Page 53 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Surgical intervention
Surgery: 1: 55%
2: 87% ICP/EVD: 1: 55%
2: 78%
DC: 9 DBS, 15 mass lesions + DBS, 1 R-ICH. Bilateral: 7
ICP: 318 -GCS3-5: 224
DC
DISCUSSION
Outcome measure
Modified GOS (long term: mean 10.2Y)
GOS (5M)
Mortality
mRS (6M)
Results
Discharge: Overall mortality: 55.2%, GCS3: GOS1: 61.4%, 2 GOS2: 6.8%, GOS3: 11.4%, GOS4: 15.9%, GOS5: 4.6%
GCS4: GOS1: 43.5%, GOS2: 17.4%, GOS3: 17.4%, GOS4:
13.0%, GOS5: 4.6% 1 year (N=29): GOS1: 56.7, GOS2: 4.5%,
GOS3: 10.4%, GOS4: 6.0%, GOS5: 3.0%, “Normal”: 11.9%, Unknown: 7.5%. Long term (N=22): 45% GOS5 or “normal”.
Overall mortality 36%. GOS5: 40%
GCS≤5 significant predictor for poor outcome (GOS1-3), (Univariate analysis p=0.009)
Mortality ICP (GCS3): OR0.64; 95%CI, 0.43-1.00. No effect on mortality for other GCS groups.
Only TBI data used:
Favorable (mRS0-2): 40%
*We didn’t include additional review data.
Decision-making in very severe traumatic brain injury
This literature review shows that mortality rate in vs-TBI patients is high and the chance to reach good outcome low. Moreover good outcome is defined quite heterogeneously. Interestingly however, in some studies low mortality and relatively good outcome rates were reported for specific patient groups. It is difficult to point out exactly what contributed to this better outcome in these patients. Good outcome seemed to be associated with factors that are known to have a positive effect such as higher GCS (at least >5), absence of pupillary abnormalities and lower age (<65 year). Factors, which might have contributed were immediate and accurate treatment. However, because comparison of studies showed huge heterogeneity, correlations between the factors mentioned above and outcome could not be determined. Nevertheless, we strongly suggest that, given the chance for successful recovery, surgical intervention should be considered in every very severe TBI patient.
Importantly, treatment-limiting decisions should not be based on the GCS alone. Although a recent review showed adequate reliability of the GCS Score, the use and general applicability has been widely criticized.86 In our review, outcome results are probably more favorable because of the exclusion of patients with a “true” GCS of 3 and inclusion of patients with a “false” GCS of 3 as a result of intubation and sedation.
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