Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study

On Behalf Of The Center-Tbi Investigators ,Maryse C Cnossen,Andrew I R Maas,Nino Stocchetti,Ewout W Steyerberg,Wilco C Peul,Mathieu Van Der Jagt,Giuseppe Citerio,Ari Ercole,David Nelson,Thomas Van Essen,David Menon,Victor Volovici,Suzanne Polinder,Hester F Lingsma,Jilske A Huijben

doi:10.1186/s13054-017-1816-9

Abstract

BackgroundNo definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI). It is therefore likely that centers and practitioners individually balance potential benefits and risks of different intracranial pressure (ICP) management strategies, resulting in practice variation. The aim of this study was to examine variation in monitoring and treatment policies for intracranial hypertension in patients with TBI.MethodsA 29-item survey on ICP monitoring and treatment was developed on the basis of literature and expert opinion, and it was pilot-tested in 16 centers. The questionnaire was sent to 68 neurotrauma centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study.ResultsThe survey was completed by 66 centers (97% response rate). Centers were mainly academic hospitals (n = 60, 91%) and designated level I trauma centers (n = 44, 67%). The Brain Trauma Foundation guidelines were used in 49 (74%) centers. Approximately 90% of the participants (n = 58) indicated placing an ICP monitor in patients with severe TBI and computed tomographic abnormalities. There was no consensus on other indications or on peri-insertion precautions. We found wide variation in the use of first- and second-tier treatments for elevated ICP. Approximately half of the centers were classified as using a relatively aggressive approach to ICP monitoring and treatment (n = 32, 48%), whereas the others were considered more conservative (n = 34, 52%).ConclusionsSubstantial variation was found regarding monitoring and treatment policies in patients with TBI and intracranial hypertension. The results of this survey indicate a lack of consensus between European neurotrauma centers and provide an opportunity and necessity for comparative effectiveness research.

Highlights

No definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI)
We examined self-perceived practices of intracranial pressure (ICP) monitoring and associated treatment policies by sending a survey to the centers participating in the CENTER-TBI study
Centers had a median of 33 (IQR 22–44) intensive care unit (ICU) beds in total and treated a median of 92 (IQR 52–160) patients with severe TBI annually

Summary

Introduction

No definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI). It is likely that centers and practitioners individually balance potential benefits and risks of different intracranial pressure (ICP) management strategies, resulting in practice variation. The aim of this study was to examine variation in monitoring and treatment policies for intracranial hypertension in patients with TBI. Secondary brain injury associated with elevated intracranial pressure (ICP) is an important cause of mortality and morbidity in patients with severe traumatic brain injury (TBI) [1]. No definitive evidence exists on how ICP should be monitored and treated [2]. Observational studies, which are easier to conduct, are at risk for confounding by indication, hampering causal inference [4, 5]

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