Bennett Tellen D, DeWitt Peter E, Greene Tom H, Srivastava Rajendu, Riva-Cambrin Jay, Nance Michael L, Bratton Susan L, Runyan Desmond K, Dean J Michael, Keenan Heather T
Pediatric Critical Care, University of Colorado School of Medicine, Aurora.
Children's Hospital Colorado, Aurora.
JAMA Pediatr. 2017 Oct 1;171(10):965-971. doi: 10.1001/jamapediatrics.2017.2127.
Intracranial pressure (ICP) monitoring is a mainstay of therapy for children with traumatic brain injury (TBI), but its overall association with patient outcome is unclear.
To test the hypothesis that ICP monitoring is associated with improved functional survival of children with severe TBI.
DESIGN, SETTING, AND PARTICIPANTS: A propensity-weighted effectiveness analysis was conducted using 2 linked national databases with data from 30 US children's hospitals from January 1, 2007, to December 31, 2012, on 3084 children with severe TBI. Clinical events including neurosurgical procedures were identified using validated computable phenotypes. Data analysis was conducted from September 1, 2016, to March 1, 2017.
Placement of an ICP monitor.
A composite of hospital mortality, discharge to hospice, or survival with placement of new tracheostomy and gastrostomy tubes.
Of the 3084 children in the study (1128 girls and 1956 boys; mean [SD] age, 7.03 [5.44] years), 1002 (32.4%) underwent ICP monitoring, with substantial hospital variation (6% to 50% by hospital). Overall, 484 children (15.7%) experienced the primary composite outcome. A propensity approach using matching weights generated good covariate balance between those who did and those who did not undergo ICP monitoring. Using a propensity-weighted logistic regression model clustered by hospital, no statistically significant difference was found in functional survival between monitored and unmonitored patients (odds ratio of poor outcome among those who underwent ICP monitoring, 1.31; 95% CI, 0.99-1.74). In a prespecified secondary analysis, no difference in mortality was found (odds ratio, 1.16; 95% CI, 0.89-1.50). Prespecified subgroup analyses of children younger and older than 2 years of age and among those with unintentional and inflicted (intentional) injuries also showed no difference in outcome with ICP monitoring.
With the use of linked national data and validated computable phenotypes, no evidence was found of a benefit from ICP monitoring on functional survival of children with severe TBI. Intracranial pressure monitoring is a widely but inconsistently used technology with incompletely demonstrated effectiveness. A large prospective cohort study or randomized trial is needed.
颅内压（ICP）监测是创伤性脑损伤（TBI）患儿治疗的主要手段，但其与患者预后的总体关联尚不清楚。
检验ICP监测与重度TBI患儿功能存活改善相关的假设。
设计、设置和参与者：使用两个相关的国家数据库进行倾向加权有效性分析，数据来自2007年1月1日至2012年12月31日美国30家儿童医院的3084例重度TBI患儿。使用经过验证的可计算表型识别包括神经外科手术在内的临床事件。数据分析于2016年9月1日至2017年3月1日进行。
放置ICP监测器。
医院死亡率、出院至临终关怀机构或存活且放置新的气管造口管和胃造口管的综合指标。
在研究的3084例患儿中（1128例女孩和1956例男孩；平均[标准差]年龄为7.03[5.44]岁），1002例（32.4%）接受了ICP监测，各医院之间存在显著差异（各医院为6%至50%）。总体而言，484例患儿（15.7%）出现了主要综合结局。使用匹配权重的倾向分析在接受和未接受ICP监测的患儿之间产生了良好的协变量平衡。使用按医院聚类的倾向加权逻辑回归模型，在接受监测和未接受监测的患者之间，功能存活方面未发现统计学上的显著差异（接受ICP监测的患者中不良结局的优势比为1.31；95%置信区间为0.99 - 1.74）。在预先设定的二次分析中，未发现死亡率有差异（优势比为1.16；95%置信区间为0.89 - 1.50）。对2岁及以下和2岁以上患儿以及无意和有意（故意）受伤患儿进行的预先设定亚组分析也显示，ICP监测在结局方面无差异。
通过使用相关的国家数据和经过验证的可计算表型，未发现ICP监测对重度TBI患儿的功能存活有获益的证据。颅内压监测是一种广泛但使用不一致的技术，其有效性尚未完全得到证实。需要进行大规模的前瞻性队列研究或随机试验。
