Intracranial pressure monitoring among children with severe traumatic brain injury

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>Well-designed studies linking intracranial pressure (ICP) monitoring with improved outcomes among children with severe traumatic brain injury (TBI) are lacking. The main objective of this study was to examine the relationship between ICP monitoring in children and in-hospital mortality following severe TBI.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>An observational study was conducted using data derived from 153 adult or mixed (adult and pediatric) trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and 29 pediatric trauma centers participating in the pediatric pilot TQIP between 2010 and 2012. Random-intercept multilevel modeling was used to examine the association between ICP monitoring and in-hospital mortality among children with severe TBI ≤16 years of age after adjusting for important confounders. This association was evaluated at the patient level and at the hospital level. In a sensitivity analysis, this association was reexamined in a propensity-matched cohort.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>A total of 1705 children with severe TBI were included in the study cohort. The overall in-hospital mortality was 14.3% of patients (n = 243), whereas the mortality of the 273 patients (16%) who underwent invasive ICP monitoring was 11% (n = 30). After adjusting for patient- and hospital-level characteristics, ICP monitoring was associated with lower in-hospital mortality (adjusted OR 0.50; 95% CI 0.30–0.85; p = 0.01). It is possible that patients who were managed with ICP monitoring were selected because of an anticipated favorable or unfavorable outcome. To further address this potential selection bias, the analysis was repeated with the hospital-specific rate of ICP monitoring use as the exposure. The adjusted OR for death of children treated at high ICP–use hospitals was 0.49 compared with those treated at low ICP-use hospitals (95% CI 0.31–0.78; p = 0.003). Variations in ICP monitoring use accounted for 15.9% of the interhospital variation in mortality among children with severe TBI. Similar results were obtained after analyzing the data using propensity score-matching methods.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>In this observational study, ICP monitoring use was associated with lower hospital mortality at both the patient and hospital levels. However, the contribution of variable ICP monitoring rates to interhospital variation in pediatric TBI mortality was modest.</jats:p></jats:sec>

Effects of Intracranial Pressure Monitoring on Mortality in Patients with Severe Traumatic Brain Injury: A Meta-Analysis

“…Finally, we excluded it by a serious discussion. Ultimately, 18 of these articles met the inclusion criteria and were used to assess the value of ICP monitoring in patients with severe TBI [12, 13, 15, 16, 25–38] (Fig 1). Of 16 observational studies and two RCTs, nine studies were conducted in America, five in Asia, three in Europe, and one in Africa.…”

“…Eighteen studies containing 7637 patients with severe TBI who were subjected to ICP monitoring and 17862 with severe TBI who were not subjected to ICP monitoring were ultimately analyzed in this meta-analysis[12, 13, 15, 16, 24–38]. Fig 2 shows a forest plot comparing the ICP monitored and no-ICP monitored groups.…”

“…In the subgroup analysis, studies were divided into two groups according to time of hospital admission. Five studies[15, 25–27, 35] reported on the ICP embedded absolutely before 2007, while 10 studies examined the same after 2007 [12, 13, 29–32, 34, 36–38]. The subgroup provided efficient evidence that ICP monitoring reduced the mortality rate after 2007 (pooled RR = 0.72, 95% CI = 0.63–0.83, p<0.01; I 2 = 68%, p for heterogeneity<0.1) but not before 2007 (pooled RR = 1.18, 95% CI = 0.89–1.56, p = 0.25; I 2 = 86%, p for heterogeneity<0.1) (Fig 3).…”

Severe Traumatic Brain Injury

“…1 In contrast, an observational study conducted in large pooled pediatric populations, using random-intercept multilevel modeling, demonstrated improvement in hospital mortality; however, this study did not examine long-term outcomes. 2 In attempts to balance the respective limitations of each study, recent work published by Bennett et al 3 in JAMA Pediatrics examines the role of ICP monitoring in both mortality and functional outcome.…”

“…Current literature has documented low rates of symptomatic intracerebral hemorrhage following ADAPT thrombectomy ranging from 2% to 7.8%; whereas, rates following SR thrombectomy often fall between 7% and 12%. 2,[4][5][6][7]12,14,18 The ASTER trial found no difference in intracerebral hemorrhage rates between the 2 techniques (ADAPT 5.3%, SR 6.5%). Embolic complications encompass emboli distal to the primary occlusion and embolization of a novel vascular territory; the latter bearing more detrimental clinical consequences.…”