Department of Neurosurgery, Duke University, Box 3807 Med Center, Durham, NC, 27710, USA.
Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA.
Neurocrit Care. 2022 Apr;36(2):350-356. doi: 10.1007/s12028-021-01394-y. Epub 2021 Nov 29.
The aim of this study was to describe the utilization patterns of brain tissue oxygen (PbtO) monitoring following severe traumatic brain injury (TBI) and determine associations with mortality, health care use, and pulmonary toxicity.
We conducted a retrospective cohort study of patients from United States trauma centers participating in the American College of Surgeons National Trauma Databank between 2008 and 2016. We examined patients with severe TBI (defined by admission Glasgow Coma Scale score ≤ 8) over the age of 18 years who survived more than 24 h from admission and required intracranial pressure (ICP) monitoring. The primary exposure was PbtO monitor placement. The primary outcome was hospital mortality, defined as death during the hospitalization or discharge to hospice. Secondary outcomes were examined to determine the association of PbtO monitoring with health care use and pulmonary toxicity and included the following: (1) intensive care unit length of stay, (2) hospital length of stay, and (3) development of acute respiratory distress syndrome (ARDS). Regression analysis was used to assess differences in outcomes between patients exposed to PbtO monitor placement and those without exposure by using propensity weighting to address selection bias due to the nonrandom allocation of treatment groups and patient dropout.
A total of 35,501 patients underwent placement of an ICP monitor. There were 1,346 (3.8%) patients who also underwent PbtO monitor placement, with significant variation regarding calendar year and hospital. Patients who underwent placement of a PbtO monitor had a crude in-hospital mortality of 31.1%, compared with 33.5% in patients who only underwent placement of an ICP monitor (adjusted risk ratio 0.84, 95% confidence interval 0.76-0.93). The development of the ARDS was comparable between patients who underwent placement of a PbtO monitor and patients who only underwent placement of an ICP monitor (9.2% vs. 9.8%, adjusted risk ratio 0.89, 95% confidence interval 0.73-1.09).
PbtO monitor utilization varied widely throughout the study period by calendar year and hospital. PbtO monitoring in addition to ICP monitoring, compared with ICP monitoring alone, was associated with a decreased in-hospital mortality, a longer length of stay, and a similar risk of ARDS. These findings provide further guidance for clinicians caring for patients with severe TBI while awaiting completion of further randomized controlled trials.
本研究旨在描述严重创伤性脑损伤（TBI）后脑组织氧（PbtO）监测的使用模式，并确定其与死亡率、医疗保健使用和肺毒性的关联。
我们对 2008 年至 2016 年期间参加美国外科医师学会国家创伤数据库的美国创伤中心的患者进行了回顾性队列研究。我们研究了年龄在 18 岁以上、入院格拉斯哥昏迷量表评分≤8 分的严重 TBI 患者，这些患者的存活时间超过 24 小时，需要颅内压（ICP）监测。主要暴露因素是 PbtO 监测仪的放置。主要结局是医院死亡率，定义为住院期间或出院至临终关怀期间的死亡。还检查了次要结局，以确定 PbtO 监测与医疗保健使用和肺毒性的关联，包括以下内容：（1）重症监护病房住院时间，（2）医院住院时间，（3）急性呼吸窘迫综合征（ARDS）的发展。使用倾向加权来解决由于治疗组的非随机分配和患者脱落导致的选择偏差，回归分析用于评估暴露于 PbtO 监测仪放置的患者与未暴露于 PbtO 监测仪放置的患者之间结局的差异。
共有 35501 名患者接受了 ICP 监测仪的放置。其中有 1346 名（3.8%）患者还接受了 PbtO 监测仪的放置，在时间跨度和医院方面存在显著差异。接受 PbtO 监测仪放置的患者的院内死亡率为 31.1%，而仅接受 ICP 监测仪放置的患者为 33.5%（调整后的风险比为 0.84，95%置信区间为 0.76-0.93）。接受 PbtO 监测仪放置的患者与仅接受 ICP 监测仪放置的患者的 ARDS 发展情况相似（9.2%对 9.8%，调整后的风险比为 0.89，95%置信区间为 0.73-1.09）。
在研究期间，PbtO 监测仪的使用在时间跨度和医院方面存在很大差异。与单独使用 ICP 监测相比，在 ICP 监测的基础上加用 PbtO 监测与院内死亡率降低、住院时间延长以及 ARDS 风险增加相关。这些发现为在等待进一步随机对照试验完成的同时，为护理严重 TBI 患者的临床医生提供了进一步的指导。
