Aiolfi Alberto, Benjamin Elizabeth, Khor Desmond, Inaba Kenji, Lam Lydia, Demetriades Demetrios
Division of Acute Care Surgery, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), Rm C5L100, Los Angeles, CA, 90033, USA.
World J Surg. 2017 Jun;41(6):1543-1549. doi: 10.1007/s00268-017-3898-6.
Brain Trauma Foundation (BTF) guidelines recommend intracranial pressure (ICP) monitoring in patients who sustained severe traumatic brain injury (TBI). Compliance to BTF guidelines is variable, and the effect of ICP monitoring on outcomes remains a controversial issue. The purpose of this study was to assess guidelines compliance in patients who sustain a severe TBI and to analyze the effect of ICP monitoring on outcomes.
Trauma Quality Improvement Program database study, which included patients with isolated severe blunt head trauma (head Abbreviated Injury Scale ≥3 with Glasgow Coma Scale <9). Patients with severe extracranial injuries excluded. Analyzed variables were demographics, comorbidities, mechanism of injuries, head injury specifics, AIS for each body area, Injury Severity Score, admission vital signs, placement of ICP catheter and craniectomy. Multivariate analysis was used to identify independent predictors for outcomes, overall and in the groups of patients with head AIS 3, 4 or 5.
During the study period 13,188 patients with isolated severe TBI met the BTF guidelines for ICP monitoring. An ICP catheter was placed in 1519 (11.5%) patients. Stepwise logistic regression analysis identified age ≥65 years, hypotension on admission, AIS 4 and AIS 5 as independent predictors for mortality. ICP monitoring was not an independent protective variable in terms of mortality (OR 1.12; 95% CI, 0.983-1.275; p = 0.088). Overall, ICP monitor placement was independently associated with increased overall complications (OR 2.089; 95% CI, 1.85-2.358; p < 0.001), infectious complications (OR 2.282; 95% CI, 2.015-2.584; p < 0.001) and poor functional independence (OR 1.889; 95% CI, 1.575-2.264; p < 0.001). Sub analysis of the groups of patients with head AIS 3, 4, and 5 failed to show any protective effect of ICP monitors against mortality. In the group of patients with head AIS 4, ICP placement was an independent predictor of mortality (OR 2206; 95% CI, 1652-2948; p < 0.001).
Compliance with the BTF guidelines for ICP monitoring is poor. ICP monitoring does not have any survival benefit in patients with isolated severe blunt TBI and is associated with more complications and increased utilization of hospital resources.
脑创伤基金会（BTF）指南建议对重度创伤性脑损伤（TBI）患者进行颅内压（ICP）监测。对BTF指南的依从性存在差异，ICP监测对预后的影响仍是一个有争议的问题。本研究的目的是评估重度TBI患者对指南的依从性，并分析ICP监测对预后的影响。
创伤质量改进计划数据库研究，纳入单纯重度钝性颅脑损伤患者（头部简明损伤量表≥3且格拉斯哥昏迷量表<9）。排除有严重颅外损伤的患者。分析的变量包括人口统计学、合并症、损伤机制、头部损伤细节、各身体部位的AIS、损伤严重程度评分、入院生命体征、ICP导管置入情况和颅骨切除术。采用多变量分析确定总体及头部AIS为3、4或5的患者组中预后的独立预测因素。
在研究期间，13188例单纯重度TBI患者符合BTF的ICP监测指南。1519例（11.5%）患者置入了ICP导管。逐步逻辑回归分析确定年龄≥65岁、入院时低血压、AIS 4和AIS 5为死亡的独立预测因素。就死亡率而言，ICP监测不是一个独立的保护变量（OR 1.12；95%CI，0.983 - 1.275；p = 0.088）。总体而言，ICP监测器的置入与总体并发症增加（OR 2.089；95%CI，1.85 - 2.358；p < 0.001）、感染性并发症增加（OR 2.282；95%CI，2.015 - 2.584；p < 0.001）和功能独立性差（OR 1.889；95%CI，1.575 - 2.264；p < 0.001）独立相关。对头部AIS为3、4和5的患者组进行亚组分析未显示ICP监测器对死亡率有任何保护作用。在头部AIS为4的患者组中，ICP置入是死亡的独立预测因素（OR 2206；95%CI，1652 - 2948；p < 0.001）。
对BTF的ICP监测指南的依从性较差。ICP监测对单纯重度钝性TBI患者没有任何生存益处，且与更多并发症及医院资源利用增加相关。
