The Brain Trauma Foundation (BTF) recommends intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) patients with Glasgow Coma Scale (GCS) of 8 or less, and an abnormal brain computed tomography. However, benefits of ICP monitoring have not been documented. We hypothesized that BTF criteria for ICP monitoring in blunt TBI do not identify patients who are likely to benefit from it.
The National Trauma Data Bank (1994-2001) was analyzed. Inclusion criteria were blunt TBI, head-abbreviated injury score (AIS) 3 to 6, age 20 to 50 years, GCS </=8, abnormal brain computed tomographic scan, and intensive care unit admission for 3 days or more. Early deaths (<48 hours) and delayed admissions (>24 hours after injury) were excluded. Patients who underwent ICP monitoring (n = 708) were compared with those did not (n = 938). Multivariate logistic regression was used to determine the relationship between ICP monitoring and survival, while controlling for overall injury severity, TBI severity, craniotomy, associated injuries, comorbidities, and complications.
ICP monitoring was performed in only 43% of patients who met BTF criteria. There were no group differences in age, gender, or GCS. After adjusting for multiple potential confounding factors including, admission GCS, age, blood pressure, head AIS, and injury severity score (ISS), ICP monitoring was associated with a 45% reduction in survival (OR = 0.55; 95% CI, 0.39-0.76; p < 0.001).
ICP monitoring in accordance with current BTF criteria is associated with worsening of survival in TBI patients. A prospective randomized controlled trial of ICP-guided therapy is needed. Until then, the use of ICP monitoring should not be used as a quality benchmark.
"To account for confounding factors that could affect outcomes, a logistic regression model was used to adjust for baseline differences between the two groups and determine adjusted odds ratios (AORs), 95% confidence intervals (CIs), and adjusted P values. All variables with a P < 0.05 were entered into the model and additional parameters that have been previously demonstrated to impact outcomes in patients with TBI (i.e., race and insurance status  ). Receiver-operator curves were created to determine area under the curve (AUC) and 95% CI to assess our regression model discrimination . "
"Current studies reporting better survival and outcome with ICP monitoring include Patel et al.  and Fakhry et al. . However, several other studies have reached the opposite conclusion, indicating worse outcome as a consequence of ICP monitoring and CPP-oriented therapy [46, 127–129]. "
[Show abstract][Hide abstract] ABSTRACT: Monitoring of intracranial pressure (ICP) has been used for decades in the fields of neurosurgery and neurology. There are multiple techniques: invasive as well as noninvasive. This paper aims to provide an overview of the advantages and disadvantages of the most common and well-known methods as well as assess whether noninvasive techniques (transcranial Doppler, tympanic membrane displacement, optic nerve sheath diameter, CT scan/MRI and fundoscopy) can be used as reliable alternatives to the invasive techniques (ventriculostomy and microtransducers). Ventriculostomy is considered the gold standard in terms of accurate measurement of pressure, although microtransducers generally are just as accurate. Both invasive techniques are associated with a minor risk of complications such as hemorrhage and infection. Furthermore, zero drift is a problem with selected microtransducers. The non-invasive techniques are without the invasive methods' risk of complication, but fail to measure ICP accurately enough to be used as routine alternatives to invasive measurement. We conclude that invasive measurement is currently the only option for accurate measurement of ICP.
Critical care research and practice 06/2012; 2012(12):950393. DOI:10.1155/2012/950393
"Other studies have not shown benefits from ICP monitoring [22-24]. Moreover, a few studies have demonstrated that ICP monitoring was associated with worsening of survival [25,26]. Potential complications of ICP monitoring include infection, hemorrhage, malfunction, obstruction, or malposition. "
[Show abstract][Hide abstract] ABSTRACT: Traumatic brain injury (TBI) is a major medical and socio-economic problem, and is the leading cause of death in children and young adults. The critical care management of severe TBI is largely derived from the "Guidelines for the Management of Severe Traumatic Brain Injury" that have been published by the Brain Trauma Foundation. The main objectives are prevention and treatment of intracranial hypertension and secondary brain insults, preservation of cerebral perfusion pressure (CPP), and optimization of cerebral oxygenation. In this review, the critical care management of severe TBI will be discussed with focus on monitoring, avoidance and minimization of secondary brain insults, and optimization of cerebral oxygenation and CPP.
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 02/2012; 20(1):12. DOI:10.1186/1757-7241-20-12 · 2.03 Impact Factor
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