Variation in Intracranial Pressure Monitoring and Outcomes in Pediatric Traumatic Brain Injury

Bennett, Tellen D.; Riva-Cambrin, Jay; Keenan, Heather T.; Korgenski, E. Kent; Bratton, Susan L.

doi:10.1001/archpediatrics.2012.322

Cited by 80 publications

(61 citation statements)

References 39 publications

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“…22 However, recent studies have shown large variation in the use of ICP monitoring technology among centers caring for children with severe TBI. 9,39 Variable conformance with the guidelines in practice probably reflects the paucity of available data from well-designed studies to support the effectiveness of ICP monitoring use in improving outcomes among children with severe TBI. 15,20 Our findings agree with those of a previous study, demonstrating that hospitals that monitor ICP more frequently have better pediatric TBI outcomes.…”

Section: Discussionmentioning

confidence: 99%

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Intracranial pressure monitoring among children with severe traumatic brain injury

Alali

Gomez

Sathya

et al. 2015

PED

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OBJECT 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

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Section: Discussionmentioning

confidence: 99%

“…The dearth of supporting evidence might explain the reported wide variability in ICP monitoring use among children with severe TBI. 9 Both the significance of this variability in managing pediatric TBI and its impact on outcome are unclear.…”

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confidence: 99%

Intracranial pressure monitoring among children with severe traumatic brain injury

Alali

Gomez

Sathya

et al. 2015

PED

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“…3,4 Despite the publication of evidence-based guidelines for the medical management of severe pediatric TBI in 2003, significant variability in the use of diagnostic and therapeutic technologies in the treatment of pediatric TBI has been documented in several studies. [3][4][5][6][7] Associations between lower rates of ICP monitoring and patient-level factors, especially young age, have been previously reported. [5][6][7] A possible link between higher volume of TBI care and increased use of ICP monitors has also been described.…”

Section: Introductionmentioning

confidence: 99%

“…[3][4][5][6][7] Associations between lower rates of ICP monitoring and patient-level factors, especially young age, have been previously reported. [5][6][7] A possible link between higher volume of TBI care and increased use of ICP monitors has also been described. 5 To better analyze the sources of patient, hospital, and regional variability in the care delivered to US children with TBI, we undertook an analysis of the American College of Surgeons National Trauma Databank (NTDB).…”

Section: Introductionmentioning

confidence: 99%

“…[5][6][7] A possible link between higher volume of TBI care and increased use of ICP monitors has also been described. 5 To better analyze the sources of patient, hospital, and regional variability in the care delivered to US children with TBI, we undertook an analysis of the American College of Surgeons National Trauma Databank (NTDB). A priori, we elected to examine the incidence and variation of 2 neurosurgical markers of potential therapeutic intensity of care and guideline adherence in the care provided to children with moderate-severe TBI: ICP monitoring and craniotomy/ craniectomy for intractable intracranial hypertension.…”

Section: Introductionmentioning

confidence: 99%

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National Variability in Intracranial Pressure Monitoring and Craniotomy for Children With Moderate to Severe Traumatic Brain Injury

2014

Neurosurgery

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

et al. 2017

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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.

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Variation in Intracranial Pressure Monitoring and Outcomes in Pediatric Traumatic Brain Injury

Cited by 80 publications

References 39 publications

Intracranial pressure monitoring among children with severe traumatic brain injury

Intracranial pressure monitoring among children with severe traumatic brain injury

National Variability in Intracranial Pressure Monitoring and Craniotomy for Children With Moderate to Severe Traumatic Brain Injury

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

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