Guideline Adherence and Outcomes in Severe Adult Traumatic Brain Injury for the CHIRAG (Collaborative Head Injury and Guidelines) Study.

We examined the effect of early intensive care unit (ICU) adherence to 2007 Brain Trauma Foundation Guideline indicators after traumatic brain injury (TBI) on inpatient mortality at a level 1 trauma center in India (Jay Prakash Narayan Apex Trauma Center [JPNATC]) and Harborview Medical Center (HMC) in U.S. among adults older than 18 years with severe TBI. At each site, ICU Guideline adherence in first 72 hours for 17 indicators was determined and expressed as a percentage. Outcomes were in-hospital mortality and Glasgow Outcome Scale (GOS) scores at 3, 6, and 12 months after discharge. JPNATC and HMC Guideline adherence rates were 74.9% [11.0] and 71.6 % (SD ±10.4), and overall in-hospital mortality was 24% and 27%, respectively. At JPNATC, less than 65% ICU Guideline adherence was associated with higher inpatient mortality (adjusted relative risk [aRR], 1.92; 95% confidence interval [CI], 1.11-3.33) and an increase in ICU Guideline adherence rate by 1% was associated with a 3% lower in-hospital mortality (aRR, 0.97; 95% CI, 0.95-0.99). Among patients discharged with a GOS score of 2-4 at JPNATC, 67% improved at 12 months (R(2) = 0.991; P < 0.01; 99% follow-up rate) compared with discharge, but 35%, 25%, and 14% of patients discharged with a GOS score of 3-5 deteriorated at 3, 6, and 12 months to a lower GOS at home. Achieving early ICU adherence to guideline indicators was feasible and associated with significantly lower in-hospital mortality at JPNATC. Although the intracranial pressure (ICP) monitoring rates varied, in-hospitals deaths were similar between the two institutions. Although long-term outcomes generally improved, patients discharged with favorable GOS score often deteriorated at home.

Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury.

PURPOSE: Data on intraoperative secondary insults in pediatric traumatic brain injury (TBI) are limited. METHODS: We examined intraoperative secondary insults during extracranial surgery in children with moderate-severe TBI and polytrauma and their association with postoperative head computed tomography (CT) scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores 24 h after surgery. After IRB approval, we reviewed the records of children <18 years with a Glasgow Coma Scale score <13 who underwent extracranial surgery within 72 h of TBI. Definitions of secondary insults were as follows: systemic hypotension (SBP <70 + 2 × age or 90 mmHg), cerebral hypotension (cerebral perfusion pressure <40 mmHg), intracranial hypertension (ICP >20 mmHg), hypoxia (oxygen saturation <90 %), hypercarbia (end-tidal CO2 >45 mmHg), hypocarbia (end-tidal CO2 <30 mmHg without hypotension and in the absence of intracranial hypertension), hyperglycemia (blood glucose >200 mg/dL), hyperthermia (temperature >38 °C), and hypothermia (temperature <35 °C). RESULTS: Data from 50 surgeries in 42 patients (median age 15.5 years, 25 males) revealed systemic hypotension during 78 %, hypocarbia during 46 %, and hypercarbia during 25 % surgeries. Intracranial hypertension occurred in 64 % and cerebral hypotension in 18 % surgeries with ICP monitoring (11/50). Hyperglycemia occurred during 17 % of the 29 surgeries with glucose monitoring. Cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension (p = 0.02 and 0.03, respectively). We did not observe an association between intraoperative secondary insults and postoperative worsening of head CT scan or TIL score. CONCLUSIONS: Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.