ObjectiveThe choice between external ventricular drain (EVD) and intraparenchymal monitor (IPM) for managing intracranial pressure in moderate-to-severe traumatic brain injury (msTBI) patients... Show moreObjectiveThe choice between external ventricular drain (EVD) and intraparenchymal monitor (IPM) for managing intracranial pressure in moderate-to-severe traumatic brain injury (msTBI) patients remains controversial. This study aimed to investigate factors associated with receiving EVD versus IPM and to compare outcomes and clinical management between EVD and IPM patients.MethodsAdult msTBI patients at 2 similar academic institutions were identified. Logistic regression was performed to identify factors associated with receiving EVD versus IPM (model 1) and to compare EVD versus IPM in relation to patient outcomes after controlling for potential confounders (model 2), through odds ratios (ORs) and 95% confidence intervals (CIs).ResultsOf 521 patients, 167 (32.1%) had EVD and 354 (67.9%) had IPM. Mean age, sex, and Injury Severity Score were comparable between groups. Epidural hemorrhage (EDH) (OR 0.43, 95% CI 0.21–0.85), greater midline shift (OR 0.90, 95% CI 0.82–0.98), and the hospital with higher volume (OR 0.14, 95% CI 0.09–0.22) were independently associated with lower odds of receiving an EVD whereas patients needing a craniectomy were more likely to receive an EVD (OR 2.04, 95% CI 1.12–3.73). EVD patients received more intense medical treatment requiring hyperosmolar therapy compared to IPM patients (64.1% vs. 40.1%). No statistically significant differences were found in patient outcomes.ConclusionsWhile EDH, greater midline shift, and hospital with larger patient volume were associated with receiving an IPM, the need for a craniectomy was associated with receiving an EVD. EVD patients received different clinical management than IPM patients with no significant differences in patient outcomes. Show less
Background Analgo-sedation plays an important role during intensive care management of traumatic brain injury (TBI) patients, however, limited evidence is available to guide practice. We sought to... Show moreBackground Analgo-sedation plays an important role during intensive care management of traumatic brain injury (TBI) patients, however, limited evidence is available to guide practice. We sought to quantify practice-pattern variation in neurotrauma sedation management, surveying an international sample of providers. Methods: An electronic survey consisting of 56 questions was distributed internationally to neurocritical care providers utilizing the Research Electronic Data Capture platform. Descriptive statistics were used to quantitatively describe and summarize the responses. Results: Ninety-five providers from 37 countries responded. 56.8% were attending physicians with primary medical training most commonly in intensive care medicine (68.4%) and anesthesiology (26.3%). Institutional sedation guidelines for TBI patients were available in 43.2%. Most common sedative agents for induction and maintenance, respectively, were propofol (87.5% and 88.4%), opioids (60.2% and 70.5%), and benzodiazepines (53.4% and 68.4%). Induction and maintenance sedatives, respectively, are mostly chosen according to provider preference (68.2% and 58.9%) rather than institutional guidelines (26.1% and 35.8%). Sedation duration for patients with intracranial hypertension ranged from 24 h to 14 days. Neurological wake-up testing (NWT) was routinely performed in 70.5%. The most common NWT frequency was every 24 h (47.8%), although 20.8% performed NWT at least every 2 h. Richmond Agitation and Sedation Scale targets varied from deep sedation (34.7%) to alert and calm (17.9%). Conclusions: Among critically ill TBI patients, sedation management follows provider preference rather than institutional sedation guidelines. Wide practice-pattern variation exists for the type, duration, and target of sedative management and NWT performance. Future comparative effectiveness research investigating these differences may help optimize sedation strategies to promote recovery. Show less
Dolmans, R.G.F.; Robertson, F.C.; Eijkholt, M.; Vliet, P. van; Broekman, M.L.D. 2023
Traumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide and many patients with TBI require intensive care unit (ICU) management. When facing a life-threatening... Show moreTraumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide and many patients with TBI require intensive care unit (ICU) management. When facing a life-threatening illness, such as TBI, a palliative care approach that focuses on noncurative aspects of care should always be considered in the ICU. Research shows that neurosurgical patients in the ICU receive palliative care less frequently than the medical patients in the ICU, which is a missed opportunity for these patients. However, providing appropriate palliative care to neurotrauma patients in an ICU can be difficult, particularly for young adult patients. The patients' prognoses are often unclear, the likelihood of advance directives is small, and the bereaved families must act as decision-makers. This article highlights the different aspects of the palliative care approach as well as barriers and challenges that accompany the TBI patient population, with a particular focus on young adult patients with TBI and the role of their family members. The article concludes with recommendations for physicians for effective and adequate communication to successfully implement the palliative care approach into standard ICU care and to improve quality of care for patients with TBI and their families. Show less
OBJECTIVE: Outcome prediction in severe traumatic brain injury (sTBI) has been studied using clinical and radiographic measurements and by using biomarkers such as glial fibrillary acidic protein,... Show moreOBJECTIVE: Outcome prediction in severe traumatic brain injury (sTBI) has been studied using clinical and radiographic measurements and by using biomarkers such as glial fibrillary acidic protein, ubiquitin C-terminal hydrolase-L1, and tau. Routine blood tests are regularly performed in patients with sTBI and could be used to predict outcomes. This study aims to investigate whether routine blood tests on admission can be predictive of outcome in patients with sTBI.METHODS: Patients with sTBI were selected from 2 institutional databases based on International Classification of Diseases Ninth and Tenth Revision codes for traumatic brain injury (TBI), ventilatory assistance >24 hours, intracranial pressure monitoring, and Glasgow Coma Score (GCS) score =8. Laboratory parameters included blood urea nitrogen, creatinine, glucose, hematocrit, hemoglobin, red blood cells, white blood cells, monocytes, lymphocytes, neutrophils, neutrophil lymphocyte ratio, platelets, international normalized ratio, prothrombin time, sodium, and potassium. Clinical outcome was measured as hospital length of stay, 30-day mortality, and favorable versus unfavorable outcome based on Glasgow Outcome Scale at 3 months.RESULTS: A total of 255 adult patients were selected. Median Injury Severity Score was 14.00 (interquartile range, 9.00-22.00). Of patients, 25.9% died within 30 days and 56.1% had an unfavorable outcome at 3 months. On multivariate analysis, low sodium level was significant for 30-day mortality and high sodium level was significant for unfavorable outcome at 3 months. However, after correction for multiple testing, no routine blood test remained significant.CONCLUSIONS: No routine blood tests measured on admission were significant predictors of outcome in patients with sTBI. Other clinical and radiologic factors may be better suited to predicting outcomes in this patient population. Show less
