Intracranial pressure monitoring

Lessons from the Intracranial Pressure Monitoring-Trial in TBI patients

Authors: Sarrafzadeh AS, Smoll NR, Unterberg AW.

BACKGROUND: Monitoring of intracranial pressure (ICP) has been used for decades in patients with severe traumatic brain injury (TBI) and is recommended in the Guidelines of the Brain Trauma Foundation. It is the standard of care in most industrialized countries.
METHODS: Chesnut et al. have now performed the first randomized trial of ICP monitoring in patients with severe TBI. Patients were randomly assigned to one of two specific protocols - ICP monitoring (n=157) or imaging and clinical exam (n=167). The study was conducted in Latin America, where ICP-monitoring is not the standard of care in most hospitals.
RESULTS: Six months after injury, patients groups had similar scores on functional status and cognition and similar cumulative mortality. Patients who underwent ICP monitoring had a significantly lower intensity of brain-specific treatment and received fewer treatments for intracranial hypertension.
CONCLUSION: The benefit of this study is that ICP-monitoring - and more advanced multimodal monitoring allows a tailored treatment avoiding an overtherapy of drugs with unfavorable side effects. For low income countries, the results of this trial are encouraging, though efforts should be done to further improve after ICU-care and outcome. However, we guard against the use of this data to reform European and North American treatment guidelines. The authors have proven that neurosurgery can be studied in an elegant fashion. Thanks to their team of neurosurgeons and neurointensivists, the outcome of TBI-patients will continue to improve, driven by clinical practice guidelines.

National Variability in Intracranial Pressure Monitoring and Craniotomy for Children with Moderate to Severe Traumatic Brain Injury

Authors: Van Cleve W, Kernic MA, Ellenbogen RG, Wang J, Zatzick DF, Bell MJ, Wainwright MS, Groner JI, Mink RB, Giza CC, Boyle LN, Mitchell PH, Rivara FP, Vavilala MS; for the PEGASUS (Pediatric Guideline Adherence and Outcomes) Project.

BACKGROUND: Traumatic brain injury (TBI) is a significant cause of mortality and disability in children. Intracranial pressure monitoring (ICPM) and craniotomy/craniectomy (CRANI) may affect outcomes. Sources of variability in the use of these interventions remain incompletely understood.

OBJECTIVE: To analyze sources of variability in the use of ICPM and CRANI.

METHODS: Retrospective cross-sectional study of patients with moderate/severe pediatric TBI using data submitted to the American College of Surgeons National Trauma Databank.

RESULTS: We analyzed data from 7,140 children at 156 US hospitals during 7 continuous years. 27.4% of children had ICPM, while 11.7% had a CRANI. Infants had lower rates of ICPM and CRANI than older children. A lower rate of ICPM was observed among children hospitalized at combined pediatric/adult trauma centers than children treated at adult-only trauma centers (RR 0.80, 95% CI 0.66 - 0.97). For ICPM and CRANI, 18.5% and 11.6%, respectively, of residual model variance was explained by between-hospital variation in care delivery, but almost no correlation was observed between within-hospital tendency towards performing these procedures.

CONCLUSION: Infants received less ICPM than older children, and children hospitalized at pediatric trauma centers received less ICPM than children at adult-only trauma centers. In addition, significant between-hospital variability existed in the delivery of ICPM and CRANI to children with moderate-severe TBI.

Significant Practice Pattern Variations Associated With Intracranial Pressure Monitoring

Authors: Olson DM, Lewis LS, Bader MK, Bautista C, Malloy R, Riemen KE, McNett MM.

PURPOSE: The purpose of this study was to describe nursing practice in the care of patients with intracranial pressure monitoring. Although standards for care of such patients have been established, there continue to be variations in the nursing practice.
METHODS: This was an observational study in which data were collected from 28 nurse-patient dyads at 16 different hospitals across the United States. Each dyad was observed for 2 hours; nursing actions and patient responses including intracranial pressure readings were documented.
RESULTS: Differences in the care of patients with intracranial pressure monitoring were prevalent. Variations in practice were prompted by healthcare provider prescriptions as well as nursing decisions. Prescriptions and interventions were often not supported by the available scientific evidence.
VIDEO ABSTRACT: For more insights from the authors, see Supplemental Digital Content 1, at http://links.lww.com/JNN/A7.

Intracranial Pressure Monitoring in Severe Traumatic Brain Injury: Results from the American College of Surgeons Trauma Quality Improvement Program

Authors: Alali AS, Fowler RA, Mainprize TG, Scales DC, Kiss A, de Mestral C, Ray JG, Nathens AB.

While existing guidelines support the utilization of intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI), the evidence suggesting benefit is limited. To evaluate the impact on outcome, we determined the relationship between ICP monitoring and mortality in centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP). Data on 10,628 adults with severe TBI were derived from 155 TQIP centers over 2009-2011. Random-intercept multilevel modeling was used to evaluate the association between ICP monitoring and mortality after adjusting for important confounders. We evaluated this relationship at the patient-level and at the institutional-level. Overall mortality (n=3,769) was 35%. Only 1,874 (17.6%) patients underwent ICP monitoring, with a mortality of 32%. The adjusted odds ratio (OR) for mortality was 0.44 (95% CI: 0.31-0.63) comparing patients with ICP monitoring to those without. It is plausible that patients receiving ICP monitoring were selected because of an anticipated favorable outcome. To overcome this limitation, we stratified hospitals into quartiles based on ICP monitoring utilization. Hospitals with higher rates of ICP monitoring use were associated with lower mortality: the adjusted OR of death was 0.52 (95% CI: 0.35-0.78) in the quartile of hospitals with highest use compared to the lowest. ICP monitoring utilization rates explained only 9.9% of variation in mortality across centers. Results were comparable irrespective of the method of case-mix adjustment. In this observational study, ICP monitoring utilization was associated with lower mortality. However, variability in ICP monitoring rates contributed only modestly to variability in institutional mortality rates. Identifying other institutional practices that impact on mortality is an important area for future research.

CORRESPONDENCE: Intracranial-Pressure Monitoring in Traumatic Brain Injury

N Engl J Med 2013; 368:1748-1752May 2, 2013DOI: 10.1056/NEJMc1301076

To the Editor:

In response to the article by Chesnut et al. (Dec. 27 issue)1 reporting results of the trial on intracranial-pressure monitoring, we want to mention that environment must be taken into consideration to understand the role of intracranial-pressure monitoring on outcome. Approximately 80% of severe traumatic brain injuries occur in austere environments,2 defined as regions lacking in prehospital and advanced care in an intensive care unit (ICU). Care within organized trauma systems has been shown to reduce mortality associated with severe traumatic brain injury.3-5 Studies of traumatic brain injury in austere environments have shown rates of death that are 2 to 3 times as high as those in environments where advanced care is available.6
As the authors mention, several patients in this study arrived after 1 hour without appropriate prehospital care. In this real scenario, ICU monitoring has very little chance of making a difference by itself.  ...

A trial of intracranial-pressure monitoring in traumatic brain injury

Authors: 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.

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.

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