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Waack AL, Lucarelli V, Leverich M, Ren G, Schroeder JL, Hoyt AT. Patterns and outcomes of intracranial pressure monitoring in traumatic brain injury: An analysis of the National Inpatient Sample. Clin Neurol Neurosurg 2024; 238:108168. [PMID: 38382131 DOI: 10.1016/j.clineuro.2024.108168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Elevated intracranial pressure (ICP) can cause progressive neurological deterioration following traumatic brain injury (TBI). ICP can be monitored to guide subsequent treatment decisions. However, there is conflicting data in the literature regarding the utility of ICP monitoring. We aim to describe patterns and outcomes of ICP monitoring in the United States with the use of a nationwide healthcare database. METHODS We performed a 5-year analysis of the Nationwide Inpatient Sample database. We identified all adult TBI patients with a Glasgow Coma Scale (GCS) measuring 3-8 using International Classification of Diseases diagnostic codes. Propensity score matching (1:2 ratio) was performed to control for demographics, injury parameters and comorbidities. Outcome measures included inpatient mortality, length of stay (LOS), cost of care, and discharge disposition. RESULTS After propensity score matching, a cohort of 1664 patients was obtained (monitored, 555; non-monitored, 1109). Index outcomes with respect to monitor and no-monitor are as follows: inpatient mortality (35.1%, 42.4%, P <0.01), median LOS (15 days, 6 days, P<0.001), median total charge (289,797 USD, 154,223 USD, P <0.001), discharge home (7.9%, 19.3%, P <0.001) and discharge to another facility (53.9%, 35.4%, P <0.001). DISCUSSION ICP monitoring in TBI patients is associated with decreased inpatient mortality and discharge to home, and it is associated with an increased hospital LOS, total charge, and chance of discharge to another facility. CONCLUSION The risks and benefits of ICP monitoring should be seriously considered when managing adults with severe TBI.
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Affiliation(s)
- Andrew L Waack
- Department of Surgery, Division of Neurosurgery, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, OH 43614, United States.
| | - Vito Lucarelli
- Department of Surgery, Division of Neurosurgery, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, OH 43614, United States
| | - Matthew Leverich
- Department of Surgery, Division of Neurosurgery, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, OH 43614, United States
| | - Gang Ren
- Department of Surgery, Division of Neurosurgery, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, OH 43614, United States
| | - Jason L Schroeder
- Department of Surgery, Division of Neurosurgery, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, OH 43614, United States; ProMedica Physicians Neurosurgery, 2130 W Central Ave., Suite 105, Toledo, OH 43606, United States
| | - Alastair T Hoyt
- Department of Surgery, Division of Neurosurgery, University of Toledo Medical Center, 3000 Arlington Ave., Toledo, OH 43614, United States
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Nattino G, Gamberini L, Brissy O, Carrara G, Chesnut R, Chiarini V, Chieregato A, Csomos A, Fleming JM, Gradisek P, Kaps R, Kyprianou T, Lazar I, Lemeshow S, Mikaszewska-Sokolewicz M, Paci G, Rossi C, Temkin N, Xirouchaki N, Giugni A, Bertolini G. Comparative Effectiveness of Intracranial Pressure Monitoring on 6-Month Outcomes of Critically Ill Patients With Traumatic Brain Injury. JAMA Netw Open 2023; 6:e2334214. [PMID: 37755832 PMCID: PMC10534270 DOI: 10.1001/jamanetworkopen.2023.34214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/25/2023] [Indexed: 09/28/2023] Open
Abstract
Importance While the relationship between persistent elevations in intracranial pressure (ICP) and poorer outcomes is well established for patients with traumatic brain injury (TBI), there is no consensus on how ICP measurements should drive treatment choices, and the effectiveness of ICP monitoring remains unknown. Objective To evaluate the effectiveness of ICP monitoring on short- and mid-term outcomes of patients with TBI. Design, Setting, and Participants CREACTIVE was a prospective cohort study that started in March 2014 and lasted 5 years. More than 8000 patients with TBI were enrolled at 83 intensive care units (ICUs) from 7 countries who joined the CREACTIVE Consortium. Patients with TBI who met the Brain Trauma Foundation guidelines for ICP monitoring were selected for the current analyses, which were performed from January to November 2022. Exposure Patients who underwent ICP monitoring within 2 days of injury (exposure group) were propensity score-matched to patients who were not monitored or who underwent monitoring 2 days after the injury (control group). Main Outcome and Measure Functional disability at 6 months as indicated by Glasgow Outcome Scale-Extended (GOS-E) score. Results A total of 1448 patients from 43 ICUs in Italy and Hungary were eligible for analysis. Of the patients satisfying the ICP-monitoring guidelines, 503 (34.7%) underwent ICP monitoring (median [IQR] age: 45 years [29-61 years]; 392 males [77.9%], 111 females [22.1%]) and 945 were not monitored (median [IQR] age: 66 years [48-78 years]; 656 males [69.4%], 289 females [30.6%]). After matching to balance the variables, worse 6-month recovery was observed for monitored patients compared with nonmonitored patients (death/vegetative state: 39.2% vs 40.6%; severe disability: 33.2% vs 25.4%; moderate disability: 15.7% vs 14.9%; good recovery: 11.9% vs 19.1%, respectively; P = .005). Monitored patients received medical therapies significantly more frequently. Conclusions and Relevance In this cohort study, ICP monitoring was associated with poorer recovery and more frequent medical interventions with their relevant adverse effects. Optimizing the value of ICP monitoring for TBI requires further investigation on monitoring indications, clinical interventions, and management protocols.
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Affiliation(s)
- Giovanni Nattino
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Lorenzo Gamberini
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Obou Brissy
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Greta Carrara
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Randall Chesnut
- Department of Neurological Surgery and School of Global Health, University of Washington, Seattle
| | - Valentina Chiarini
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Arturo Chieregato
- Neurointensive Care Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Akos Csomos
- Hungarian Army Medical Center, Budapest, Hungary
| | - Joanne M. Fleming
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Primoz Gradisek
- Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Rafael Kaps
- General Hospital Novo Mesto, Novo Mesto, Slovenia
| | - Theodoros Kyprianou
- University of Nicosia Medical School, Nicosia, Cyprus
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Isaac Lazar
- Pediatric Intensive Care Unit, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Stanley Lemeshow
- Division of Biostatistics, College of Public Health, Ohio State University, Columbus
| | | | - Giulia Paci
- Hospital Nursing Management, AUSL Romagna, Maurizio Bufalini Hospital, Cesena, Italy
| | - Carlotta Rossi
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Nancy Temkin
- Department of Neurological Surgery and Department of Biostatistics, University of Washington, Seattle
| | | | - Aimone Giugni
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Guido Bertolini
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
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Ghanem G, Haase D, Brzezinski A, Ogawa R, Asachi P, Chiem A. Ultrasound detected increase in optic disk height to identify elevated intracranial pressure: a systematic review. Ultrasound J 2023; 15:26. [PMID: 37227512 DOI: 10.1186/s13089-023-00324-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 04/27/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Elevated intracranial pressure (eICP) is a serious medical emergency that requires prompt identification and monitoring. The current gold standards of eICP detection require patient transportation, radiation, and can be invasive. Ocular ultrasound has emerged as a rapid, non-invasive, bedside tool to measure correlates of eICP. This systematic review seeks to explore the utility of ultrasound detected optic disc elevation (ODE) as an ultrasonographic finding of eICP and to study its sensitivity and specificity as a marker of eICP. METHODS This systematic review followed the preferred reporting items for systematic reviews and meta-analyses guidelines. We systematically searched PubMed, EMBASE, and Cochrane Central for English articles published before April 2023; yielding 1,919 total citations. After eliminating duplicates, and screening the records, we identified 29 articles that addressed ultrasonographically detected ODE. RESULTS The 29 articles included a total of 1249 adult and pediatric participants. In patients with papilledema, the mean ODE ranged between 0.6 mm and 1.2 mm. Proposed cutoff values for ODE ranged between 0.3 mm and 1 mm. The majority of studies reported a sensitivity between 70 and 90%, and specificity ranged from 69 to 100%, with a majority of studies reporting a specificity of 100%. CONCLUSIONS ODE and ultrasonographic characteristics of the optic disc may aid in differentiating papilledema from other conditions. Further research on ODE elevation and its correlation with other ultrasonographic signs is warranted as a means to increase the diagnostic accuracy of ultrasound in the setting of eICP.
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Affiliation(s)
- Ghadi Ghanem
- David Geffen School of Medicine, University of California, Los Angeles, USA.
| | - David Haase
- Department of Emergency Medicine, David Geffen School of Medicine UCLA, Olive View UCLA Medical Center, Los Angeles, USA
| | - Agatha Brzezinski
- Department of Emergency Medicine, David Geffen School of Medicine UCLA, Olive View UCLA Medical Center, Los Angeles, USA
| | - Rikke Ogawa
- UCI Libraries, University of California, Irvine, USA
| | - Parsa Asachi
- David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Alan Chiem
- Department of Emergency Medicine, David Geffen School of Medicine UCLA, Olive View UCLA Medical Center, Los Angeles, USA
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Dietvorst S, Depreitere B, Meyfroidt G. Beyond intracranial pressure: monitoring cerebral perfusion and autoregulation in severe traumatic brain injury. Curr Opin Crit Care 2023; 29:85-88. [PMID: 36762674 DOI: 10.1097/mcc.0000000000001026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Severe traumatic brain injury (TBI) remains the most prevalent neurological condition worldwide. Observational and interventional studies provide evidence to recommend monitoring of intracranial pressure (ICP) in all severe TBI patients. Existing guidelines focus on treating elevated ICP and optimizing cerebral perfusion pressure (CPP), according to fixed universal thresholds. However, both ICP and CPP, their target thresholds, and their interaction, need to be interpreted in a broader picture of cerebral autoregulation, the natural capacity to adjust cerebrovascular resistance to preserve cerebral blood flow in response to external stimuli. RECENT FINDINGS Cerebral autoregulation is often impaired in TBI patients, and monitoring cerebral autoregulation might be useful to develop personalized therapy rather than treatment of one size fits all thresholds and guidelines based on unidimensional static relationships. SUMMARY Today, there is no gold standard available to estimate cerebral autoregulation. Cerebral autoregulation can be triggered by performing a mean arterial pressure (MAP) challenge, in which MAP is increased by 10% for 20 min. The response of ICP (increase or decrease) will estimate the status of cerebral autoregulation and can steer therapy mainly concerning optimizing patient-specific CPP. The role of cerebral metabolic changes and its relationship to cerebral autoregulation is still unclear and awaits further investigation.
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Affiliation(s)
| | | | - Geert Meyfroidt
- Department of Intensive Care, University Hospitals Leuven, Leuven, Belgium
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Foote CW, Jarvis S, Doan XL, Guice J, Cruz B, Vanier C, Betancourt A, Bar-Or D, Palacio CH. Correlation between intracranial pressure monitoring for severe traumatic brain injury with hospital length of stay and discharge disposition: a retrospective observational cohort study. Patient Saf Surg 2022; 16:40. [PMID: 36581936 PMCID: PMC9801642 DOI: 10.1186/s13037-022-00350-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/21/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Intracranial pressure (ICP) monitoring is recommended for severe traumatic brain injuries (TBI) but some data suggests it may not improve outcomes. The objective was to investigate the effect of ICP monitoring among TBI. METHODS This retrospective observational cohort study (1/1/2015-6/1/2020) included severe TBI patients. Outcomes [discharge destination, length of stay (LOS)] were compared by ICP monitoring and were stratified by GCS (3 vs. 4-8), α < 0.05. RESULTS Of the123 patients who met inclusion criteria, 47% received ICP monitoring. There were baseline differences in the two groups characteristics, ICP monitored patients were younger (p = 0.02), had a subarachnoid hemorrhage less often (p = 0.04), and a subdural hematoma more often (p = 0.04) than those without ICP monitors. ICP monitored patients had a significantly longer median LOS (12 vs. 3, p < 0.01) than patients without monitoring. There was a trend towards more ICP monitored patients discharged home (40% vs. 23%, p = 0.06). Among patients with GCS = 3, ICP monitored patients had a longer LOS (p < 0.01) with no significant differences in discharge destinations. For those with a GCS of 4-8, ICP monitoring was associated with a longer LOS (p = 0.01), but fewer were discharged to a skilled nursing facility or long-term care (p = 0.01). CONCLUSIONS For TBI patients, ICP monitoring was associated with an increased LOS, with no significant differences in discharge destinations when compared to those without ICP monitoring. However, among only those with a GCS of 4-8, ICP monitoring was associated with a decreased proportion of patients discharged to a skilled nursing facility or long-term acute care .
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Affiliation(s)
- Christopher W. Foote
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA ,Valley Health Systems, Graduate Medical Education, 2075 East Flamingo Rd, Las Vegas, NV 89119 USA
| | - Stephanie Jarvis
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO 80113 USA
| | - Xuan-Lan Doan
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA ,Valley Health Systems, Graduate Medical Education, 2075 East Flamingo Rd, Las Vegas, NV 89119 USA
| | - Jordan Guice
- grid.416653.30000 0004 0450 5663Brooke Army Medical Center, 8551 Roger Brooke Dr, San Antonio, TX 78219 USA
| | - Bianca Cruz
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA
| | - Cheryl Vanier
- grid.430773.40000 0000 8530 6973Touro University, School of Medicine, 874 American Pacific Dr, Henderson, NV 89014 USA
| | - Alejandro Betancourt
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA
| | - David Bar-Or
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO 80113 USA
| | - Carlos H. Palacio
- McAllen Medical Center, South Texas Health System, 301 W Expy 83, McAllen, TX 78503 USA ,Valley Health Systems, Graduate Medical Education, 2075 East Flamingo Rd, Las Vegas, NV 89119 USA
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Intracranial-Pressure-Monitoring-Assisted Management Associated with Favorable Outcomes in Moderate Traumatic Brain Injury Patients with a GCS of 9-11. J Clin Med 2022; 11:jcm11226661. [PMID: 36431137 PMCID: PMC9694446 DOI: 10.3390/jcm11226661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: With a mortality rate of 10−30%, a moderate traumatic brain injury (mTBI) is one of the most variable traumas. The indications for intracranial pressure (ICP) monitoring in patients with mTBI and the effects of ICP on patients’ outcomes are uncertain. The purpose of this study was to examine the indications of ICP monitoring (ICPm) and its effects on the long-term functional outcomes of mTBI patients. Methods: Patients with Glasgow Coma Scale (GCS) scores of 9−11 at Tangdu hospital, between January 2015 and December 2021, were enrolled and treated in this retrospective cohort study. We assessed practice variations in ICP interventions using the therapy intensity level (TIL). Six-month mortality and a Glasgow Outcome Scale Extended (GOS-E) score were the main outcomes. The secondary outcome was neurological deterioration (ND) events. The indication and the estimated impact of ICPm on the functional outcome were investigated by using binary regression analyses. Results: Of the 350 patients, 145 underwent ICP monitoring-assisted management, and the other 205 patients received a standard control based on imaging or clinical examinations. A GCS ≤ 10 (OR 1.751 (95% CI 1.216−3.023), p = 0.003), midline shift (mm) ≥ 2.5 (OR 3.916 (95% CI 2.076−7.386) p < 0.001), and SDH (OR 1.772 (95% CI 1.065−2.949) p = 0.028) were predictors of ICP. Patients who had ICPm (14/145 (9.7%)) had a decreased 6-month mortality rate compared to those who were not monitored (40/205 (19.5%), p = 0.011). ICPm was linked to both improved neurological outcomes at 6 months (OR 0.815 (95% CI 0.712−0.933), p = 0.003) and a lower ND rate (2 = 11.375, p = 0.010). A higher mean ICP (17.32 ± 3.52, t = −6.047, p < 0.001) and a more significant number of ICP > 15 mmHg (27 (9−45.5), Z = −5.406, p < 0.001) or ICP > 20 mmHg (5 (0−23), Z = −4.635, p < 0.001) 72 h after injury were associated with unfavorable outcomes. The best unfavorable GOS-E cutoff value of different ICP characteristics showed that the mean ICP was >15.8 mmHg (AUC 0.698; 95% CI, 0.606−0.789, p < 0.001), the number of ICP > 15 mmHg was >25.5 (AUC 0.681; 95% CI, 0.587−0.774, p < 0.001), and the number of ICP > 20 mmHg was >6 (AUC 0.660; 95% CI, 0.561−0.759, p < 0.001). The total TIL score during the first 72 h post-injury in the non-ICP group (9 (8, 11)) was lower than that of the ICP group (13 (9, 17), Z = −8.388, p < 0.001), and was associated with unfavorable outcomes. Conclusion: ICPm-assisted management was associated with better clinical outcomes six months after discharge and lower incidences of ND for seven days post-injury. A mean ICP > 15.8 mmHg, the number of ICP > 15 mmHg > 25.5, or the number of ICP > 20 mmHg > 6 implicate an unfavorable long-term prognosis after 72 h of an mTBI.
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The Significance of Intracranial Pressure Monitoring for Reducing Mortality in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:1956908. [PMID: 36254239 PMCID: PMC9569199 DOI: 10.1155/2022/1956908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
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.
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El-Swaify ST, Kamel M, Ali SH, Bahaa B, Refaat MA, Amir A, Abdelrazek A, Beshay PW, Basha AKMM. Initial neurocritical care of severe traumatic brain injury: New paradigms and old challenges. Surg Neurol Int 2022; 13:431. [DOI: 10.25259/sni_609_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Early neurocritical care aims to ameliorate secondary traumatic brain injury (TBI) and improve neural salvage. Increased engagement of neurosurgeons in neurocritical care is warranted as daily briefings between the intensivist and the neurosurgeon are considered a quality indicator for TBI care. Hence, neurosurgeons should be aware of the latest evidence in the neurocritical care of severe TBI (sTBI).
Methods:
We conducted a narrative literature review of bibliographic databases (PubMed and Scopus) to examine recent research of sTBI.
Results:
This review has several take-away messages. The concept of critical neuroworsening and its possible causes is discussed. Static thresholds of intracranial pressure (ICP) and cerebral perfusion pressure may not be optimal for all patients. The use of dynamic cerebrovascular reactivity indices such as the pressure reactivity index can facilitate individualized treatment decisions. The use of ICP monitoring to tailor treatment of intracranial hypertension (IHT) is not routinely feasible. Different guidelines have been formulated for different scenarios. Accordingly, we propose an integrated algorithm for ICP management in sTBI patients in different resource settings. Although hyperosmolar therapy and decompressive craniectomy are standard treatments for IHT, there is a lack high-quality evidence on how to use them. A discussion of the advantages and disadvantages of invasive ICP monitoring is included in the study. Addition of beta-blocker, anti-seizure, and anticoagulant medications to standardized management protocols (SMPs) should be considered with careful patient selection.
Conclusion:
Despite consolidated research efforts in the refinement of SMPs, there are still many unanswered questions and novel research opportunities for sTBI care.
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Affiliation(s)
- Seif Tarek El-Swaify
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Menna Kamel
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sara Hassan Ali
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Bassem Bahaa
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Abdelrahman Amir
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Pavly Wagih Beshay
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience. Pediatr Rep 2022; 14:352-365. [PMID: 35997419 PMCID: PMC9397046 DOI: 10.3390/pediatric14030042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/04/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Intracranial hypertension (IC-HTN) is significantly associated with higher risk for an unfavorable outcome in pediatric trauma. Intracranial pressure (ICP) monitoring is widely becoming a standard of neurocritical care for children. Methods: The present study was designed to evaluate influences of IC-HTN on clinical outcomes of pediatric TBI patients. Demographic, injury severity, radiologic characteristics were used as possible predictors of IC-HTN or of functional outcome. Results: A total of 118 pediatric intensive care unit (PICU) patients with severe TBI (sTBI) were included. Among sTBI cases, patients with GCS < 5 had significantly higher risk for IC-HTN and for mortality. Moreover, there was a statistically significant positive correlation between IC-HTN and severity scoring systems. Kaplan−Meier analysis determined a significant difference for good recovery among patients who had no ICP elevations, compared to those who had at least one episode of IC-HTN (log-rank chi-square = 11.16, p = 0.001). A multivariable predictive logistic regression analysis distinguished the ICP-monitored patients at risk for developing IC-HTN. The model finally revealed that higher ISS and Helsinki CT score increased the odds for developing IC-HTN (p < 0.05). Conclusion: The present study highlights the importance of ICP-guided clinical practices, which may lead to increasing percentages of good recovery for children.
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Abstract
PURPOSE OF REVIEW The aim of this study was to provide an overview on advances in intracranial pressure (ICP) protocols for care, moving from traditional to more recent concepts. RECENT FINDINGS Deep understanding of mechanics and dynamics of fluids and solids have been introduced for intracranial physiology. The amplitude or the harmonics of the cerebral-spinal fluid and the cerebral blood waves shows more information about ICP than just a numeric threshold. When the ICP overcome the compensatory mechanisms that maintain the compliance within the skull, an intracranial compartment syndrome (ICCS) is defined. Autoregulation monitoring emerge as critical tool to recognize CPP management. Measurement of brain tissue oxygen will be a critical intervention for diagnosing an ICCS. Surgical procedures focused on increasing the physiological compliance and increasing the volume of the compartments of the skull. SUMMARY ICP management is a complex task, moving far than numeric thresholds for activation of interventions. The interactions of intracranial elements requires new interpretations moving beyond classical theories. Most of the traditional clinical studies supporting ICP management are not generating high class evidence. Recommendations for ICP management requires better designed clinical studies using new concepts to generate interventions according to the new era of personalized medicine.
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Ahmad M, Qurneh A, Saleh M, Aladaileh M, Alhamad R. The effect of implementing adult trauma clinical practice guidelines on outcomes of trauma patients and healthcare providers. Int Emerg Nurs 2022; 61:101143. [DOI: 10.1016/j.ienj.2021.101143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 12/16/2021] [Accepted: 12/29/2021] [Indexed: 11/05/2022]
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Basha AK, Mahmoud MA, Al Ashwal MI, Aglan O, ElShawady SB, Abdel-Latif AM, Elsayed AM, AbdelGhany W. Management of Severe Traumatic Brain Injury: A Single Institution Experience in a Middle-Income Country. Front Surg 2021; 8:690723. [PMID: 34746219 PMCID: PMC8570277 DOI: 10.3389/fsurg.2021.690723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Severe traumatic brain injury (TBI) is a major public health problem usually resulting in mortality or severe disabling morbidities of the victims. Intracranial pressure (ICP) monitoring is recently recognized as an imperative modality in the management of severe TBI, whereas growing evidence, based on randomized controlled trials (RCTs), suggests that ICP monitoring does not affect the outcome when compared with clinical and radiological data-based management. Also, ICP monitoring carries a considerable risk of intracranial infection that cannot be overlooked. The aim of this study is to assess the different aspects of our current local institutional management of severe TBI using non-invasive ICP monitoring for a potential need to change our management strategy. Methods: We retrospectively reviewed our data of TBI from June 2019 through January 2020. Patients with severe TBI were identified. Their demographics, Glasgow coma score (GCS) at presentation, treatments received, and imaging data were extracted from the charts. Glasgow outcome scale extended (GOS-E) at 6 months was also assessed for the patients. Results: Twenty patients with severe TBI were identified on chart review. Ten patients received only medical treatment measures to lower the ICP, whereas the other 10 patients had additional surgical interventions. In one patient, a ventriculostomy tube was inserted to monitor ICP and to drain cerebrospinal fluid (CSF). This was complicated by ventriculostomy-associated infection (VAI) and the tube was removed. In our cohort, the total mortality rate was 40%. The average GOS-E for the survivor patients managed without ICP monitoring based on the clinical and radiological data was 6.2 at 6 months follow-up. The 6-month overall good outcome, based on GOS-E, was 33.3%. Conclusion: Although recent guidelines advocate for the use of ICP monitoring in the management of severe TBI, they remain underutilized in our practice due to many factors. External ventricular drains were mainly used to drain CSF; however, the higher rates of VAIs in our institution compared with the literature-reported rates are not in favor of the use of ICP monitoring. We recommend doing a comparative study between our current practice using clinical-and radiological-based management and subdural or intraparenchymal bolts. More structured RCTs are needed to validate these findings in our setting.
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Affiliation(s)
| | | | | | - Osama Aglan
- Neurosurgery Department, Ain Shams University, Cairo, Egypt
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Çelik K, Demiryurek BE. The association between intracranial pressure and optic nerve sheath diameter on patients with head trauma. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:879-885. [PMID: 34706017 DOI: 10.1590/0004-282x-anp-2020-0478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although intracranial pressure (ICP) monitoring is the gold standard method for measuring intracranial pressure after traumatic brain injury, optic nerve sheath diameter (ONSD) measurement with ultrasound (US) is also used in the evaluation of ICP. OBJECTIVE To investigate the association between a series of OSND measurements by US and changes in clinical presentation of the patient. METHODS Prospective study including 162 patients with traumatic brain injury. Age, sex, cerebral CT findings, ONSD levels by US at minutes 0, 60, and 120, Glasgow Coma Scale (GCS) within same period, change of consciousness, treatment, and mortality data were reviewed. The association of ONSD levels with GCS, change of consciousness, treatment, and mortality was evaluated. RESULTS There was no difference in ONSD changes in the patients' sample within the period (p=0.326). ONSD significantly increased in patients who died (p<0.001), but not in those who survived (p=0.938). There was no significant change in ONSD of the patients who received anti-edema therapy (p=801), but significantly increased ONSD values were found in those who received anti-edema therapy (p=0.03). Patients without change of consciousness did not have any significant change in ONSD (p=0.672), but ONSD values increased in patients who consciousness became worse, and decreased in those who presented a recovery (respectively, p<0.001, p=0.002). A negative correlation was detected between ONSD values and GSC values measured at primary, secondary, and tertiary time periods (for all p<0.001). CONCLUSIONS ONSD follow-up may be useful to monitor ICP increase in patients with acute traumatic brain injury.
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Affiliation(s)
- Kaan Çelik
- Abant İzzet Baysal University Education and Research Hospital, Department of Emergency, Bolu, Turkey
| | - Bekir Enes Demiryurek
- Abant İzzet Baysal University Education and Research Hospital, Department of Neurology, Bolu, Turkey
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Pérez-Sánchez J, Carrillo de Gea JM, Rodríguez Barceló S, Toval Á, Fernández-Alemán JL, García-Berná JA, Popović M, Toval A. Intracranial pressure analysis software: A mapping study and proposal. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 209:106334. [PMID: 34450483 DOI: 10.1016/j.cmpb.2021.106334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/28/2021] [Indexed: 06/13/2023]
Abstract
Introduction Intracranial pressure (ICP) monitoring and analysis are techniques that are, each year, applied to millions of patients with pathologies with million of patients annually. The detection of the so called A and B-waves, and the analysis of subtle changes in C-waves, which are present in ICP waveform, may indicate decreased intracranial compliance, and may improve the clinical outcome. Despite the advances in the field of computerized data analysis, the visual screening of ICP continues to be the means principally employed to detect these waves. To the best of our knowledge, no review study has addressed automated ICP analysis in sufficient detail and a need to research the state of the art of ICP analysis has, therefore, been identified. Methodology This paper presents a systematic mapping study to provide answers to 7 research questions: publication time, venue and source trends, medical tasks undertaken, research methods used, computational systems developed, validation methodology, tools and systems employed for evaluation and research problems identified. An ICP software prototype is presented and evaluated as a consequence of the results. Results A total of 23 papers, published between 1990 and 2020, were selected from 6 online databases. After analyzing these papers, the following information was obtained: diagnosis and monitoring medical tasks were addressed to the same extent, and the main research method used was evaluation research. Several computational systems were identified in the papers, the main one being image classification, while the main analysis objective was single pulse analysis. Correlation with expert analysis was the most frequent validation method, and few of the papers stated the use of a published dataset. Few authors referred to the tools used to build or evaluate the proposed solutions. The most frequent research problem was the need for new analysis methods. These results have inspired us to propose a software prototype with which provide an automated solution that integrates ICP analysis and monitoring techniques. Conclusions The papers in this study were selected and classified with regard to ICP automated analysis methods. Several research gaps were identified, which the authors of this study have employed as a based on which to recommend future work. Furthermore, this study has identified the need for an empirical comparison between methods, which will require the use and development of certain standard metrics. An in-depth analysis conducted by means of systematic literature review is also required. The software prototype evaluation provided positive results, showing that the prototype may be a reliable system for A-wave detection.
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Affiliation(s)
- Juanjo Pérez-Sánchez
- Department of Informatics and Systems, Faculty of Computer Science, University of Murcia, Murcia, Spain.
| | - Juan M Carrillo de Gea
- Department of Informatics and Systems, Faculty of Computer Science, University of Murcia, Murcia, Spain.
| | | | - Ángel Toval
- Department of Human Anatomy and Psychobiology, Faculty of Medicine, University of Murcia, Murcia, Spain; Institute of Biomedical Research of Murcia, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain.
| | - José L Fernández-Alemán
- Department of Informatics and Systems, Faculty of Computer Science, University of Murcia, Murcia, Spain.
| | - José A García-Berná
- Department of Informatics and Systems, Faculty of Computer Science, University of Murcia, Murcia, Spain.
| | - Miroljub Popović
- Department of Human Anatomy and Psychobiology, Faculty of Medicine, University of Murcia, Murcia, Spain; Institute of Biomedical Research of Murcia, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain.
| | - Ambrosio Toval
- Department of Informatics and Systems, Faculty of Computer Science, University of Murcia, Murcia, Spain.
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Barami K, Pemberton J, Banerjee A, London J, Bandy W. A Retrospective Analysis of Intracranial Pressure Monitoring and Outcomes in Adults after Severe Traumatic Brain Injury at Kaiser Permanente Trauma Centers. Perm J 2021; 25. [PMID: 35348072 DOI: 10.7812/tpp/20.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The role of intracranial pressure (ICP) monitoring in improving outcomes after severe traumatic brain injury especially at level II trauma centers remains controversial. A retrospective analysis was undertaken to assess the impact of ICP monitoring on mortality and long-term functional outcome in adults after severe traumatic brain injury at level II trauma centers. METHODS The data were extracted from the Kaiser Permanente trauma database. Inclusion criteria were adults (≥ 18 years) with severe traumatic brain injury (Glasgow Coma Scale score, < 9) admitted to 2 level II trauma centers in Northern California from 2014 to 2019. RESULTS Of 199 patients, 58 (29.1%) underwent ICP monitoring. The monitored subgroup was significantly younger (< 65 years), had lower Glasgow Coma Scale scores (3-5), underwent cranial procedures (craniotomy or decompressive craniectomy) more often, and had greater injury severity scores (≥ 15). Despite monitored patients being more severely injured, there was no significant difference in mortality or 6-month favorable outcomes between monitored and nonmonitored patients, including patients who underwent cranial procedures. Increased monitoring frequency and reduction in overall mortality was seen throughout the study period yet with a parallel reduction in both groups. CONCLUSION ICP monitoring may not impact in-patient mortality or long-term outcomes at level II trauma centers. Improved outcomes may be more related to identifying patients who may benefit from ICP-guided therapy rather than simply increasing the overall use of it. Last, our pattern of care and outcomes are comparable to level I trauma centers and our findings may serve as a benchmark for future studies.
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Affiliation(s)
- Kaveh Barami
- Department of Neurosurgery, Kaiser Vacaville, Vacaville, CA
| | | | - Amit Banerjee
- Department of Neurosurgery, Kaiser Sacramento, Sacramento, CA
| | - Jason London
- Department of Trauma Surgery, Kaiser South Sacramento, Sacramento, CA
| | - William Bandy
- Department of Trauma Surgery, Kaiser Vacaville, Vacaville, CA
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Scarboro M, McQuillan KA. Traumatic Brain Injury Update. AACN Adv Crit Care 2021; 32:29-50. [PMID: 33725106 DOI: 10.4037/aacnacc2021331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Traumatic brain injury is a devastating, life-changing event in most cases. After the primary brain insult, it is helpful to use evidence-based monitoring techniques to guide implementation of essential interventions to minimize secondary injury and thereby improve patient outcomes. An update on multimodal neuromonitoring is provided in this narrative review, with discussion of tools and techniques currently used in the treatment of patients with brain injury. Neuroprotective treatments, from the well-studied targeted temperature management to new potential therapeutics under investigation, such as glyburide, also are presented.
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Affiliation(s)
- Maureen Scarboro
- Maureen Scarboro is Acute Care Nurse Practitioner, Neurosurgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Karen A McQuillan
- Karen A. McQuillan is Lead Clinical Nurse Specialist, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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Pan Y, Xue Y, Zhao P, Ding J, Ren Z, Xu J. Significance of ICP-related parameters for the treatment and outcome of severe traumatic brain injury. J Int Med Res 2020; 48:300060520941291. [PMID: 32854551 PMCID: PMC7459188 DOI: 10.1177/0300060520941291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective To analyze the significance of intracranial pressure (ICP)-related parameters
on outcome in patients with severe traumatic brain injury. The ICP-related
parameters included ICP, ICP dose (DICP), regression of the correlation
coefficient between amplitude and pressure (RAP), pressure reactivity index
(PRx), and cerebral perfusion pressure (CPP). Methods A retrospective analysis was performed using clinical information from 29
patients with severe traumatic brain injury who were admitted to the
Department of Neurosurgery from January 2018 to January 2019. All patients
underwent ICP probe implantation after admission. Patients were followed up
for 6 months after discharge, and were categorized into either the favorable
or unfavorable outcome group based on their Glasgow Outcome Scale score. The
differences in ICP, DICP, RAP, PRx, and CPP between the two groups were
analyzed for their effects on outcome. Results The average ICP, DICP, PRx, and RAP values in patients with favorable
outcomes were significantly lower than in patients with unfavorable
outcomes, while CPP values were significantly higher in the favorable
outcome group. Conclusion Average ICP, DICP, PRx, RAP, and CPP values may indicate disease status and
relate to patient outcomes. It is important to use multiple parameters to
predict patients’ disease severity and prognosis.
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Affiliation(s)
- Yuchun Pan
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Yuanfeng Xue
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Penglai Zhao
- Department of Neurosurgery, Brain Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Junhong Ding
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Zhiwen Ren
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Jian Xu
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
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Hoffman H, Bunch KM, Furst T, Chin LS. Use of Intracranial Pressure Monitoring in Patients with Severe Traumatic Brain Injury. World Neurosurg 2020; 142:e385-e395. [PMID: 32668331 DOI: 10.1016/j.wneu.2020.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The Brain Trauma Foundation (BTF) recommends intracranial pressure (ICP) monitoring for all salvageable patients with an abnormal computed tomography (CT) scan and a Glasgow Coma Scale <9. Studies have shown that compliance with this recommendation is low. We sought to obtain contemporary national rates of ICP monitor placement in patients with severe traumatic brain injury (TBI). METHODS Patients from the National Trauma Data Bank from 2013 to 2017 who met BTF criteria for ICP monitoring were included. Placement of an intraparenchymal ICP monitor or an external ventricular drain was queried. Binary logistic regression was used to determine factors that influenced the placement of an ICP monitor. RESULTS A total of 21,374 patients with severe TBI and an abnormal CT scan were included in the study. An ICP monitor was placed in 6543 patients (30.6%). ICP monitor placement increased modestly from 28.6% in 2013 to 32.8% in 2017. The pooled odds of ICP monitor placement between 2014 and 2017 were not different from 2013 (odds ratio, 1.04; 95% confidence interval, 0.99-1.09), but the adjusted odds of ICP monitor placement in 2017 were significantly greater (odds ratio, 1.18; 95% confidence interval, 1.06-1.30). Treatment at a teaching hospital, subdural hematoma, multiple intracranial abnormalities on CT, and greater Injury Severity Score were associated with ICP monitor placement, whereas older age was negatively associated with ICP monitor placement. CONCLUSIONS The rate of ICP monitoring in patients with severe TBI who meet BTF criteria is low and increased only slightly from 2013 to 2017.
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Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA.
| | - Katherine M Bunch
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Taylor Furst
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Lawrence S Chin
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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