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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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Alali AS, Temkin N, Barber J, Pridgeon J, Chaddock K, Dikmen S, Hendrickson P, Videtta W, Lujan S, Petroni G, Guadagnoli N, Urbina Z, Chesnut RM. A clinical decision rule to predict intracranial hypertension in severe traumatic brain injury. J Neurosurg 2019; 131:612-619. [PMID: 30265194 DOI: 10.3171/2018.4.jns173166] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 12/17/2017] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While existing guidelines support the treatment of intracranial hypertension in severe traumatic brain injury (TBI), it is unclear when to suspect and initiate treatment for high intracranial pressure (ICP). The objective of this study was to derive a clinical decision rule that accurately predicts intracranial hypertension. METHODS Using Delphi methods, the authors identified a set of potential predictors of intracranial hypertension and a clinical decision rule a priori by consensus among a group of 43 neurosurgeons and intensivists who have extensive experience managing severe TBI without ICP monitoring. To validate these predictors, the authors used data from a Latin American trial (n = 150; BEST TRIP). To report on the performance of the rule, they calculated sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals. In a secondary analysis, the rule was validated using data from a North American trial (n = 131; COBRIT). RESULTS The final predictors and the clinical decision rule were approved by 97% of participants in the consensus working group. The predictors are divided into major and minor criteria. High ICP would be considered suspected in the presence of 1 major or ≥ 2 minor criteria. Major criteria are: compressed cisterns (CT classification of Marshall diffuse injury [DI] III), midline shift > 5 mm (Marshall DI IV), or nonevacuated mass lesion. Minor criteria are: Glasgow Coma Scale (GCS) motor score ≤ 4, pupillary asymmetry, abnormal pupillary reactivity, or Marshall DI II. The area under the curve for the logistic regression model that contains all the predictors was 0.86. When high ICP was defined as > 22 mm Hg, the decision rule performed with a sensitivity of 93.9% (95% CI 85.0%-98.3%), a specificity of 42.3% (95% CI 31.7%-53.6%), a positive predictive value of 55.5% (95% CI 50.7%-60.2%), and a negative predictive value of 90% (95% CI 77.1%-96.0%). The sensitivity of the clinical decision rule improved with higher ICP cutoffs up to a sensitivity of 100% when intracranial hypertension was defined as ICP > 30 mm Hg. Similar results were found in the North American cohort. CONCLUSIONS A simple clinical decision rule based on a combination of clinical and imaging findings was found to be highly sensitive in distinguishing patients with severe TBI who would suffer intracranial hypertension. It could be used to identify patients who require ICP monitoring in high-resource settings or start ICP-lowering treatment in environments where resource limitations preclude invasive monitoring.Clinical trial registration no.: NCT02059941 (clinicaltrials.gov).
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Affiliation(s)
- Aziz S Alali
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Nancy Temkin
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center.,Departments of2Biostatistics
| | - Jason Barber
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Jim Pridgeon
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Kelley Chaddock
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Sureyya Dikmen
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center.,3Rehabilitation Medicine, and
| | - Peter Hendrickson
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Walter Videtta
- 4Hospital Nacional Profesor Alejandro Posadas, Buenos Aire
| | - Silvia Lujan
- 5Hospital de Emergencias Dr. Clemente Alvarez, Rosario
| | | | - Nahuel Guadagnoli
- 6Hospital Emergencia, Hospital Privado de Rosario, Rosario, Argentina; and
| | | | - Randall M Chesnut
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center.,8Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
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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: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 2012; 367:2471-81. [PMID: 23234472 PMCID: PMC3565432 DOI: 10.1056/nejmoa1207363] [Citation(s) in RCA: 761] [Impact Index Per Article: 63.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed. METHODS We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging-clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance). RESULTS There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging-clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups. CONCLUSIONS For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01068522.).
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Affiliation(s)
- Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA 98104, USA.
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Chesnut RM, Temkin N, Carney N, Dikmen S, Pridgeon J, Barber J, Celix JM, Chaddock K, Cherner M, Hendrix T, Lujan S, Machamer J, Petroni G, Rondina C, Videtta W. Traumatic brain injury in Latin America: lifespan analysis randomized control trial protocol*. Neurosurgery 2012; 71:1055-63. [PMID: 22986600 PMCID: PMC3549327 DOI: 10.1227/neu.0b013e31827276b7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although in the developed world the intracranial pressure (ICP) monitor is considered the standard of care for patients with severe traumatic brain injury (TBI), its usefulness to direct treatment decisions has never been tested rigorously. OBJECTIVE The primary focus was to conduct a high-quality, randomized, controlled trial to determine whether ICP monitoring used to direct TBI treatment improves patient outcomes. By providing education, equipment, and structure, the project will enhance the research capacity of the collaborating investigators and will foster the collaborations established during earlier studies. METHODS Study centers were selected that routinely treated ICP based on clinical examination and computed tomography imaging using internal protocols. We randomized patients to either an ICP monitor group or an imaging and clinical examination group. Treatment decisions for the ICP monitor group are guided by ICP monitoring based on established guidelines. Treatment decisions for the imaging and clinical examination group are made using a single protocol derived from those previously being used at those centers. EXPECTED OUTCOMES There are 2 study hypotheses: (1) patients with severe TBI whose acute care treatment is managed using ICP monitors will have improved outcomes and 2) incorporating ICP monitoring in the care of patients with severe TBI will minimize complications and decrease length of intensive care unit stay. DISCUSSION This clinical trial tests the effectiveness of a management protocol based on technology considered pivotal to brain trauma treatment in the developed world: the ICP monitor. A randomized, controlled trial of ICP monitoring has never been performed-a critical gap in the evidence base that supports the role of ICP monitoring in TBI care. As such, the results of this randomized, controlled trial will have global implications regardless of the level of development of the trauma system.
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Affiliation(s)
- Randall M. Chesnut
- University of Washington, Harborview Medical Center, Departments of Neurological Surgery & Orthopaedics and Sports Medicine, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Nancy Temkin
- University of Washington, Harborview Medical Center, Departments of Neurological Surgery & Biostatistics, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Nancy Carney
- Oregon Health & Science University, Department of Medical Informatics and Clinical Epidemiology, 3181 SW Sam Jackson Park Road, Portland, OR 97239, Phone: 503-494-0663, Fax: 503-494-4551
| | - Sureyya Dikmen
- University of Washington, Harborview Medical Center, Departments of Rehabilitation Medicine & Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Jim Pridgeon
- University of Washington, Harborview Medical Center, Department of Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Jason Barber
- University of Washington, Harborview Medical Center, Department of Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Juanita M. Celix
- University of Washington, Harborview Medical Center, Department of Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Kelley Chaddock
- University of Washington, Harborview Medical Center, Department of Neurological Surgery, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Marianna Cherner
- University of California, San Diego, Department of Psychiatry, 9500 Gilman Drive, MC: 0603, La Jolla, CA 92093-0603, Phone: 619-543-5048 Fax: 619-543-1235
| | - Terence Hendrix
- Clinical Research Study Coordinator, HIV Neurobehavioral Research Programs (HNRP), University of California, San Diego, 220 Dickinson St., Suite B MC 8231, San Diego, CA 92103-8231, Phone: 619-543-8873, Fax: 619-543-1235
| | - Silvia Lujan
- Hospital de Emergencias, “Dr. Clemente Alvarez”, Pellegrini 3205, Rosario, Santa Fe, Argentina, Phone: 54-341-4808111, Fax: 54-341-4231087
| | - Joan Machamer
- University of Washington, Harborview Medical Center, Department of Rehabilitation Medicine, 325 Ninth Ave, Box 359766, Seattle, WA 98104, Phone: 206-744-9322, Fax: 206-744-9943
| | - Gustavo Petroni
- Hospital de Emergencias, “Dr. Clemente Alvarez”, Pellegrini 3205, Rosario, Santa Fe, Argentina, Phone: 54-341-4808111, Fax: 54-341-4231087
| | - Carlos Rondina
- Hospital de Emergencias, “Dr. Clemente Alvarez”, Pellegrini 3205, Rosario, Santa Fe, Argentina, Phone: 54-341-4808111, Fax: 54-341-4231087
| | - Walter Videtta
- Hospital Nacional Professor Alejandro Posadas, Acda. Illia y Marconi, El Palomar, Buenos Aires, Argentina, Phone: 54-114-4699290, Fax: 54-114-4699290
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Carney N, Lujan S, Dikmen S, Temkin N, Petroni G, Pridgeon J, Barber J, Machamer J, Cherner M, Chaddock K, Hendrix T, Rondina C, Videtta W, Celix JM, Chesnut R. Intracranial pressure monitoring in severe traumatic brain injury in latin america: process and methods for a multi-center randomized controlled trial. J Neurotrauma 2012; 29:2022-9. [PMID: 22435793 DOI: 10.1089/neu.2011.2019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In patients with severe traumatic brain injury (TBI), the influence on important outcomes of the use of information from intracranial pressure (ICP) monitoring to direct treatment has never been tested in a randomized controlled trial (RCT). We are conducting an RCT in six trauma centers in Latin America to test this question. We hypothesize that patients randomized to ICP monitoring will have lower mortality and better outcomes at 6-months post-trauma than patients treated without ICP monitoring. We selected three centers in Bolivia to participate in the trial, based on (1) the absence of ICP monitoring, (2) adequate patient accession and data collection during the pilot phase, (3) preliminary institutional review board approval, and (4) the presence of equipoise about the value of ICP monitoring. We conducted extensive training of site personnel, and initiated the trial on September 1, 2008. Subsequently, we included three additional centers. A total of 176 patients were entered into the trial as of August 31, 2010. Current enrollment is 81% of that expected. The trial is expected to reach its enrollment goal of 324 patients by September of 2011. We are conducting a high-quality RCT to answer a question that is important globally. In addition, we are establishing the capacity to conduct strong research in Latin America, where TBI is a serious epidemic. Finally, we are demonstrating the feasibility and utility of international collaborations that share resources and unique patient populations to conduct strong research about global public health concerns.
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Affiliation(s)
- Nancy Carney
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon 97239, USA.
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Luyt DK, Pridgeon J, Brown J, Peek G, Firmin R, Pandya HC. Extracorporeal life support for children with meningococcal septicaemia. Acta Paediatr 2004; 93:1608-11. [PMID: 15841769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVE To describe the short-term outcome of children with meningococcal sepsis treated with extracorporeal membrane oxygenation (ECMO) in a single centre. DESIGN Retrospective analysis of case notes. SETTING The Heartlink ECMO Centre, Glenfield Hospital, Leicester. PATIENTS Eleven children (8 boys) out of a total caseload of 800 patients were treated for meningococcal sepsis with ECMO. INTERVENTIONS Extracorporeal membrane oxygenation. RESULTS All children with meningococcal sepsis treated with ECMO had a Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS) > or = 12 (positive predictive risk of death of approximately 90%). Five children had adult respiratory distress syndrome (ARDS) and six had refractory shock with multi-organ dysfunction syndrome (MODS) at presentation for ECMO. All five children in the ARDS group survived, four of five receiving veno-venous (VV-) ECMO therapy. In contrast, only one of six children with refractory shock with MODS survived, all of whom required veno-arterial (VA-) ECMO therapy. CONCLUSIONS Most children with meningococcal sepsis and severe ARDS can be successfully treated with VV-ECMO. In contrast, children with refractory shock and MODS die despite treatment with VA-ECMO. This report does not resolve whether ECMO therapy offers any advantage over conventional therapy in treating severe meningococcal sepsis.
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Affiliation(s)
- D K Luyt
- Heartlink ECMO Centre, Glenfield Hospital, Leicester, United Kingdom
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Abstract
AIM Bowel wall thickening on transabdominal ultrasound scanning (USS) correlates well with Crohn's disease (CD) activity. However, the role of USS in the assessment of CD has not been fully defined. This study compared USS and barium follow-through (BaFT) in the assessment of CD. METHODS A retrospective case series was undertaken of 24 children with CD who underwent USS and BaFT during the same period of clinical disease activity. RESULTS For terminal ileum abnormality, all 13 cases with abnormal USS had abnormality on BaFT. USS did not detect five cases with affected terminal ileum and two cases with isolated proximal small-bowel CD. CONCLUSION BaFT is a more sensitive indicator of small-bowel CD than USS. USS has good positive predictive value of distal small-bowel CD, but BaFT should be performed in the presence of a normal USS where there is strong clinical evidence of CD.
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Affiliation(s)
- A R Bremner
- Division of Infection, Inflammation and Repair, Southampton University School of Medicine, Southampton, UK
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