ABSTRACT
BACKGROUND: We leveraged the data of the international CREACTIVE consortium to investigate whether the outcome of traumatic brain injury (TBI) patients admitted to intensive care units (ICU) in hospitals without on-site neurosurgical capabilities (no-NSH) would differ had the same patients been admitted to ICUs in hospitals with neurosurgical capabilities (NSH). METHODS: The CREACTIVE observational study enrolled more than 8000 patients from 83 ICUs. Adult TBI patients admitted to no-NSH ICUs within 48 h of trauma were propensity-score matched 1:3 with patients admitted to NSH ICUs. The primary outcome was the 6-month extended Glasgow Outcome Scale (GOS-E), while secondary outcomes were ICU and hospital mortality. RESULTS: A total of 232 patients, less than 5% of the eligible cohort, were admitted to no-NSH ICUs. Each of them was matched to 3 NSH patients, leading to a study sample of 928 TBI patients where the no-NSH and NSH groups were well-balanced with respect to all of the variables included into the propensity score. Patients admitted to no-NSH ICUs experienced significantly higher ICU and in-hospital mortality. Compared to the matched NSH ICU admissions, their 6-month GOS-E scores showed a significantly higher prevalence of upper good recovery for cases with mild TBI and low expected mortality risk at admission, along with a progressively higher incidence of poor outcomes with increased TBI severity and mortality risk. CONCLUSIONS: In our study, centralization of TBI patients significantly impacted short- and long-term outcomes. For TBI patients admitted to no-NSH centers, our results suggest that the least critically ill can effectively be managed in centers without neurosurgical capabilities. Conversely, the most complex patients would benefit from being treated in high-volume, neuro-oriented ICUs.
Subject(s)
Brain Injuries, Traumatic , Neurosurgery , Adult , Glasgow Coma Scale , Glasgow Outcome Scale , Hospitals , Humans , Intensive Care UnitsABSTRACT
. The tracheo-team in the management of intracranic pressure during a dilatative tracheostomy in severe head trauma: the impact of a checklist. INTRODUCTION: Percutaneous dilatative tracheostomy (PDT) is a common technique in neurosurgical intensive care. However, it may cause imbalances of brain parameters causing secondary damages. AIM: To assess the intra cranic pressure (ICP) values and the safety of PDT performed by a tracheo-team of doctors and nurses, according to a procedure described in a checklist, in patients with severe head trauma. METHODS: All patients with severe head trauma, admitted from 2005 to 2015, exposed to PDT and with monitoring, before and after the PDT, of brain parameters (ICP and cerebral perfusion pressure) and mechanical ventilation, were included. The PDT was performed according to a checklist developed by the ward staff. RESULTS: 1571 patients with severe head trauma were admitted: 721 underwent a PDT, the ICP was monitored in 422. A temporary increase of ICP (>30mmhg) was overall observed in 11.5% of cases among those with baseline ICP >20, >20 and <10mmhg, respectively in 25, 8 and 4% of cases. Major complications were not observed; minor complications were <4%. CONCLUSIONS: Overall and intracranial hypertension complications PDT related are lower than reported in the literature. A checklist for PDT with tracheo-team of nurses and doctors with experience in neuro intensive care allows a safe and reliable management of the procedure in severe head trauma patients.
