Page 56 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 2
Insertion of ICP monitor would appear to be based on physicians’ judgement, rather than guidelines, possibly inducing confounding by indication. More severely injured patients are more likely to receive ICP monitoring guided care, but, because being in a worse condition they are prone for worse outcome. Also, patients can be considered to be unsalvageable and because of withholding aggressive therapy (including ICP monitoring), only the patients with an expected chance of survival get a chance, resulting in better outcome in ICP monitored cohorts.
Lack of adherence to guidelines has been previously reported in various studies. A recent study 101 reported major variation in adherence between studies (range 18- 100%), with only 31% for the BTF ICP monitoring guidelines, possibly caused by scepticism resulting from the absence of high quality evidence and the invasive character of the intervention.101 Substantial variation in ICP monitoring indications and subsequent treatment decisions is also reported.101, 102 We expected high rates of ICP monitoring in included s-TBI cohorts, but found an unweighted mean of 42%. Two studies found poor adherence rates (10.8% and 46% in two studies), corresponding with the literature.23, 25, 26 Investigating the effect of adherence on survival, literature delivers non-conclusive evidence of benefit,96 no benefit 99 and even an increase in complications and use of hospital resources.103
The relative lack of guideline adherence for ICP monitoring for patients with vs-TBI may also reflect the lack of specific recommendations for this group. International TBI guidelines from BTF and NICE organizations are largely based on best available level III evidence and use GCS 3-8 as s-TBI category.104, 105 In the BTF-Guidelines the vs-TBI subgroup is separately mentioned only three times and are considered to be part of the GCS 3-8 s-TBI group.104 There is no mentioning of the GCS 3-5 subgroup in the 2nd edition of the BTF Guidelines for the Acute Medical Management of s-TBI in Infants, Children, and Adolescents.106 Recent studies conclude both absence of benefit 107 as higher survival and improved outcome, without higher hospital costs following guidelines.108, 109
We suggest that therapy guided by ICP monitoring following the guideline recommendations should also be used in vs-TBI patients, since positive effects and good outcome are reported. Because worse results are most likely due to complications, ICP monitoring devices should be removed as soon as possible, hopefully avoiding adverse effects of overtreatment.
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