Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study

Clinical article

Peep Talving M.D., Ph.D., Efstathios Karamanos M.D., Pedro G. Teixeira M.D., Dimitra Skiada M.D., Lydia Lam M.D., Howard Belzberg M.D., Kenji Inaba M.D., and Demetrios Demetriades M.D., Ph.D.
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  • Division of Acute Care Surgery (Trauma, Emergency Surgery and Surgical Critical Care), Department of Surgery, Keck School of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California
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Object

The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on outcomes.

Methods

This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score ≥ 3) between January 2010 and December 2011. Demographics, clinical characteristics, laboratory profile, head CT scans, injury severity indices, and interventions were collected. The study population was stratified into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes included compliance with BTF guidelines, overall in-hospital mortality, and mortality due to brain herniation. Secondary outcomes were ICU and hospital lengths of stay. Multiple regression analyses were deployed to determine the effect of ICP monitoring on outcomes.

Results

A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guidelines was 46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/craniotomy were significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing age were negatively associated with the placement of ICP monitoring devices. The overall in-hospital mortality was significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly, mortality due to brain herniation was significantly higher for the group not undergoing ICP monitoring (21.7% vs 12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay were significantly longer in patients subjected to ICP monitoring.

Conclusions

Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients managed according to the BTF ICP guidelines experienced significantly improved survival.

Abbreviations used in this paper:AIS = Abbreviated Injury Scale; AOR = adjusted odds ratio; AUC = area under the curve; BTF = Brain Trauma Foundation; CPP = cerebral perfusion pressure; GCS = Glasgow Coma Scale; ICH = intracranial hemorrhage; ICP = intracranial pressure; INR = international normalized ratio; IPH = intraparenchymal hemorrhage; ISS = Injury Severity Score; LOS = length of stay; NTDB = National Trauma Data Bank; PT = prothrombin time; PTT = partial thromboplastin time; SAH = subarachnoid hemorrhage; SBP = systolic blood pressure; SDH = subdural hematoma; TBI = traumatic brain injury.

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Contributor Notes

Address correspondence to: Peep Talving, M.D., Ph.D., Department of Surgery, Division of Acute Care Surgery, (Trauma, Emergency Surgery and Surgical Critical Care), Keck School of Medicine, LAC + USC Medical Center, 2051 Marengo St., Rm. IPT-C5L100, Los Angeles, CA 90033. email: peep.talving@surgery.usc.edu.

Please include this information when citing this paper: published online August 23, 2013; DOI: 10.3171/2013.7.JNS122255.

  • 1

    Bratton SL, , Chestnut RM, , Ghajar J, , McConnell Hammond FF, , Harris OA, & Hartl R, : Guidelines for the management of severe traumatic brain injury. VIII. Intracranial pressure thresholds. J Neurotrauma 24:Suppl 1 S55S58, 2007. (Erratum in J Neurotrauma 25:276–278, 2008)

    • Search Google Scholar
    • Export Citation
  • 2

    Bulger EM, , Nathens AB, , Rivara FP, , Moore M, , MacKenzie EJ, & Jurkovich GJ: Management of severe head injury: institutional variations in care and effect on outcome. Crit Care Med 30:18701876, 2002

    • Search Google Scholar
    • Export Citation
  • 3

    Chesnut RM, , Temkin N, , Carney N, , Dikmen S, , Rondina C, & Videtta W, : A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 367:24712481, 2012

    • Search Google Scholar
    • Export Citation
  • 4

    Cremer OL, , van Dijk GW, , van Wensen E, , Brekelmans GJ, , Moons KG, & Leenen LP, : Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med 33:22072213, 2005

    • Search Google Scholar
    • Export Citation
  • 5

    Fakhry SM, , Trask AL, , Waller MA, & Watts DD: Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma 56:492500, 2004

    • Search Google Scholar
    • Export Citation
  • 6

    Hesdorffer DC, , Ghajar J, & Iacono L: Predictors of compliance with the evidence-based guidelines for traumatic brain injury care: a survey of United States trauma centers. J Trauma 52:12021209, 2002

    • Search Google Scholar
    • Export Citation
  • 7

    Hukkelhoven CW, , Steyerberg EW, , Rampen AJ, , Farace E, , Habbema JD, & Marshall LF, : Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. J Neurosurg 99:666673, 2003

    • Search Google Scholar
    • Export Citation
  • 8

    Idris Z, , Ghani RI, , Musa KI, , Ibrahim MI, , Abdullah M, & Nyi NN, : Prognostic study of using different monitoring modalities in treating severe traumatic brain injury. Asian J Surg 30:200208, 2007

    • Search Google Scholar
    • Export Citation
  • 9

    Jeevaratnam DR, & Menon DK: Survey of intensive care of severely head injured patients in the United Kingdom. BMJ 312:944947, 1996

  • 10

    Lane PL, , Skoretz TG, , Doig G, & Girotti MJ: Intracranial pressure monitoring and outcomes after traumatic brain injury. Can J Surg 43:442448, 2000

    • Search Google Scholar
    • Export Citation
  • 11

    Lee TT, , Galarza M, & Villanueva PA: Diffuse axonal injury (DAI) is not associated with elevated intracranial pressure (ICP). Acta Neurochir (Wien) 140:4146, 1998

    • Search Google Scholar
    • Export Citation
  • 12

    Lobato RD, , Sarabia R, , Rivas JJ, , Cordobes F, , Castro S, & Muñoz MJ, : Normal computerized tomography scans in severe head injury. Prognostic and clinical management implications. J Neurosurg 65:784789, 1986

    • Search Google Scholar
    • Export Citation
  • 13

    Miller MT, , Pasquale M, , Kurek S, , White J, , Martin P, & Bannon K, : Initial head computed tomographic scan characteristics have a linear relationship with initial intracranial pressure after trauma. J Trauma 56:967973, 2004

    • Search Google Scholar
    • Export Citation
  • 14

    Myburgh JA, , Cooper DJ, , Finfer SR, , Venkatesh B, , Jones D, & Higgins A, : Epidemiology and 12-month outcomes from traumatic brain injury in Australia and New Zealand. J Trauma 64:854862, 2008

    • Search Google Scholar
    • Export Citation
  • 15

    Narayan RK, , Kishore PR, , Becker DP, , Ward JD, , Enas GG, & Greenberg RP, : Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury. J Neurosurg 56:650659, 1982

    • Search Google Scholar
    • Export Citation
  • 16

    Palmer S, , Bader MK, , Qureshi A, , Palmer J, , Shaver T, & Borzatta M, : The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. J Trauma 50:657664, 2001

    • Search Google Scholar
    • Export Citation
  • 17

    Patel HC, , Menon DK, , Tebbs S, , Hawker R, , Hutchinson PJ, & Kirkpatrick PJ: Specialist neurocritical care and outcome from head injury. Intensive Care Med 28:547553, 2002

    • Search Google Scholar
    • Export Citation
  • 18

    Poca MA, , Sahuquillo J, , Báguena M, , Pedraza S, , Gracia RM, & Rubio E: Incidence of intracranial hypertension after severe head injury: a prospective study using the Traumatic Coma Data Bank classification. Acta Neurochir Suppl 71:2730, 1998

    • Search Google Scholar
    • Export Citation
  • 19

    Sahjpaul R, & Girotti M: Intracranial pressure monitoring in severe traumatic brain injury—results of a Canadian survey. Can J Neurol Sci 27:143147, 2000

    • Search Google Scholar
    • Export Citation
  • 20

    Shafi S, , Diaz-Arrastia R, , Madden C, & Gentilello L: Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival. J Trauma 64:335340, 2008

    • Search Google Scholar
    • Export Citation
  • 21

    Stocchetti N, , Penny KI, , Dearden M, , Braakman R, , Cohadon F, & Iannotti F, : Intensive care management of head-injured patients in Europe: a survey from the European Brain Injury Consortium. Intensive Care Med 27:400406, 2001

    • Search Google Scholar
    • Export Citation
  • 22

    Thurman DJ, , Alverson C, , Dunn KA, , Guerrero J, & Sniezek JE: Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehabil 14:602615, 1999

    • Search Google Scholar
    • Export Citation
  • 23

    Wilkins IA, , Menon DK, & Matta BF: Management of comatose head-injured patients: are we getting any better?. Anaesthesia 56:350352, 2001

    • Search Google Scholar
    • Export Citation

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