Functional Outcome After Intracranial Pressure Monitoring for Children With Severe Traumatic Brain Injury

Abstract

IMPORTANCE 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.OBJECTIVE To test the hypothesis that ICP monitoring is associated with improved functional survival of children with severe TBI. DESIGN, SETTING, AND PARTICIPANTSA 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.EXPOSURE Placement of an ICP monitor. MAIN OUTCOMES AND MEASURESA composite of hospital mortality, discharge to hospice, or survival with placement of new tracheostomy and gastrostomy tubes. RESULTSOf 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. CONCLUSIONS AND RELEVANCEWith 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.

Impact of the Timing of Placement of an Intracranial Pressure Monitor on Outcomes in Children with Severe Traumatic Brain Injury

“…This also attests to the heterogeneity of the TBI population and variations in factors on the level of both the patient and the hospital that affect the use of ICP monitoring, as reported in other studies [13]. The mortality rate of 24% for the whole sTBI cohort, after excluding those who died within 24 h, is similar to the mortality in other studies of pediatric sTBI which used patient data from the National Trauma Data Bank, a large multi-institutional database similar to VPS [11, 12]. …”

Fully automated, real-time, calibration-free, continuous noninvasive estimation of intracranial pressure in children

“…In children with moderate TBI, management often occurs without the benefit of ICP monitoring. 2,3 Historically, various initial ICP target values have been used to guide treatment, from less than 15 mm Hg, to less than 20 mm Hg, or even less than 25 mm Hg. 10 Use of cerebral perfusion pressure to guide care also requires knowledge of ICP.…”

Monitoring and Measurement of Intracranial Pressure in Pediatric Head Trauma

“…A subsequent study by Bennet et al (63) found no evidence that ICP monitoring in pediatric patients with severe TBI improved outcome. However, unlike the groups formed by Alkhoury et al (62), the initial assessment of patients in the ICP monitoring group revealed poorer Injury Severity Scores, head Abbreviated Injury Scale scores and GCS scores and a higher risk of an intracranial hemorrhage.…”