Admission Glasgow Coma Score Research Articles

Outcomes of patients with severe sepsis after the first 6 hours of resuscitation at a regional referral hospital in Uganda

IntroductionThe optimal resuscitation strategy for patients with severe sepsis in resource-limited settings is unknown. Therefore, we determined the association between intravenous fluids, changes in vital signs and lactate after the first 6 hours of resuscitation from severe sepsis, and in-hospital mortality at a hospital in Uganda. Materials and methodsWe enrolled patients admitted with severe sepsis to Mbarara Regional Referral Hospital and obtained vital signs and point-of-care blood lactate concentration at admission and after 6 hours of resuscitation. We used logistic regression to determine predictors of in-hospital mortality. ResultsWe enrolled 218 patients and had 6 hour postresuscitation data for 202 patients. The median (interquartile range) age was 35 (26-50) years, 49% of patients were female, and 57% were HIV infected. The in-hospital mortality was 32% and was associated with admission Glasgow Coma Score (adjusted odds ratio [aOR], 0.749; 95% confidence interval [CI], 0.642-0.875; P < .001), mid-upper arm circumference (aOR, 0.876; 95% CI, 0.797-0.964; P = .007), and 6-hour systolic blood pressure (aOR, 0.979; 95% CI, 0.963-0.995; P = .009) but not lactate clearance of 10% or greater (aOR, 1.2; 95% CI, 0.46-3.10; P = .73). ConclusionsIn patients with severe sepsis in Uganda, obtundation and wasting were more closely associated with in-hospital mortality than lactate clearance of 10% or greater.

Haloperidol Use in Acute Traumatic Brain Injury: A Safety Analysis

Background: The association of delirium with poor outcomes creates a complex picture in traumatic brain injury patients by exacerbating an already increased risk for neurobehavioral sequelae. Haloperidol is commonly used for agitation and delirium; however, adverse events are concerns associated with its use in traumatic brain injury patients. The objective of this study was to assess the safety of haloperidol for the management of agitation and delirium in acute traumatic brain injury. Methods: A retrospective cohort study was conducted of adult ICU patients admitted from January 2007 to October 2009 with traumatic brain injury and admission Glasgow Coma Score ≤ 12. Incidence of complications (seizures, neuroleptic malignant syndrome, QTc prolongation, extrapyramidal symptoms, hematologic disturbances) and haloperidol prescribing patters were assessed. Results: A total of 101 patients were included (56 non-haloperidol, 45 haloperidol). There was no difference in types of brain injury. Haloperidol was initiated on average day 8 of admission, and the median daily dose was 9 mg for a median duration of 4 days. The haloperidol group received more analgesics (morphine equivalents) [714 vs. 252 mg, p<0.001], and more patients in the haloperidol group received benzodiazepines compared to non-haloperidol group [98% vs. 79%, p=0.005]. There was no significant increase in adverse events associated with haloperidol use. Patients in the haloperidol group who developed complications received a higher mean daily dose [p=0.013]. There was no difference in length of mechanical ventilation but the haloperidol group had a longer hospital length of stay. Conclusion: Treatment of agitation and delirium with haloperidol in acute traumatic brain injury patients is not associated with an increased incidence of complications.

Efficiency of Hematocrit, Lymphocyte, C-Reactive Protein and Transferrin Levels in Predicting Mortality in Intensive Care Unit Patients

The effectiveness of many physiological parameters and laboratory tests was investigated in predicting mortality. In this study, we investigated hematocrit, C-reactive protein, transferrin and total lymphocyte count along with Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scores of patients who were hospitalized in the intensive care unit. The data were retrospectively analyzed from hospital information management system, doctors' records and nurse observing forms. The mortality rate was 42.6%. The Acute Physiology and Chronic Health Evaluation II scores were significantly higher in cases with mortality compared to those without mortality. The admission and discharge Glasgow Coma Scores were significantly lower in patients who showed mortality compared with patients without mortality. Admission and discharge hematocrit and transferrin values were significantly lower in cases with mortality compared to those without mortality. Discharge C-reactive protein values were significantly higher in cases with mortality compared to those without mortality. Discharge total lymphocyte count values were significantly lower in cases with mortality compared to those without mortality. Consequently, we believe that hematocrit and transferrin values at the time of admission to the intensive care unit and total lymphocyte count and C-reactive protein at the time of discharge from the intensive care unit can be effective in predicting mortality.

Synergistic Effect of Combined Hollow Viscus Injuries on Intra-Abdominal Abscess Formation

The strong association between penetrating colon injuries and intra-abdominal abscess (IAA) formation is well established and attributed to high colon bacterial counts. Since trauma patients are rarely fasting at injury, stomach and small bowel colony counts are also elevated. We hypothesized that there is a synergistic effect of increased IAA formation with concomitant stomach and/or colon injuries when compared to small bowel injuries alone. Consecutive patients at a level one trauma center with penetrating small bowel (SB), stomach (S), and/or colon (C) injuries from 1996 to 2012 were reviewed. Logistic regression determined associations with IAA, adjusting for age, gender, Injury Severity Score (ISS), admission Glasgow Coma Score, transfusions, and concurrent pancreas or liver injury. A total of 1518 patients (91% male, ISS = 15.9 ± 8.4) were identified: 496 (33%) SB, 231 (15%) S, 288 (19%) C, 40 (3%) S + SB, 69 (5%) S + C, 338 (22%) C + SB, and 56 (4%) S + C + SB. 148 (10%) patients developed IAA: 4 per cent SB, 9 per cent S, 10 per cent C, 5 per cent S + SB, 22 per cent S + C, 13 per cent C + SB, and 25 per cent S + C + SB. Multiple logistic regression demonstrated that ISS, 24 hour blood transfusions, and concomitant pancreatic or liver injuries were associated with IAA. Compared with reference SB, S or S + SB injuries were no more likely to develop IAA. However, S + C, SB + C, and S + C + SB injuries were significantly more likely to have IAA. In conclusion, combined stomach + colon, small bowel + colon, and stomach, colon, + small bowel injuries have a synergistic effect leading to increased IAA formation after penetrating injuries. Heightened clinical suspicion for IAA formation is necessary in these combined hollow viscus injury patients.

Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank.

IntroductionPatients with mild traumatic brain injury (TBI) as defined by an admission Glasgow Coma Score (GCS) of 14–15 often do not require neurosurgical interventions, but which patients will go on to require neurosurgical care has been difficult to predict. We hypothesized that injury patterns would be associated with need for eventual neurosurgical intervention in mild TBI.MethodsThe National Trauma Databank (2007–2012) was queried for patients with blunt injury and a diagnosis of TBI with an emergency department GCS of 14–15. Patients were stratified by age and injury type. Multiple logistic regression for neurosurgical intervention was run with patient demographics, physiologic variables, and injury diagnoses as dependent variables.ResultsThe study included 50,496 patients, with an overall 8.8 % rate of neurosurgical intervention. Neurosurgical intervention rates varied markedly according to injury type, and were only correlated with age for patients with epidural and subdural hemorrhage. In multiple logistic regression, TBI diagnoses were predictive of need for neurosurgical interventions; moreover, after controlling for injury type and severity score, age was not significantly associated with requiring neurosurgical intervention.ConclusionsWe found that in mild TBI, injury pattern is associated with eventual need for neurosurgical intervention. Patients with cerebral contusion or subarachnoid hemorrhage are much less likely to require neurosurgical intervention, and the effects of age are not significant after controlling for other patient factors. Prospective studies should validate this finding so that treatment guidelines can be updated to better allocate ICU resources.

The Effect of Red Blood Cell Transfusion on Cerebral Autoregulation in Patients with Severe Traumatic Brain Injury.

Red blood cell (RBC) transfusion is associated with inconsistent changes in brain tissue oxygenation (PbO2). Previous studies have failed to consider alterations in cerebral autoregulation. Our objective was to investigate the effect of RBC transfusion on cerebral autoregulation, as measured by pressure reactivity index (PRx). Retrospective analysis of 28 severe traumatic brain injury (TBI) patients from a prospective registry between 2007 and 2014. We recorded hemoglobin (Hb) concentration, intracranial pressure, PbO2, cerebral perfusion pressure, PRx, and cerebral lactate/pyruvate ratio for 6 h before and after RBC transfusion. We also recorded body temperature, PaO2, PCO2, pH, and fraction of inspired oxygen. Subgroups of normoxia (PbO2 >20 mmHg) and hypoxia (PbO2 <20 mmHg) prior to transfusion were defined a priori. The median age was 36 years [interquartile range (IQR) 27-49], 32% were female. The median admission Glasgow Coma score was 5 (IQR 4-9) and injury severity score was 16 (IQR 9-21). Overall, mean Hb concentration [80 g/L (SD 7) to 89 g/L (SD 8), p < 0.001] and PbO2 increased [23.5 mmHg (SD 8) to 25.0 mmHg (SD 9), p = 0.033] following transfusion. PRx increased post-transfusion [0.028 (SD 0.29) to 0.11 (SD 0.24), p = 0.034], indicating worsening cerebrovascular pressure reactivity. In patients with mean PbO2 >20 mmHg pre-transfusion (n = 20), the PRx increased significantly [-0.052 (SD 0.24) to 0.079 (SD 0.22), p = 0.007] but did not change in patients with PbO2 <20 mmHg: PRx [0.22 (SD 0.34) to 0.18 (SD 0.30), p = 0.36]. RBC transfusion in severe TBI patients results in worsening PRx, indicating impaired cerebral autoregulation.

Severe Pediatric Head Injury During the Iraq and Afghanistan Conflicts.

Much has been written about injuries sustained by US and coalition soldiers during the Global War on Terrorism campaigns. However, injuries to civilians, including children, have been less well documented. To describe the epidemiologic features and outcomes associated with isolated severe head injury in children during Operations Enduring Freedom and Iraqi Freedom (OEF and OIF). A retrospective review of children (<18 years old) in the Joint Theater Trauma Registry with isolated head injury (defined as an Abbreviated Injury Score Severity Code >3) and treated at a US combat support hospital in Iraq or Afghanistan (2004-2012). The primary outcome was in-hospital mortality. We identified 647 children with severe isolated head injuries: 337 from OEF, 268 from OIF, and 42 nontheater specific. Most were boys (76%; median age = 8 years). Penetrating injuries were most common (60.6%). Overall, 330 (51%) children underwent a craniotomy/craniectomy; 156 (24.1%) succumbed to their injuries. Admission Glasgow Coma Score was predictive of survival among the entire cohort and each of the individual conflicts. Male sex also significantly increased the odds of survival for the entire group and OEF, but not for OIF. Closed-head injury improved the predictive ability of our model but did not reach statistical significance as an independent factor. This is the largest study of combat-related isolated head injuries in children. Admission Glasgow Coma Score and male sex were found to be predictive of survival. Assets to comprehensively care for the pediatric patient should be established early in future conflicts.

Primary decompressive craniectomy for poor-grade middle cerebral artery aneurysms with associated intracerebral hemorrhage

ObjectiveAggressive surgery seems mandatory for poor-grade middle cerebral artery (MCA) aneurysm with associated intracerebral hemorrhage (ICH). However, primary decompressive craniectomy (DC) is controversial. We performed a case control study to define the role of primary DC. Materials and methodsWe analyzed data from the two cohorts: a multicenter prospective poor-grade aSAH registry study (AMPAS); and the National Clinical Research Center for Neurological Diseases (NCRC-ND) database of poor-grade patients. Outcome was assessed by modified Rankin Scale (mRS) and was dichotomized into favorable (mRS 0–3) and unfavorable outcome (mRS 4–6). We compared major complication rates, mortality and outcomes between primary DC and control groups. ResultsTwenty-four patients with primary DC were included in the study group. Fourteen patients without DC were included in the control group. Patients with younger age and lower Glasgow coma score (GCS) more often underwent primary DC. Major complications did not differ between the two groups. Fourteen (58%) patients had a favorable outcome, and the mortality was 29%. Primary DC appeared to have lower in-hospital mortality and have better outcome. Adjusting for age and admission GCS, primary DC was not significantly associated with decreased mortality and improved outcomes. ConclusionsAlthough primary DC does not increase postoperative complication and mortality risk, current results showed primary DC does not seem to be significantly associated with improved outcomes. However, more than one half of patients most benefit from primary DC. Further prospective controlled studies are warranted to clarify the issue.

Physical Therapist Treatment of Patients in the Neurological Intensive Care Unit: Description of Practice

Although studies have established the safety and feasibility of physical therapy in the critical care setting, minimal information about physical therapist practice in the neurological intensive care unit (NICU) is available. This study describes physical therapists' treatment of people admitted to a NICU. People admitted to the NICU with a diagnosis of subarachnoid hemorrhage, subdural hematoma, intracranial hemorrhage, or trauma were retrospectively studied. Data on patient demographics, use of mechanical ventilation, and intracranial pressure (ICP) monitoring were collected. For each physical therapy session, the length of the session, the location (NICU or post-NICU setting), and the presence of mechanical ventilation or ICP monitoring were recorded. Data on safety parameters, including vital sign response, falls, and dislodgement of lines, were collected. Over 1 year, 180 people were admitted to the NICU; 86 were evaluated by a physical therapist, for a total of 293 physical therapy sessions in the NICU (n=132) or post-NICU setting (n=161). Only one session (0.3%) was stopped, secondary to an increase in ICP. The first physical therapy session occurred on NICU day 3.0 (25%-75% interquartile range=2.0-6.0). Patients received a median of 3.4 sessions per week (25%-75% interquartile range=1.8-5.9). Patients with mechanical ventilation received less frequent physical therapy sessions than those without mechanical ventilation. Patients with ICP monitoring received less frequent sessions than those without ICP monitoring. However, after multivariate analysis, only the admission Glasgow Coma Score was independently associated with physical therapy frequency in the NICU. Patients were more likely to stand, transfer, and walk in the post-NICU setting than in the NICU. The results are limited by the retrospective, single-center nature of the study. There is inherent bias of evaluating only those patients who had physical therapy, and therapists were unable to completely adjust for the severity of illness of a given patient. Physical therapy was performed safely in the NICU. Patients who required invasive support received less frequent physical therapy.

Geriatric High-Energy Polytrauma With Orthopedic Injuries: Clinical Predictors of Mortality.

Background:The impact of orthopedic injuries in the elderly patient with multi-trauma and the effect of operative fixation on these injuries have not been thoroughly evaluated.Methods:We reviewed geriatric patients (aged 65 and older) between 2004 and 2010 at a level 1 trauma center who sustained high-energy polytrauma (injury and severity score [ISS] ≥ 16) with associated orthopedic injuries. Patients were excluded if they had severe head and spine injuries, died on arrival, or had low-energy mechanisms of injury. Logistic regression was conducted to identify factors that predict mortality.Results:There were 154 patients who comprised our study group with an average age of 76 years and an ISS of 23. There were 96 males and 58 females. Overall, 52 patients died within 1 year of their admission: 21 patients during their initial hospital stay and 31 patients within 1 year following admission. In all, 64 (42%) patients underwent operative stabilization of their orthopedic injuries. Increased mortality was seen (P < .05) in female patients, those with lower admission Glasgow coma score, and those who underwent orthopedic surgery. Patients had worse outcomes if they sustained femur (P = .014), clavicle, or scapular fractures (P = .027). Other factures associated with higher mortality included pelvic/acetabular injury requiring surgery (P = .019) or spine fractures treated nonoperatively (P = .014).Conclusion:The effect of orthopedic injuries on this geriatric polytrauma group contribute to worse outcomes when they included clavicle, scapula, and femur fractures. We also found that pelvic/acetabular fractures treated operatively and nonoperative spine fractures were associated with higher mortality rates. Risk/benefit consideration is suggested when contemplating operative intervention in these patients.

Optic nerve sheath diameter on computed tomography is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury.

Assess the relationship between optic nerve sheath diameter (ONSD) measured on bedside portable computed tomography (CT) scans and simultaneously measured intracranial pressure (ICP) in patients with severe traumatic brain injury. Retrospective cohort study of 57 patients admitted between 2009 and 2013. Linear and logistic regression were used to model the correlation and discrimination between ONSD and ICP or intracranial hypertension, respectively. The cohort had a mean age of 40 years (SD 16) and a median admission Glasgow coma score of 7 (IQR 4-10). The between-rater agreement by intraclass coefficient was 0.89 (95 % CI 0.83-0.93, P < 0.001). The mean ONSD was 6.7 mm (SD 0.75) and the mean ICP during CT was 21.3 mmHg (SD 8.4). Using linear regression, there was a strong correlation between ICP and ONSD (r = 0.74, P < 0.001). ONSD had an area under the curve to discriminate elevated ICP (≥20 mmHg vs. <20 mmHg) of 0.83 (95 % CI 0.73-0.94). Using a cutoff of 6.0 mm, ONSD had a sensitivity of 97 %, specificity of 42 %, positive predictive value of 67 %, and a negative predictive value of 92 %. Comparing linear regression models, ONSD was a much stronger predictor of ICP (R(2) of 0.56) compared to other CT features (R(2) of 0.21). Simultaneous measurement of ONSD on CT and ICP were strongly correlated and ONSD was discriminative for intracranial hypertension. ONSD was much more predictive of ICP than other CT features. There was excellent agreement between raters in measuring ONSD.

The effect of craniectomy size on mortality, outcome, and complications after decompressive craniectomy at a rural trauma center

ABSTRACT Introduction: Decompressive craniectomy (DC) has increasing support with current studies suggesting an improvement in both survival rates and outcomes with this intervention. However, questions surround this procedure; specifically, no evidence has indicated the optimal craniectomy size. Larger craniectomy is thought to better decrease intracranial pressure, but with a possible increase in complication rates. Our hypothesis is that a larger craniectomy may improve mortality and outcome, but may increase complication rates. Materials and Methods: A retrospective observational therapeutic study was undertaken to determine if craniectomy size is related to complication rates, mortality, or outcome. Our institution's Trauma Registry was searched for patients undergoing DC. Craniectomy size was measured by antero-posterior (AP) diameter. Mortality, outcome (through admission and discharge Glasgow Coma Score and Glasgow Outcome Scale), and complications (such as re-bleeding, re-operation, hygroma, hydrocephalus, infection, and syndrome of the trephined) were noted. Complications, mortality, and outcome were then compared to craniectomy size, to determine if any relation existed to support our hypothesis. Results: 20 patients met criteria for inclusion in this study. Craniectomy size as measured by AP diameter was correlated with a statistically significant improvement in mortality within the group. All patients with a craniectomy size less than 10 cm died. However, outcome was not significantly related to craniectomy size in the group. Similarly, complication rates did not differ significantly compared to craniectomy size. Discussion: This study provides Level 3 evidence that craniectomy size may be significantly related to improved mortality within our group, supporting our initial hypothesis; however, no significant improvement in outcome was seen. Similarly, in contrast to our hypothesis, complication rates did not significantly correlate with craniectomy size.

ABSTRACT 334

Background and aims: Cerebral pressure reactivity (PR) describes the dependence of cerebrovascular diameter on transmural pressure. Disturbance of PR is common after traumatic brain injury (TBI) in adults and is predictive of poor outcome. We investigated the association between PR disturbance and outcome in paediatric TBI. Aims: Methods: We conducted a prospective observational study of TBI patients requiring monitoring of arterial (ABP) and intracranial (ICP) pressures. ABP and ICP were recorded using computer software (ICM+). The local ethics committee granted a waiver of consent for the study. An index of PR (PRx) was calculated by correlating slow fluctuations in ABP and ICP over 5 minute periods. Outcome was recorded 6 months after hospital discharge using the modified Glasgow Outcome Score (mGOS). Results: Thirty-six patients were included, all treated for TBI at the Royal Children’s Hospital in Melbourne, Australia between 2006 and 2013. Age ranged from 5 months to 16 years (median 10yrs), male/female ratio was 2.6:1 and the median admission Glasgow Coma Score (GCS) was 6.5. PRx was associated with mGOS (Spearman’s R=0.42, p=.02), as was CPP (R=-0.37, p=.05) and subarachnoid haemorrhage on initial imaging (R=0.57, p=.003). PRx was dependent on cerebral perfusion pressure (CPP), being optimal within a narrow range of CPP (Figure).FigureConclusions: Impairment of cerebral pressure reactivity is associated with worse outcome after TBI in children. The state of pressure reactivity is dependent on CPP in many patients.

The effect of craniectomy size on mortality, outcome, and complications after decompressive craniectomy at a rural trauma center

Introduction:Decompressive craniectomy (DC) has increasing support with current studies suggesting an improvement in both survival rates and outcomes with this intervention. However, questions surround this procedure; specifically, no evidence has indicated the optimal craniectomy size. Larger craniectomy is thought to better decrease intracranial pressure, but with a possible increase in complication rates. Our hypothesis is that a larger craniectomy may improve mortality and outcome, but may increase complication rates.Materials and Methods:A retrospective observational therapeutic study was undertaken to determine if craniectomy size is related to complication rates, mortality, or outcome. Our institution's Trauma Registry was searched for patients undergoing DC. Craniectomy size was measured by antero-posterior (AP) diameter. Mortality, outcome (through admission and discharge Glasgow Coma Score and Glasgow Outcome Scale), and complications (such as re-bleeding, re-operation, hygroma, hydrocephalus, infection, and syndrome of the trephined) were noted. Complications, mortality, and outcome were then compared to craniectomy size, to determine if any relation existed to support our hypothesis.Results:20 patients met criteria for inclusion in this study. Craniectomy size as measured by AP diameter was correlated with a statistically significant improvement in mortality within the group. All patients with a craniectomy size less than 10 cm died. However, outcome was not significantly related to craniectomy size in the group. Similarly, complication rates did not differ significantly compared to craniectomy size.Discussion:This study provides Level 3 evidence that craniectomy size may be significantly related to improved mortality within our group, supporting our initial hypothesis; however, no significant improvement in outcome was seen. Similarly, in contrast to our hypothesis, complication rates did not significantly correlate with craniectomy size.

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Introduction: Administration of seizure prophylaxis is routinely provided by many clinicians after traumatic brain injury. The most recent guidelines from the Brain Trauma Foundation weakly recommend the practice and suggest provision of anti-epileptics only for the prevention of early-seizures. Previous literature suggests that the incidence of post-traumatic seizure ranges from 10 to 40% in patients not receiving prophylaxis. Much of this literature is over 20 years old. Since that time, clinicians have developed a better understanding of traumatic brain injury and great advances have been made in the care of the critically ill patient. Furthermore, the use of seizure prophylaxis is not without potential pitfalls including the potential for adverse effects, drug interactions and increased drug cost. Our local practice during the study period was not to provide seizure prophylaxis unless patients became symptomatic. Methods: This retrospective cohort study included all adult patients admitted to University of South Alabama Medical Center with blunt or penetrating head trauma from September 2009- December 2012. Patients were identified using the local trauma registry database. Patients with seizure were identified using ICD-09 codes significant for seizures. Patients were excluded if they were on any anti-epileptic medications prior to hospitalization. We sought to investigate whether patients who didn't receive seizure prophylaxis had a higher incidence of post-traumatic seizure compared to previous medical literature. Additional study goals include comparison of patients who did and did not develop seizure during their hospital stay. Results: 1203 patients met study criteria and were included in the analysis. Of those, 38 patients (2.9%) had at least one seizure during their hospital stay. No patients received seizure prophylaxis prior to seizure development. The mean Injury Severity Score (ISS) for all patients was 20, with most patients having experienced blunt trauma (88.9%). Mean admission Glasgow Coma Score (GCS) for all patients was 10. No differences were noted in severity of injury, mechanism of injury and admission GCS among patients who developed seizure compared to those who did not. ICU length of stay (8.1 vs. 7.3 days) and hospital length of stay (10.9 vs. 8.7 days) were similar between the two groups, respectively. The in-hospital death rate was lower in the patients who experienced seizure during their hospital stay (8.3% vs. 13.9%). The rate of patients who were discharged to a medical facility or required home-health care after discharge did not differ among patients who developed an in-hospital seizure compared to those who did not (16.6% vs. 17.6%). Conclusions: Our study suggests that the rate of seizure after traumatic brain injury is much lower than rates described in previous literature. These findings may be explained by improvements in overall management of traumatic brain injury. Our study suggests that the development of a seizure during hospital stay did not have a detrimental effect on patient outcomes including mortality, hospital length of stay, ICU length of stay and post-discharge disposition, respectively. These findings are hypothesis-generating and need to be confirmed in a larger, multicenter randomized study.

Tracheostomy in craniectomised survivors after traumatic brain injury: A cross-sectional analytical study

BackgroundDecompressive craniectomy (DC) is a life-saving measure for traumatic brain injury (TBI). However, survivors may remain in a vegetative or minimally conscious state and require tracheostomy to facilitate airway management. In this cross-sectional analytical study, we investigated the predictors for tracheostomy requirement and influence of tracheostomy timing on outcomes in craniectomised survivors after TBI. MethodsWe enrolled 160 patients undergoing DC and surviving >7 days after TBI in this 3-year retrospective study. The patients were subdivided into 2 groups based on whether tracheostomy was (N=38) or was not (N=122) performed. We identified intergroup differences in early clinical parameters. Multivariable logistic regression was used to adjust for independent predictors of the need for tracheostomy. Early tracheostomy was defined as the performance of the procedure within the first 10 days after DC. Intensive care unit (ICU) stay, hospital stay, mortality, and Glasgow outcome scale (GOS) were analysed according to the timing of the tracheostomy procedure. ResultsAfter TBI, 24% of craniectomised survivors required tracheostomy. In the multivariate logistic regression mode, the significant factors related to the need for tracheostomy were age (odds ratio=1.041; p=0.002), the Glasgow coma score (GCS) at admission (odds ratio=0.733; p=0.005), and normal status of basal cisterns (odds ratio=0.000; p=0.008). The ICU stay was shorter for patients with early tracheostomy than for those undergoing late tracheostomy (p=0.004). The timing of tracheostomy had no influence on the hospital stay, mortality, or GOS. ConclusionAge and admission GCS were independent predictors of the need for tracheostomy in craniectomised survivors after TBI. If tracheostomy is necessary, an earlier procedure may assist in patient care.

Clinical Characteristics, Management, and Functional Outcomes in Chinese Patients Within the First Year After Intracerebral Hemorrhage: Analysis from China National Stroke Registry

The aim of this study was to understand the association between clinical characteristics, medical management, and functional outcomes in Chinese patients with nontraumatic intracerebral hemorrhage (ICH). The China National Stroke Registry (CNSR) was a prospective cohort study that included 132 Chinese hospitals. Logistic regression was used to determine the risk factors associated with poor outcomes at 3, 6, and 12 months, post-ICH onset. Three thousand two hundred fifty five ICH patients with follow-up information up to 1 year post-ICH were included in this study. 49.1%, 47.1%, and 46.0% of ICH patients had poor outcomes at 3, 6, and 12 months, respectively. Age, admission systolic blood pressure, admission Glasgow Coma Score, hematoma volume, withdrawal of support, and complication of gastrointestinal hemorrhage were associated with poor outcomes at 3 and 12 months. Stroke unit care was associated with good outcome at 3 months. Intensive care unit (ICU)/Neurology ICU care was associated with poor outcome at 3 months. This is the first report of long-term functional outcomes in ICH patients from mainland China. Our study elucidates the risk factors that may influence functional outcomes post-ICH and therefore facilitate the development of management strategies to improve ICH care in China.

Characteristics of acute treatment costs of traumatic brain injury in Eastern China—a multi-centre prospective observational study

IntroductionThis study investigated acute treatment costs and related factors for traumatic brain injuries (TBI) in eastern China based on a prospective multicentre study. Materials and methodsData were prospectively collected from 80 hospitals in eastern China by standardized structured questionnaires during 2004. Included patients were admitted to hospitals via an emergency service with a diagnosis of TBI. The total acute hospitalization treatment costs derived from unsubsidized total hospital billings were used as the main outcome measure. Univariate and multivariable regression models were used to examine factors associated with each outcome. ResultsIn total, 13,007 TBI cases were identified from 80 hospitals in eastern China. The median cost per hospitalization was $879 US (range, $72–45,894). The median cost per day was $79 (interquartile range, $49–126). The hospitalization costs varied based on the cause of TBI, with a median of $1017 for traffic accidents, $816 for falls, $490 for blows to the head, and $712 for falls. The hospitalization costs also varied by injury type with a mean of $918 for TBI associated with other injuries and $831 for isolated TBI. Using multiple regression analyses, lower admission Glasgow Coma score, longer hospital stay (LOS), male sex, transient patient status, traffic accident, injury occurring on a construction site, treatment at a tertiary hospital, neurosurgical intensive care unit (NICU) or ICU stay, associated polytrauma, and those who needed a neurosurgical operation had significantly higher total acute hospitalization costs than those of other groups. Good recovery and self-paying patients had lower total costs. A double LOS was associated with a 1.61 (95% confidence interval, 1.59–1.62) times higher hospital cost. ConclusionOur results have potential implications for health-care resource planning during TBI treatment. Measures to prevent traffic accidents and reduce the LOS may help to reduce acute hospitalization costs.

Abstract 3443: No Exacerbation of Perihematomal Edema or Ventricular Volume with Intraventricular Tissue Plasminogen Activator in Patients with Spontaneous Intraventricular Hemorrhage

Introduction: In severe spontaneous intraventricular hemorrhage (IVH), intraventricular (IVR) administration of tissue plasminogen activator (tPA) results in more rapid clearing of blood from the ventricles than with external ventricular drainage (EVD) alone. However, experimental studies suggest tPA may be neurotoxic in compromised brain tissue and may exacerbate perihematomal edema. Methods: We used computerized volumetrics to assess change in intracerebral hemorrhage (ICH), IVH, ventricular and peri-ICH edema (PHE) volumes at 2-5 (T1) and 5-9 (T2) days following diagnostic CT scans (T0) of 20 patients (10 tPA treated; 10 controls) with IVH requiring EVD. Control patients from a hospital database treated with EVD alone were matched by IVH and ICH volume to tPA-treated patients. Treated patients came from two multicenter trials involving 100 patients with IVH, and spontaneous ICH volume &lt;30cc and received a median of 4 doses (range 1-8) of tPA. Results: There were no significant differences between matched pairs in terms of age, admission Glasgow Coma Score, Graeb IVH score, PHE volume, total ventricular volume, or ICH volume. Median IVH volume was larger in the tPA-treated group (26.2 cc iqr10.2 vs. 23.1 cc iqr9.2; P=0.02). IVR tPA resulted in more rapid clearance of IVH as determined by T2-T0 decrease in Graeb score and median IVH volume (tPA: -18.7 (10.8) cc; control:-7.6 (3.2) cc; P=0.005). Ratios of PHE to ICH volume were non-significantly higher in control vs. tPA treated patients at T1 and T2 [control:tPA = 0.82:0.77 (T1);P=0.44 and 0.64:0.56 (T2);P=0.48]. Total ventricular volume was significantly larger in the control group at T2 (median: 41.7 (36.9) cc vs. tPA: 24.5 (11.9) cc; P=0.02) and cumulative median cerebrospinal fluid drainage was non-significantly higher (control: 1079 (463) cc vs. tPA: 639 (428) cc; P=0.08). Ventriculitis was more frequent in the control group (4 vs. 2 episodes; P=0.08) as was shunt dependence (4 vs. 0 cases; P=0.04). Conclusions: For case matched large IVH with small ICH volume, IVR tPA enhances lysis of intraventricular blood clots, accelerates resolution of post-hemorrhagic hydrocephalus and has no significant impact on perihematomal edema.

Swallowing dysfunction after prolonged intubation: analysis of risk factors in trauma patients

Background The clinical significance of post-extubation swallowing dysfunction (PSD) is profound, resulting in both increased morbidity and mortality. Specific risk factors have not been described in an injured patient cohort. The purpose of this pilot study was to elucidate independent factors that predict PSD in this population. Methods A retrospective cohort analysis was performed on 150 consecutive trauma patients intubated for more than 48 hours. Assessment of swallowing function after extubation was performed by a simple bedside speech pathology evaluation. Patients then were divided into 2 groups: those with and those without PSD. Backwards stepwise logistic regression analysis then was used to determine independent predictors of PSD after controlling for important injury characteristics and patient demographics. Results The incidence of PSD in our study cohort was 41%. Patients with PSD, although older than non-PSD patients (48 vs 37.5 y; P = .001), were similar with respect to admission Glasgow coma score (GCS) and injury severity score. Regression analysis revealed that age older than 55 years (odds ratio, 2.60; P = .037; 95% confidence interval, 1.1–6.4) and ventilator days (odds ratio, 1.14; P = .001; 95% confidence interval, 1.1–1.2) were significant independent risk factors for PSD. Interpretation of these odds ratios revealed that those patients older than age 55 had more than a 2.5-fold greater risk of PSD. The risk increased by 14% for every day a patient required intubation. There was no significant association between PSD and injury severity score, GCS, presence of medical comorbidities, or development of nosocomial pneumonia. Conclusions PSD is a common occurrence in trauma patients. Age older than 55 years and ventilator days are independent risk factors for PSD. Injury severity, altered GCS upon arrival, comorbidities, and nosocomial pneumonia were not independent risk factors for PSD in our cohort. These results suggest that older patients with extended intensive care unit stays and ventilator requirements may benefit from early swallowing evaluation.