Where should patients with severe traumatic brain injury be managed? All patient should be managed in a neurocritical care unit

Ketamine for Critically Ill Patients with Severe Acute Brain Injury: A Systematic Review with Meta-analysis and Trial Sequential Analysis of Randomized Clinical Trials

BACKGROUND

Patients with severe acute brain injury have a high risk of a poor clinical outcome due to primary and secondary brain injury. Ketamine reportedly inhibits cortical spreading depolarization, an electrophysiological phenomenon that has been associated with secondary brain injury, making ketamine potentially attractive for patients with severe acute brain injury. The aim of this systematic review is to explore the current literature regarding ketamine for patients with severe acute brain injury.

METHODS

We systematically searched international databases for randomized clinical trials comparing ketamine by any regimen versus placebo, no intervention, or any control drug for patients with severe acute brain injury. Two authors independently reviewed and selected trials for inclusion, extracted data, assessed risk of bias, and performed analysis using Review Manager and Trial Sequential Analysis. Evidence certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation. The primary outcomes were the proportion of participants with an unfavorable functional outcome, the proportion of participants with one or more serious adverse events, and quality of life.

RESULTS

We identified five randomized trials comparing ketamine versus sufentanil, fentanyl, other sedatives, or saline (total N = 149 participants). All outcomes were at overall high risk of bias. The proportions of participants with one or more serious adverse events did not differ between ketamine and sufentanil or fentanyl (relative risk 1.45, 95% confidence interval 0.81-2.58; very low certainty). Trial sequential analysis showed that further trials are needed.

CONCLUSIONS

The level of evidence regarding the effects of ketamine on functional outcome and serious adverse events in patients with severe acute brain injury is very low. Ketamine may markedly, modestly, or not at all affect these outcomes. Large randomized clinical trials at low risk of bias are needed.

Variation in Severity-Adjusted Resource use and Outcome for Neurosurgical Emergencies in the Intensive Care Unit

BACKGROUND

The correlation between the standardized resource use ratio (SRUR) and standardized hospital mortality ratio (SMR) for neurosurgical emergencies is not known. We studied SRUR and SMR and the factors affecting these in patients with traumatic brain injury (TBI), nontraumatic intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH).

METHODS

We extracted data of patients treated in six university hospitals in three countries (2015-2017). Resource use was measured as SRUR based on purchasing power parity-adjusted direct costs and either intensive care unit (ICU) length of stay (costSRURlength of stay) or daily Therapeutic Intervention Scoring System scores (costSRURTherapeutic Intervention Scoring System). Five a priori defined variables reflecting differences in structure and organization between the ICUs were used as explanatory variables in bivariable models, separately for the included neurosurgical diseases.

RESULTS

Out of 28,363 emergency patients treated in six ICUs, 6,162 patients (22%) were admitted with a neurosurgical emergency (41% nontraumatic ICH, 23% SAH, 13% multitrauma TBI, and 23% isolated TBI). The mean costs for neurosurgical admissions were higher than for nonneurosurgical admissions, and the neurosurgical admissions corresponded to 23.6-26.0% of all direct costs related to ICU emergency admissions. A higher physician-to-bed ratio was associated with lower SMRs in the nonneurosurgical admissions but not in the neurosurgical admissions. In patients with nontraumatic ICH, lower costSRURs were associated with higher SMRs. In the bivariable models, independent organization of an ICU was associated with lower costSRURs in patients with nontraumatic ICH and isolated/multitrauma TBI but with higher SMRs in patients with nontraumatic ICH. A higher physician-to-bed ratio was associated with higher costSRURs for patients with SAH. Larger units had higher SMRs for patients with nontraumatic ICH and isolated TBI. None of the ICU-related factors were associated with costSRURs in nonneurosurgical emergency admissions.

CONCLUSIONS

Neurosurgical emergencies constitute a major proportion of all emergency ICU admissions. A lower SRUR was associated with higher SMR in patients with nontraumatic ICH but not for the other diagnoses. Different organizational and structural factors seemed to affect resource use for the neurosurgical patients compared with nonneurosurgical patients. This emphasizes the importance of case-mix adjustment when benchmarking resource use and outcomes.

Ketamine for critically ill patients with severe acute brain injury: Protocol for a systematic review with meta-analysis and Trial Sequential Analysis of randomised clinical trials

INTRODUCTION

Intensive care for patients with severe acute brain injury aims both to treat the immediate consequences of the injury and to prevent and treat secondary brain injury to ensure a good functional outcome. Sedation may be used to facilitate mechanical ventilation, for treating agitation, and for controlling intracranial pressure. Ketamine is an N-methyl-D-aspartate receptor antagonist with sedative, analgesic, and potentially neuroprotective properties. We describe a protocol for a systematic review of randomised clinical trials assessing the beneficial and harmful effects of ketamine for patients with severe acute brain injury.

METHODS AND ANALYSIS

We will systematically search international databases for randomised clinical trials, including CENTRAL, MEDLINE, Embase, and trial registries. Two authors will independently review and select trials for inclusion, and extract data. We will compare ketamine by any regimen versus placebo, no intervention, or other sedatives or analgesics for patients with severe acute brain injury. The primary outcomes will be functional outcome at maximal follow up, quality of life, and serious adverse events. We will also assess secondary and exploratory outcomes. The extracted data will be analysed using Review Manager and Trials Sequential Analysis. Evidence certainty will be graded using GRADE.

ETHICS AND DISSEMINATION

The results of the systematic review will be disseminated through peer-reviewed publication. With the review, we hope to inform future randomised clinical trials and improve clinical practice.

PROSPERO NO

CRD42021210447.

Relationship between hospital volume and outcomes in patients with traumatic brain injury: A retrospective observational study using a national inpatient database in Japan

BACKGROUND

The relationship between hospital volume and outcome after traumatic brain injury (TBI) is not completely understood in a real clinical setting. We investigated whether patients admitted with TBI achieved better outcomes in high-volume hospitals than in low-volume hospitals using a national inpatient database in Japan.

METHODS

This retrospective cohort study used the Diagnosis Combination Procedure database in Japan. We included patients with TBI admitted to hospitals with a Japan Coma Scale (JCS) score ≥2 between April 1, 2013 and March 31, 2014. Hospital volume was defined as the annual number of all admissions with TBI in individual hospitals. The hospital volume was categorized into four volume groups: low (≤60 admissions per hospital), medium-low (61-120 admissions per hospital), medium-high (121-180 admissions per hospital) and high (≥181 admissions per hospital). The outcomes of interest included 28-day mortality and survival discharge with complete dependency defined as a Barthel Index score of 0 at discharge. We used multivariate logistic regression models fitted with generalized estimating equations to evaluate relationships between the hospital volume and the outcomes. The hospital volume was evaluated both as categorical variables defined above and as continuous variables.

RESULTS

The analysis dataset consisted of 20,146 eligible patients. Of these, 2,784 died within 28days (13.8%) and 3,409 were completely dependent among 16,996 patients discharged alive (20.1%). Multivariate analyses found that there was no significant difference between the high-volume and low-volume groups for 28-day mortality (adjusted odds ratio [OR] 0.79, 95% confidence interval [CI] 0.58-1.06 for the high-volume group) or complete dependency at discharge (adjusted OR 0.94, 95% CI 0.71-1.23 for the high-volume group). The results were the same when the hospital volume was evaluated as a continuous variable.

CONCLUSIONS

Hospital volume did not appear to influence outcomes in patients with TBI. High-volume hospitals may not be necessarily beneficial for patients with TBI exhibiting impaired consciousness as a whole.

An evaluation of the clinical and cost-effectiveness of alternative care locations for critically ill adult patients with acute traumatic brain injury

BACKGROUND

For critically ill adult patients with acute traumatic brain injury (TBI), we assessed the clinical and cost-effectiveness of: (a) Management in dedicated neurocritical care units versus combined neuro/general critical care units within neuroscience centres. (b) 'Early' transfer to a neuroscience centre versus 'no or late' transfer for those who present at a non-neuroscience centre.

METHODS

The Risk Adjustment In Neurocritical care (RAIN) Study included prospective admissions following acute TBI to 67 UK adult critical care units during 2009-11. Data were collected on baseline case-mix, mortality, resource use, and at six months, Glasgow Outcome Scale Extended (GOSE), and quality of life (QOL) (EuroQol 5D-3L). We report incremental effectiveness, costs and cost per Quality-Adjusted Life Year (QALY) of the alternative care locations, adjusting for baseline differences with validated risk prediction models. We tested the robustness of results in sensitivity analyses.

FINDINGS

Dedicated neurocritical care unit patients (N = 1324) had similar six-month mortality, higher QOL (mean gain 0.048, 95% CI -0.002 to 0.099) and increased average costs compared with those managed in combined neuro/general units (N = 1341), with a lifetime cost per QALY gained of £14,000. 'Early' transfer to a neuroscience centre (N = 584) was associated with lower mortality (odds ratio 0.52, 0.34-0.80), higher QOL for survivors (mean gain 0.13, 0.032-0.225), but positive incremental costs (£15,001, £11,123 to £18,880) compared with 'late or no transfer' (N = 263). The lifetime cost per QALY gained for 'early' transfer was £11,000.

CONCLUSIONS

For critically ill adult patients with acute TBI, within neuroscience centres management in dedicated neurocritical care units versus combined neuro/general units led to improved QoL and higher costs, on average, but these differences were not statistically significant. This study finds that 'early' transfer to a neuroscience centre is associated with reduced mortality, improvement in QOL and is cost-effective.

Xenon improves neurologic outcome and reduces secondary injury following trauma in an in vivo model of traumatic brain injury

OBJECTIVES

To determine the neuroprotective efficacy of the inert gas xenon following traumatic brain injury and to determine whether application of xenon has a clinically relevant therapeutic time window.

DESIGN

Controlled animal study.

SETTING

University research laboratory.

SUBJECTS

Male C57BL/6N mice (n = 196).

INTERVENTIONS

Seventy-five percent xenon, 50% xenon, or 30% xenon, with 25% oxygen (balance nitrogen) treatment following mechanical brain lesion by controlled cortical impact.

MEASUREMENTS AND MAIN RESULTS

Outcome following trauma was measured using 1) functional neurologic outcome score, 2) histological measurement of contusion volume, and 3) analysis of locomotor function and gait. Our study shows that xenon treatment improves outcome following traumatic brain injury. Neurologic outcome scores were significantly (p < 0.05) better in xenon-treated groups in the early phase (24 hr) and up to 4 days after injury. Contusion volume was significantly (p < 0.05) reduced in the xenon-treated groups. Xenon treatment significantly (p < 0.05) reduced contusion volume when xenon was given 15 minutes after injury or when treatment was delayed 1 or 3 hours after injury. Neurologic outcome was significantly (p < 0.05) improved when xenon treatment was given 15 minutes or 1 hour after injury. Improvements in locomotor function (p < 0.05) were observed in the xenon-treated group, 1 month after trauma.

CONCLUSIONS

These results show for the first time that xenon improves neurologic outcome and reduces contusion volume following traumatic brain injury in mice. In this model, xenon application has a therapeutic time window of up to at least 3 hours. These findings support the idea that xenon may be of benefit as a neuroprotective treatment in patients with brain trauma.

Using barriers analysis to refine a novel model of neurocritical care

BACKGROUND

In order to deliver specialized neurocritical care (NCC) without a dedicated neurological intensive care unit (ICU), we established a virtual NCC unit within an existing mixed level III ICU. This initiative required changes to patient allocation, physician staffing, and care protocols. In advance of its implementation, we gaged readiness, assessed barriers, and solicited feedback from staff.

METHODS

Clinicians at our academic hospital and trauma centre in Toronto, Ontario were the subjects of this concurrent mixed methods study. Eighteen stakeholders were individually interviewed. 116 of 217 eligible ICU staff participated in the survey and 36 staff attended the focus group sessions.

RESULTS

From the survey, the most significant barriers to this reorganization were staff anxiety about coping (28 %) and a concern that patients would not receive better care (24 %). Noteworthy obstacles about the use of protocols were their lack of flexibility (19 %) and that implementation was seen as impractical (16 %). Seventeen barriers were proposed through an open-ended survey question. Content analysis revealed general resistance, educational challenges, workflow adjustment to a diagnosis-based rounding pattern and coordination conflicts to be the central barriers. These findings were confirmed in focus group discussions, with a lack of resources as an additional important challenge.

CONCLUSIONS

A new workable model for NCC has been developed, facilitated by this analysis. Steps to overcome barriers demonstrated in this study include additional educational measures, changes to the rounding protocols, and patient allocation algorithms.

The Optimum Location of Care for Traumatic Brain Injury Patients Admitted to Non-Specialist Hospitals

Early secondary transfer and specialist care may offer a survival benefit for head injury patients with non-surgical lesions initially admitted to non-specialist intensive care units. However, results must be interpreted with caution due to a high risk of bias.

Level of evidence: 1B−, an individual cohort study with wide confidence intervals

The effectiveness of specialist neuroscience care in severe traumatic brain injury: a systematic review

BACKGROUND

UK trauma services are currently undergoing reconfiguration, but the optimum management pathway for head-injured patients is uncertain. We therefore performed a systematic review to assess the effects of routine inter-hospital transfer and specialist neuroscience care on mortality and disability in patients with non-surgical severe traumatic brain injury injured nearest to a non-specialist acute hospital.

METHODS

A protocol was registered with PROSPERO (CRD42012002021) and review methodology followed Cochrane Collaboration recommendations. A peer reviewed search strategy was implemented in an exhaustive range of information sources, including all major bibliographic databases, between 1973 and July 2013. Selection of eligible studies, extraction of relevant data and bias assessment were then performed by two independent reviewers. In the absence of homogeneous effect estimates at low risk of bias a narrative synthesis was pre-specified.

RESULTS

Four cohort studies, including a total of 4688 patients, were identified as potentially eligible after screening and bias assessment. Confounding by indication, arising from selective transfer of less severely injured patients, was the main limitation of included studies, with overall risk of bias rated as high for both mortality and disability effect estimates. Adjusted odds ratios for mortality favoured secondary transfer, ranging from 1.92 (95% CI 1.25-2.95) to 2.09 (95% CI 1.59-2.74). No convincing association was observed between non-specialist care and unfavourable outcome with a conditional odds ratio of 1.13 (95% CI 0.36-3.6).

CONCLUSIONS

There is limited evidence supporting a strategy of secondary transfer of severe non-surgical traumatic brain injury patients to specialist neuroscience centres. Randomised controlled trials powered to detect clinically plausible treatment effects should be considered to definitively investigate effectiveness.

Intracranial pressure monitoring, cerebral perfusion pressure estimation, and ICP/CPP-guided therapy: a standard of care or optional extra after brain injury?

Measurement of intracranial pressure (ICP) and mean arterial pressure (MAP) is used to derive cerebral perfusion pressure (CPP) and to guide targeted therapy of acute brain injury (ABI) during neurointensive care. Here we provide a narrative review of the evidence for ICP monitoring, CPP estimation, and ICP/CPP-guided therapy after ABI. Despite its widespread use, there is currently no class I evidence that ICP/CPP-guided therapy for any cerebral pathology improves outcomes; indeed some evidence suggests that it makes no difference, and some that it may worsen outcomes. Similarly, no class I evidence can currently advise the ideal CPP for any form of ABI. 'Optimal' CPP is likely patient-, time-, and pathology-specific. Further, CPP estimation requires correct referencing (at the level of the foramen of Monro as opposed to the level of the heart) for MAP measurement to avoid CPP over-estimation and adverse patient outcomes. Evidence is emerging for the role of other monitors of cerebral well-being that enable the clinician to employ an individualized multimodality monitoring approach in patients with ABI, and these are briefly reviewed. While acknowledging difficulties in conducting robust prospective randomized studies in this area, such high-quality evidence for the utility of ICP/CPP-directed therapy in ABI is urgently required. So, too, is the wider adoption of multimodality neuromonitoring to guide optimal management of ICP and CPP, and a greater understanding of the underlying pathophysiology of the different forms of ABI and what exactly the different monitoring tools used actually represent.

Effective management of severe traumatic brain injury in a district hospital

The authors investigated how effectively adults with severe traumatic brain injury (TBI) can be managed in a district general hospital intensive care unit offering intracranial pressure monitoring (ICPM) receiving advice from a neurosurgical unit. A single-centre case series with retrospective review of prospectively collected information was undertaken of 44 consecutive patients presenting over seven years from January 2003 to January 2010 with severe traumatic brain injury to a single district general hospital intensive care unit serving a population of 500,000 adults. A prospectively entered clinical database was used to obtain information including patient demographics, Glasgow Coma Score (GCS) on admission, ICPM insertion, ICPM-related complications, inpatient mortality and neurosurgical advice. Case notes were used to ratify information and obtain neurorehabilitation clinic functional outcome scores. Forty-four patients were identified (40 male, age range 16-77 years). Mortality in intensive care was 30%. Twenty-eight patients received frontal twist drill ICPM following neurosurgical advice. ICPM had 2 (7%) device malfunctions but no other complications. Twelve additional patients were transferred to tertiary centres. Patients (23 of 31) who survived ICU stay (74%) were referred to neurorehabilitation. Mean clinic follow-up was 14 months. All patients had a Glasgow Outcome Score (GOS) of 3 or 4 at initial clinic assessment. Twenty-two improved to GOS to 4 or 5 at clinic discharge. One patient died prior to clinic discharge. Carefully selected patients with severe TBI can be managed safely and effectively in a district general hospital offering ICPM insertion if transfer to a neurosurgical centre is not possible. Neurosurgical advice regarding patient selection and on-going management is fundamental to provide a good service. Protocol driven therapies provide a useful systematic approach to doctors who do not deal with severe TBI on a routine basis.