treatment policies in patients with TBI and intracranial hypertension. The results of this survey indicate a lack of consensus between European neurotrauma centers and provide an opportunity and necessity for comparative effectiveness research.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1816-9) contains supplementary material, which is available to authorized users.

Structure, Process, and Culture of Intensive Care Units Treating Patients with Severe Traumatic Brain Injury: Survey of Centers Participating in the American College of Surgeons Trauma Quality Improvement Program

Outcome after severe traumatic brain injury (TBI) differs substantially between hospitals. Explaining this variation begins with understanding the differences in structures and processes of care, particularly at intensive care units (ICUs) where acute TBI care takes place. We invited trauma medical directors (TMDs) from 187 centers participating in the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) to complete a survey. The survey domains included ICU model, type, availability of specialized units, staff, training programs, standard protocols and order sets, approach to withdrawal of life support, and perceived level of neurosurgeons' engagement in the ICU management of TBI. One hundred forty-two TMDs (76%) completed the survey. Severe TBI patients are admitted to dedicated neurocritical care units in 52 hospitals (37%), trauma ICUs in 44 hospitals (31%), general ICUs in 34 hospitals (24%), and surgical ICUs in 11 hospitals (8%). Fifty-seven percent are closed units. Board-certified intensivists directed 89% of ICUs, whereas 17% were led by neurointensivists. Sixty percent of ICU directors were general surgeons. Thirty-nine percent of hospitals had critical care fellowships and 11% had neurocritical care fellowships. Fifty-nine percent of ICUs had standard order sets and 61% had standard protocols specific for TBI, with the most common protocol relating to intracranial pressure management (53%). Only 43% of TMDs were satisfied with the current level of neurosurgeons' engagement in the ICU management of TBI; 46% believed that neurosurgeons should be more engaged; 11% believed they should be less engaged. In the largest survey of North American ICUs caring for TBI patients, there is substantial variation in the current approaches to ICU care for TBI, highlighting multiple opportunities for comparative effectiveness research.

Variation in Structure and Process of Care in Traumatic Brain Injury: Provider Profiles of European Neurotrauma Centers Participating in the CENTER-TBI Study

Introduction

The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study.

Methods

We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions.

Results

All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers.

Conclusion

Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches.

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.

Placement of intracranial pressure monitors by neurointensivists: case series and a systematic review

PRIMARY OBJECTIVE

Placement of an intracranial pressure (ICP) monitor to guide the management of patients with severe traumatic brain injury (TBI) has been historically performed by neurosurgeons. It is hypothesized that ICP monitors can be placed by non-surgeon neurointensivists, with placement success and complication rates comparable to neurosurgeons.

RESEARCH DESIGN

Retrospective review and systematic review of the literature.

METHODS AND PROCEDURES

This study reviewed the medical records of patients with TBI who required insertion of parenchymal ICP monitors performed by four neurointensivists in a large level I trauma centre. Patient data recorded were age, gender, CT findings, ICP monitor placement, location and length of placement, complications related to the ICP monitor and patient outcomes.

MAIN OUTCOMES AND RESULTS

Thirty-eight (38) monitors (Camino) were placed. Patients' average age was 43.0 years (SD = 21.6); 76% were males. The location of monitor was right frontal in 89% and left frontal in 11%. Mean ICP was 24 (SD = 15), duration of ICP monitor was 4.9 days (SD = 3.6). All monitors were placed successfully. There were no major technical complications, no episodes of major catheter-induced intracranial haemorrhage and no infectious complications. These findings were comparable to published outcomes from neurosurgeon placements.

CONCLUSIONS

It is believed that insertion of ICP monitors by neurointensivists is safe and may aid in providing prompt monitoring of patients with severe TBI.

Emergency neurological life support: airway, ventilation, and sedation

Airway management is central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Therefore, airway, ventilation, and sedation were chosen as an Emergency Neurological Life Support (ENLS) protocol. Reviewed topics include airway management; the decision to intubate; when and how to intubate with attention to cardiovascular status; mechanical ventilation settings; and the use of sedation, including how to select sedative agents based on the patient's neurological status.

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.

Effect of ultrasound treatment on brain edema in a traumatic brain injury model with the weight drop method

BACKGROUND

For the treatment of traumatic brain edema, an efficient modality has not yet emerged. There have been many studies to date which have reported the employment of low-frequency ultrasound for blood-brain barrier disruption (BBBD). However, the authors have observed that low-intensity ultrasound increases water permeability without cellular damage in cartilage cells. We have therefore attempted to observe the effects of applying this low-intensity ultrasound to an experimental animal model.

METHODS

A traumatic brain injury rat model was established according to the weight drop method developing the traumatic brain edema. The degree of BBBD was measured by the changes in the water content and spectrophotometric absorbance of Evans blue dye in the cerebrum after low-frequency ultrasound.

RESULTS

The cerebral water content levels showed that the BBBD gradually increased after impact and thereafter decreased after 6 h. After low-frequency ultrasound exposure, the values of water content and spectrophotometric absorbance of Evans blue dye were the lowest at 0 h, and were increased at 2 and 5 h of ultrasonic exposure (after impact).

CONCLUSION

We suggest that traumatic brain edema in the rat model may be alleviated by low-frequency ultrasound, and low-frequency ultrasound might be proposed as a novel treatment modality for brain edema.

Long-Term Follow-up of Patients with Post-Traumatic Refractory High Intracranial Pressure Treated with Lumbar Drainage

Drainage of cerebrospinal fluid by means of external lumbar drainage (ELD) is controversial in the adult population with traumatic brain injury. We report our experience with ELD in the treatment of post-traumatic high intracranial pressure (ICP) and the results of the long-term follow-up in these patients.

We undertook clinical evaluation of 30 patients with traumatic brain injury and high ICP treated with second-tier measures or with first-tier measures if second-tier measures were contraindicated. The study involved a retrospective review of collected data. Outcome at intensive care unit discharge and three to five years after injury were evaluated with the Glasgow Outcome Scale.

The mean age of patients was 34.9±12.5 years and 25 (83%) were male. The median (interquartile range) Glasgow Coma score was 8 (7 to 10). ICP before and one hour after ELD placement was 33.7±9.0 and 12.5±4.8 mmHg respectively, a decrease in 21.2±8.3 mmHg (P <0.0001). ELD was placed after a mean of 8.6±3.9 days. Cerebrospinal fluid drainage was maintained for a mean of 6.6±3.5 days. Four patients (13%) required ELD replacement and one patient developed a cerebrospinal fluid infection (3%). No pupillary changes were noted within 48 hours of ELD placement. Long-term outcome was favourable (good recovery or moderate disability) in 62% of the patients studied.

The use of ELD resulted in a marked decrease in ICP. These patients presented a good outcome in 62% of the cases in the long-term evaluation. Few complications related with ELD use were noted.

The brain monitoring with Information Technology (BrainIT) collaborative network: EC feasibility study results and future direction

BACKGROUND

The BrainIT group works collaboratively on developing standards for collection and analyses of data from brain-injured patients and to facilitate a more efficient infrastructure for assessing new health care technology with the primary objective of improving patient care. European Community (EC) funding supported meetings over a year to discuss and define a core dataset to be collected from patients with traumatic brain injury using IT-based methods. We now present the results of a subsequent EC-funded study with the aim of testing the feasibility of collecting this core dataset across a number of European sites and discuss the future direction of this research network.

METHODS

Over a 3-year period, data collection client- and web-server-based tools were developed and core data (grouped into nine categories) were collected from 200 head-injured patients by local nursing staff in 22 European neuro-intensive care centres. Data were uploaded through the BrainIT website and random samples of received data were selected automatically by computer for validation by data validation staff against primary sources held in each local centre. Validated data were compared with originally transmitted data and percentage error rates calculated by data category. Feasibility was assessed in terms of the proportion of missing data, accuracy of data collected and limitations reported by users of the IT methods.

FINDINGS

Thirteen percent of data files required cleaning. Thirty "one-off" demographic and clinical data elements had significant amounts of missing data (>15%). Validation staff conducted 19,461 comparisons between uploaded database data with local data sources and error rates were commonly less than or equal to 6%, the exception being the surgery data class where an unacceptably high error rate of 34% was found. Nearly 10,000 therapies were successfully recorded with start-times but approximately a third had inaccurate or missing "end-times" which limits the analysis of duration of therapy. Over 40,000 events and procedures were recorded but events with long durations (such as transfers) were more likely to have end-times missed.

CONCLUSIONS

The BrainIT core dataset is a rich dataset for hypothesis generation and post hoc analyses, provided that studies avoid known limitations in the dataset. Limitations in the current IT-based data collection tools have been identified and have been addressed. In order for multi-centre data collection projects to be viable, the resource intensive validation procedures will require a more automated process and this may include direct electronic access to hospital-based clinical data sources for both validation purposes and for minimising the duplication of data entry. This type of infrastructure may foster and facilitate the remote monitoring of patient management and protocol adherence in future trials of patient management and monitoring.

Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version

Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2(nd) Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006-2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3(rd) Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade "A" (very strong recommendation), Grade "B" (strong recommendation) and Grade "0" (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3(rd) Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.

Neurologic Outcome of Posttraumatic Refractory Intracranial Hypertension Treated With External Lumbar Drainage

BACKGROUND

Refractory intracranial hypertension (ICH) to second level measures after severe traumatic brain injury (TBI) is associated with mortality up to 84% to 100%. The use of external lumbar drainage (ELD) has been described in these patients. We report our experience with the use of ELD in 17 cases of refractory ICH after severe TBI.

METHODS

In our Level 3 Intensive Care Unit (ICU) at a university hospital, ICH is treated according to a progressive approach following the Brain Trauma Foundation guidelines. When second level measures fail to control ICH, we use an ELD as a rescue therapy if basal cisterns are discernible. Outcome at ICU discharge and 6 months after injury were analyzed using Glasgow Outcome Scale (GOS).

RESULTS

Mean age was 32.5 +/- 13.3 years. ICH was reduced in all patients. ICP before ELD was 30.9 +/- 7.9 mm Hg and after ELD 14.1 +/- 5.9 mm Hg. Four patients (24%) had an ICH rebound after 5 days of ELD placement and died in the ICU. At 6 months after TBI, 13 patients (76%) presented a good outcome (GOS score of 4 and 5). No patient presented pupillary changes or cerebrospinal fluid infection during ELD use.

CONCLUSION

External lumbar drainage is an effective and safe procedure to treat refractory ICH when basal cisterns are discernible. Control of refractory ICH with ELD is associated with an important reduction of mortality and a good functional recovery at 6 months.

Outcome after surgical decompression of severe traumatic brain injury

One of the factors that affects outcome following severe traumatic brain injury is development and progression of cerebral oedema with associated increase in intracranial pressure (ICP). Uncontrolled elevations of ICP may compromise energy metabolism of the injured brain and lead to secondary injury, affecting neurological outcome of the patient. Decompressive craniectomy has been used for over a century as a treatment of refractory brain swelling in a variety of neurological conditions. However, conclusive evidence of whether it has a beneficial or adverse affect on outcome is lacking. This article reviews the existing evidence on the role of decompressive craniectomy in management of patients with traumatic brain injury and stresses the need for randomised controlled trials.

Survey of traumatic brain injury management in European Brain-IT centres year 2001

BACKGROUND

The aim of this study was to obtain basic knowledge about the current local conditions and neurointensive care of traumatic brain injury (TBI) in the new multi-centre collaborative BrainIT group.

MATERIALS AND METHODS

The survey comprised a background part on local policies (Part A), and a case study section (Part B). The information was gathered by questionnaire followed by telephone interviews. Twenty-three BrainIT centres participated in the survey and answers from two respondents were available from 18 of the sites.

RESULTS

The average proportion of agreement between duplicate respondents was 0.778 (range 0.415-1.00). All BrainIT centres monitored ICP. The treatment protocols seem to have a pattern concerning escalation of treatment of intracranial hypertension: 1/ evacuation of mass lesions and head elevation; 2/ increased sedation and mannitol; 3/ hyperventilation; 4/ ventricular drainage; 5/ craniectomy and barbituates.

CONCLUSIONS

There seemed to be an agreement on neurointensive care policies within the BrainIT group. The suggested order of treatment was generally in accordance with published guidelines although the suggested order and combinations of different treatments varied. Variation of treatment within the range of prescribed standards provides optimal conditions for an interesting future analysis of treatment and monitoring data in reality using the BrainIT database.

The effect of N-acetylcysteine on posttraumatic changes after controlled cortical impact in rats

OBJECTIVE

The antioxidant potential N-Acetylcysteine (NAC) and its improvement of posttraumatic mitrochondrial dysfunction have been reported. This study investigated the effect of NAC on posttraumatic changes after controlled cortical Impact (CCI) injury.

DESIGN AND SETTING

Prospective randomized controlled animal study.

METHODS

A moderate left focal cortical contusion was induced using CCI. Either NAC (163 mg/kg bw) or physiological saline was administered intraperitoneally immediately and 2 and 4 h after trauma. Blood gases, temperature, mean arterial blood pressure (MABP), and intracranial pressure (ICP) were monitored. Twenty-four hours after trauma brains were removed and either posttraumatic edema was quantified gravimetrically (n=24], or contusion volume was determined morphometrically using slices staining and computerized image analysis (n=24]. Laser Doppler flowmetry was used to assess pericontusional cortical perfusion before trauma, 30 min and 4 and 24 h after trauma (n=14].

MEASUREMENTS AND RESULTS

Physiological parameters remained within normal limits. ICP measurements and water content in traumatized hemispheres did not differ between the groups. Relative contusion volume of the left hemisphere was slightly but nonsignificantly diminished in NAC-treated animals (4.7+/-0.4% vs. 5.9+/-0.5% in controls). In both groups pericontusional perfusion was significantly reduced at 4 h followed by a state of hyperperfusion at 24 h with no differences between the groups.

CONCLUSIONS

Despite previously reported neuroprotective abilities of NAC, no positive effect on posttraumatic perfusion, brain edema formation, or contusion volume after focal brain injury was observed in this study.