Intracranial pressure monitoring in severe traumatic brain injuries: a closer look at level 1 trauma centers in the United States

Abstract

Introduction: The Brain Trauma Foundation (BTF) recently updated recommendations for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). The effect of ICP monitoring on outcomes is controversial, and compliance with BTF guidelines is variable. The purpose of this study was to assess both compliance and outcomes at level I trauma centers.

Materials and methods: The American College of Surgeons Trauma Quality Improvement Program database was queried for all patients admitted to level I trauma centers with isolated blunt severe TBI (AIS>3, GCS<9) who met criteria for ICP monitoring. Patients who had severe extracranial injuries, craniectomy, or death in the first 24h were excluded. Comparison between groups with and without ICP monitoring was made, analyzing demographics, comorbidities, mechanism of injury, head Abbreviated Injury Scale (AIS), vital signs on admission, head CT scan findings. Outcomes included in-hospital mortality, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, systemic complications, and functional independence at discharge. Multivariable analysis was used to identify independent risk factors for each of the outcomes.

Results: Overall, 4880 patients were included. ICP monitoring was used in 529 patients (10.8%). Stepwise logistic regression analysis identified ICP monitor placement as an independent risk factor for mortality (OR 1.63; 95% CI 1.28-2.07; p<0.001), mechanical ventilation (OR 5.74 95% CI 4.42-7.46; p<0.001), ICU length of stay (OR 4.03; 95% CI 2.94-5.52; p<0.001), systemic complications (OR 2.78; 95% CI 2.29-3.37; p<0.001), and decreased functional independence at discharge (OR 1.71 95% CI 1.29-2.26; p<0.001). Subgroup analysis of patients with head AIS 3, 4, and 5 confirmed that ICP monitors remained an independent risk factor for mortality in both head AIS 4 and 5.

Conclusions: Compliance with BTF guidelines for ICP monitoring is low, even at level I trauma centers. In this study, ICP monitoring was associated with poor outcomes, and was found to be an independent risk factor for mortality. Further studies are needed to determine the optimal role of ICP monitoring in the management of severe TBI.

Keywords: ICP monitoring; Isolated severe head trauma; Level 1 trauma center; Outcomes.