Hostname: page-component-76fb5796d-skm99 Total loading time: 0 Render date: 2024-04-27T01:17:30.063Z Has data issue: false hasContentIssue false
  • English
  • Français

External Ventricular Drains and Mortality in Patients with Severe Traumatic Brain Injury

Published online by Cambridge University Press:  02 December 2014

Donald E. G. Griesdale ,
Jonathan McEwen ,
Tobias Kurth  and
Dean R. Chittock
Donald E. G. Griesdale*
Affiliation:
Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia & Program of Critical Care Medicine, Vancouver General Hospital, Vancouver BC Department of Anesthesia, University of British Columbia & Program of Critical Care Medicine, Vancouver General Hospital, Vancouver BC Department of Medicine, Division of Critical Care Medicine, University of British Columbia & Program of Critical Care Medicine, Vancouver General Hospital, Vancouver BC
Jonathan McEwen
Affiliation:
Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia & Program of Critical Care Medicine, Vancouver General Hospital, Vancouver BC Department of Anesthesia, University of British Columbia & Program of Critical Care Medicine, Vancouver General Hospital, Vancouver BC
Tobias Kurth
Affiliation:
Inserm Unit 708 Neuroepidemiology, University Pierre et Marie Currie, Paris, France Department of Epidemiology, Harvard School of Public Health & Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
Dean R. Chittock
Affiliation:
Department of Medicine, Division of Critical Care Medicine, University of British Columbia & Program of Critical Care Medicine, Vancouver General Hospital, Vancouver BC
*
Critical Care Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver British Columbia, V5Z 1M9, Canada.
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Purpose:

To determine our institutional adherence to the Brain Trauma Foundation guidelines with respect to intracranial pressure (ICP) monitoring, and examine the relationship between external ventricular drain (EVD) use and mortality.

Materials & Methods:

Retrospective cohort study of 171 patients with severe traumatic brain injury (TBI). Propensity score adjusted logistic regression was used to model the association between EVD use and mortality.

Results:

EVDs were inserted in 98 of 171 patients. Of the 73 patients without an EVD, 63 (86%) would have qualified for ICP monitoring under the current guidelines. EVDs were in situ for a median of 8 days (SD 6). In adjusted analyses, EVD use was associated with hospital mortality (OR 2.8, 95% CI: 1.1 - 7.1, p=0.04) and 28-day mortality (OR 2.1, 95% CI: 0.80 - 5.6, p=0.13). We observed significant modification of the association between EVD and 28-day mortality by GCS within 12 hours (p-interaction = 0.04), indicating strong association only among those patients with GCS score of at least 6 (OR 5.0, 95% CI: 1.5 - 16.7, p<0.01).

Conclusions:

The association of EVD with 28-day mortality was only apparent among patients with GCS score of ≥ 6. Further research is warranted to further refine which patients may benefit from ICP monitoring.

Résumé:

RÉSUMÉ:Objectif:

Cette étude visait à déterminer la fidélité de notre institution aux lignes directrices de la Brain Trauma Foundation concernant la surveillance de la pression intracrânienne (PIC) et à examiner la relation entre l'utilisation d'un drain ventriculaire externe (DVE) et la mortalité.

Matériels et méthodes:

Il s'agit d'une étude rétrospective portant sur une cohorte de 171 patients atteints de lésion cérébrale traumatique (LCT). Nous avons utilisé une analyse de régression logistique ajustée pour l'indice de tendance pour modéliser l'association entre l'utilisation d'un DVE et la mortalité.

Résultats:

Un DVE a été mis en place chez 98 des 171 patients. Parmi les 73 patients qui n'ont pas reçu de DVE, 63 patients (86%) auraient dû en recevoir un selon les lignes directrices actuelles. La médiane du temps pendant lequel le DVE a été laissé en place était de 8 jours (écart type de 6 jours). Les analyses ajustées ont montré que l'utilisation d'un DVE était associée à la mortalité hospitalière (RC 2,8; IC à 95% de 1,1 à 7,1; p = 0,04) et à la mortalité au cours des 28 premiers jours (RC 2,1; IC à 95% de 0,80 à 5,6; p = 0,13). Nous avons observé que l'association entre le DVE et la mortalité au cours des 28 premiers jours était modifiée significativement par le score à l'échelle de coma de Glasgow (SCG) dans les 12 premières heures (p-interaction = 0,04), ce qui indique une association importante seulement chez les patients dont le SCG était d'au moins 6 (RC 5,0; IC à 95% de 1,5 à 16,7; p < 0,01).

Conclusions:

L'association entre le DVE et la mortalité au cours des 28 premiers jours n'était évidente que chez les patients dont le SCG était de 6 ou plus. Il faudra effectuer d'autres recherches pour mieux définir quels patients sont susceptibles de bénéficier de la surveillance de la PIC.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 37 , Issue 1 , January 2010 , pp. 43 - 48
Copyright
Copyright © The Canadian Journal of Neurological 2010

References

1. Langlois, JA, Rutland-Brown, W, Wald, MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375–8.CrossRefGoogle ScholarPubMed
2. Rusnak, M, Janciak, I, Majdan, M, Wilbacher, I, Mauritz, W., Australian Severe TBI Study Investigators. Severe traumatic brain injury in austria VI: effects of guideline-based management. Wien Klin Wochenschr. 2007;119(1-2):64–71.CrossRefGoogle Scholar
3. Fakhry, SM, Trask, AL, Waller, MA, Watts, DD., IRTC Neurotrauma Task Force. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma. 2004;56(3):492–9.Google Scholar
4. Patel, HC, Menon, DK, Tebbs, S, Hawker, R, Hutchinson, PJ, Kirkpatrick, PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28(5):547–53.Google Scholar
5. Palmer, S, Bader, MK, Qureshi, A, Palmer, J, Shaver, T, Borzatta, M, et al. The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. Americans Associations for Neurologic Surgeons. J Trauma. 2001;50(4):657–64.CrossRefGoogle Scholar
6. Saul, TG, Ducker, TB. Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg. 1982;56(4):498–503.Google Scholar
7. Juul, N, Morris, GF, Marshall, SB, Marshall, LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. J Neurosurg. 2000;92:1–6.CrossRefGoogle ScholarPubMed
8. Narayan, RK, Kishore, PR, Becker, DP, Ward, JD, Enas, GG, Greenberg, RP, et al. Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury. J Neurosurg. 1982;56(5):650–9.CrossRefGoogle ScholarPubMed
9. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. VI. indications for intracranial pressure monitoring. J Neurotrauma. 2007;24 Suppl 1:S37–44.Google Scholar
10. Sahjpaul, R, Girotti, M. Intracranial pressure monitoring in severe traumatic brain injury-results of a Canadian survey. Can J Neurol Sci. 2000;27(2):143–7.Google Scholar
11. Shafi, S, Diaz-Arrastia, R, Madden, C, Gentilello, L. Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival. J Trauma. 2008;64(2):335–40.Google ScholarPubMed
12. Cook, DJ, Walter, SD, Cook, RJ, Griffith, LE, Guyatt, GH, Leasa, D, et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med. 1998;129(6):433–40.CrossRefGoogle ScholarPubMed
13. Girard, TD, Kress, JP, Fuchs, BD, Thomason, JW, Schweickert, WD, Pun, BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126–34.Google Scholar
14. 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. Crit Care Med. 2005;33(10):2207–13.Google Scholar
15. Stocchetti, N, Colombo, A, Ortolano, F, Videtta, W, Marchesi, R, Longhi, L, et al. Time course of intracranial hypertension after traumatic brain injury. J Neurotrauma. 2007;24(8):1339–46.CrossRefGoogle ScholarPubMed
16. Chittock, DR, Dhingra, VK, Ronco, JJ, Russell, JA, Forrest, DM, Tweeddale, M, et al. Severity of illness and risk of death associated with pulmonary artery catheter use. Crit Care Med. 2004;32(4):911–5.Google Scholar
17. National, Heart, Lung, , and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wheeler, AP, Bernard, GR, Thompson, BT, Schoenfeld, D, Wiedemann, HP, et al. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006;354(21): 2213–24.Google Scholar
18. Chittock, DR. The pulmonary artery catheter and critical care: the cart is before the horse. Crit Care Med. 2006;34(6):1820–2.CrossRefGoogle ScholarPubMed
19. Mauritz, W, Steltzer, H, Bauer, P, Dolanski-Aghamanoukjan, L, Metnitz, P. Monitoring of intracranial pressure in patients with severe traumatic brain injury: an Austrian prospective multicenter study. Intensive Care Med. 2008;34(7):1208–15.CrossRefGoogle ScholarPubMed
20. Peduzzi, P, Concato, J, Kemper, E, Holford, TR, Feinstein, AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373–9.Google Scholar
21. Cepeda, MS, Boston, R, Farrar, JT, Strom, BL. Comparison of logistic regression versus propensity score when the number of events is low and there are multiple confounders. Am J Epidemiol. 2003;158(3):280–7.CrossRefGoogle ScholarPubMed
22. Miller, JD, Butterworth, JF, Gudeman, SK, Faulkner, JE, Choi, SC, Selhorst, JB, et al. Further experience in the management of severe head injury. J Neurosurg. 1981;54(3):289–99.CrossRefGoogle ScholarPubMed