Abstract
PurposeTo study variation in, and clinical impact of high Therapy Intensity Level (TIL) treatments for elevated intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across European Intensive Care Units (ICUs).MethodsWe studied high TIL treatments (metabolic suppression, hypothermia (< 35 °C), intensive hyperventilation (PaCO2 < 4 kPa), and secondary decompressive craniectomy) in patients receiving ICP monitoring in the ICU stratum of the CENTER-TBI study. A random effect logistic regression model was used to determine between-centre variation in their use. A propensity score-matched model was used to study the impact on outcome (6-months Glasgow Outcome Score-extended (GOSE)), whilst adjusting for case-mix severity, signs of brain herniation on imaging, and ICP.Results313 of 758 patients from 52 European centres (41%) received at least one high TIL treatment with significant variation between centres (median odds ratio = 2.26). Patients often transiently received high TIL therapies without escalation from lower tier treatments. 38% of patients with high TIL treatment had favourable outcomes (GOSE ≥ 5). The use of high TIL treatment was not significantly associated with worse outcome (285 matched pairs, OR 1.4, 95% CI [1.0–2.0]). However, a sensitivity analysis excluding high TIL treatments at day 1 or use of metabolic suppression at any day did reveal a statistically significant association with worse outcome.ConclusionSubstantial between-centre variation in use of high TIL treatments for TBI was found and treatment escalation to higher TIL treatments were often not preceded by more conventional lower TIL treatments. The significant association between high TIL treatments after day 1 and worse outcomes may reflect aggressive use or unmeasured confounders or inappropriate escalation strategies.Take home messageSubstantial variation was found in the use of highly intensive ICP-lowering treatments across European ICUs and a stepwise escalation strategy from lower to higher intensity level therapy is often lacking. Further research is necessary to study the impact of high therapy intensity treatments.Trial registrationThe core study was registered with ClinicalTrials.gov, number NCT02210221, registered 08/06/2014, https://clinicaltrials.gov/ct2/show/NCT02210221?id=NCT02210221&draw=1&rank=1 and with Resource Identification Portal (RRID: SCR_015582).
Highlights
Limiting the impact of secondary insults by controlling harmful levels of intracranial pressure (ICP) is an essential part of Traumatic Brain Injury (TBI) care in the intensive care unit (ICU)
In order to examine whether this definition of aggressiveness based on use of a monitoring modality translated into aggressive management, we examined whether the percentage use of ICP monitoring in centres was related to the random effects of the use of high Therapy Intensity Level (TIL) per in the centre
Baseline characteristics A total of 758 patients from 52 centres in Europe received ICP monitoring with documented TIL measurements during their ICU stay (Fig. 1, Additional file 4: Supplement 4, Additional file 6: Supplement 6)
Summary
Limiting the impact of secondary insults by controlling harmful levels of intracranial pressure (ICP) is an essential part of Traumatic Brain Injury (TBI) care in the intensive care unit (ICU). Interventions used to reduce ICP are typically titrated to balance their clinical effect against their side effects, which may be significant or even lifethreatening The intensity of such interventions can be quantified by the therapy intensity level (TIL) score. The stepwise approach to treatment of raised ICP aims to use low tier therapies in the first instance, reserving more aggressive (and hazardous) high TIL treatments only for when these fail. Despite this proposed framework for rational use of ICP therapies, past studies have found wide variations between centres in their deployment [4, 5]. While some studies report efficacy of high TIL therapies when properly targeted in terms of patient group and timing [6], other publications have given rise to concern that they may be ineffective in improving ultimate outcomes, and result in increased survival with severe disability [7, 8]
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