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Factors influencing intracranial pressure monitoring guideline compliance and outcome after severe traumatic brain injury.
MedLine Citation:
PMID:  22488001     Owner:  NLM     Status:  Publisher    
Abstract/OtherAbstract:
OBJECTIVE:: To determine adherence to Brain Trauma Foundation guidelines for intracranial pressure monitoring after severe traumatic brain injury, to investigate if characteristics of patients treated according to guidelines (ICP+) differ from those who were not (ICP-), and whether guideline compliance is related to 6-month outcome. DESIGN:: Observational multicenter study. PATIENTS:: Consecutive severe traumatic brain injury patients (≥16 yrs, n = 265) meeting criteria for intracranial pressure monitoring. MEASUREMENTS AND MAIN RESULTS:: Data on demographics, injury severity, computed tomography findings, and patient management were registered. The Glasgow Outcome Scale Extended was dichotomized into death (Glasgow Outcome Scale Extended = 1) and unfavorable outcome (Glasgow Outcome Scale Extended 1-4). Guideline compliance was 46%. Differences between the monitored and nonmonitored patients included a younger age (median 44 vs. 53 yrs), more abnormal pupillary reactions (52% vs. 32%), and more intracranial pathology (subarachnoid hemorrhage 62% vs. 44%; intraparenchymal lesions 65% vs. 46%) in the ICP+ group. Patients with a total intracranial lesion volume of ~150 mL and a midline shift of ~12 mm were most likely to receive an intracranial pressure monitor and probabilities decreased with smaller and larger lesions and shifts. Furthermore, compliance was low in patients with no (Traumatic Coma Databank I -10%) visible intracranial pathology. Differences in case-mix resulted in higher a priori probabilities of dying (median 0.51 vs. 0.35, p<.001) and unfavorable outcome (median 0.79 vs. 0.63, p<.001) in the ICP+ group. After correction for baseline and clinical characteristics with a propensity score, intracranial pressure monitoring guideline compliance was not associated with mortality (odds ratio 0.93, 95% confidence interval 0.47-1.85, p = .83) nor with unfavorable outcome (odds ratio 1.81, 95% confidence interval 0.88-3.73, p = .11). CONCLUSIONS:: Guideline noncompliance was most prominent in patients with minor or very large computed tomography abnormalities. Intracranial pressure monitoring was not associated with 6-month outcome, but multiple baseline differences between monitored and nonmonitored patients underline the complex nature of examining the effect of intracranial pressure monitoring in observational studies.
Authors:
Heleen A R Biersteker; Teuntje M J C Andriessen; Janneke Horn; Gaby Franschman; Joukje van der Naalt; Cornelia W E Hoedemaekers; Hester F Lingsma; Iain Haitsma; Pieter E Vos
Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2012-4-6
Journal Detail:
Title:  Critical care medicine     Volume:  -     ISSN:  1530-0293     ISO Abbreviation:  -     Publication Date:  2012 Apr 
Date Detail:
Created Date:  2012-4-10     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0355501     Medline TA:  Crit Care Med     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Affiliation:
From the Departments of Neurology (HARB, TMJCA, PEV) and Intensive Care Medicine (CWEH), Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands; Department of Intensive Care Medicine (JH), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Anesthesiology (GF), VU University Medical Center, Amsterdam, The Netherlands; Department of Neurology (JvdN), University Medical Center Groningen, Groningen, The Netherlands; Department of Public Health (HFL), Erasmus Medical Center, Center for Medical Decision Making, Rotterdam, The Netherlands; and Department of Neurosurgery (IH), Erasmus Medical Center, Rotterdam, The Netherlands.
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