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Chesnut RM, Temkin N, Videtta W, Lujan S, Petroni G, Pridgeon J, Dikmen S, Chaddock K, Hendrix T, Barber J, Machamer J, Guadagnoli N, Hendrickson P, Alanis V, La Fuente G, Lavadenz A, Merida R, Sandi Lora F, Romero R, Pinillos O, Urbina Z, Figueroa J, Ochoa M, Davila R, Mora J, Bustamante L, Perez C, Leiva J, Carricondo C, Mazzola AM, Guerra J. The Roles of Protocols and Protocolization in Improving Outcome From Severe Traumatic Brain Injury. Neurosurgery 2023:00006123-990000000-00986. [PMID: 38051042 DOI: 10.1227/neu.0000000000002777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/02/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Our Phase-I parallel-cohort study suggested that managing severe traumatic brain injury (sTBI) in the absence of intracranial pressure (ICP) monitoring using an ad hoc Imaging and Clinical Examination (ICE) treatment protocol was associated with superior outcome vs nonprotocolized management but could not differentiate the influence of protocolization from that of the specific protocol. Phase II investigates whether adopting the Consensus REVised Imaging and Clinical Examination (CREVICE) protocol improved outcome directly or indirectly via protocolization. METHODS We performed a Phase-II sequential parallel-cohort study examining adoption of the CREVICE protocol from no protocol vs a previous protocol in patients with sTBI older than 13 years presenting ≤24 hours after injury. Primary outcome was prespecified 6-month recovery. The study was done mostly at public South American centers managing sTBI without ICP monitoring. Fourteen Phase-I nonprotocol centers and 5 Phase-I protocol centers adopted CREVICE. Data were analyzed using generalized estimating equation regression adjusting for demographic imbalances. RESULTS A total of 501 patients (86% male, mean age 35.4 years) enrolled; 81% had 6 months of follow-up. Adopting CREVICE from no protocol was associated with significantly superior results for overall 6-month extended Glasgow Outcome Score (GOSE) (protocol effect = 0.53 [0.11, 0.95], P = .013), mortality (36% vs 21%, HR = 0.59 [0.46, 0.76], P < .001), and orientation (Galveston Orientation and Amnesia Test discharge protocol effect = 10.9 [6.0, 15.8], P < .001, 6-month protocol effect = 11.4 [4.1, 18.6], P < .005). Adopting CREVICE from ICE was associated with significant benefits to GOSE (protocol effect = 0.51 [0.04, 0.98], P = .033), 6-month mortality (25% vs 18%, HR = 0.55 [0.39, 0.77], P < .001), and orientation (Galveston Orientation and Amnesia Test 6-month protocol effect = 9.2 [3.6, 14.7], P = .004). Comparing both groups using CREVICE, those who had used ICE previously had significantly better GOSE (protocol effect = 1.15 [0.09, 2.20], P = .033). CONCLUSION Centers managing adult sTBI without ICP monitoring should strongly consider protocolization through adopting/adapting the CREVICE protocol. Protocolization is indirectly supported at sTBI centers regardless of resource availability.
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Affiliation(s)
- Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, USA
- School of Global Health, University of Washington, Seattle, Washington, USA
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Walter Videtta
- Terapia Intensiva, Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina
| | - Silvia Lujan
- Hospital Emergencia, Dr Clemente Alvarez, Rosario, Argentina
- Centro de Informatica e Investigacion Clinica, Rosario, Argentina
| | - Gustavo Petroni
- School of Global Health, University of Washington, Seattle, Washington, USA
| | - Jim Pridgeon
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Kelley Chaddock
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Joan Machamer
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nahuel Guadagnoli
- Hospital Emergencia, Dr Clemente Alvarez, Rosario, Argentina
- Centro de Informatica e Investigacion Clinica, Rosario, Argentina
| | - Peter Hendrickson
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Victor Alanis
- Terapia Intensiva, Hospital San Juan de Dios, Santa Cruz de la Sierra, Bolivia
| | - Gustavo La Fuente
- Terapia Intensiva, Hospital Japones, Santa Cruz de la Sierra, Bolivia
| | | | - Roberto Merida
- Terapia Intensiva, Hospital San Juan de Dios, Tarija, Bolivia
| | | | - Ricardo Romero
- Terapia Intensiva, Fundacion Clinica Campbell, Barranquilla, Colombia
| | - Oscar Pinillos
- Terapia Intensiva, Clinica Universitaria Rafael Uribe, Cali, Colombia
| | - Zulma Urbina
- Terapia Intensiva, Hospital Erasmo Meoz ICU No 1, Cucuta, Colombia
| | - Jairo Figueroa
- Terapia Intensiva, Hospital Erasmo Meoz ICU No 2, Cucuta, Colombia
| | - Marcelo Ochoa
- Terapia Intensiva, Hospital José Carrasco Artega, Cuenca, Ecuador
| | - Rafael Davila
- Terapia Intensiva, Hospital Luis Razetti, Barinas, Venezuela
| | - Jacobo Mora
- Terapia Intensiva, Hospital Luis Razetti, Barcelona, Venezuela
| | - Luis Bustamante
- Terapia Intensiva, Delicia Conception Hospital Masvernat, Concordia, Entre Ríos, Argentina
| | - Carlos Perez
- Terapia Intensiva, Hospital Justo José de Urquiza, Concepción del Uruguay, Entre Ríos, Argentina
| | - Jorge Leiva
- Terapia Intensiva, Hospital Córdoba, Córdoba, Argentina
| | | | | | - Juan Guerra
- Terapia Intensiva, Hospital COSSMIL Militar, Louisiana Paz, Bolivia
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Chesnut RM, Temkin N, Videtta W, Lujan S, Petroni G, Pridgeon J, Dikmen S, Chaddock K, Hendrix T, Barber J, Machamer J, Guadagnoli N, Hendrickson P, Alanis V, La Fuente G, Lavadenz A, Merida R, Lora FS, Romero R, Pinillos O, Urbina Z, Figueroa J, Ochoa M, Davila R, Mora J, Bustamante L, Perez C, Leiva J, Carricondo C, Mazzola AM, Guerra J. Testing the Impact of Protocolized Care of Patients With Severe Traumatic Brain Injury Without Intracranial Pressure Monitoring: The Imaging and Clinical Examination Protocol. Neurosurgery 2023; 92:472-480. [PMID: 36790211 PMCID: PMC10158870 DOI: 10.1227/neu.0000000000002251] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 08/30/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Most patients with severe traumatic brain injury (sTBI) in low- or-middle-income countries and surprisingly many in high-income countries are managed without intracranial pressure (ICP) monitoring. The impact of the first published protocol (Imaging and Clinical Examination [ICE] protocol) is untested against nonprotocol management. OBJECTIVE To determine whether patients treated in intensive care units (ICUs) using the ICE protocol have lower mortality and better neurobehavioral functioning than those treated in ICUs using no protocol. METHODS This study involved nineteen mostly public South American hospitals. This is a prospective cohort study, enrolling patients older than 13 years with sTBI presenting within 24 h of injury (January 2014-July 2015) with 6-mo postinjury follow-up. Five hospitals treated all sTBI cases using the ICE protocol; 14 used no protocol. Primary outcome was prespecified composite of mortality, orientation, functional outcome, and neuropsychological measures. RESULTS A total of 414 patients (89% male, mean age 34.8 years) enrolled; 81% had 6 months of follow-up. All participants included in composite outcome analysis: average percentile (SD) = 46.8 (24.0) nonprotocol, 56.9 (24.5) protocol. Generalized estimating equation (GEE) used to account for center effects (confounder-adjusted difference [95% CI] = 12.2 [4.6, 19.8], P = .002). Kaplan-Meier 6-month mortality (95% CI) = 36% (30%, 43%) nonprotocol, 25% (19%, 31%) protocol (GEE and confounder-adjusted hazard ratio [95% CI] = .69 [.43, 1.10], P = .118). Six-month Extended Glasgow Outcome Scale for 332 participants: average Extended Glasgow Outcome Scale score (SD) = 3.6 (2.6) nonprotocol, 4.7 (2.8) protocol (GEE and confounder-adjusted and lost to follow-up-adjusted difference [95% CI] = 1.36 [.55, 2.17], P = .001). CONCLUSION ICUs managing patients with sTBI using the ICE protocol had better functional outcome than those not using a protocol. ICUs treating patients with sTBI without ICP monitoring should consider protocolization. The ICE protocol, tested here and previously, is 1 option.
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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
- Medicina Intensiva, Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina;
| | - Silvia Lujan
- Hospital Emergencia, Dr Clemente Alvarez, Rosario, Argentina;
| | - Gustavo Petroni
- 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
- Medicina Intensiva, Hospital San Juan de Dios, Santa Cruz de la Sierra, Bolivia;
| | - Gustavo La Fuente
- Medicina Intensiva, Hospital Japones, Santa Cruz de la Sierra, Bolivia;
| | | | - Roberto Merida
- Medicina Intensiva, Hospital San Juan de Dios, Tarija, Bolivia;
| | | | - Ricardo Romero
- Medicina Intensiva, Fundacion Clinica Campbell, Barranquilla, Colombia;
| | - Oscar Pinillos
- Medicina Intensiva, Clinica Universitaria Rafael Uribe, Cali, Colombia;
| | - Zulma Urbina
- Medicina Intensiva, Hospital Erasmo Meoz ICU No 1, Cucuta, Colombia;
| | - Jairo Figueroa
- Medicina Intensiva, Hospital Erasmo Meoz ICU No 2, Cucuta, Colombia;
| | - Marcelo Ochoa
- Medicina Intensiva, Hospital José Carrasco Artega, Cuenca, Ecuador;
| | - Rafael Davila
- Medicina Intensiva, Hospital Luis Razetti, Barinas, Venezuela;
| | - Jacobo Mora
- Medicina Intensiva, Hospital Luis Razetti, Barcelona, Venezuela;
| | - Luis Bustamante
- Medicina Intensiva, Delicia Conception Hospital Masvernat, Concordia, Entre Ríos, Argentina;
| | - Carlos Perez
- Medicina Intensiva, Hospital Justo José de Urquiza, Concepción del Uruguay, Entre Ríos, Argentina;
| | - Jorge Leiva
- Medicina Intensiva, Hospital Córdoba, Córdoba, Argentina;
| | | | - Ana Maria Mazzola
- Medicina Intensiva, Hospital San Felipe, San Nicolás, Buenos Aires, Argentina;
| | - Juan Guerra
- Medicina Intensiva, Hospital COSSMIL Militar, La Paz, Bolivia
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Bonow RH, Barber J, Temkin NR, Videtta W, Rondina C, Petroni G, Lujan S, Alanis V, La Fuente G, Lavadenz A, Merida R, Jibaja M, Gonzáles L, Falcao A, Romero R, Dikmen S, Pridgeon J, Chesnut RM. The Outcome of Severe Traumatic Brain Injury in Latin America. World Neurosurg 2017; 111:e82-e90. [PMID: 29229352 DOI: 10.1016/j.wneu.2017.11.171] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) disproportionately affects lower- and middle-income countries (LMIC). The factors influencing outcomes in LMIC have not been examined as rigorously as in higher-income countries. METHODS This study was conducted to examine clinical and demographic factors influencing TBI outcomes in Latin American LMIC. Data were prospectively collected during a randomized trial of intracranial pressure monitoring in severe TBI and a companion observational study. Participants were aged ≥13 years and admitted to study hospitals with Glasgow Coma Scale score ≤8. The primary outcome was Glasgow Outcome Scale, Extended (GOS-E) score at 6 months. Predictors were analyzed using a multivariable proportional odds model created by forward stepwise selection. RESULTS A total of 550 patients were identified. Six-month outcomes were available for 88%, of whom 37% had died and 44% had achieved a GOS-E score of 5-8. In multivariable proportional odds modeling, higher Glasgow Coma Scale motor score (odds ratio [OR], 1.41 per point; 95% confidence interval [CI], 1.23-1.61) and epidural hematoma (OR, 1.83; 95% CI, 1.17-2.86) were significant predictors of higher GOS-E score, whereas advanced age (OR, 0.65 per 10 years; 95% CI, 0.57-0.73) and cisternal effacement (P < 0.001) were associated with lower GOS-E score. Study site (P < 0.001) and race (P = 0.004) significantly predicted outcome, outweighing clinical variables such as hypotension and pupillary examination. CONCLUSIONS Mortality from severe TBI is high in Latin American LMIC, although the rate of favorable recovery is similar to that of high-income countries. Demographic factors such as race and study site played an outsized role in predicting outcome; further research is required to understand these associations.
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Affiliation(s)
- Robert H Bonow
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | | | - Gustavo Petroni
- Hospital de Emergencias Dr. Clemente Alvarez, Rosario, Argentina
| | - Silvia Lujan
- Hospital de Emergencias Dr. Clemente Alvarez, Rosario, Argentina
| | - Victor Alanis
- University Hospital San Juan De Dios, Santa Cruz de la Sierra, Bolivia
| | | | | | | | | | | | - Antonio Falcao
- Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | | | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - James Pridgeon
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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