Introduction: While intracranial pressure monitoring has been historically used in patients with severe traumatic brain injury (GCS 8 or lower), recent data has questioned its efficacy in decreasing mortality in this patient population. Several studies have suggested that ICP monitoring is not superior to care based on imaging and clinical examination and leads to prolonged mechanical ventilation and ICU care.
Methods: We conducted a retrospective analysis of 36,929 patients with severe traumatic brain injury (TBI) collected by the Pennsylvania Trauma Systems Foundation. The statewide registry includes all patients greater than 18 years old with a diagnosis of TBI and Glasgow Coma Scale (GCS) of 8 or lower that were admitted from January 2000 to December 2017. Patients who were dead on arrival were excluded from the analysis.
Results: Of the 36,929 patients in this study, 73.6% of them were males and the median age was 43.0±21.3 years old. A GCS of 3 was recorded in 72.6% of patients and 21.2% of patients had a GCS 6 or higher. An ICP monitor was placed in 17.8% of patients (n=1,704) in 2000-2004, 16.7% (n=1,815) in 2005-2009, 16.4% (n=1,787) in 2010-2014, and declined to 12.8% (n=719) from 2015-2017 (p<0.001). The most statistically significant decrease in ICP monitor use was noted from 2014 (16.4%) to 2015 (14.1%, p=0.042). The percent decrease in ICP monitoring from 2000-14 to 2015-17 was equivalent for patients with GCS scores of 3-5 (- 4.0%) and GCS 6-8 (- 4.6%).
Conclusions: As more studies emerged that demonstrated limited benefit of ICP monitoring in improving care in patients with severe TBI, there was a significant statewide decline in use of ICP monitors after 2014. However, most of these studies were based on small patient populations, necessitating more randomized controlled trials to further elucidate the benefits and limitations of ICP monitoring.
Patient Care: Our hope is to describe the recent change in direction in the care of patients with severe TBI and inspire new, larger studies to further elucidate the circumstances were ICP monitoring can be of benefit.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Understand the implications of the existing literature in Neurocritical care and the current trend.
2) Inspire treating physicians and researchers to design more studies to better understand the circumstances where ICP monitoring can be of benefit.
References: 1) Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-pressure
monitoring in traumatic brain injury. N Engl J Med. 2012;367(26):2471-
2) Shafi S, Diaz-Arrastia R, Madden C, Gentilello L. Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival. The Journal of trauma. 2008;64(2):335-40.
Cremer OL, van Dijk GW, van Wensen E, Brekelmans GJ, Moons KG, Leenen LP, et al. Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Critical care medicine. 2005;33(10):2207-13.