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 (original) (raw)
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Relationship of “dose” of intracranial hypertension to outcome in severe traumatic brain injury
Journal of Neurosurgery, 2008
Object It has recently been suggested that the degree of intracranial pressure (ICP) above the treatment goal can be estimated by the area under the curve (AUC) of ICP versus time in patients with severe traumatic brain injury (TBI). The objective of this study was to determine whether the calculated “ICP dose”—the ICP AUC—is related to mortality rate, outcome, and Marshall CT classification. Methods Of 135 patients (age range 1–82 years) with severe TBI treated during a 5-year period at the authors' institution, 113 patients underwent ICP monitoring (84%). Ninety-three patients with a monitoring time > 24 hours were included for analysis of ICP AUC calculated using the trapezoidal method. Computed tomography scans were assessed according to the Marshall TBI classification. Patients with Glasgow Outcome Scale scores at 6 months and > 3 years were separated into 2 groups based on outcome. Results Sixty patients (65%) had ICP values > 20 mm Hg, and 12 (13%) developed seve...
A clinical decision rule to predict intracranial hypertension in severe traumatic brain injury
Journal of Neurosurgery, 2018
OBJECTIVEWhile existing guidelines support the treatment of intracranial hypertension in severe traumatic brain injury (TBI), it is unclear when to suspect and initiate treatment for high intracranial pressure (ICP). The objective of this study was to derive a clinical decision rule that accurately predicts intracranial hypertension.METHODSUsing Delphi methods, the authors identified a set of potential predictors of intracranial hypertension and a clinical decision rule a priori by consensus among a group of 43 neurosurgeons and intensivists who have extensive experience managing severe TBI without ICP monitoring. To validate these predictors, the authors used data from a Latin American trial (n = 150; BEST TRIP). To report on the performance of the rule, they calculated sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals. In a secondary analysis, the rule was validated using data from a North American trial (n = 131; COBRIT).RESULTSTh...
Journal of neurotrauma, 2017
Neuromonitoring can be used to observe intracranial pathological conditions in neurointensive care, but use of intracranial pressure (ICP) monitoring is low in Japan. In this study, we retrospectively investigated the effects of ICP monitoring in treatment of severe traumatic brain injury (TBI) using data from the Japan Neurotrauma Data Bank (JNTDB). The study was conducted in 1,091 subjects enrolled in the JNTDB (Project 2009) from July 2009 to June 2011. The subjects were divided into those treated with and without ICP monitoring in intensive care for severe TBI. Age at admission, sex, level of consciousness (Glasgow Coma Scale (GCS)), pupillary findings, findings on head CT, treatment, and outcome were compared between these groups. The subjects were also classified into two groups based on the outcome. Relationships between patient background factors, including ICP, and clinical outcome were evaluated. The rate of ICP monitoring in treatment of severe TBI was 28%. Therapies were...
Journal of Neurosurgery, 2012
Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor. Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, in...
Pakistan journal of neurological surgery, 2023
Objective: Traumatic brain injury (TBI) is a medical condition causing disability, morbidity, and mortality in the world. The present research aimed to assess the impact of intracranial pressure (ICP) monitored therapy on mortality in patients with severe traumatic brain injury. Materials and Methods: A randomized controlled trial was conducted at the Department of Neurosurgery, Jinnah Hospital Lahore. Forty patients of both genders, aged between 15 to 60 years were randomly selected and divided into two groups (Control & Experimental). Patients injured within 24 hours with a Glasgow Coma Scale (GCS) of 8 or less and showing radiological evidence of raised intracranial pressure were included. Patients with extradural hematoma, penetrating injury, or those requiring any surgery were excluded from the study. Data were analyzed using SPSS version 20. Results: No significant difference was found in mean age and gender among the two groups. The GCS of the control group was 6.2 ± 1.6 while that of the experimental group was 6.7 ± 1.6. The mean of the maximum ICP of the experimental group was 25.31 ± 8.48 mm of Hg. There was a significant difference in the mean duration of ventilation between the two groups. In the control group, 10 (50.0%) patients expired whereas in the experimental group, 8 (40.0%) patients expired. The proportion of mortality was higher in the control group but the difference was not statistically significant between the two groups (P value: 0.525). Conclusion: Intracranial pressure-monitored therapy was effective but statistically showed no significant superiority over unmonitored management. Therefore, it is recommended that ICP monitoring should be used as a part and additional tool of a multimodal approach to severe traumatic brain injury.
Child's Nervous System, 2020
Purpose Intracranial hypertension (ICH) is a common and treatable complication after severe traumatic brain injury (sTBI) in children. Describing the incidence and risk factors for developing ICH after sTBI could impact clinical practice. Methods Retrospective cohort study from 2006 to 2015 at two university-affiliated level I pediatric trauma centers of children admitted with accidental or abusive TBI, a post-resuscitation Glasgow Coma Score (GCS) of 8 or less, and an invasive intracranial pressure (ICP) monitor. Bivariate and multivariable logistic regression analysis were performed to identify demographic, injury, and imaging characteristics in patients who received ICP directed therapies for ICH (ICP > 20 mmHg). Results Eight to 5% (271/321) of monitored patients received ICP directed therapy for ICH during their PICU stay. Ninety-seven percent of patients had an abnormality on CT scan by either the Marshall or the Rotterdam score. Of the analyzed clinical and radiologic variables, only presence of hypoxia prior to PICU arrival, female sex, and a higher Injury Severity Score (ISS) were associated with increased risk of ICH (p < 0.05). Conclusions In this retrospective study of clinical practice of ICP monitoring in children after sTBI, the vast majority of children had an abnormal CT scan and experienced ICH requiring clinical intervention. Commonly measured clinical variables and radiologic classification scores did not significantly add to the prediction for developing of ICH and further efforts are needed to define low-risk populations that would not develop ICH.
Anaesthesia and intensive care, 2011
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 in...
Intensive Care Medicine, 2008
Objective: The goals of this study were to elucidate reasons why patients did or did not receive intracranial pressure (ICP) monitoring and to describe factors influencing hospital mortality after severe traumatic brain injury (TBI). Design: Prospective multicenter cohort study. Patients and participants: 88,274 patients consecutively admitted to 32 medical, surgical and mixed Austrian ICUs between 1998 and 2004. Interventions: None. Measurements and results: 1,856 patients (2.1% of all ICU admissions) exhibited severe TBI (GCS < 9); of these, 1,031 (56%) had ICP monitoring. The "worst" and the "best" cases were both less likely to receive ICP monitoring. Younger patients, female patients, and patients with isolated TBI were more likely to receive ICP monitoring. Compared with large centers ICP was monitored more frequently [odds ratio (OR) 3.09, CI 2.42-3.94] in medium-sized centers. The 20% of patients with the highest likelihood to receive ICP monitoring were monitored in 91% of cases, and had the lowest hospital mortality (31%, OR 0.78, CI 0.37-1.64). Multivariate analysis revealed that severity of illness, TBI severity, isolated TBI, and the number of cases treated per year were associated with hospital outcome. Compared with the large centers, ORs for hospital mortality were 1.85 (CI 1.42-2.40) for patients from mediumsized centers and 1.91 (CI 1.24-2.93) for patients from small centers. Conclusions: ICP monitoring may possibly have some beneficial effects, but this needs further evaluation. Patients with severe TBI should be admitted to experienced centers with high patient volumes since this might improve hospital mortality rates.
Intracranial hypertension after traumatic brain injury
Indian Journal of Critical Care Medicine, 2004
Traumatic brain injury is a devastating problem with both high mortality and high subsequent morbidity. Injury to the brain occurs both at the time of the initial trauma (the primary injury) and subsequently due to ongoing cerebral ischaemia (the secondary injury). Hypotension and hypoxaemia are well recognized causes of this secondary injury. In the intensive care unit raised intracranial pressure (intracranial hypertension) is seen frequently after a severe diffuse brain injury and leads to cerebral ischaemia by compromising cerebral perfusion. This paper reviews the pathophysiology of intracranial hypertension and summarises current and experimental approaches to its management in the intensive care unit.