Page 55 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Decision-making in very severe traumatic brain injury
mechanism of trauma (fall), the frequent occurrence of contusions and (sub)acute
subdural hematomas, the use of anticoagulants, but also the presence of some degree
of brain atrophy that may allow for more volume compensation. Conversely, however, 2 the lack of cognitive reserve may adversely affect outcome.
Future research is needed to identify specific (subgroups of) patients in whom aggressive surgical intervention will result in good outcome, preferably with a certainty that can be useful in multidisciplinary decision-making. Until that time, physicians should not withhold aggressive treatment options in s-TBI patients, young or old, who have some potential of achieving good outcome even with ominous neurological signs. A more reserved attitude regarding aggressive therapy may be justified in patients in whom a combination of different features indicate very low chances of regaining an acceptable quality of life and no signs of any improvement exist following initial optimal therapy.
ICP monitor
We found no consensus of benefit on mortality rates from ICP monitoring because all three possible outcomes were reported: reduced mortality,21, 24 no difference and higher mortality.25 The same inconclusiveness was found in a recent review and meta- analysis 95 and other studies reporting both benefit,96, 97 and no benefit.98, 99
Both the sickest and least sick patients appear to receive less ICP monitor placement 22, 100 and ICP monitoring placement seemed to be influenced by high age,21-23 which reflects a tendency towards overall lower intensity of care in elderly TBI patients.92
The reported lower mortality rates for vs-TBI patients compared to s-TBI patients, can be explained by a decreased advantage of ICP monitoring guided therapy for less severe TBI patients with ongoing, potentially disadvantageous, exposure to intensive therapies.25 ICP monitoring guided therapy was associated with increased mortality for GCS 7-8 patients (OR12.89) 27 and had a larger protective impact on patients with GCS=3.23, 57 Included studies showed ICP monitored patients with longer duration of mechanical ventilation,25-27 higher need for tracheostomy 27 and significantly longer ICU stays.22, 25-27, 57 These results were confirmed by literature 95, 98 and are likely to influence outcome.
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