Although existing guidelines support the utilization of intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI), the evidence suggesting benefit is limited. To evaluate ...the impact on outcome, we determined the relationship between ICP monitoring and mortality in centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP). Data on 10,628 adults with severe TBI were derived from 155 TQIP centers over 2009-2011. Random-intercept multilevel modeling was used to evaluate the association between ICP monitoring and mortality after adjusting for important confounders. We evaluated this relationship at the patient level and at the institutional level. Overall mortality (n=3769) was 35%. Only 1874 (17.6%) patients underwent ICP monitoring, with a mortality of 32%. The adjusted odds ratio (OR) for mortality was 0.44 95% confidence interval (CI), 0.31-0.63, when comparing patients with ICP monitoring to those without. It is plausible that patients receiving ICP monitoring were selected because of an anticipated favorable outcome. To overcome this limitation, we stratified hospitals into quartiles based on ICP monitoring utilization. Hospitals with higher rates of ICP monitoring use were associated with lower mortality: The adjusted OR of death was 0.52 (95% CI, 0.35-0.78) in the quartile of hospitals with highest use, compared to the lowest. ICP monitoring utilization rates explained only 9.9% of variation in mortality across centers. Results were comparable irrespective of the method of case-mix adjustment. In this observational study, ICP monitoring utilization was associated with lower mortality. However, variability in ICP monitoring rates contributed only modestly to variability in institutional mortality rates. Identifying other institutional practices that impact on mortality is an important area for future research.
Trauma is the leading cause of death among US children. Whether pediatric trauma centers (PTCs), mixed trauma centers (MTCs), or adult trauma centers (ATCs) offer a survival benefit compared with one ...another when treating injured children is controversial. Ascertaining the optimal care environment will better inform quality improvement initiatives and accreditation standards.
To evaluate the association between type of trauma center (PTC, MTC, or ATC) and in-hospital mortality among young children (5 years and younger), older children (aged 6-11 years), and adolescents (aged 12-18 years).
In this retrospective cohort study, injured children aged 18 years or younger who were hospitalized in the United States from January 1, 2010, to December 31, 2013, were observed for the duration of their admission until discharge or death. We included patients with an Abbreviated Injury Score of 2 or greater in at least 1 body region. Random-intercept multilevel regression was used to evaluate the association between center type and in-hospital mortality after adjusting for confounders. Stratified analyses in young children, older children, and adolescents were performed. We conducted secondary analyses limited to patients with severe injuries (Injury Severity Score ≥25). Both analyses were performed between January 1 and August 31, 2014. Data were derived from 252 US level I and II trauma centers voluntarily participating in the American College of Surgeons adult or pediatric Trauma Quality Improvement Program.
In-hospital mortality.
We identified 175 585 injured children. Crude mortality rates were 2.3% for children treated at ATCs, 1.8% for children treated at MTCs, and 0.6% for children treated at PTCs. After adjustment, children had higher odds of dying when treated at ATCs (odds ratio OR, 1.57; 95% CI, 1.15-2.14) and MTCs (OR, 1.45; 95% CI, 1.05-2.01) compared with those treated at PTCs. In stratified analyses, young children had higher odds of death when treated at ATCs vs PTCs (OR, 1.78; 95% CI, 1.05-3.40), but there was no association between center type and mortality among older children (OR, 1.17; 95% CI, 0.65-2.11) and adolescents (OR, 1.23; 95% CI, 0.82-1.85). Results were similar in analyses of severely injured children: those treated at ATCs (OR, 1.75; 95% CI, 1.25-2.44) and MTCs (OR, 1.62; 95% CI, 1.15-2.29) had higher odds of death when compared with those treated at PTCs.
Injured children treated at ATCs and MTCs had higher in-hospital mortality compared with those treated at PTCs. This association was most evident in younger children and remained significant in severely injured children. Quality improvement initiatives geared toward ATCs and MTCs are required to provide optimal care to injured children.
To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis.
Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited ...contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death.
This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication.
From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury 0.28% vs 0.53%, relative risk (RR)=0.53, 95% confidence interval CI: 0.31-0.90, of major bile duct injury or death (1.36% vs 1.88%, RR=0.72, 95% CI: 0.56-0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR=0.73, 95% CI: 0.47-1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7-2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR=1.07, 95% CI: 0.99-1.16) or in conversion among laparoscopic cases (11% vs 10%, RR=1.02, 95% CI: 0.93-1.13).
These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.
Targeted temperature management improves survival and neurologic outcomes for adult out-of-hospital cardiac arrest survivors but may alter the accuracy of tests for predicting neurologic outcome ...after cardiac arrest.
We systematically searched Medline, Embase, CINAHL, and CENTRAL from database inception to September 2012.
Citations were screened for studies that examined diagnostic tests to predict poor neurologic outcome or death following targeted temperature management in adult cardiac arrest survivors.
Data on study outcomes and quality were abstracted in duplicate. We constructed contingency tables for each diagnostic test and calculated sensitivity, specificity, and positive and negative likelihood ratios.
Of 2,737 citations, 20 studies (n = 1,845) met inclusion criteria. Meta-analysis showed that three tests accurately predicted poor neurologic outcome with low false-positive rates: bilateral absence of pupillary reflexes more than 24 hours after a return of spontaneous circulation (false-positive rate, 0.02; 95% CI, 0.01-0.06; summary positive likelihood ratio, 10.45; 95% CI, 3.37-32.43), bilateral absence of corneal reflexes more than 24 hours (false-positive rate, 0.04; 95% CI, 0.01-0.09; positive likelihood ratio, 6.8; 95% CI, 2.52-18.38), and bilateral absence of somatosensory-evoked potentials between days 1 and 7 (false-positive rate, 0.03; 95% CI, 0.01-0.07; positive likelihood ratio, 12.79; 95% CI, 5.35-30.62). False-positive rates were higher for a Glasgow Coma Scale motor score showing extensor posturing or worse (false-positive rate, 0.09; 95% CI, 0.06-0.13; positive likelihood ratio, 7.11; 95% CI, 5.01-10.08), unfavorable electroencephalogram patterns (false-positive rate, 0.07; 95% CI, 0.04-0.12; positive likelihood ratio, 8.85; 95% CI, 4.87-16.08), myoclonic status epilepticus (false-positive rate, 0.05; 95% CI, 0.02-0.11; positive likelihood ratio, 5.58; 95% CI, 2.56-12.16), and elevated neuron-specific enolase (false-positive rate, 0.12; 95% CI, 0.06-0.23; positive likelihood ratio, 4.14; 95% CI, 1.82-9.42). The specificity of available tests improved when these were performed beyond 72 hours. Data on neuroimaging, biomarkers, or combination testing were limited and inconclusive.
Simple bedside tests and somatosensory-evoked potentials predict poor neurologic outcome for survivors of cardiac arrest treated with targeted temperature management, and specificity improves when performed beyond 72 hours. Clinicians should use caution with these predictors as they carry the inherent risk of becoming self-fulfilling.
The aim of this study was to examine the relationship between early arterial oxygenation thresholds and long-term outcome after severe traumatic brain injury (TBI).
In a post hoc analysis of a ...randomized trial, adults with severe TBI were classified based on exposure to different levels of arterial oxygenation as measured using the average of arterial partial pressure of oxygen (PaO2) values obtained within 24 hours of admission. Potentially important PaO2 thresholds were defined a priori. The primary outcome was Glasgow Outcome Scale-Extended (GOSE) score at 6 months. Secondary outcomes were cognitive outcomes measured using a battery of 9 neuropsychological tests administered at 6 months, and 6-month mortality.
In adjusted analyses, oxygenation thresholds of 150 and 200 mm Hg were associated with better functional outcome at 6 months (adjusted OR for better functional outcome on GOSE 1.82 95% CI 1.12-2.94 and 1.59 95% CI 1.06-2.37, respectively) and improved cognitive outcome at 6 months (adjusted beta coefficients for better cognitive percentile across 9 neuropsychological tests: 6.9 95% CI 1.3-12.5 and 6.8 95% CI 2.4-11.3, respectively). There was no significant association between oxygenation level and 6-month mortality except at a PaO2 threshold of 200 mm Hg (OR for death 0.36, 95% CI 0.18-0.71). Higher or lower oxygenation thresholds were not associated with functional or cognitive outcome.
In this observational study, the relationship between early arterial oxygenation and long-term functional and cognitive TBI outcomes appears to be U-shaped. Mild levels of hyperoxemia within the first 24 hours after injury were associated with better long-term functional and cognitive outcomes. These findings highlight the importance of examining balanced oxygen supplementation as a potential strategy to improve TBI outcomes in future research.
To determine if beta-(β)-blockers improve outcomes after acute traumatic brain injury (TBI).
There have been no new inpatient pharmacologic therapies to improve TBI outcomes in a half-century. ...Treatment of TBI patients with β-blockers offers a potentially beneficial approach.
Using MEDLINE, EMBASE, and CENTRAL databases, eligible articles for our systematic review and meta-analysis (PROSPERO CRD42016048547) included adult (age ≥ 16 years) blunt trauma patients admitted with TBI. The exposure of interest was β-blocker administration initiated during the hospitalization. Outcomes were mortality, functional measures, quality of life, cardiopulmonary morbidity (e.g., hypotension, bradycardia, bronchospasm, and/or congestive heart failure). Data were analyzed using a random-effects model, and represented by pooled odds ratio (OR) with 95% confidence intervals (CI) and statistical heterogeneity (I).
Data were extracted from 9 included studies encompassing 2005 unique TBI patients with β-blocker treatment and 6240 unique controls. Exposure to β-blockers after TBI was associated with a reduction of in-hospital mortality (pooled OR 0.39, 95% CI: 0.27-0.56; I = 65%, P < 0.00001). None of the included studies examined functional outcome or quality of life measures, and cardiopulmonary adverse events were rarely reported. No clear evidence of reporting bias was identified.
In adults with acute TBI, observational studies reveal a significant mortality advantage with β-blockers; however, quality of evidence is very low. We conditionally recommend the use of in-hospital β-blockers. However, we recommend further high-quality trials to answer questions about the mechanisms of action, effectiveness on subgroups, dose-response, length of therapy, functional outcome, and quality of life after β-blocker use for TBI.
The optimal timing of tracheostomy in patients with severe traumatic brain injury (TBI) is controversial; observational studies have been challenged through confounding by indication, and ...interventional studies have rarely enrolled patients with isolated TBI.
We included a cohort of adults with isolated TBI who underwent tracheostomy within 1 of 135 participating centers in the American College of Surgeons' Trauma Quality Improvement Program, during 2009 to 2011. Patients were classified as having undergone early tracheostomy (ET, ≤8 days) versus late tracheostomy (>8 days). Outcomes were compared between propensity score-matched groups to reduce confounding by indication. In sensitivity analyses, we used time-dependent proportional hazard regression to address immortal time bias and assessed the association between hospital ET rate and patients' outcome at the hospital level.
From 1,811 patients, a well-balanced propensity-matched cohort of 1,154 patients was defined. After matching, ET was associated with fewer mechanical ventilation days (median, 10 days vs. 16 days; rate ratio RR, 0.70; 95% confidence interval CI, 0.66-0.75), shorter intensive care unit stay (median, 13 days vs. 19 days; RR, 0.70; 95% CI, 0.66-0.75), shorter hospital length of stay (median, 20 days vs. 27 days; RR, 0.80; 95% CI, 0.74-0.86), and lower odds of pneumonia (41.7% vs. 52.7%; odds ratio OR, 0.64; 95% CI, 0.51-0.80), deep venous thrombosis (8.2% vs. 14.4%; OR, 0.53; 95% CI, 0.37-0.78), and decubitus ulcer (4.0% vs. 8.9%; OR, 0.43; 95% CI, 0.26-0.71) but no significant difference in pulmonary embolism (1.8% vs. 3.3%; OR, 0.52; 95% CI, 0.24-1.10). Hospital mortality was similar between both groups (8.4% vs. 6.8%; OR, 1.25; 95% CI, 0.80-1.96). Results were consistent using several alternate analytic methods.
In this observational study, ET was associated with a shorter duration of mechanical ventilation, intensive care unit stay, and hospital stay but not hospital mortality. ET may represent a mechanism to reduce in-hospital morbidity for patients with TBI.
Therapeutic study, level II.
While existing guidelines support the treatment of intracranial hypertension in severe traumatic brain injury (TBI), it is unclear when to suspect and initiate treatment for high intracranial ...pressure (ICP). The objective of this study was to derive a clinical decision rule that accurately predicts intracranial hypertension.
Using Delphi methods, the authors identified a set of potential predictors of intracranial hypertension and a clinical decision rule a priori by consensus among a group of 43 neurosurgeons and intensivists who have extensive experience managing severe TBI without ICP monitoring. To validate these predictors, the authors used data from a Latin American trial (n = 150; BEST TRIP). To report on the performance of the rule, they calculated sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals. In a secondary analysis, the rule was validated using data from a North American trial (n = 131; COBRIT).
The final predictors and the clinical decision rule were approved by 97% of participants in the consensus working group. The predictors are divided into major and minor criteria. High ICP would be considered suspected in the presence of 1 major or ≥ 2 minor criteria. Major criteria are: compressed cisterns (CT classification of Marshall diffuse injury DI III), midline shift > 5 mm (Marshall DI IV), or nonevacuated mass lesion. Minor criteria are: Glasgow Coma Scale (GCS) motor score ≤ 4, pupillary asymmetry, abnormal pupillary reactivity, or Marshall DI II. The area under the curve for the logistic regression model that contains all the predictors was 0.86. When high ICP was defined as > 22 mm Hg, the decision rule performed with a sensitivity of 93.9% (95% CI 85.0%-98.3%), a specificity of 42.3% (95% CI 31.7%-53.6%), a positive predictive value of 55.5% (95% CI 50.7%-60.2%), and a negative predictive value of 90% (95% CI 77.1%-96.0%). The sensitivity of the clinical decision rule improved with higher ICP cutoffs up to a sensitivity of 100% when intracranial hypertension was defined as ICP > 30 mm Hg. Similar results were found in the North American cohort.
A simple clinical decision rule based on a combination of clinical and imaging findings was found to be highly sensitive in distinguishing patients with severe TBI who would suffer intracranial hypertension. It could be used to identify patients who require ICP monitoring in high-resource settings or start ICP-lowering treatment in environments where resource limitations preclude invasive monitoring.Clinical trial registration no.: NCT02059941 (clinicaltrials.gov).
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