University of Washington, Harborview Medical Center, Seattle, Washington, USA.
Medicina Intensiva, Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina.
Neurosurgery. 2023 Mar 1;92(3):472-480. doi: 10.1227/neu.0000000000002251. Epub 2022 Dec 12.
Most patients with severe traumatic brain injury (sTBI) in low- or-middle-income countries and surprisingly many in high-income countries are managed without intracranial pressure (ICP) monitoring. The impact of the first published protocol (Imaging and Clinical Examination [ICE] protocol) is untested against nonprotocol management.
To determine whether patients treated in intensive care units (ICUs) using the ICE protocol have lower mortality and better neurobehavioral functioning than those treated in ICUs using no protocol.
This study involved nineteen mostly public South American hospitals. This is a prospective cohort study, enrolling patients older than 13 years with sTBI presenting within 24 h of injury (January 2014-July 2015) with 6-mo postinjury follow-up. Five hospitals treated all sTBI cases using the ICE protocol; 14 used no protocol. Primary outcome was prespecified composite of mortality, orientation, functional outcome, and neuropsychological measures.
A total of 414 patients (89% male, mean age 34.8 years) enrolled; 81% had 6 months of follow-up. All participants included in composite outcome analysis: average percentile (SD) = 46.8 (24.0) nonprotocol, 56.9 (24.5) protocol. Generalized estimating equation (GEE) used to account for center effects (confounder-adjusted difference [95% CI] = 12.2 [4.6, 19.8], P = .002). Kaplan-Meier 6-month mortality (95% CI) = 36% (30%, 43%) nonprotocol, 25% (19%, 31%) protocol (GEE and confounder-adjusted hazard ratio [95% CI] = .69 [.43, 1.10], P = .118). Six-month Extended Glasgow Outcome Scale for 332 participants: average Extended Glasgow Outcome Scale score (SD) = 3.6 (2.6) nonprotocol, 4.7 (2.8) protocol (GEE and confounder-adjusted and lost to follow-up-adjusted difference [95% CI] = 1.36 [.55, 2.17], P = .001).
ICUs managing patients with sTBI using the ICE protocol had better functional outcome than those not using a protocol. ICUs treating patients with sTBI without ICP monitoring should consider protocolization. The ICE protocol, tested here and previously, is 1 option.
在低收入和中等收入国家，大多数严重创伤性脑损伤（sTBI）患者，令人惊讶的是，在高收入国家也有许多患者在没有颅内压（ICP）监测的情况下接受治疗。首个发表的方案（成像和临床检查[ICE]方案）对非方案治疗的影响尚未得到检验。
确定在使用 ICE 方案的重症监护病房（ICU）中接受治疗的患者的死亡率是否低于未使用方案治疗的患者，且神经行为功能是否更好。
本研究涉及 19 家主要的南美洲公立医院。这是一项前瞻性队列研究，纳入了年龄在 13 岁以上、损伤后 24 小时内出现 sTBI 并在损伤后 6 个月进行随访的患者。5 家医院对所有 sTBI 病例均采用 ICE 方案治疗；14 家医院未采用方案治疗。主要结局是预先规定的死亡率、定向力、功能结局和神经心理学测量的复合指标。
共纳入 414 例患者（89%为男性，平均年龄 34.8 岁）；81%患者完成了 6 个月的随访。所有纳入复合结局分析的患者：非方案组平均百分位数（SD）=46.8（24.0），方案组 56.9（24.5）。使用广义估计方程（GEE）来考虑中心效应（校正混杂因素后的差异[95%CI]=12.2[4.6,19.8]，P=.002）。Kaplan-Meier 6 个月死亡率（95%CI）为非方案组 36%（30%,43%），方案组 25%（19%,31%）（GEE 和校正混杂因素后的危险比[95%CI]=.69[.43,1.10]，P=.118）。对 332 例患者进行 6 个月扩展格拉斯哥预后评分：非方案组平均扩展格拉斯哥预后评分（SD）=3.6（2.6），方案组 4.7（2.8）（GEE 和校正混杂因素和失访调整后的差异[95%CI]=1.36[.55,2.17]，P=.001）。
在使用 ICE 方案治疗 sTBI 的 ICU 中，患者的功能结局要好于未使用方案的患者。未进行 ICP 监测的 sTBI 患者治疗的 ICU 应考虑方案化。在这里和以前测试过的 ICE 方案是一种选择。
