Clinical outcomes and end-of-life treatment in 596 patients with isolated traumatic brain injury: a retrospective comparison of two Dutch level-I trauma centers

Menco J S Niemeyer; Denise Jochems; Jan C Van Ditshuizen; Janneke de Kanter; Lotte Cremers; Martijn van Hattem; Dennis Den Hartog; Roderick Marijn Houwert; Luke P H Leenen; Karlijn J P van Wessem

doi:10.1007/s00068-023-02407-5

Clinical outcomes and end-of-life treatment in 596 patients with isolated traumatic brain injury: a retrospective comparison of two Dutch level-I trauma centers

Eur J Trauma Emerg Surg. 2024 Jan 16. doi: 10.1007/s00068-023-02407-5. Online ahead of print.

Authors

Affiliations

¹ Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. M.J.S.Niemeyer@UMC-Utrecht.nl.
² Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
³ Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
⁴ Trauma Center Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
⁵ Department of Radiology, UMC Division Imaging and Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
⁶ Department of Radiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands.
⁷ Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.

PMID: 38226991
DOI: 10.1007/s00068-023-02407-5

Abstract

Purpose: With an increasingly older population and rise in incidence of traumatic brain injury (TBI), end-of-life decisions have become frequent. This study investigated the rate of withdrawal of life sustaining treatment (WLST) and compared treatment outcomes in patients with isolated TBI in two Dutch level-I trauma centers.

Methods: From 2011 to 2016, a retrospective cohort study of patients aged ≥ 18 years with isolated moderate-to-severe TBI (Abbreviated Injury Scale (AIS) head ≥ 3) was conducted at the University Medical Center Rotterdam (UMC-R) and the University Medical Center Utrecht (UMC-U). Demographics, radiologic injury characteristics, clinical outcomes, and functional outcomes at 3-6 months post-discharge were collected.

Results: The study population included 596 patients (UMC-R: n = 326; UMC-U: n = 270). There were no statistical differences in age, gender, mechanism of injury, and radiologic parameters between both institutes. UMC-R patients had a higher AIShead (UMC-R: 5 [4-5] vs. UMC-U: 4 [4-5], p < 0.001). There was no difference in the prehospital Glasgow Coma Scale (GCS). However, UMC-R patients had lower GCSs in the Emergency Department and used more prehospital sedation. Total in-hospital mortality was 29% (n = 170), of which 71% (n = 123) occurred after WLST. Two percent (n = 10) remained in unresponsive wakefulness syndrome (UWS) state during follow-up.

Discussion: This study demonstrated a high WLST rate among deceased patients with isolated TBI. Demographics and outcomes were similar for both centers even though AIShead was significantly higher in UMC-R patients. Possibly, prehospital sedation might have influenced AIS coding. Few patients persisted in UWS. Further research is needed on WLST patients in a broader spectrum of ethics, culture, and complex medical profiles, as it is a growing practice in modern critical care.

Level of evidence: Level III, retrospective cohort study.

Keywords: End of life; ICU; In-hospital mortality; Traumatic brain injury; Withdrawal of life sustaining treatment.