Dolmans Rianne G F, Barber Jason, Foreman Brandon, Temkin Nancy R, Okonkwo David O, Robertson Claudia S, Manley Geoffrey T, Rosenthal Eric S
Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.
Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
Neurocrit Care. 2025 Apr;42(2):551-561. doi: 10.1007/s12028-024-02054-7. Epub 2024 Aug 13.
Interventions to reduce intracranial pressure (ICP) in patients with traumatic brain injury (TBI) are multimodal but variable, including sedation-dosing strategies. This article quantifies the different sedation intensities administered in patients with moderate to severe TBI (msTBI) using the therapy intensity level (TIL) across different intensive care units (ICUs), including the use of additional ICP-lowering therapies.
Within the prospective Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, we performed a retrospective analysis of adult patients with msTBI admitted to an ICU for a least 5 days from seven US level 1 trauma centers who received invasive ICP monitoring and intravenous sedation. Sedation intensity was classified prospectively as one of three ordinal levels as part of the validated TIL score, which were collected at least once a day.
A total of 127 patients met inclusion criteria (mean age 41.6 ± 17.7 years; 20% female). The median Injury Severity Score was 27 (interquartile range 17-33), with a median admission Glasgow Coma Score of 3 (interquartile range 3-7); 104 patients had severe TBI (82%), and 23 patients had moderate TBI (18%). The sedation intensity score was highest on the first ICU day (2.69 ± 1.78), independent of patient severity. Time to reaching each sedation intensity level varied by site. Sedation level I was reached within 24 h for all sites, but sedation levels II and III were reached variably between days 1 and 3. Sedation level III was never reached by two of seven sites. The total TIL score was highest on the first ICU day, with a modest decrease for each subsequent ICU day, but there was high site-specific practice-pattern variation.
Intensity of sedation and other therapies for elevated ICP for patients with msTBI demonstrate large practice-pattern variation across level 1 trauma centers within the TRACK-TBI cohort study, independent of patient severity. Optimizing sedation strategies using patient-specific physiologic and pathoanatomic information may optimize patient outcomes.
创伤性脑损伤（TBI）患者降低颅内压（ICP）的干预措施是多模式的，但各不相同，包括镇静给药策略。本文使用治疗强度水平（TIL）对不同重症监护病房（ICU）中中度至重度TBI（msTBI）患者的不同镇静强度进行量化，包括使用额外的降低ICP治疗。
在前瞻性的创伤性脑损伤转化研究与临床知识（TRACK-TBI）研究中，我们对来自美国七个一级创伤中心的成年msTBI患者进行了回顾性分析，这些患者入住ICU至少5天，接受了有创ICP监测和静脉镇静。作为经过验证的TIL评分的一部分，镇静强度被前瞻性地分类为三个序数水平之一，每天至少收集一次。
共有127例患者符合纳入标准（平均年龄41.6±17.7岁；20%为女性）。损伤严重程度评分中位数为27（四分位间距17 - 33），入院时格拉斯哥昏迷评分中位数为3（四分位间距3 - 7）；104例患者为重度TBI（82%），23例患者为中度TBI（18%）。镇静强度评分在ICU的第一天最高（2.69±1.78），与患者严重程度无关。达到每个镇静强度水平的时间因地点而异。所有地点在24小时内达到镇静水平I，但镇静水平II和III在第1天至第3天之间达到的情况各不相同。七个地点中有两个从未达到镇静水平III。总TIL评分在ICU的第一天最高，随后的每个ICU日略有下降，但存在高度的地点特异性实践模式差异。
在TRACK-TBI队列研究中，msTBI患者镇静及其他治疗ICP升高的强度在一级创伤中心之间存在很大的实践模式差异，与患者严重程度无关。利用患者特异性生理和病理解剖信息优化镇静策略可能会改善患者预后。
