Introduction: Detecting increased intracranial pressure (ICP) is the cornerstone of management and treatment of severe traumatic brain injury (sTBI) patients. Multimodality monitoring (MMM) incorporates brain tissue oxygen (PbtO2), intracranial temperature, cerebral blood flow (rCBF), and electrocorticography (dEEG) to enhance the detection of critical secondary brain injuries. Few studies have focused on the safety and feasibility of this approach in those with sTBI. Our institution adopted a standard for MMM using a new four-lumen bolt to facilitate simultaneous placement of multiple probes through a single bur hole.
Methods: Data was retrospectively collected from consecutive adult patients with sTBI admitted to the Neuroscience Intensive Care Unit (NSICU) between April 2015-March 2017 who underwent four-lumen bolt placement and MMM as part of management and treatment protocols. Demographics, injury characteristics, probe placement, and duration of monitoring for each probe was recorded. NSICU and hospital length of stay (LOS), discharge disposition, and device related complications were also reported.
Results: Forty patients were included (mean age = 43.0 ± 17.3 SD), 85% were male. Bolt placement occurred a median of 17.7 hours (interquartile range: 8.3-16.9 hours) from sTBI. One-third had minor complications (e.g. small tract hemorrhage, intracranial bone chips, or pneumocephalus) with insertion. Suboptimal probe placement occurred in 12.5%, two patients had probe insertion-related bleeds, but none had clinically significant complications. Average total neuromonitoring time was 94.0± 21.4 hours. Average NSICU and hospital LOS was 12.2 and 15.2 days respectively. Hospital mortality was 45%; the majority was associated with family withdrawal of life-sustaining support.
Conclusions: We conclude that use of a new four-lumen bolt facilitates MMM via a single bur hole and can be done safely in severe TBI patients without clinically significant complications. This alternative to single ICP monitoring can yield advancements in patient care.
Patient Care: Safe utilization of a four-lumen bolt allows for wider adoption of multimodality monitoring for treatment of patients with severe traumatic brain injury.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the components of a novel, single bur hole advanced neuromonitoring protocol, 2) Recognize the average time to bolt, duration of monitoring, and relative safety of this procedure in a population of with severe TBI, 3) Define common subclinical complications that may be encountered after placement of advanced neuromonitoring devices.