Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study

Abstract

BackgroundNo definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI). It is therefore likely that centers and practitioners individually balance potential benefits and risks of different intracranial pressure (ICP) management strategies, resulting in practice variation. The aim of this study was to examine variation in monitoring and treatment policies for intracranial hypertension in patients with TBI.MethodsA 29-item survey on ICP monitoring and treatment was developed on the basis of literature and expert opinion, and it was pilot-tested in 16 centers. The questionnaire was sent to 68 neurotrauma centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study.ResultsThe survey was completed by 66 centers (97% response rate). Centers were mainly academic hospitals (n = 60, 91%) and designated level I trauma centers (n = 44, 67%). The Brain Trauma Foundation guidelines were used in 49 (74%) centers. Approximately 90% of the participants (n = 58) indicated placing an ICP monitor in patients with severe TBI and computed tomographic abnormalities. There was no consensus on other indications or on peri-insertion precautions. We found wide variation in the use of first- and second-tier treatments for elevated ICP. Approximately half of the centers were classified as using a relatively aggressive approach to ICP monitoring and treatment (n = 32, 48%), whereas the others were considered more conservative (n = 34, 52%).ConclusionsSubstantial variation was found regarding monitoring and treatment policies in patients with TBI and intracranial hypertension. The results of this survey indicate a lack of consensus between European neurotrauma centers and provide an opportunity and necessity for comparative effectiveness research.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1816-9) contains supplementary material, which is available to authorized users.

Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis

“…GOSE Glasgow Outcome Scale extended, ICP intracranial pressure, MOR median odds ratio combinations of these different factors. As for monitoring and management variations among centers, heterogeneity was not unexpected: previous studies [19][20][21] and surveys [22][23][24] found profound dissimilarities between centers in monitoring and treatment policies similar to our study.…”

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

“…Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and accounts for around 30% of all injury-related deaths [1]. Following the primary cerebral insult, TBI management focuses on the prevention and treatment of secondary brain damage, including intracranial pressure (ICP) control [2]. Pupillary examination, and in particular pupillary light reactivity, plays a fundamental role in this setting and has both diagnostic and prognostic value [3].…”

Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient

“…Pupillary light reactivity is a well-described prognostic variable in the setting of severe head injury. The literature is full of evidence demonstrating that alterations of the pupillary light reflex, pupil size, and/or anisocoria are correlated with outcome following traumatic brain injury (TBI) [8]. In fact, neurosurgeons triage patients to surgical evacuation of mass lesions or conservative therapy according to the pupillary status [9].…”