Well then write this up as a proposed protocol and deliver it to all emergency rooms and intensive care centers all over the word. JUST WRITING THIS ARTICLE DOES NOTHING! Action is required and it is up to you to accomplish that action. You'd be fired in my laboratory if you didn't do that followup.
Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study
- et al.
Published:July, 2021DOI:https://doi.org/10.1016/S1474-4422(21)00138-1
Summary
Background
The indications for intracranial pressure (ICP) monitoring in patients with acute
brain injury and the effects of ICP on patients’ outcomes are uncertain. The aims
of this study were to describe current ICP monitoring practises for patients with
acute brain injury at centres around the world and to assess variations in indications
for ICP monitoring and interventions, and their association with long-term patient
outcomes.
Methods
We did a prospective, observational cohort study at 146 intensive care units (ICUs)
in 42 countries. We assessed for eligibility all patients aged 18 years or older who
were admitted to the ICU with either acute brain injury due to primary haemorrhagic
stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic
brain injury. We included patients with altered levels of consciousness at ICU admission
or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale
(GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at
least 5 (not obeying commands). Patients not admitted to the ICU or with other forms
of acute brain injury were excluded from the study. Between-centre differences in
use of ICP monitoring were quantified by using the median odds ratio (MOR). We used
the therapy intensity level (TIL) to quantify practice variations in ICP interventions.
Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended
(GOSE) score. A propensity score method with inverse probability of treatment weighting
was used to estimate the association between use of ICP monitoring and these 6 month
outcomes, independently of measured baseline covariates. This study is registered
with ClinicalTrial.gov, NCT03257904.
Findings
Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility
and 2395 patients were included in the study, including 1287 (54%) with traumatic
brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid
haemorrhage. The median age of patients was 55 years (IQR 39–69) and 1567 (65%) patients
were male. Considerable variability was recorded in the use of ICP monitoring across
centres (MOR 4·5, 95% CI 3·8–4·9 between two randomly selected centres for patients
with similar covariates). 6 month mortality was lower in patients who had ICP monitoring
(441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p<0·0001).
ICP monitoring was associated with significantly lower 6 month mortality in patients
with at least one unreactive pupil (hazard ratio [HR] 0·35, 95% CI 0·26–0·47; p<0·0001),
and better neurological outcome at 6 months (odds ratio 0·38, 95% CI 0·26–0·56; p=0·0025).
Median TIL was higher in patients with ICP monitoring (9 [IQR 7–12]) than in those
who were not monitored (5 [3–8]; p<0·0001) and an increment of one point in TIL was
associated with a reduction in mortality (HR 0·94, 95% CI 0·91–0·98; p=0·0011).
Interpretation
The use of ICP monitoring and ICP management varies greatly across centres and countries.
The use of ICP monitoring might be associated with a more intensive therapeutic approach
and with lower 6-month mortality in more severe cases. Intracranial hypertension treatment
guided by monitoring might be considered in severe cases due to the potential associated
improvement in long-term clinical results.
Funding
University of Milano-Bicocca and the European Society of Intensive Care Medicine.
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