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Suehiro E, Tanaka T, Kawashima M, Matsuno A. Challenges in the Treatment of Severe Traumatic Brain Injury Based on Data in the Japan Neurotrauma Data Bank. Neurol Med Chir (Tokyo) 2023; 63:43-47. [PMID: 36436980 PMCID: PMC9995150 DOI: 10.2176/jns-nmc.2022-0276] [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: 11/25/2022] Open
Abstract
The Japan Neurotrauma Data Bank is a source of epidemiological data for patients with severe traumatic brain injury (TBI) and is sponsored by the Japan Society of Neurotraumatology. In this report, we examined the changes in the treatment of severe TBI in Japan based on data of the Japan Neurotrauma Data Bank. Controlling and decreasing intracranial pressure (ICP) are the primary objective of severe TBI treatment. Brain-oriented whole-body control or neurocritical care, including control of cerebral perfusion pressure, respiration, and infusion, are also increasingly considered important because cerebral tissues require oxygenation to improve the outcomes of patients with severe TBI. The introduction of neurocritical care in Japan was delayed compared with that in Western countries. However, the rate of ICP monitoring increased from 28.0% in 2009 to 36.7% in 2015 and is currently likely to be higher. Neurocritical care has also become more common, but the functional prognosis of patients has not significantly improved in Japan. Changes in the background of patients with severe TBI suggest the need for improvement of acute-phase treatment for elderly patients. Appropriate social rehabilitation from the subacute to chronic phases and introduction of cellular therapeutics are also needed for patients with TBI.
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Affiliation(s)
- Eiichi Suehiro
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
| | - Tatsuya Tanaka
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
| | - Masatou Kawashima
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
| | - Akira Matsuno
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
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Jeong TS, Choi DH, Kim WK. Comparison of Outcomes at Trauma Centers versus Non-Trauma Centers for Severe Traumatic Brain Injury. J Korean Neurosurg Soc 2023; 66:63-71. [PMID: 35996944 PMCID: PMC9837480 DOI: 10.3340/jkns.2022.0163] [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: 07/13/2022] [Accepted: 08/22/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Traumatic brain injury (TBI) is one of the most common injuries in patients with multiple trauma, and it associates with high post-traumatic mortality and morbidity. A trauma center was established to provide optimal treatment for patients with severe trauma. This study aimed to compare the treatment outcomes of patients with severe TBI between non-trauma and trauma centers based on data from the Korean Neuro-Trauma Data Bank System (KNTDBS). METHODS From January 2018 to June 2021, 1122 patients were enrolled in the KNTDBS study. Among them, 253 patients from non-traumatic centers and 253 from trauma centers were matched using propensity score analysis. We evaluated baseline characteristics, the time required from injury to hospital arrival, surgery-related factors, neuromonitoring, and outcomes. RESULTS The time from injury to hospital arrival was shorter in the non-trauma centers (110.2 vs. 176.1 minutes, p=0.012). The operation time was shorter in the trauma centers (156.7 vs. 128.1 minutes, p0.003). Neuromonitoring was performed in nine patients (3.6%) in the non-trauma centers and 67 patients (26.5%) in the trauma centers (p<0.001). Mortality rates were lower in trauma centers than in non-trauma centers (58.5% vs. 47.0%, p=0.014). The average Glasgow coma scale (GCS) at discharge was higher in the trauma centers (4.3 vs. 5.7, p=0.011). For the Glasgow outcome scale-extended (GOSE) at discharge, the favorable outcome (GOSE 5-8) was 17.4% in the non-trauma centers and 27.3% in the trauma centers (p=0.014). CONCLUSION This study showed lower mortality rates, higher GCS scores at discharge, and higher rates of favorable outcomes in trauma centers than in non-trauma centers. The regional trauma medical system seems to have a positive impact in treating patients with severe TBI.
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Affiliation(s)
- Tae Seok Jeong
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Dae Han Choi
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea,Address for correspondence : Dae Han Choi Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel : +82-32-460-3304, Fax : +82-32-460-3899, E-mail :
| | - Woo Kyung Kim
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - KNTDB Investigators
- Korea Neuro-Trauma Data Bank Committee, Korean Neurotraumatology Society, Korea
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3
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Dynamic prediction of mortality after traumatic brain injury using a machine learning algorithm. NPJ Digit Med 2022; 5:96. [PMID: 35851612 PMCID: PMC9293936 DOI: 10.1038/s41746-022-00652-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 07/06/2022] [Indexed: 11/08/2022] Open
Abstract
Intensive care for patients with traumatic brain injury (TBI) aims to optimize intracranial pressure (ICP) and cerebral perfusion pressure (CPP). The transformation of ICP and CPP time-series data into a dynamic prediction model could aid clinicians to make more data-driven treatment decisions. We retrained and externally validated a machine learning model to dynamically predict the risk of mortality in patients with TBI. Retraining was done in 686 patients with 62,000 h of data and validation was done in two international cohorts including 638 patients with 60,000 h of data. The area under the receiver operating characteristic curve increased with time to 0.79 and 0.73 and the precision recall curve increased with time to 0.57 and 0.64 in the Swedish and American validation cohorts, respectively. The rate of false positives decreased to ≤2.5%. The algorithm provides dynamic mortality predictions during intensive care that improved with increasing data and may have a role as a clinical decision support tool.
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Lumba-Brown A, Prager EM, Harmon N, McCrea MA, Bell MJ, Ghajar J, Pyne S, Cifu DX. A Review of Implementation Concepts and Strategies Surrounding Traumatic Brain Injury Clinical Care Guidelines. J Neurotrauma 2021; 38:3195-3203. [PMID: 34714147 DOI: 10.1089/neu.2021.0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: (1) possible etiologies of inadequate adoption and implementation; (2) enablers to successful implementation strategies; and (3) strategies to mitigate the barriers to adoption and implementation of future research.
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Affiliation(s)
- Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University, Stanford, California, USA
| | | | | | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Neurosurgery Research Laboratory, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Michael J Bell
- Pediatrics, Critical Care Medicine, Children's National Hospital, Washington DC, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Scott Pyne
- Traumatic Brain Injury Center of Excellence, Defense Health Agency, Silver Spring, Maryland, USA
| | - David X Cifu
- Virginia Commonwealth University School of Medicine, and Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
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Cnossen MC, Scholten AC, Lingsma HF, Synnot A, Tavender E, Gantner D, Lecky F, Steyerberg EW, Polinder S. Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review. J Neurotrauma 2021; 38:1072-1085. [PMID: 26431625 PMCID: PMC8054518 DOI: 10.1089/neu.2015.4121] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, PubMed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult patients with TBI. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18-100%) and was higher in guideline recommendations based on strong evidence compared with those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale, and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal, and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.
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Affiliation(s)
- Maryse C. Cnossen
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Hester F. Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Anneliese Synnot
- Center for Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Australia
- Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Emma Tavender
- Australian Satellite of Cochrane EPOC group, Melbourne, Australia
| | - Dashiell Gantner
- Center for Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Australia
| | - Fiona Lecky
- Department of Emergency Medicine, University of Sheffield, University of Manchester and Salford Royal Hospital NHS Foundation Trust, and 2012 NICE Head Injury Guideline Development Group, United Kingdom
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
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Batomen B, Moore L, Carabali M, Tardif PA, Champion H, Nandi A. Effectiveness of trauma centre verification: a systematic review and meta-analysis. Can J Surg 2021; 64:E25-E38. [PMID: 33450148 PMCID: PMC7955829 DOI: 10.1503/cjs.016219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background There is a growing trend toward verification of trauma centres, but its impact remains unclear. This systematic review aimed to synthesize available evidence on the effectiveness of trauma centre verification. Methods We conducted a systematic search of the CINAHL, Embase, HealthStar, MEDLINE and ProQuest databases, as well as the websites of key injury organizations for grey literature, from inception to June 2019, without language restrictions. Our population consisted of injured patients treated at trauma centres. The intervention was trauma centre verification. Comparison groups comprised nonverified trauma centres, or the same centre before it was first verified or re-verified. The primary outcome was in-hospital mortality; secondary outcomes included adverse events, resource use and processes of care. We computed pooled summary estimates using random-effects meta-analysis. Results Of 5125 citations identified, 29, all conducted in the United States, satisfied our inclusion criteria. Mortality was the most frequently investigated outcome (n = 20), followed by processes of care (n = 12), resource use (n = 12) and adverse events (n = 7). The risk of bias was serious to critical in 22 studies. We observed an imprecise association between verification and decreased mortality (relative risk 0.74, 95% confidence interval 0.52 to 1.06) in severely injured patients. Conclusion Our review showed mixed and inconsistent associations between verification and processes of care or patient outcomes. The validity of the published literature is limited by the lack of robust controls, as well as any evidence from outside the US, which precludes extrapolation to other health care jurisdictions. Quasiexperimental studies are needed to assess the impact of trauma centre verification. Systematic reviews registration PROSPERO no. CRD42018107083
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Affiliation(s)
- Brice Batomen
- From the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Batomen, Carabali); the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Moore) and the Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Moore, Tardif); the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md. (Champion); and the Institute for Health and Social Policy, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Nandi)
| | - Lynne Moore
- From the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Batomen, Carabali); the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Moore) and the Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Moore, Tardif); the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md. (Champion); and the Institute for Health and Social Policy, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Nandi)
| | - Mabel Carabali
- From the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Batomen, Carabali); the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Moore) and the Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Moore, Tardif); the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md. (Champion); and the Institute for Health and Social Policy, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Nandi)
| | - Pier-Alexandre Tardif
- From the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Batomen, Carabali); the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Moore) and the Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Moore, Tardif); the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md. (Champion); and the Institute for Health and Social Policy, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Nandi)
| | - Howard Champion
- From the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Batomen, Carabali); the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Moore) and the Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Moore, Tardif); the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md. (Champion); and the Institute for Health and Social Policy, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Nandi)
| | - Arijit Nandi
- From the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Batomen, Carabali); the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Moore) and the Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de recherche du CHU de Québec - Université Laval, Québec, Que. (Moore, Tardif); the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md. (Champion); and the Institute for Health and Social Policy, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Que. (Nandi)
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Hospital-level intracranial pressure monitoring utilization and functional outcome in severe traumatic brain injury: a post hoc analysis of prospective multicenter observational study. Scand J Trauma Resusc Emerg Med 2021; 29:5. [PMID: 33407751 PMCID: PMC7789401 DOI: 10.1186/s13049-020-00825-7] [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: 07/23/2020] [Accepted: 12/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Several observational studies have shown that hospital-level intracranial pressure (ICP) monitoring utilization varies considerably in patients with severe traumatic brain injury (TBI). However, the relationship between hospital-level ICP monitoring utilization and clinical functional outcomes is unknown. This study examined whether patients with severe TBI treated at hospitals with high ICP monitoring utilization have better functional outcomes. Methods A post hoc analysis of the data from a prospective multicenter cohort study in Japan was undertaken, and included severe TBI patients (Glasgow Come Scale score ≤ 8). The primary exposure was hospital-level ICP monitoring utilization. Patients treated at hospitals with more than 80% ICP monitoring utilization were assigned to a high group and the others to a low group. The primary endpoint was a favorable functional outcome at 6 months after injury, defined as a Glasgow Outcome Scale score of good recovery or moderate disability. We conducted multiple logistic regression analyses adjusted for potential confounders. Results Of the 427 included patients, 60 were assigned to the high group and 367 to the low group. Multiple logistic regression analysis revealed that patients in the high group had significantly better functional outcome (adjusted odds ratio [OR]: 2.36; 95% confidence interval [CI]: 1.17–4.76; p = 0.016). Multiple logistic regression analysis adjusted for additional confounders supported this result (adjusted OR: 2.30; 95% CI: 1.07–4.92; p = 0.033). Conclusion Treatment at hospitals with high ICP monitoring utilization for severe TBI patients could be associated with better functional outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-020-00825-7.
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Chalouhi N, Mouchtouris N, Saiegh FA, Starke RM, Theofanis T, Das SO, Jallo J. Comparison of Outcomes in Level I vs Level II Trauma Centers in Patients Undergoing Craniotomy or Craniectomy for Severe Traumatic Brain Injury. Neurosurgery 2020; 86:107-111. [PMID: 30690608 PMCID: PMC6911730 DOI: 10.1093/neuros/nyy634] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 01/17/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) carries a devastatingly high rate of morbidity and mortality. OBJECTIVE To assess whether patients undergoing craniotomy/craniectomy for severe TBI fare better at level I than level II trauma centers in a mature trauma system. METHODS The data were extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients > 18 yr with severe TBI (Glasgow Coma Scale [GCS] score less than 9) undergoing craniotomy or craniectomy in the state of Pennsylvania from January 1, 2002 through September 30, 2017. RESULTS Of 3980 patients, 2568 (64.5%) were treated at level I trauma centers and 1412 (35.5%) at level II centers. Baseline characteristics were similar between the 2 groups except for significantly worse GCS scores at admission in level I centers (P = .002). The rate of in-hospital mortality was 37.6% in level I centers vs 40.4% in level II centers (P = .08). Mean Functional Independence Measure (FIM) scores at discharge were significantly higher in level I (10.9 ± 5.5) than level II centers (9.8 ± 5.3; P < .005). In multivariate analysis, treatment at level II trauma centers was significantly associated with in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.03-1.37; P = .01) and worse FIM scores (odds ratio, 1.4; 95% confidence interval, 1.1-1.7; P = .001). Mean hospital and ICU length of stay were significantly longer in level I centers (P < .005). CONCLUSION This study showed superior functional outcomes and lower mortality rates in patients undergoing a neurosurgical procedure for severe TBI in level I trauma centers.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Fadi Al Saiegh
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M Starke
- Department of Neurosurgery & Radiology, Miami Miller School of Medicine, Miami University Hospital, Miami, Florida
| | - Thana Theofanis
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Somnath O Das
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Jack Jallo
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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9
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Yeates EO, Grigorian A, Schubl SD, Kuza CM, Joe V, Lekawa M, Borazjani B, Nahmias J. Chemoprophylaxis and Venous Thromboembolism in Traumatic Brain Injury at Different Trauma Centers. Am Surg 2020. [DOI: 10.1177/000313482008600433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patients with severe traumatic brain injury (TBI) are at an increased risk of venous thromboembolism (VTE). Because of concerns of worsening intracranial hemorrhage, clinicians are hesitant to start VTE chemoprophylaxis in this population. We hypothesized that ACS Level I trauma centers would be more aggressive with VTE chemoprophylaxis in adults with severe TBI than Level II centers. We also predicted that Level I centers would have a lower risk of VTE. We queried the Trauma Quality Improvement Program (2010–2016) database for patients with Abbreviated Injury Scale scores of 4 and 5 of the head and compared them based on treating the hospital trauma level. Of 204,895 patients with severe TBI, 143,818 (70.2%) were treated at Level I centers and 61,077 (29.8%) at Level II centers. The Level I cohort had a higher rate of VTE chemoprophylaxis use (43.2% vs 23.3%, P < 0.001) and a shorter median time to chemoprophylaxis (61.9 vs 85.9 hours, P < 0.001). Although Level I trauma centers started VTE chemoprophylaxis more often and earlier than Level II centers, there was no difference in the risk of VTE ( P = 0.414) after controlling for covariates. Future prospective studies are warranted to evaluate the timing, safety, and efficacy of early VTE chemoprophylaxis in severe TBI patients.
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Affiliation(s)
- Eric O. Yeates
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Areg Grigorian
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Sebastian D. Schubl
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Catherine M. Kuza
- Department of Anesthesiology, University of Southern California Medical Center, Los Angeles, California
| | - Victor Joe
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Michael Lekawa
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Boris Borazjani
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Jeffry Nahmias
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
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10
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Abstract
BACKGROUND Pediatric readiness among US emergency departments is not universal. Trauma hospitals adhere to standards that may support day-to-day readiness for children. METHODS In 2013 4,146 emergency departments participated in the NPRP to assess compliance with the 2009 Guidelines to Care for Children in the Emergency Department. Probabilistic linkage (90%) to the 2009 American Hospital Association survey found 1,247 self-identified trauma hospitals (levels 1, 2, 3, 4). Relationship between trauma hospital level and weighted pediatric readiness score (WPRS) on a 100-point scale was performed; significance was assessed using a Kruskal-Wallis test and pediatric readiness elements using χ. Adjusted relative risks were calculated using modified Poisson regression, controlling for pediatric volume, hospital configuration, and geography. RESULTS The overall WPRS among all trauma hospitals (1,247) was 71.8. Among those not self-identified as a children's hospital or emergency department approved for pediatrics (EDAP) (1088), Level 1 and 2 trauma hospitals had higher WPRS than level 3 and 4 trauma hospitals, 83.5 and 71.8, respectively versus 64.9 and 62.6. Yet, compared with EDAP trauma hospitals (median 90.5), level 1 general trauma hospitals were less likely to have critical pediatric-specific elements. Common gaps among general trauma hospitals included presence of interfacility transfer agreements for children, measurement of pediatric weights solely in kilograms, quality improvement processes with pediatric-specific metrics, and disaster plans that include pediatric-specific needs. CONCLUSION Self-identified trauma hospital level may not translate to pediatric readiness in emergency departments. Across all levels of general non-EDAP, nonchildren's trauma hospitals, gaps in pediatric readiness exist. Nonchildren's hospital EDs (i.e., EDAPs) can be prepared to meet the emergency needs of all children and trauma hospital designation should incorporate these core elements of pediatric readiness. LEVEL OF EVIDENCE Care management, level III.
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11
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Remick K, Cramer A. Hear Our Voice: Every Child, Every Day; Pediatric Emergency Care Services in the United States. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Lepard JR, Walters BC. In Reply: A Bibliometric Analysis of Neurosurgical Practice Guidelines. Neurosurgery 2020; 86:E405-E406. [PMID: 31814019 DOI: 10.1093/neuros/nyz539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jacob R Lepard
- Department of Neurological Surgery The University of Alabama at Birmingham Birmingham, Alabama
| | - Beverly C Walters
- Department of Neurological Surgery The University of Alabama at Birmingham Birmingham, Alabama
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Chesnut RM, Temkin N, Videtta W, Petroni G, Lujan S, Pridgeon J, Dikmen S, Chaddock K, Barber J, Machamer J, Guadagnoli N, Hendrickson P, Aguilera S, Alanis V, Bello Quezada ME, Bautista Coronel E, Bustamante LA, Cacciatori AC, Carricondo CJ, Carvajal F, Davila R, Dominguez M, Figueroa Melgarejo JA, Fillipi MM, Godoy DA, Gomez DC, Lacerda Gallardo AJ, Guerra Garcia JA, Zerain GLF, Lavadenz Cuientas LA, Lequipe C, Grajales Yuca GV, Jibaja Vega M, Kessler ME, López Delgado HJ, Sandi Lora F, Mazzola AM, Maldonado RM, Mezquia de Pedro N, Martínez Zubieta JR, Mijangos Méndez JC, Mora J, Ochoa Parra JM, Pahnke PB, Paranhos J, Piñero GR, Rivadeneira Pilacuán FA, Mendez Rivera MN, Romero Figueroa RL, Rubiano AM, Saraguro Orozco AM, Silesky Jiménez JI, Silva Naranjo L, Soler Morejon C, Urbina Z. Consensus-Based Management Protocol (CREVICE Protocol) for the Treatment of Severe Traumatic Brain Injury Based on Imaging and Clinical Examination for Use When Intracranial Pressure Monitoring Is Not Employed. J Neurotrauma 2020; 37:1291-1299. [PMID: 32013721 DOI: 10.1089/neu.2017.5599] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Globally, intracranial pressure (ICP) monitoring use in severe traumatic brain injury (sTBI) is inconsistent and susceptible to resource limitations and clinical philosophies. For situations without monitoring, there is no published comprehensive management algorithm specific to identifying and treating suspected intracranial hypertension (SICH) outside of the one ad hoc Imaging and Clinical Examination (ICE) protocol in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST:TRIP) trial. As part of an ongoing National Institutes of Health (NIH)-supported project, a consensus conference involving 43 experienced Latin American Intensivists and Neurosurgeons who routinely care for sTBI patients without ICP monitoring, refined, revised, and augmented the original BEST:TRIP algorithm. Based on BEST:TRIP trial data and pre-meeting polling, 11 issues were targeted for development. We used Delphi-based methodology to codify individual statements and the final algorithm, using a group agreement threshold of 80%. The resulting CREVICE (Consensus REVised ICE) algorithm defines SICH and addresses both general management and specific treatment. SICH treatment modalities are organized into tiers to guide treatment escalation and tapering. Treatment schedules were developed to facilitate targeted management of disease severity. A decision-support model, based on the group's combined practices, is provided to guide this process. This algorithm provides the first comprehensive management algorithm for treating sTBI patients when ICP monitoring is not available. It is intended to provide a framework to guide clinical care and direct future research toward sTBI management. Because of the dearth of relevant literature, it is explicitly consensus based, and is provided solely as a resource (a "consensus-based curbside consult") to assist in treating sTBI in general intensive care units in resource-limited environments.
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Affiliation(s)
- Randall M Chesnut
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Nancy Temkin
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Walter Videtta
- Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina
| | - Gustavo Petroni
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- Hospital Emergencia, Dr. Clemente Alvarez, Rosario, Argentina
| | - Jim Pridgeon
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Sureyya Dikmen
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Kelley Chaddock
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jason Barber
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Joan Machamer
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Peter Hendrickson
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Victor Alanis
- Hospital San Juan de Dios, Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Felipe Carvajal
- Hospital Municipal Eva Peron de Merlo, Provincia Buenos Aires, Argentina
| | - Rafael Davila
- Hospital Universitario Luis Razetti, Barcelona, Venezuela
| | - Mario Dominguez
- Hospital Universitario Provincial "Arnaldo Milián Castro," Santa Clara, Cuba
| | | | | | | | | | | | | | | | | | | | | | | | | | - Hubiel J López Delgado
- Neurosurgery, Critical Care Medicine, CEDIMAT, Plaza de la Salud Juan, Santo Domingo, Dominican Republic
| | | | | | | | | | | | | | - Jacobo Mora
- Hospital Universitario Luis Razetti, Barcelona, Venezuela
| | - Johnny Marcelo Ochoa Parra
- Hospital José Carrasco Arteaga. IESS. Cuenca Facultad de Medicina, Universidad del Azuay, Cuenca, Ecuador
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Whitfill TM, Remick KE, Olson LM, Richards R, Brown KM, Auerbach MA, Gausche-Hill M. Statewide Pediatric Facility Recognition Programs and Their Association with Pediatric Readiness in Emergency Departments in the United States. J Pediatr 2020; 218:210-216.e2. [PMID: 31757472 DOI: 10.1016/j.jpeds.2019.10.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/10/2019] [Accepted: 10/09/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To describe the relationship between statewide pediatric facility recognition (PFR) programs and pediatric readiness in emergency departments (EDs) in the US. STUDY DESIGN Data were extracted from the 2013 National Pediatric Readiness Project assessment (4083 EDs). Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) based on a 100-point scale. Descriptive statistics were used to compare WPRS between recognized and nonrecognized EDs and between states with or without a PFR program. A linear mixed model with WPRS was used to evaluate state PFR programs on pediatric readiness. RESULTS Eight states were identified with a PFR program. EDs in states with a PFR program had a higher WPRS compared with states without a PFR program (overall a 9.1-point higher median WPRS; P < .001); EDs recognized in a PFR program had a 21.7-point higher median WPRS compared with nonrecognized EDs (P < .001); and between states with a statewide PFR program, there was high variability of participation within the states. We found state-level PFR programs predicted a higher WPRS compared with states without a PFR program (β = 5.49; 95% CI 2.76-8.23). CONCLUSIONS Statewide PFR programs are based on national guidelines and identify those EDs that adhere to a standard level of readiness for children. These statewide PFR initiatives are associated with higher pediatric readiness. As scalable strategies are needed to improve emergency care for children, our study suggests that statewide PFR programs may be one way to improve pediatric readiness and underscores the need for further implementation and evaluation.
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Affiliation(s)
- Travis M Whitfill
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Katherine E Remick
- Office of the Medical Director, Austin-Travis County EMS System, Austin, TX; Dell Medical School at the University of Texas, Austin, TX; San Marcos/Hays County EMS System, San Marcos, TX; EMS for Children Innovation and Improvement Center, Houston, TX
| | - Lenora M Olson
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT
| | - Rachel Richards
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, UT
| | - Kathleen M Brown
- Department of Emergency Medicine, The George Washington University School of Medicine, Washington, DC; Children's National Medical Center, Washington, DC
| | - Marc A Auerbach
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Marianne Gausche-Hill
- Departments of Emergency Medicine and Pediatrics, Harbor-UCLA Medical Center, Torrance, CA; Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA; Emergency Medical Services Agency, Department of Health Services, Los Angeles County, Los Angeles, CA
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15
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The Initiation of Rehabilitation Therapies and Observed Outcomes in Pediatric Traumatic Brain Injury. Rehabil Nurs 2019; 43:327-334. [PMID: 30395558 DOI: 10.1097/rnj.0000000000000116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Pediatric traumatic brain injury (TBI) is associated with immense physical, emotional, social, and economic burden. This study examined timing and frequency of rehabilitation services provided by the inpatient interdisciplinary team in children admitted for a TBI. Understanding the timing and frequency of rehabilitation services could guide TBI recovery. DESIGN AND METHODS This is a 3-year prospective observational study of previously healthy children (n = 35) admitted for a TBI to an urban Level 1 trauma hospital. Children with mild, moderate, and severe TBI were included. Initiation and frequency of the interdisciplinary rehabilitation team's care and neurocognitive-functional outcomes were analyzed. Outcome measures included the Glasgow Outcome Scale-Extended Pediatrics and the Speech Pathology Neurocognitive-Functional Evaluation at hospital discharge and first follow-up visit. RESULTS The initiation and the frequency of rehabilitation services were found in all severities of TBI. Timing and frequency of services also aligned with varied severities. Children with moderate TBI showed the most improvement in Glasgow Outcome Scale-Extended Pediatrics and the Speech Pathology Neurocognitive-Functional Evaluation on their first follow-up visit, whereas children with mild and severe TBI demonstrated little change in outcome at their first follow-up visit and had varied services based on their hospital course. CONCLUSION Services by interdisciplinary rehabilitation teams were provided across all brain injury severity groups, despite the lack of comprehensive rehabilitation guidelines. Varied neurocognitive and functional outcome changes measured found children with moderate TBI had the greatest change in outcomes. Further research is warranted to assess the timing and frequency of services and their relationship to neurocognitive-functional outcomes.
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van Essen TA, den Boogert HF, Cnossen MC, de Ruiter GCW, Haitsma I, Polinder S, Steyerberg EW, Menon D, Maas AIR, Lingsma HF, Peul WC. Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study. Acta Neurochir (Wien) 2019; 161:435-449. [PMID: 30569224 PMCID: PMC6407836 DOI: 10.1007/s00701-018-3761-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/30/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe. METHODS A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP). RESULTS The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions. CONCLUSION Despite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care.
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Affiliation(s)
- Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, The Netherlands.
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland (UNCH), The Hague, The Netherlands.
| | - Hugo F den Boogert
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maryse C Cnossen
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Godard C W de Ruiter
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland (UNCH), The Hague, The Netherlands
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland (UNCH), The Hague, The Netherlands
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17
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Lindfors M, Vehviläinen J, Siironen J, Kivisaari R, Skrifvars MB, Raj R. Temporal changes in outcome following intensive care unit treatment after traumatic brain injury: a 17-year experience in a large academic neurosurgical centre. Acta Neurochir (Wien) 2018; 160:2107-2115. [PMID: 30191364 DOI: 10.1007/s00701-018-3670-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 08/31/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of morbidity and mortality. However, it remains undetermined whether long-term outcomes after TBI have improved over the past two decades. METHODS We conducted a retrospective analysis of consecutive TBI patients admitted to an academic neurosurgical ICU during 1999-2015. Primary outcomes of interest were 6-month all-cause mortality (available for all patients) and 6-month Glasgow Outcome Scale (GOS, available from 2005 onwards). GOS was dichotomized to favourable and unfavourable functional outcome. Temporal changes in outcome were assessed using multivariate logistic regression analysis, adjusting for age, sex, GCS motor score, pupillary light responsiveness, Marshall CT classification and major extracranial injury. RESULTS Altogether, 3193 patients were included. During the study period, patient age and admission Glasgow Coma Scale score increased, while the overall TBI severity did not change. Overall unadjusted 6-month mortality was 25% and overall unadjusted unfavourable outcome (2005-2015) was 44%. There was no reduction in the adjusted odds of 6-month mortality (OR 0.98; 95% CI 0.96-1.00), but the adjusted odds of favourable functional outcome significantly increased (OR 1.08; 95% CI 1.04-1.11). Subgroup analysis showed outcome improvements only in specific subgroups (conservatively treated patients, moderate-to-severe TBI patients, middle-aged patients). CONCLUSIONS During the past two decades, mortality after significant TBI has remained largely unchanged, but the odds of favourable functional outcome have increased significantly in specific subgroups, implying an improvement in quality of care. These developments have been paralleled by notable changes in patient characteristics, emphasizing the importance of continuous epidemiological monitoring.
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Hirschi R, Rommel C, Letsinger J, Nirula R, Hawryluk GWJ. Brain Trauma Foundation Guideline Compliance: Results of a Multidisciplinary, International Survey. World Neurosurg 2018; 116:e399-e405. [PMID: 29751187 DOI: 10.1016/j.wneu.2018.04.215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Brain Trauma Foundation (BTF) guidelines reflect evidence-based best practices in management of traumatic brain injury. The aim of this study was to examine self-reported physician compliance and predictors of compliance related to BTF guidelines. METHODS We conducted an international, multidisciplinary survey examining self-reported adherence to BTF guidelines and multiple factors potentially affecting adherence. We also surveyed intracranial pressure monitoring practices. RESULTS Of 154 physician respondents, 15.9% reported their institutions "always" follow BTF guidelines and 72.2% reported that they follow them "most of the time." Personal volume of traumatic brain injury cases and years in practice were not significantly related to adherence. Reported adherence varied significantly in association with respondent's institutional trauma level (P = 0.0010): 17.3% of practitioners at level I, 13.0% at level II, and 0% at level III trauma centers reported "always" following guidelines. Reported adherence to guidelines also varied significantly in association with provider specialty (P = 0.015) and institutional volume of severe traumatic brain injury cases (P = 0.008). Regarding intracranial pressure monitoring practices, 52% of respondents used external ventricular drains, 21% used intraparenchymal monitors, and 27% had no preference (P < 0.001). Of respondents not routinely using external ventricular drains, 36% claimed to "always" follow guidelines. There was no apparent association between type of intracranial pressure monitoring used and reported guideline adherence. CONCLUSIONS Few respondents reported their institutions "always" follow BTF guidelines. General surgeons and providers at high-volume level I trauma centers were more likely to comply with guidelines. Differences in survey responses based on provider and institutional characteristics may help target educational efforts.
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Affiliation(s)
- Ryan Hirschi
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Casey Rommel
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joshua Letsinger
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Gregory W J Hawryluk
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA.
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19
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Huijben JA, Volovici V, Cnossen MC, Haitsma IK, Stocchetti N, Maas AIR, Menon DK, Ercole A, Citerio G, Nelson D, Polinder S, Steyerberg EW, Lingsma HF, van der Jagt M. Variation in general supportive and preventive intensive care management of traumatic brain injury: a survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:90. [PMID: 29650049 PMCID: PMC5898014 DOI: 10.1186/s13054-018-2000-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/19/2018] [Indexed: 12/20/2022]
Abstract
Background General supportive and preventive measures in the intensive care management of traumatic brain injury (TBI) aim to prevent or limit secondary brain injury and optimize recovery. The aim of this survey was to assess and quantify variation in perceptions on intensive care unit (ICU) management of patients with TBI in European neurotrauma centers. Methods We performed a survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We analyzed 23 questions focused on: 1) circulatory and respiratory management; 2) fever control; 3) use of corticosteroids; 4) nutrition and glucose management; and 5) seizure prophylaxis and treatment. Results The survey was completed predominantly by intensivists (n = 33, 50%) and neurosurgeons (n = 23, 35%) from 66 centers (97% response rate). The most common cerebral perfusion pressure (CPP) target was > 60 mmHg (n = 39, 60%) and/or an individualized target (n = 25, 38%). To support CPP, crystalloid fluid loading (n = 60, 91%) was generally preferred over albumin (n = 15, 23%), and vasopressors (n = 63, 96%) over inotropes (n = 29, 44%). The most commonly reported target of partial pressure of carbon dioxide in arterial blood (PaCO2) was 36–40 mmHg (4.8–5.3 kPa) in case of controlled intracranial pressure (ICP) < 20 mmHg (n = 45, 69%) and PaCO2 target of 30–35 mmHg (4–4.7 kPa) in case of raised ICP (n = 40, 62%). Almost all respondents indicated to generally treat fever (n = 65, 98%) with paracetamol (n = 61, 92%) and/or external cooling (n = 49, 74%). Conventional glucose management (n = 43, 66%) was preferred over tight glycemic control (n = 18, 28%). More than half of the respondents indicated to aim for full caloric replacement within 7 days (n = 43, 66%) using enteral nutrition (n = 60, 92%). Indications for and duration of seizure prophylaxis varied, and levetiracetam was mostly reported as the agent of choice for both seizure prophylaxis (n = 32, 49%) and treatment (n = 40, 61%). Conclusions Practice preferences vary substantially regarding general supportive and preventive measures in TBI patients at ICUs of European neurotrauma centers. These results provide an opportunity for future comparative effectiveness research, since a more evidence-based uniformity in good practices in general ICU management could have a major impact on TBI outcome. Electronic supplementary material The online version of this article (10.1186/s13054-018-2000-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jilske A Huijben
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Neurosurgery, Office H-703, Erasmus MC Stroke Center and Brain Tumor Center, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maryse C Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Iain K Haitsma
- Department of Neurosurgery, Office H-703, Erasmus MC Stroke Center and Brain Tumor Center, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Suzanne Polinder
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Hester F Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care and Erasmus MC Stroke Center, Erasmus Medical Center, Rotterdam, the Netherlands
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Severe brain trauma injury: when no intracranial pressure monitoring is available. ROMANIAN NEUROSURGERY 2018. [DOI: 10.2478/romneu-2018-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Dash HH, Chavali S. Management of traumatic brain injury patients. Korean J Anesthesiol 2018; 71:12-21. [PMID: 29441170 PMCID: PMC5809702 DOI: 10.4097/kjae.2018.71.1.12] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 01/07/2023] Open
Abstract
Traumatic brain injury (TBI) has been called the ‘silent epidemic’ of modern times, and is the leading cause of mortality and morbidity in children and young adults in both developed and developing nations worldwide. In recent years, the treatment of TBI has undergone a paradigm shift. The management of severe TBI is ideally based on protocol-based guidelines provided by the Brain Trauma Foundation. The aims and objectives of its management are prophylaxis and prompt management of intracranial hypertension and secondary brain injury, maintenance of cerebral perfusion pressure, and ensuring adequate oxygen delivery to injured brain tissue. In this review, the authors discuss protocol-based approaches to the management of severe TBI as per recent guidelines.
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Affiliation(s)
- Hari Hara Dash
- Department of Anesthesiology and Pain Medicine, Fortis Memorial Research Institute, Gurgaon, India
| | - Siddharth Chavali
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Development of a Severe Traumatic Brain Injury Consensus-Based Treatment Protocol Conference in Latin America. World Neurosurg 2017; 110:e952-e957. [PMID: 29203307 DOI: 10.1016/j.wneu.2017.11.142] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Severe traumatic brain injury (sTBI) is a significant global health problem disproportionately affecting low- and middle-income countries (LMICs). Management of intracranial hypertension in sTBI is crucial to survival and optimal recovery. Practitioners in high-income countries routinely use intracranial pressure (ICP) monitors although their usefulness has been questioned. ICP monitors are usually unavailable in LMICs. No consensus-based/tested protocols or literature exists for sTBI treatment without ICP monitoring. METHODS Investigators developed serial SurveyMonkey surveys for Latin American neurointensivists and neurosurgeons to determine current practice. These clinicians had extensive routine ongoing experience in sTBI without ICP monitoring. Surveys were administered and analyzed before/during/after a 2015 Buenos Aires consensus conference. Investigators identified areas of convergence blinded from colleagues' responses. A 47-clinician task force, representing 15 countries, who routinely manage patients with sTBI without monitors developed consensus-based treatment guidelines during a 3-day facilitated conference. RESULTS Elements were added to the protocol at an 80% agreement threshold. Follow-on surveys resolved remaining elements to 97% agreement. The protocol addresses both tapering (on improvement) and neuroworsening. Staged treatment options were identified, plus unique clinical practice issues. This process introduced a research method to a large multidisciplinary group of LMIC clinicians. This report describes the process used to develop an LMIC-specific protocol that is transferable to other diseases/injuries. The protocol is being tested in 5 LMICs. CONCLUSIONS We derived consensus-based guidelines for sTBI treatment without ICP monitoring, and introduced a research method to a large multidisciplinary group of LMIC clinicians naive to such methods.
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Chesnut RM, Temkin N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Alanis V, Falcao A, de la Fuenta G, Gonzalez L, Jibaja M, Lavarden A, Sandi F, Mérida R, Romero R, Pridgeon J, Barber J, Machamer J, Chaddock K. A Method of Managing Severe Traumatic Brain Injury in the Absence of Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol. J Neurotrauma 2017; 35:54-63. [PMID: 28726590 DOI: 10.1089/neu.2016.4472] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The imaging and clinical examination (ICE) algorithm used in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) randomized controlled trial is the only prospectively investigated clinical protocol for traumatic brain injury management without intracranial pressure (ICP) monitoring. As the default literature standard, it warrants careful evaluation. We present the ICE protocol in detail and analyze the demographics, outcome, treatment intensity, frequency of intervention usage, and related adverse events in the ICE-protocol cohort. The 167 ICE protocol patients were young (median 29 years) with a median Glasgow Coma Scale motor score of 4 but with anisocoria or abnormal pupillary reactivity in 40%. This protocol produced outcomes not significantly different from those randomized to the monitor-based protocol (favorable 6-month extended Glasgow Outcome Score in 39%; 41% mortality rate). Agents commonly employed to treat suspected intracranial hypertension included low-/moderate-dose hypertonic saline (72%) and mannitol (57%), mild hyperventilation (adjusted partial pressure of carbon dioxide 30-35 mm Hg in 73%), and pressors to maintain cerebral perfusion (62%). High-dose hyperosmotics or barbiturates were uncommonly used. Adverse event incidence was low and comparable to the BEST TRIP monitored group. Although this protocol should produce similar/acceptable results under circumstances comparable to those in the trial, influences such as longer pre-hospital times and non-specialist transport personnel, plus an intensive care unit model of aggressive physician-intensive care by small groups of neurotrauma-focused intensivists, which differs from most high-resource models, support caution in expecting the same results in dissimilar settings. Finally, this protocol's ICP-titration approach to suspected intracranial hypertension (vs. crisis management for monitored ICP) warrants further study.
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Affiliation(s)
- Randall M Chesnut
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Nancy Temkin
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Sureyya Dikmen
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Carlos Rondina
- 2 Hospital Emergencia , Dr. Clemente Alvarez, Rosario, Argentina
| | - Walter Videtta
- 3 Hospital Nacional Professor Alejandro Posadas , Buenos Aires, Argentina
| | - Gustavo Petroni
- 2 Hospital Emergencia , Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- 2 Hospital Emergencia , Dr. Clemente Alvarez, Rosario, Argentina
| | - Victor Alanis
- 4 Hospital San Juan de Dios , Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Freddy Sandi
- 10 Hospital Obrero No 1 de La Paz , La Paz, Bolivia
| | | | | | - Jim Pridgeon
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Jason Barber
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Joan Machamer
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
| | - Kelley Chaddock
- 1 University of Washington , Harborview Medical Center, Seattle, Washington
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24
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Cnossen MC, Huijben JA, van der Jagt M, Volovici V, van Essen T, Polinder S, Nelson D, Ercole A, Stocchetti N, Citerio G, Peul WC, Maas AIR, Menon D, Steyerberg EW, Lingsma HF. 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. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:233. [PMID: 28874206 PMCID: PMC5586023 DOI: 10.1186/s13054-017-1816-9] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/10/2017] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Maryse C Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
| | - Jilske A Huijben
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,Department of Neurosurgery, Erasmus MC, Rotterdam, The Netherlands
| | - Thomas van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne Polinder
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - David Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Ari Ercole
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David Menon
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ewout W Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hester F Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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25
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Directions for Use of Intracranial Pressure Monitoring in the Treatment of Severe Traumatic Brain Injury Using Data from The Japan Neurotrauma Data Bank. J Neurotrauma 2017; 34:2230-2234. [DOI: 10.1089/neu.2016.4948] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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26
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Organización de la asistencia y manejo inicial del traumatismo craneoencefálico grave en España: resultados de una encuesta nacional. Neurocirugia (Astur) 2017; 28:167-175. [DOI: 10.1016/j.neucir.2017.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/29/2016] [Accepted: 01/01/2017] [Indexed: 01/23/2023]
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27
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Gómez PA, Castaño-León AM, Lora D, Cepeda S, Lagares A. Evolución temporal en las características de la tomografía computarizada, presión intracraneal y tratamiento quirúrgico en el traumatismo craneal grave: análisis de la base de datos de los últimos 25 años en un servicio de neurocirugía. Neurocirugia (Astur) 2017; 28:1-14. [DOI: 10.1016/j.neucir.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/05/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
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28
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Edavettal M, Gross BW, Rittenhouse K, Alzate J, Rogers A, Estrella L, Miller JA, Rogers FB. An Analysis of Beta-Blocker Administration Pre-and Post-Traumatic Brain Injury with Subanalyses for Head Injury Severity and Myocardial Injury. Am Surg 2016. [DOI: 10.1177/000313481608201227] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A growing body of literature indicates that beta-blocker administration after traumatic brain injury (TBI) is cerebroprotective, limiting secondary injury; however, the effects of preinjury beta blocker status remain poorly understood. We sought to characterize the effects of pre- and post-injury beta-blocker administration on mortality with subanalyses accounting for head injury severity and myocardial injury. In a Level II trauma center, all admissions of patients ≥18 years with a head Abbreviated Injury Scale Score ≥2, Glasgow Coma Scale ≤13 from May 2011 to May 2013 were queried. Demographic, injury-specific, and outcome variables were analyzed using univariate analyses. Subsequent multivariate analyses were conducted to determine adjusted odds of mortality for beta-blocker usage controlling for age, Injury Severity Score, head Abbreviated Injury Scale, arrival Glasgow Coma Scale, ventilator use, and intensive care unit stay. A total of 214 trauma admissions met inclusion criteria: 112 patients had neither pre- nor postinjury beta-blocker usage, 46 patients had preinjury beta-blocker usage, and 94 patients had postinjury beta-blocker usage. Both unadjusted and adjusted odds ratios of preinjury beta-blocker were insignificant with respect to mortality. However, postinjury in-hospital administration of beta blockers was found to significantly in the decrease of mortality in both univariate ( P = 0.002) and multivariate analyses ( P = 0.001). Our data indicate that beta-blocker administration post-TBI in hospital reduces odds of mortality; however, preinjury beta-blocker usage does not. Additionally, myocardial injury is a useful indicator for beta-blocker administration post-TBI. Further research into which beta blockers confer the best benefits as well as the optimal period of beta-blocker administration post-TBI is recommended.
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Affiliation(s)
- Mathew Edavettal
- From Trauma Services, Lancaster General Health, Lancaster, Pennsylvania
| | - Brian W. Gross
- From Trauma Services, Lancaster General Health, Lancaster, Pennsylvania
| | | | - James Alzate
- From Trauma Services, Lancaster General Health, Lancaster, Pennsylvania
| | - Amelia Rogers
- From Trauma Services, Lancaster General Health, Lancaster, Pennsylvania
| | - Lisa Estrella
- From Trauma Services, Lancaster General Health, Lancaster, Pennsylvania
| | - Jo Ann Miller
- From Trauma Services, Lancaster General Health, Lancaster, Pennsylvania
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29
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30
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Brolliar SM, Moore M, Thompson HJ, Whiteside LK, Mink RB, Wainwright MS, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Ng Boyle L, Mitchell PH, Rivara FP, Vavilala MS. A Qualitative Study Exploring Factors Associated with Provider Adherence to Severe Pediatric Traumatic Brain Injury Guidelines. J Neurotrauma 2016; 33:1554-60. [PMID: 26760283 PMCID: PMC5003009 DOI: 10.1089/neu.2015.4183] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Despite demonstrated improvement in patient outcomes with use of the Pediatric Traumatic Brain Injury (TBI) Guidelines (Guidelines), there are differential rates of adherence. Provider perspectives on barriers and facilitators to adherence have not been elucidated. This study aimed to identify and explore in depth the provider perspective on factors associated with adherence to the Guidelines using 19 focus groups with nurses and physicians who provided acute management for pediatric patients with TBI at five university-affiliated Level 1 trauma centers. Data were examined using deductive and inductive content analysis. Results indicated that three inter-related domains were associated with clinical adherence: 1) perceived guideline credibility and applicability to individual patients, 2) implementation, dissemination, and enforcement strategies, and 3) provider culture, communication styles, and attitudes towards protocols. Specifically, Guideline usefulness was determined by the perceived relevance to the individual patient given age, injury etiology, and severity and the strength of the evidence. Institutional methods to formally endorse, codify, and implement the Guidelines into the local culture were important. Providers wanted local protocols developed using interdisciplinary consensus. Finally, a culture of collaboration, including consistent, respectful communication and interdisciplinary cooperation, facilitated adherence. Provider training and experience, as well as attitudes towards other standardized care protocols, mirror the use and attitudes towards the Guidelines. Adherence was determined by the interaction of each of these guideline, institutional, and provider factors acting in concert. Incorporating provider perspectives on barriers and facilitators to adherence into hospital and team protocols is an important step toward improving adherence and ultimately patient outcomes.
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Affiliation(s)
- Sarah M Brolliar
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Megan Moore
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Hilaire J Thompson
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Lauren K Whiteside
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Richard B Mink
- 2 Harbor-University of California ; Los Angeles BioMedical Research Institute, Los Angeles, California
| | - Mark S Wainwright
- 3 Ann and Robert H. Lurie Children's Hospital of Chicago , Chicago, Illinois
| | | | | | - Christopher C Giza
- 6 Mattel Children's Hospital, University of California , Los Angeles, Los Angeles, California
| | - Douglas F Zatzick
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Richard G Ellenbogen
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Linda Ng Boyle
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Pamela H Mitchell
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Frederick P Rivara
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
| | - Monica S Vavilala
- 1 Harborview Injury Prevention and Research Center, University of Washington , Seattle, Washington
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31
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Ohrt-Nissen S, Colville-Ebeling B, Kandler K, Hornbech K, Steinmetz J, Ravn J, Lehnert P. Indication for resuscitative thoracotomy in thoracic injuries-Adherence to the ATLS guidelines. A forensic autopsy based evaluation. Injury 2016; 47:1019-24. [PMID: 26563482 DOI: 10.1016/j.injury.2015.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/21/2015] [Accepted: 10/17/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The appropriate indications for Resuscitative Thoracotomy (RT) are still debated in the literature and various guidelines have been proposed. This study aimed to evaluate whether Advanced Trauma Life Support (ATLS) guidelines for RT were applied correctly and to evaluate the proportion of deceased patients with potentially reversible thoracic lesions (PRTL). METHODS The database at the Department of Forensic Medicine at Copenhagen University was queried for autopsy cases with thoracic lesions indicated by the SNOMED autopsy coding system. Patients were included if thoracic lesions were caused by a traumatic event with trauma team activation. Patient cases were blinded for any surgical intervention and evaluated independently by two reviewers for indications or contraindications for RT as determined by the ATLS guidelines. Second, autopsy reports were evaluated for the presence of PRTL. RESULTS Sixty-seven patients met the inclusion criteria. Two were excluded due to insufficient data. The overall agreement with guidelines was 86% and 77% for blunt and penetrating trauma, respectively. For patients submitted to RT the overall agreement with guidelines was 63% being 45% and 74% for blunt and penetrating trauma, respectively. For patients who did not undergo RT the agreement with guidelines was 100%. In all cases where RT was performed in agreement between guidelines and the clinical decision the autopsy reports showed PRTL in 16 (84%) patients. In cases of non-agreement PRTL were found in 9 (82%) patients. CONCLUSIONS Agreement with ATLS guidelines for RT was 63% for intervention and 100% for non-intervention in deceased patients with thoracic trauma. Agreement was higher for penetrating trauma than for blunt trauma. The adherence to guidelines did not improve the ability to predict autopsy findings of PRTL. Although the study has methodical limitations it represents a novel approach to the evaluation of the clinical use of RT guidelines.
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Affiliation(s)
- S Ohrt-Nissen
- Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark.
| | - B Colville-Ebeling
- Department of Forensic Medicine, Copenhagen University, Copenhagen, Denmark.
| | - K Kandler
- Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark.
| | - K Hornbech
- Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark.
| | - J Steinmetz
- Department of Anesthesiology and Trauma Centre, HOC, Rigshospitalet, Copenhagen, Denmark.
| | - J Ravn
- Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark.
| | - P Lehnert
- Department of Thoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen East, Denmark.
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32
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Graves JM, Kannan N, Mink RB, Wainwright MS, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Boyle LN, Mitchell PH, Rivara FP, Wang J, Rowhani-Rahbar A, Vavilala MS. Guideline Adherence and Hospital Costs in Pediatric Severe Traumatic Brain Injury. Pediatr Crit Care Med 2016; 17:438-43. [PMID: 26934664 PMCID: PMC4856557 DOI: 10.1097/pcc.0000000000000698] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Adherence to pediatric traumatic brain injury guidelines has been associated with improved survival and better functional outcome. However, the relationship between guideline adherence and hospitalization costs has not been examined. To evaluate the relationship between adherence to pediatric severe traumatic brain injury guidelines, measured by acute care clinical indicators, and the total costs of hospitalization associated with severe traumatic brain injury. DESIGN Retrospective cohort study. SETTING Five regional pediatric trauma centers affiliated with academic medical centers. PATIENTS Demographic, injury, treatment, and charge data were included for pediatric patients (17 yr) with severe traumatic brain injury. INTERVENTIONS Percent adherence to clinical indicators was determined for each patient. Cost-to-charge ratios were used to estimate ICU and total hospital costs for each patient. Generalized linear models evaluated the association between healthcare costs and adherence rate. MEASUREMENTS AND MAIN RESULTS Cost data for 235 patients were examined. Estimated mean adjusted hospital costs were $103,485 (95% CI, 98,553-108,416); adjusted ICU costs were $82,071 (95% CI, 78,559-85,582). No association was found between adherence to guidelines and total hospital or ICU costs, after adjusting for patient and injury characteristics. Adjusted regression model results provided cost ratio equal to 1.01 for hospital and ICU costs (95% CI, 0.99-1.03 and 0.99-1.02, respectively). CONCLUSIONS Adherence to severe pediatric traumatic brain injury guidelines at these five leading pediatric trauma centers was not associated with increased hospitalization and ICU costs. Therefore, cost should not be a factor as institutions and providers strive to provide evidence-based guideline driven care of children with severe traumatic brain injury.
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Affiliation(s)
- Janessa M. Graves
- College of Nursing-Spokane, Washington State University, Spokane, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Nithya Kannan
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Departments of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Richard B. Mink
- Department of Pediatrics, Harbor-UCLA and Los Angeles BioMedical Research Institute, Torrance, CA
| | - Mark S. Wainwright
- Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jonathan I. Groner
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Michael J. Bell
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher C. Giza
- Department of Neurosurgery and Division of Pediatric Neurology, Mattel Children’s Hospital, UCLA, Los Angeles, CA
| | - Douglas F. Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Richard G. Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, WA
- Department of Global Health Medicine, University of Washington, Seattle, WA
| | - Linda Ng Boyle
- Department of Industrial and Systems Engineering, University of Washington, Seattle, WA
| | | | - Frederick P. Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Department of Epidemiology, University of Washington, Seattle, WA
- Departments of Pediatrics, University of Washington, Seattle, WA
| | - Jin Wang
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Departments of Pediatrics, University of Washington, Seattle, WA
| | - Ali Rowhani-Rahbar
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Monica S. Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Departments of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
- Departments of Pediatrics, University of Washington, Seattle, WA
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Faul M, Xu L, Sasser SM. Hospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults. PREHOSP EMERG CARE 2016; 20:594-600. [PMID: 26986195 DOI: 10.3109/10903127.2016.1149651] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Guidelines suggest that Traumatic Brain Injury (TBI) related hospitalizations are best treated at Level I or II trauma centers because of continuous neurosurgical care in these settings. This population-based study examines TBI hospitalization treatment paths by age groups. METHODS Trauma center utilization and transfers by age groups were captured by examining the total number of TBI hospitalizations from National Inpatient Sample (NIS) and the number of TBI hospitalizations and transfers in the Trauma Data Bank National Sample Population (NTDB-NSP). TBI cases were defined using diagnostic codes. RESULTS Of the 351,555 TBI related hospitalizations in 2012, 47.9% (n = 168,317) were directly treated in a Level I or II trauma center, and an additional 20.3% (n = 71,286) were transferred to a Level I or II trauma center. The portion of the population treated at a trauma center (68.2%) was significantly lower than the portion of the U.S. population who has access to a major trauma center (90%). Further, nearly half of all transfers to a Level I or II trauma center were adults aged 55 and older (p < 0.001) and that 20.2% of pediatric patients arrive by non-ambulatory means. CONCLUSION Utilization of trauma center resources for hospitalized TBIs may be low considering the established lower mortality rate associated with treatment at Level I or II trauma centers. The higher transfer rate for older adults may suggest rapid decline amid an unrecognized initial need for a trauma center care. A better understanding of hospital destination decision making is needed for patients with TBI.
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Han J, Yang S, Zhang C, Zhao M, Li A. Impact of Intracranial Pressure Monitoring on Prognosis of Patients With Severe Traumatic Brain Injury: A PRISMA Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e2827. [PMID: 26886639 PMCID: PMC4998639 DOI: 10.1097/md.0000000000002827] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
To evaluate the influences of using intracranial pressure (ICP) monitoring on the prognosis of patients with severe traumatic brain injury. Systematic search were conducted in PubMed, Embase, Cochrane Library, Wanfang, and CNKI. The eligible studies were identified for pooling analysis under fixed- or random effects model. Hospital mortality, functional outcomes, length of hospital stay, and the related complications in patients were extracted. Six randomized controlled trials with 880 cases and 12 cohort studies with 12,606 cases were included. Combined analysis found that ICP monitoring was effective for reducing the risk rate of electrolyte disturbances (RR = 0.47, 95% confidence interval (CI): 0.63-0.90), rate of renal failure (RR = 0.50, 95% CI: 0.30-0.83), and for improving favorable prognosis (RR = 1.15, 95% CI: 1.00-1.35). However, ICP monitoring was not significant for hospital mortality (RR = 0.91, 95% CI: 0.77-0.1.06), decreasing rate of pulmonary infection (RR = 0.93, 95% CI: 0.76-1.14), rate of mechanical ventilation (RR = 1.02, 95% CI: 0.86-1.09), and duration of hospital stays (weighted mean difference (WMD) = 0.06, 95% CI: -0.03, 0.16). ICP monitoring may not reduce the risk of hospital mortality, but plays a role in decreasing the rate of electrolyte disturbances, rate of renal failure, and increasing favorable functional outcome. However, effect of other outcomes need to be further confirmed in the future randomized controlled trials (RCTs) with larger sample size.
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Affiliation(s)
- Jinsong Han
- From the Department of Neurosurgery, First Affiliated Hospital of Chinese PLA General Hospital, Medical School of Chinese PLA, Beijing (JH, SY, MZ, AL); Quanjian Tumor Hospital of Tianjin, Tianjin (SY); and Department of Medical Reform and Development, China-Japan Friendship Hospital, Beijing (CZ), China
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Jaronczyk M, Boyan W, Goldfarb M. Postoperative Ultrasound Evaluation of Gastric Distention: A Pilot Study. Am Surg 2016. [DOI: 10.1177/000313481608200227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michael Jaronczyk
- Monmouth Medical Center Department of Surgery Long Branch, New Jersey
| | - William Boyan
- Monmouth Medical Center Department of Surgery Long Branch, New Jersey
| | - Michael Goldfarb
- Monmouth Medical Center Department of Surgery Long Branch, New Jersey
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Gaastra B, Longworth A, Matta B, Snelson C, Whitehouse T, Murphy N, Veenith T. The ageing population is neglected in research studies of traumatic brain injury. Br J Neurosurg 2016; 30:221-6. [DOI: 10.3109/02688697.2015.1119240] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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37
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Tan TK, Cheng MH, Sim EY. Options for managing raised intracranial pressure. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815598444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
This article reviews the current monitoring and management options for raised intracranial pressure (ICP), primarily in traumatic head injuries, in line with current literature and guidelines. The use of ICP monitoring is useful in managing, predicting outcomes, following the progression and guiding interventions of neurological disease states. Patients with raised ICP should be monitored closely in a neurocritical care setting where appropriate interventions can be instituted based on available monitoring parameters. Various first- and second-tier methods should be considered, with the primary goal to decrease secondary insult to brain tissue for best outcomes.
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Affiliation(s)
- Tong Khee Tan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Ming Hua Cheng
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Eileen Yilin Sim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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Chesnut RM, Temkin N, Dikmen S, Rondina C, Videtta W, Lujan S, Petroni G, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T. Ethical and methodological considerations on conducting clinical research in poor and low-income countries: Viewpoint of the authors of the BEST TRIP ICP randomized trial in Latin America. Surg Neurol Int 2015; 6:116. [PMID: 26229731 PMCID: PMC4513298 DOI: 10.4103/2152-7806.159841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/08/2014] [Indexed: 11/04/2022] Open
Affiliation(s)
- Randall M. Chesnut
- Department of Neurological Surgery and Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, USA
| | - Nancy Temkin
- Department of Neurological Surgery and Biostatistics, Harborview Medical Center, University of Washington, Seattle, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine and Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Carlos Rondina
- President Fundacion ALAS, Hospital de Emergencias, “Dr. Clemente Alvarez,” University of California, San Diego, California, USA
| | - Walter Videtta
- President Latin American Brain Injury Consortium, Hospital Nacional Professor Alejandro Posadas, University of California, San Diego, California, USA
| | - Silvia Lujan
- Latin American Outcomes Examiner/Trainer/Coordinator/Data monitor, Hospital de Emergencias, “Dr. Clemente Alvarez,” CIIC, University of California, San Diego, California, USA
| | - Gustavo Petroni
- Latin American Outcomes Examiner/Trainer/Coordinator/Data monitor, Hospital de Emergencias, “Dr. Clemente Alvarez,” CIIC, University of California, San Diego, California, USA
| | - James Pridgeon
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Jason Barber
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Joan Machamer
- Department of Rehabilitation Medicine, Harborview Medical Center, University of Washington, Seattle, USA
| | - Kelley Chaddock
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Juanita M. Celix
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Marianna Cherner
- Department of Psychiatry, Neuropsychologist, Outcome measures consultant (Spanish), University of California, San Diego, California, USA
| | - Terence Hendrix
- Latin America Site Outcomes Coordinator, Clinical Research Study Coordinator, HIV Neurobehavioral Research Programs (HNRP), University of California, San Diego, California, USA
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Lagares A, Munarriz PM, Ibáñez J, Arikán F, Sarabia R, Morera J, Gabarrós A, Horcajadas Á. Variabilidad en el manejo de la hemorragia subaracnoidea aneurismática en España: análisis de la base de datos multicéntrica del Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía. Neurocirugia (Astur) 2015; 26:167-79. [DOI: 10.1016/j.neucir.2014.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 11/04/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
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Harrison DA, Griggs KA, Prabhu G, Gomes M, Lecky FE, Hutchinson PJA, Menon DK, Rowan KM. External Validation and Recalibration of Risk Prediction Models for Acute Traumatic Brain Injury among Critically Ill Adult Patients in the United Kingdom. J Neurotrauma 2015; 32:1522-37. [PMID: 25898072 DOI: 10.1089/neu.2014.3628] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
This study validates risk prediction models for acute traumatic brain injury (TBI) in critical care units in the United Kingdom and recalibrates the models to this population. The Risk Adjustment In Neurocritical care (RAIN) Study was a prospective, observational cohort study in 67 adult critical care units. Adult patients admitted to critical care following acute TBI with a last pre-sedation Glasgow Coma Scale score of less than 15 were recruited. The primary outcomes were mortality and unfavorable outcome (death or severe disability, assessed using the Extended Glasgow Outcome Scale) at six months following TBI. Of 3626 critical care unit admissions, 2975 were analyzed. Following imputation of missing outcomes, mortality at six months was 25.7% and unfavorable outcome 57.4%. Ten risk prediction models were validated from Hukkelhoven and colleagues, the Medical Research Council (MRC) Corticosteroid Randomisation After Significant Head Injury (CRASH) Trial Collaborators, and the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) group. The model with the best discrimination was the IMPACT "Lab" model (C index, 0.779 for mortality and 0.713 for unfavorable outcome). This model was well calibrated for mortality at six months but substantially under-predicted the risk of unfavorable outcome. Recalibration of the models resulted in small improvements in discrimination and excellent calibration for all models. The risk prediction models demonstrated sufficient statistical performance to support their use in research and audit but fell below the level required to guide individual patient decision-making. The published models for unfavorable outcome at six months had poor calibration in the UK critical care setting and the models recalibrated to this setting should be used in future research.
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Affiliation(s)
- David A Harrison
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
| | - Kathryn A Griggs
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
| | - Gita Prabhu
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
| | - Manuel Gomes
- 2 Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine , London, United Kingdom
| | - Fiona E Lecky
- 3 School of Health and Related Research, University of Sheffield , Regent Court, Sheffield, United Kingdom
| | - Peter J A Hutchinson
- 4 Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - David K Menon
- 5 Division of Anaesthesia, University of Cambridge , Cambridge, United Kingdom
| | - Kathryn M Rowan
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
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Abstract
PURPOSE OF REVIEW In recent years, we have begun to better understand how to monitor the injured brain, look for less common complications and importantly, reduce unnecessary and potentially harmful intervention. However, the lack of consensus regarding triggers for intervention, best neuromonitoring techniques and standardization of therapeutic approach is in need of more careful study. This review covers the most recent evidence within this exciting and dynamic field. RECENT FINDINGS The role of intracranial pressure monitoring has been challenged; however, it still remains a cornerstone in the management of the severely brain-injured patient and should be used to compliment other techniques, such as clinical examination and serial imaging.The use of multimodal monitoring continues to be refined and it may be possible to use them to guide novel brain resuscitation techniques, such as the use of exogenous lactate supplementation in the future. SUMMARY Neurocritical care management of traumatic brain injury continues to evolve. However, it is important not to use a 'one-treatment-fits-all' approach, and perhaps look to use targeted therapies to individualize treatment.
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Macdonald RL. Support for Obamacare? J Neurosurg 2015; 123:402-4. [PMID: 25955876 DOI: 10.3171/2014.10.jns142006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Surgery, University of Toronto, Ontario, Canada
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Lee JC, Rittenhouse K, Bupp K, Gross B, Rogers A, Rogers FB, Horst M, Estrella L, Thurmond J. An analysis of Brain Trauma Foundation traumatic brain injury guideline compliance and patient outcome. Injury 2015; 46:854-8. [PMID: 25661105 DOI: 10.1016/j.injury.2014.12.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/05/2014] [Accepted: 12/19/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Evidence-based guidelines for the care of severe traumatic brain injury have been available from the Brain Trauma Foundation (BTF) since 1995. A total of 15 recommendations compose the current guidelines. Although each individual guideline has been validated in isolation, to date, little research has examined the guidelines in composite. We examined the relationship between compliance with the BTF severe TBI guidelines and mortality. MATERIALS AND METHODS In a Pennsylvania-verified, mature Level II trauma centre, patients with an admission Glasgow Coma Scale (GCS) ≤ 8 and an abnormal head CT from 2007 to 2012 were queried from the trauma registry. Exclusion criteria included: patients who sustained a non-survivable injury (AIS head 6), died ≤ 24 h, and/or were transferred to a paediatric trauma centre. Strict adherence to the BTF guidelines was determined in a binary fashion (yes/no). We then calculated each patient's percent compliance with total number of guidelines. Bivariate analysis was used to find significant predictors of mortality (p<0.05), including percent BTF guidelines compliance. Significant factors were added to a multivariable logistic regression model to look at mortality rates across the percent compliance spectrum. RESULTS 185 Patients met inclusion criteria. Percent compliance ranged from 28.6% to 94.4%, (median=71.4%). Following adjustment for age, AIS head, and GCS motor, patients with 55-75% compliance (AOR: 0.20; 95%CI: 0.06-0.70) and >75% compliance (AOR: 0.27; 95%CI: 0.08-0.94) had reduced odds of mortality, as compared to <55% compliance to the BTF guidelines. When the unadjusted rate of mortality was compared across the compliance spectrum, the odds of mortality decreased as compliance increased until 75%, and then reversed. CONCLUSION Our data indicate that full compliance with all 15 severe TBI guidelines is difficult to achieve and may not be necessary to optimally care for patients.
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Affiliation(s)
- John C Lee
- Trauma Services, Lancaster General Health,, 555 N, Duke Street, Lancaster, PA 17601, United States.
| | - Katelyn Rittenhouse
- Trauma Services, Lancaster General Health,, 555 N, Duke Street, Lancaster, PA 17601, United States.
| | - Katherine Bupp
- Trauma Services, Lancaster General Health,, 555 N, Duke Street, Lancaster, PA 17601, United States.
| | - Brian Gross
- Trauma Services, Lancaster General Health,, 555 N, Duke Street, Lancaster, PA 17601, United States.
| | - Amelia Rogers
- Trauma Services, Lancaster General Health,, 555 N, Duke Street, Lancaster, PA 17601, United States.
| | - Frederick B Rogers
- Trauma Services, Lancaster General Health,, 555 N, Duke Street, Lancaster, PA 17601, United States.
| | - Michael Horst
- Trauma Services, Lancaster General Health,, 555 N, Duke Street, Lancaster, PA 17601, United States.
| | - Lisa Estrella
- Trauma Services, Lancaster General Health,, 555 N, Duke Street, Lancaster, PA 17601, United States.
| | - James Thurmond
- Trauma Services, Lancaster General Health,, 555 N, Duke Street, Lancaster, PA 17601, United States.
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Abstract
Traumatic brain injury (TBI) is a leading cause of death, and in a recent analysis it was found that nearly one-third of all injury-related deaths in the US have at least one diagnosis of TBI (CDC-Quickstats, 2010). This chapter presents the burden of TBI as regards age group, gender, costs, race, emergency department (ED) visits, hospitalizations, and deaths. Injury trends over a 15 year period are examined. Rehabilitation estimates and disability estimates are also available. Through good epidemiology we can better understand the causes of TBI and design more effective intervention programs to reduce injury. Important sources of evidence for this chapter include mostly studies from the US because of their leading work in the epidemiology of this important injury.
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Affiliation(s)
- Mark Faul
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Victor Coronado
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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Patel PA, Mallow PJ, Vassar M, Rizzo JA, Pandya BJ, Kruzikas DT. Traumatic Brain Injury: Patient Characteristics, Hospital Costs and Trends Over Time. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2014; 2:108-118. [PMID: 37663583 PMCID: PMC10471361 DOI: 10.36469/9893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Background: Traumatic brain injury (TBI) is an increasingly diagnosed condition, but the trends in TBI visits and the cost of which have not been quantified from the hospital perspective. Objectives: To quantify the costs of TBI stratified by inpatient and outpatient visits and to examine trends in TBI incidence over time. Methods: This descriptive study utilized data for 2007-2012 from the Premier hospital database, which includes clinical and utilization information from hospitals across the United States. TBI was identified through International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Descriptive data were obtained to identify the TBI costs, visit costs, patient characteristics, and intertemporal trends in TBI rates. Results: TBI patients were treated on an outpatient basis 88% of the time. Nearly 45% (44.3%) of TBI patients requiring inpatient admissions were age 65 or over, and 20% of TBI patients treated as an outpatient were age 75 or over. Children aged 4 or younger accounted for nearly 14% of TBI cases treated on an outpatient basis. TBI patients treated in the inpatient setting incurred fairly long hospital visits (mean 4.8 days; median 3.0 days) and substantial hospital costs (mean $12,717; median $8,176). The rate of TBI visits have risen substantially over time, especially among children under age 18 years and patients in the Northeast US Census Region. Conclusion: TBI is a serious medical condition that appears to be on the rise. Large differences exist between the hospital costs associated with TBIs treated in the inpatient and outpatient settings. Further research to understand factors affecting the costs and clinical outcomes of TBI can help refine treatment strategies to enhance patient outcomes while providing cost effective care.
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Affiliation(s)
| | - Peter J Mallow
- CTI Clinical Trial and Consulting Services, Cincinnati, OH, USA
| | - Mary Vassar
- University of California Brain and Spinal Injury Center, San Francisco, CA, USA
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Vavilala MS, Kernic MA, Wang J, Kannan N, Mink RB, Wainwright MS, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Boyle LN, Mitchell PH, Rivara FP. Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury. Crit Care Med 2014; 42:2258-66. [PMID: 25083982 PMCID: PMC4167478 DOI: 10.1097/ccm.0000000000000507] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. DESIGN Retrospective multicenter cohort study. SETTING Five regional pediatric trauma centers affiliated with academic medical centers. PATIENTS Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91-0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08-0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01-0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06-0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98-0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58-0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63-0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53- 0.86). CONCLUSIONS Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.
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Affiliation(s)
- Monica S. Vavilala
- Departments of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, Departments of Pediatrics, University of Washington, Seattle, WA, Departments of Neurological Surgery and Global Health Medicine, University of Washington, Seattle, WA
| | - Mary A. Kernic
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Jin Wang
- Departments of Pediatrics, University of Washington, Seattle, WA
| | - Nithya Kannan
- Departments of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Richard B. Mink
- Department of Pediatrics, Harbor-UCLA and Los Angeles BioMedical Research Institute, Torrance, CA
| | - Mark S. Wainwright
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jonathan I. Groner
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Michael J. Bell
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher C. Giza
- Department of Neurosurgery and Division of Pediatric Neurology, Mattel Children's Hospital, UCLA, Los Angeles, CA
| | - Douglas F. Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Richard G. Ellenbogen
- Departments of Neurological Surgery and Global Health Medicine, University of Washington, Seattle, WA
| | - Linda Ng Boyle
- Department of Industrial and Systems Engineering, University of Washington, Seattle, WA
| | | | - Frederick P. Rivara
- Department of Epidemiology, University of Washington, Seattle, WA, Departments of Pediatrics, University of Washington, Seattle, WA
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Hartings JA, Vidgeon S, Strong AJ, Zacko C, Vagal A, Andaluz N, Ridder T, Stanger R, Fabricius M, Mathern B, Pahl C, Tolias CM, Bullock MR. Surgical management of traumatic brain injury: a comparative-effectiveness study of 2 centers. J Neurosurg 2014; 120:434-46. [DOI: 10.3171/2013.9.jns13581] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Mass lesions from traumatic brain injury (TBI) often require surgical evacuation as a life-saving measure and to improve outcomes, but optimal timing and surgical technique, including decompressive craniectomy, have not been fully defined. The authors compared neurosurgical approaches in the treatment of TBI at 2 academic medical centers to document variations in real-world practice and evaluate the efficacies of different approaches on postsurgical course and long-term outcome.
Methods
Patients 18 years of age or older who required neurosurgical lesion evacuation or decompression for TBI were enrolled in the Co-Operative Studies on Brain Injury Depolarizations (COSBID) at King's College Hospital (KCH, n = 27) and Virginia Commonwealth University (VCU, n = 24) from July 2004 to March 2010. Subdural electrode strips were placed at the time of surgery for subsequent electrocorticographic monitoring of spreading depolarizations; injury characteristics, physiological monitoring data, and 6-month outcomes were collected prospectively. CT scans and medical records were reviewed retrospectively to determine lesion characteristics, surgical indications, and procedures performed.
Results
Patients enrolled at KCH were significantly older than those enrolled at VCU (48 vs 34 years, p < 0.01) and falls were more commonly the cause of TBI in the KCH group than in the VCU group. Otherwise, KCH and VCU patients had similar prognoses, lesion types (subdural hematomas: 30%–35%; parenchymal contusions: 48%–52%), signs of mass effect (midline shift ≥ 5 mm: 43%–52%), and preoperative intracranial pressure (ICP). At VCU, however, surgeries were performed earlier (median 0.51 vs 0.83 days posttrauma, p < 0.05), bone flaps were larger (mean 82 vs 53 cm2, p < 0.001), and craniectomies were more common (performed in 75% vs 44% of cases, p < 0.05). Postoperatively, maximum ICP values were lower at VCU (mean 22.5 vs 31.4 mm Hg, p < 0.01). Differences in incidence of spreading depolarizations (KCH: 63%, VCU: 42%, p = 0.13) and poor outcomes (KCH: 54%, VCU: 33%, p = 0.14) were not significant. In a subgroup analysis of only those patients who underwent early (< 24 hours) lesion evacuation (KCH: n = 14; VCU: n = 16), however, VCU patients fared significantly better. In the VCU patients, bone flaps were larger (mean 85 vs 48 cm2 at KCH, p < 0.001), spreading depolarizations were less common (31% vs 86% at KCH, p < 0.01), postoperative ICP values were lower (mean: 20.8 vs 30.2 mm Hg at KCH, p < 0.05), and good outcomes were more common (69% vs 29% at KCH, p < 0.05). Spreading depolarizations were the only significant predictor of outcome in multivariate analysis.
Conclusions
This comparative-effectiveness study provides evidence for major practice variation in surgical management of severe TBI. Although ages differed between the 2 cohorts, the results suggest that a more aggressive approach, including earlier surgery, larger craniotomy, and removal of bone flap, may reduce ICP, prevent cortical spreading depolarizations, and improve outcomes. In particular, patients requiring evacuation of subdural hematomas and contusions may benefit from decompressive craniectomy in conjunction with lesion evacuation, even when elevated ICP is not a factor in the decision to perform surgery.
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Affiliation(s)
| | | | | | - Chris Zacko
- 3Department of Neurological Surgery, University of Miami, Florida
| | - Achala Vagal
- 4Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Thomas Ridder
- 5Division of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia; and
| | - Richard Stanger
- 5Division of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia; and
| | - Martin Fabricius
- 6Department of Clinical Neurophysiology, Glostrup Hospital, Copenhagen, Denmark
| | - Bruce Mathern
- 5Division of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia; and
| | - Clemens Pahl
- 7Critical Care Medicine, King's College London, United Kingdom
| | | | - M. Ross Bullock
- 3Department of Neurological Surgery, University of Miami, Florida
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Fuller G, Pallot D, Coats T, Lecky F. The effectiveness of specialist neuroscience care in severe traumatic brain injury: a systematic review. Br J Neurosurg 2013; 28:452-60. [PMID: 24313333 DOI: 10.3109/02688697.2013.865708] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Gordon Fuller
- Emergency Medicine Research in Sheffield, Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield , Sheffield , UK
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English SW, Turgeon AF, Owen E, Doucette S, Pagliarello G, McIntyre L. Protocol management of severe traumatic brain injury in intensive care units: a systematic review. Neurocrit Care 2013; 18:131-42. [PMID: 22890909 DOI: 10.1007/s12028-012-9748-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
To examine clinical trials and observational studies that compared use of management protocols (MPs) versus usual care for adult intensive care unit (ICU) patients with acute severe traumatic brain injury (TBI) on 6-month neurologic outcome (Glasgow Outcome Scale, GOS) and mortality, major electronic databases were searched from 1950 to April 18, 2011. Abstracts from major international meetings were searched to identify gray literature. A total of 6,151 articles were identified; 488 were reviewed in full and 13 studies were included. Data on patient and MP characteristics, outcomes and methodological quality were extracted. All 13 included studies were observational. A random effects model showed that use of MPs was associated with a favorable neurologic outcome (GOS 4 or 5) at 6 months (odds ratio [OR] and 95 % confidence interval [CI] 3.84 (2.47-5.96)) but not 12 months (OR, 95 % CI 0.87 (0.56-1.36)). Use of MPs was associated with reduced mortality at hospital discharge and 6 months (OR and 95 % CI 0.72 (0.45-1.14) and 0.33 (0.13-0.82) respectively), but not 12 months (OR, 95 % CI 0.79 (0.5-1.24)). Sources of heterogeneity included variation in study design, methodological quality, MP design, MP neurophysiologic endpoints, and type of ICU. MPs for severe TBI were associated with reductions in death and improved neurologic outcome. Although no definitive conclusions about the efficacy of MPs for severe TBI can be drawn from our study, these results should encourage the conduct of randomized controlled trials to more rigorously examine the efficacy of MPs for severe TBI.
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Affiliation(s)
- Shane W English
- Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, ON, Canada
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