Prevalence, management and outcomes of traumatic brain injury patients admitted to an Irish intensive care unit

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<ul><li><p>ORIGINAL ARTICLE</p><p>Prevalence, management and outcomes of traumatic brain injurypatients admitted to an Irish intensive care unit</p><p>S. Frohlich P. Johnson J. Moriarty</p><p>Received: 7 October 2010 / Accepted: 5 January 2011 / Published online: 11 February 2011</p><p> Royal Academy of Medicine in Ireland 2011</p><p>Abstract</p><p>Background Traumatic brain injury is one of the leading</p><p>causes of death and disability among young people.</p><p>However outcomes from traumatic brain injury can be</p><p>improved by use of parameters such as intracranial pres-</p><p>sure monitoring (ICP) to guide treatment, early surgical</p><p>intervention and management of these patients in a neu-</p><p>rosurgical centre.</p><p>Aims To examine the incidence of traumatic brain injury,</p><p>compliance with best practice guidelines and outcomes in</p><p>patients admitted to an intensive care unit in a major</p><p>teaching hospital in Ireland.</p><p>Methods Retrospective chart review.</p><p>Results Forty-six patients were admitted over a 3-year</p><p>period, half of whom had GCS \8. Medical managementwas appropriate but only two patients were transferred to a</p><p>neurosurgical centre and none received ICP monitoring.</p><p>Overall mortality of 37% was higher than international</p><p>norms.</p><p>Conclusions Irish patients with severe head injury do not</p><p>currently receive care in accordance with international</p><p>evidence-based guidelines.</p><p>Keywords Traumatic brain injury Intracranial pressuremonitoring Neurosurgery Outcomes</p><p>Introduction</p><p>Traumatic brain injury (TBI) is a major cause of death,</p><p>disability and economic cost to Irish society. One of the</p><p>central concepts emerging from research into traumatic</p><p>brain injury is that all neurological damage from TBI does</p><p>not occur at the time of impact, but evolves over the</p><p>ensuing hours and days [1]. Improved outcomes result</p><p>when these secondary, delayed insults resulting in reduced</p><p>cerebral perfusion to the injured brain are prevented or</p><p>overcome. This is reflected in the progressive reduction in</p><p>mortality from severe TBI from 50% to under 25% over the</p><p>last 30 years, even when adjusted for injury severity, age</p><p>and other prognostic factors [2]. The trend in reduced</p><p>mortality and improved outcomes is, in part due to evi-</p><p>dence-based protocols that emphasize monitoring and</p><p>maintaining adequate cerebral perfusion [3, 4]. The most</p><p>comprehensive available guidelines produced by a collab-</p><p>oration between the Brain Trauma Foundation, American</p><p>Association of Neurological Surgeons (AANS) and Con-</p><p>gress of Neurological Surgeons (CNS) have been widely</p><p>adopted by intensive care units in Europe and the USA.</p><p>The third edition of the evidence-based guidelines for the</p><p>Management of Severe Traumatic Brain Injury were pub-</p><p>lished in 2007, following the first and second edition in</p><p>1995 and 2000 [5, 6]. The guidelines address key topics</p><p>useful for the management of severe TBI in patients with a</p><p>Glasgow Coma Score of 38. Studies suggest that the</p><p>consistent application of ICU-based protocols improves</p><p>outcomes and reduces mortality and length of stay [79].</p><p>Our retrospective clinical audit was performed in a</p><p>S. Frohlich (&amp;)National SpR Academic Fellowship Programme,</p><p>Mater Misercordiae Hospital, Dublin 7, Ireland</p><p>e-mail: frohlics@yahoo.co.uk</p><p>P. Johnson</p><p>Anaesthesia and Intensive Care Medicine,</p><p>Our Ladies Hospital for Sick Children, Dublin 12, Ireland</p><p>J. Moriarty</p><p>Intensive Care Medicine, St Jamess University Hospital,</p><p>Dublin 8, Ireland</p><p>123</p><p>Ir J Med Sci (2011) 180:423427</p><p>DOI 10.1007/s11845-011-0674-8</p></li><li><p>University teaching hospital in Ireland. Our aims were to</p><p>determine the incidence, demographics and outcomes of</p><p>patients with severe traumatic brain injury admitted to the</p><p>intensive care unit, examine our compliance with the Brain</p><p>Trauma Foundation Guidelines and identify areas for</p><p>improvement.</p><p>Methods</p><p>A retrospective clinical audit was undertaken examining</p><p>ICU admissions over the 3-year period, 20052007.</p><p>Patients who were admitted to ICU due to traumatic brain</p><p>injury were identified from the Intensive Care admission</p><p>register. Though some patients had ancillary injuries, only</p><p>patients in whom TBI was the main diagnosis were</p><p>included for audit purposes. A chart review was undertaken</p><p>for each admission. Demographic data, clinical informa-</p><p>tion, radiological findings, treatments received, monitoring</p><p>received and Glasgow Outcome Score were recorded.</p><p>Treatment given was compared with best international</p><p>practice, as per the Brain Trauma Foundation guidelines,</p><p>and compliance with the guidelines recorded.</p><p>Results</p><p>A total of 46 patients were admitted to the intensive care</p><p>unit over the 3-year study period with a primary diag-</p><p>nosis of traumatic brain injury; 89% were admitted</p><p>directly from the hospitals emergency department and</p><p>11% were transferred from other hospitals. Of the</p><p>patients, 80% were male with a mean age of 43 years</p><p>(17). The most common aetiology was assault (37%),</p><p>with road traffic accidents (33%) and falls (24%) also</p><p>common. Positive blood alcohol levels were recorded in</p><p>26% of patients.</p><p>GCS at the time of hospital admission ranged from 3 to</p><p>14, with a mean of 7.93 (4.46). Of the patients, 56% were</p><p>classified as having severe traumatic brain injury (admis-</p><p>sion GCS 38). All patients underwent CT scanning prior</p><p>to ICU admission and 98% of the patients were intubated at</p><p>the time of ICU admission.</p><p>The mean length of stay in the ICU was 5.45 days</p><p>(range 130 days). Survivors had a shorter length of stay</p><p>(4.15 days) than non-survivors (7.25 days). Mean hospital</p><p>length of stay was 26 days (range 2287 days). The severe</p><p>traumatic brain injury group (GCS 38) had a much longer</p><p>hospital stay (mean = 44 days) than the moderate trau-</p><p>matic brain injury group (GCS 815), which had a mean</p><p>length of stay of 10.9 days. In 93% of cases, a neurosur-</p><p>gical opinion was sought. Two patients were transferred to</p><p>a neurosurgical centre for further treatment.</p><p>Good compliance was achieved with the guidelines for</p><p>medical management as set out by the Brain Trauma</p><p>Foundation (Table 1). All patients complied with guide-</p><p>lines for oxygenation and blood pressure control. All</p><p>patients received appropriate thromboprophylaxis and</p><p>32% of the patients who fulfilled criteria for seizure</p><p>prophylaxis received the same. Appropriate ventilation to</p><p>normocapnia occurred in 91% of the cases. Mannitol was</p><p>used in 11% of cases, though in the absence of ICP</p><p>monitoring it was difficult to assess compliance with the</p><p>guidelines. As much as 64% of the patients fulfilled</p><p>Brain Trauma Foundation guidelines for ICP monitoring,</p><p>but due to unavailability of ICP monitoring facilities no</p><p>patient received ICP monitoring. All patients received</p><p>appropriate nutritional support. Periprocedural antibio-</p><p>tics at the time of intubation are recommended, but</p><p>received in only 29% of patients. The role of prophy-</p><p>lactic hypothermia is uncertain and was not used in any</p><p>of our patients.</p><p>A total of 15 (37%) patients fulfilled the Brain Trauma</p><p>Foundation guidelines for surgical intervention. (Table 2)</p><p>Indications were due to subdural haematoma or traumatic</p><p>parenchymal lesions. There was no incidence of epidural</p><p>haematoma or posterior fossa lesions requiring surgery.</p><p>Two patients in this group were transferred to a neuro-</p><p>surgical centre for further treatment. The mortality rate in</p><p>the group who fulfilled criteria for surgical intervention</p><p>was 67%.</p><p>The overall mortality was 37%. Of those who survived,</p><p>62% made a complete recovery with the remainder suf-</p><p>fering varying degrees of neurological impairment. In the</p><p>severe TBI group, mortality was significantly higher (54%)</p><p>than in the moderate (15%) group (P \ 0.05, Fishers test).Additionally complete recovery was less likely in the</p><p>severe TBI group (23%) than in the moderate TBI group</p><p>(65%). (P \ 0.05, Fishers test) (Tables 3, 4).</p><p>Discussion</p><p>Traumatic brain injury in Ireland remains mainly an</p><p>affliction of the young male population. Criminal assault</p><p>and alcohol are factors in a large number of injuries.</p><p>Though the majority of patients were admitted from the</p><p>hospitals emergency department, the transfer of four</p><p>patients with a primary diagnosis of TBI from an outside</p><p>hospital to a non-neurosurgical centre is a cause for</p><p>concern.</p><p>Medical management of TBI patients in the ICU was</p><p>broadly appropriate and in compliance with international</p><p>guidelines. All patients underwent timely CT imaging</p><p>(within 1 h of request). Appropriate blood pressure and</p><p>oxygenation parameters and ventilator strategy were</p><p>424</p><p>123</p></li><li><p>employed in almost all cases. The low use of seizure</p><p>prophylaxis (32%) is at odds with best practice guidelines.</p><p>Prophylactic anticonvulsants can decrease the incidence of</p><p>early posttraumatic seizures from 14.2 to 3.6% [10]. Low</p><p>level of mannitol use was acceptable in the absence of ICP</p><p>monitoring.</p><p>Table 1 Compliance with medical guidelines</p><p>Clinical parameters Guidelines Numbers Compliance (%)</p><p>Blood pressure BP should be monitored and hypotension (systolic</p><p>BP \ 90 mmHg) avoided (Level 2)43 93</p><p>Oxygenation Oxygenation should be monitored and hypoxia</p><p>(PaO2 \ 60 mmHg) avoided (Level 3)46 100</p><p>DVT prophylaxis Graduated compression stockings or mechanical compression</p><p>stockings should be used until mobile (Level 3)</p><p>46 100</p><p>Seizure prophylaxis Anticonvulsants are indicated to decrease the incidence of</p><p>early posttraumatic seizures (within 7 days of injury)</p><p>8 32</p><p>Ventilation Prophylactic hyperventilation (PaCO2 \ 25 mmHg) is notrecommended (Level 2)</p><p>41 89</p><p>Mannitol use Mannitol (dose 0.251 g/kg) is effective for control of raised</p><p>ICP. Arterial hypotension should be avoided (Level 2)</p><p>Restrict mannitol use prior to ICP monitoring to patients with</p><p>signs of transtentorial herniation or progressive neurological</p><p>deterioration (Level 3)</p><p>5 n/a</p><p>Steroid use The use of steroids is not recommended 0 100</p><p>ICP monitoring Intracranial pressure (ICP) should be monitored in all</p><p>salvageable patients with a severe traumatic brain injury and</p><p>an abnormal CT scan. (Level 2)</p><p>ICP is indicated in patients with severe TBI with a normal CT</p><p>scan if over 40 years, unilateral/bilateral motor posturing or</p><p>SBP \ 90 mmHg (Level 2)</p><p>0 0</p><p>Nutrition Patients should be fed to gain full caloric replacement by day 7</p><p>postinjury</p><p>46 46</p><p>Infection prophylaxis Periprocedural antibiotics for intubation should be</p><p>administered to reduce the incidence of pneumonia (Level 2)</p><p>13 29</p><p>Prophylactic hypothermia Pooled data indicate that prophylactic hypothermia is not</p><p>significantly associated with decreased mortality. It is,</p><p>however, associated with higher Glasgow Outcome Scores</p><p>(Level 3)</p><p>0 n/a</p><p>Table 2 Compliance with surgical guidelines</p><p>Clinical condition Consensus guidelines Numbers Compliance (%)</p><p>Acute epidural haematoma EDH [30 cm3 should be evacuated regardless of GCSEDH \30 cm3 with \15 mm midline thickness and \5 mm midline</p><p>shift with GCS [8 with no focal deficit can be managedconservatively in a neurosurgical centre</p><p>0 n/a</p><p>Acute subdural haematoma Thickness [10 mm or midline shift [5 mm should be managedsurgically</p><p>All patients with acute SDH and GCS \9 should undergo ICPmonitoring</p><p>If GCS \9 and does not meet the criteria above should undergosurgery if ICP exceeds 20 mmHg</p><p>6</p><p>2</p><p>17</p><p>0</p><p>Traumatic parenchymal lesions Neurological deterioration related to lesion, refractory ICP or mass</p><p>effect on CT</p><p>Any lesion[50cm3 in volume or[20 cm3 in frontal or temporal lobewith [5 mm midline shift and GCS \8</p><p>5</p><p>2</p><p>20</p><p>0</p><p>Posterior fossa mass lesions Mass effect on CT or neurological compromise referable to the lesion 0 n/a</p><p>425</p><p>123</p></li><li><p>None of our patients had intracranial pressure monitor-</p><p>ing (ICP). Brain Trauma Foundation guidelines dictate that</p><p>intracranial pressure should be monitored in all salvageable</p><p>patients who present with a GCS score of 38 after</p><p>resuscitation, and who have an abnormal CT scan [1].</p><p>Additionally, ICP monitoring may be indicated in patients</p><p>over 40 years, with severe TBI and a normal CT scan, who</p><p>have other features of severe injury such as unilateral or</p><p>bilateral motor posturing or systolic blood pressure</p><p>\90 mmHg [1]. The main objective of intracranial pres-sure monitoring is to maintain adequate cerebral perfusion</p><p>and oxygenation and avoid secondary injury. Cerebral</p><p>perfusion pressure (CPP), an indirect measure of cerebral</p><p>perfusion, incorporates mean arterial pressure (MAP) and</p><p>ICP parameters. CPP values below 50 are associated with</p><p>poor outcome. The only way to reliably determine CPP and</p><p>cerebral hypoperfusion is to continuously monitor ICP and</p><p>blood pressure [1113]. Protocols that incorporate ICP</p><p>monitoring and other advanced monitoring have demon-</p><p>strated improved outcomes when compared with earlier</p><p>time periods without a protocol [14, 15]. Additionally, the</p><p>frequency of ICP monitoring in trauma centres has been</p><p>reported to be associated with improved outcomes [16].</p><p>Intracranial pressure monitoring is not available in Ireland</p><p>outside of existing neurosurgical centres, limiting the</p><p>option of ICP-guided therapy for patients with traumatic</p><p>brain injury.</p><p>Analysis of the radiological and clinical evidence and</p><p>comparison with current Brain Trauma Foundation guide-</p><p>lines suggested that 34% of our patients may have</p><p>benefitted from surgical intervention. A decision to</p><p>undertake operative intervention depends on many other</p><p>factors, which may not be borne out in a retrospective chart</p><p>review. As a result, this component of our data is inherently</p><p>inaccurate, but the figure does raise the concern that</p><p>without resource constraints more patients might receive</p><p>surgical intervention.</p><p>The finding that only two of our patients were managed</p><p>in a neurosurgical centre points to significant capacity</p><p>constraint within the neurosurgical services in Ireland. The</p><p>practice in Ireland and much of Europe is that trauma</p><p>patients are transferred to the nearest emergency depart-</p><p>ment, where they are triaged, stabilized and transferred to a</p><p>specialist hospital if their injuries require such treatment.</p><p>This contrasts sharply with the USA, where all patients</p><p>with head injuries are brought initially to a Level 1 trauma</p><p>centre, which by definition has on-site neurosurgical ser-</p><p>vices. Our practice in Ireland can delay the transport of</p><p>patients to receive neurosurgery, and transfers depend</p><p>entirely on the available capacity at our existing centres.</p><p>Odds of death for patients with severe TBI managed in a</p><p>non-neurosurgical centre are twice that of patients man-</p><p>aged in a neurosurgical centre [17]. The improved out-</p><p>comes in a neurosurgical centre relate to both surgical</p><p>intervention and institution of specialist packages of care</p><p>such as targeted control of intracranial pressures [15, 18].</p><p>Though patients with surgical lesions are typically given</p><p>preference for transfer to neurosurgical centres, patients</p><p>with non surgically treatable head injuries have a higher</p><p>mortality [19], and interventions such as decompressive</p><p>craniectomy may be beneficial [20, 21]. Additionally,</p><p>outcome after traumatic brain injury is better in high-vol-</p><p>ume centres than in those seeing fewer head-injured</p><p>patients [22]. Currently, 53% of patients with severe TBI in</p><p>the UK are transferred to receive neurosurgic...</p></li></ul>

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