Marked reduction in mortality in patients with severe traumatic brain injury

Gerber, Linda M.; Chiu, Ya Lin; Carney, Nancy; Härtl, Roger; Ghajar, Jamshid

doi:10.3171/2013.8.jns13276

Cited by 197 publications

(125 citation statements)

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“…Guidelines for the management of severe TBI (hereafter referred to as guidelines) have been published by the Brain Trauma Foundation (BTF), and adherence to these guidelines has been associated with a significant reduction in the mortality rate. 3,15 The guidelines include a Level II recommendation for the use of mannitol for the treatment of high intracranial pressure (ICP) and state that "mannitol is effective in reducing ICP in the management of traumatic intracranial hypertension" and that "current evidence is not strong enough to make recommendations on the use, concentration and method of administration of hypertonic saline for the treatment of traumatic intracranial hypertension." 4 Intracranial hypertension and cerebral hypoperfusion are common occurrences after severe TBI and are associated with worse outcome, whereas a response to ICPlowering treatment is associated with a decreased mortality rate.…”

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Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Mangat

Chiu²,

Gerber

et al. 2015

JNS

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ObJect Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. MetHODS The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chisquare test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. reSultS A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). cONcluSiONS HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.http://thejns.org/doi/abs/10.3171/2014....

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Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Mangat

Chiu²,

Gerber

et al. 2015

JNS

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“…A recent study involving patients from the state of New York has shown that outcome for severe head trauma has been improved from a 2-week mortality of 22% in 2001 down to 13.3% in 2009 using treatments according to US Brain Trauma Foundation guidelines (Gerber LM et al, 2013). The outcome results at the end of the period appear to approach those …”

Section: Discussionmentioning

confidence: 99%

Severe traumatic brain injury management and clinical outcome using the Lund concept

2014

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“…Nonetheless, several studies aft er 1990 have reported improvements in patient outcome as a result of, for instance, TBI care guideline development 93,94 and aggressive neurointensive treatment regimes. [95][96][97][98] A common and biased interpretation of improved patient outcome appears when comparing outcomes from recent randomized controlled trials (RCTs) with older observational studies. Such comparisons should be interpreted with great caution.…”

Section: Pa Ent Outcomementioning

confidence: 99%

Prognostic models in traumatic brain injury

Raj

2015

Acta Anaesthesiol Scand

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Background Prognostic models are important tools for heterogeneity adjustment in traumatic brain injury (TBI). Prognoses after TBI have been particularly challenging to predict, with limited availability of robust prognostic models. TBI patients are by definition trauma patients, and often treated in the intensive care unit (ICU). Several prognostic models for ICU and trauma patients have been developed, although their applicability in patients with TBI is uncertain. Recently, however, some new prognostic models specifically designed for patients with TBI were introduced. Still, the optimal type of prognostic model in TBI remains unknown. Aim This aims to investigate the applicability of different types of prognostic models in patients with TBI and to develop novel models with enhanced performance to previous models, focusing on long‐ term outcome prediction. Methods Four patient databases of patients with TBI treated in the ICU were used to validate three TBI specific models, two computerized tomography (CT) scoring systems, one trauma scoring system, and three intensive care scoring systems. Models were validated by assessing their discrimination using area under the curve (AUC), calibration, and explanatory variation. Logistic regression was used for model customization and development. Models were internally validated using a resample bootstrap technique or a split‐sample technique. Primary outcome was 6‐month mortality and unfavorable neurological outcome by the Glasgow Outcome Scale. 30‐day in‐hospital mortality was used for the trauma scoring system. Results Study populations ranged from 342 to 9915 patients. The TBI models showed the best performance with AUCs between 0.80 and 0.85, followed by the intensive care scoring systems and the CT scores with AUCs between 0.68 to 0.80 and 0.63 to 0.70, respectively. Most models showed poor calibration, although good calibration was achieved following customization. The trauma scoring system exhibited modest to good discrimination (AUC 0.76–0.89) for short‐term mortality prediction but poor calibration. Several new prognostic models, with statistically significant superior performance to previous models were created, among them a combined TBI‐ICU model (‘IMPACT‐APACHE’) and a novel CT scoring system (‘The Helsinki CT score’). Using a TBI‐specific model, based on admission characteristics, up to 40% of the patient's final long‐term outcome could be predicted. Conclusion The TBI models showed superior predictive performance to the intensive care and trauma scoring systems, showing that TBI patients are a highly specific population in the trauma and ICU setting. Thus, the use of a TBI‐specific model is advocated in the setting of TBI. The newly proposed models were found to be significant improvements over previous models, but require external validation to show generalizability.

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Marked reduction in mortality in patients with severe traumatic brain injury

Cited by 197 publications

References 29 publications

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Severe traumatic brain injury management and clinical outcome using the Lund concept

Prognostic models in traumatic brain injury

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