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

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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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Most cited references 21

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Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI): a prospective longitudinal observational study.

Andrew I.R. Maas, David K. Menon, Ewout W. Steyerberg … (2015)

Current classification of traumatic brain injury (TBI) is suboptimal, and management is based on weak evidence, with little attempt to personalize treatment. A need exists for new precision medicine and stratified management approaches that incorporate emerging technologies.

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A most stubborn bias: no adjustment method fully resolves confounding by indication in observational studies.

Jaclyn L.F. Bosco, Rebecca A. Silliman, Soe Thwin … (2010)

To evaluate the effectiveness of methods that control for confounding by indication, we compared breast cancer recurrence rates among women receiving adjuvant chemotherapy with those who did not. In a medical record review-based study of breast cancer treatment in older women (n=1798) diagnosed between 1990 and 1994, our crude analysis suggested that adjuvant chemotherapy was positively associated with recurrence (hazard ratio [HR]=2.6; 95% confidence interval [CI]=1.9, 3.5). We expected a protective effect, so postulated that the crude association was confounded by indications for chemotherapy. We attempted to adjust for this confounding by restriction, multivariable regression, propensity scores (PSs), and instrumental variable (IV) methods. After restricting to women at high risk for recurrence (n=946), chemotherapy was not associated with recurrence (HR=1.1; 95% CI=0.7, 1.6) using multivariable regression. PS adjustment yielded similar results (HR=1.3; 95% CI=0.8, 2.0). The IV-like method yielded a protective estimate (HR=0.9; 95% CI=0.2, 4.3); however, imbalances of measured factors across levels of the IV suggested residual confounding. Conventional methods do not control for unmeasured factors, which often remain important when addressing confounding by indication. PS and IV analysis methods can be useful under specific situations, but neither method adequately controlled confounding by indication in this study.

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Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury.

John D. Pickard, M Balestreri, Marek Czosnyka … (2005)

To investigate the relationships between intracranial pressure (ICP), cerebral perfusion pressure (CPP), and outcome after traumatic brain injury. A retrospective analysis of prospectively recorded data from 429 patients after head injury requiring intensive treatment on the Neuroscience Intensive Annex and the Neuro Critical Care Unit, Cambridge, UK. ICP, CPP, and arterial blood pressure (ABP) were continuously recorded. Mean values of pressures were compared to outcome assessed at 6 months after injury (using the Glasgow Outcome Scale). The mortality rate was greater in those having mean ICP greater than 20 mmHg (17% below versus 47% above; p < 0.0001). The mortality rate was dramatically increased for CPP below 55 mmHg (81% below versus 23% above; p < 0.0001). For values of CPP greater than 95 mmHg, favorable outcome was less frequent (50% below versus 28% above; p < 0.033). The rate of severe disability showed the tendency to increase with CPP ( r = 0.87; p = 0.02), suggesting that a higher CPP does not help in achieving favorable outcomes. ICP was greater in those who died in comparison to those who survived (27 +/- 19 mmHg versus 16 +/- 6 mmHg; p < 0.10 - 7), and CPP was lower (68 +/- 21 versus 76 +/- 10 mmHg; p < 0.0002). There was no difference between mean ICP and CPP in good/moderate and severe disability outcome groups. High ICP is strongly associated with fatal outcome. Excessive CPP seems to reduce the probability of achieving a favorable outcome following head trauma.

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Author and article information

Contributors

Maryse C. Cnossen: 0031 107038994 , m.c.cnossen@erasmusmc.nl

Jilske A. Huijben: j.a.huijben@erasmusmc.nl

Mathieu van der Jagt: m.vanderjagt@erasmusmc.nl

Victor Volovici: v.volovici@erasmusmc.nl

Thomas van Essen: t.a.van_Essen@lumc.nl

Suzanne Polinder: s.polinder@erasmusmc.nl

David Nelson: david.nelson@sll.se

Ari Ercole: ae105@cam.ac.uk

Nino Stocchetti: stocchet@policlinico.mi.if

Giuseppe Citerio: Giuseppe.citerio@unimib.it

Wilco C. Peul: w.c.peul@lumc.nl

Andrew I. R. Maas: Andrew.maas@uza.be

David Menon: dkm13@wbic.cam.ac.uk

Ewout W. Steyerberg: e.steyerberg@erasmusmc.nl

Hester F. Lingsma: h.lingsma@erasmusmc.nl

Journal

Journal ID (nlm-ta): Crit Care

Title: Critical Care

Publisher: BioMed Central (London )

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Electronic): 6 September 2017

Publication date PMC-release: 6 September 2017

Publication date Collection: 2017

Volume: 21

Electronic Location Identifier: 233

Affiliations

[1 ]ISNI 000000040459992X, GRID grid.5645.2, Center for Medical Decision Making, Department of Public Health, Erasmus MC, ; Rotterdam, The Netherlands

[2 ]ISNI 000000040459992X, GRID grid.5645.2, Department of Intensive Care, Erasmus MC, ; Rotterdam, The Netherlands

[3 ]ISNI 000000040459992X, GRID grid.5645.2, Department of Neurosurgery, Erasmus MC, ; Rotterdam, The Netherlands

[4 ]ISNI 0000000089452978, GRID grid.10419.3d, Department of Neurosurgery, , Leiden University Medical Center, ; Leiden, The Netherlands

[5 ]ISNI 0000 0004 1937 0626, GRID grid.4714.6, Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, ; Stockholm, Sweden

[6 ]ISNI 0000000121885934, GRID grid.5335.0, Division of Anesthesia, , University of Cambridge, Addenbrooke’s Hospital, ; Cambridge, UK

[7 ]ISNI 0000 0004 1757 2822, GRID grid.4708.b, Department of Pathophysiology and Transplants, , University of Milan, ; Milan, Italy

[8 ]ISNI 0000 0004 1757 8749, GRID grid.414818.0, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, ; Milan, Italy

[9 ]ISNI 0000 0001 2174 1754, GRID grid.7563.7, School of Medicine and Surgery, , University of Milano Bicocca, ; Milan, Italy

[10 ]ISNI 0000 0004 1756 8604, GRID grid.415025.7, Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, ; Monza, Italy

[11 ]Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands

[12 ]Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium

[13 ]ISNI 0000000089452978, GRID grid.10419.3d, Department of Medical Statistics and Bioinformatics, , Leiden University Medical Center, ; Leiden, The Netherlands

Article

Publisher ID: 1816

DOI: 10.1186/s13054-017-1816-9

PMC ID: 5586023

PubMed ID: 28874206

SO-VID: 8c20048e-b476-4d46-9e00-dcfafa99ab0b

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 22 May 2017

Date accepted : 10 August 2017

Funding

Funded by: European Commission FP7

Funded by: FundRef http://dx.doi.org/10.13039/501100008358, Hersenstichting;

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: traumatic brain injury,intracranial hypertension,icp,icu,comparative effectiveness research,survey

Data availability:

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: traumatic brain injury, intracranial hypertension, icp, icu, comparative effectiveness research, survey

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

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Abstract

Background

Methods

Results

Conclusions

Electronic supplementary material

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Irish Journal of Paramedicine

Most cited references 21

Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI): a prospective longitudinal observational study.

A most stubborn bias: no adjustment method fully resolves confounding by indication in observational studies.

Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury.

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