Utilization of Brain Tissue Oxygenation Monitoring and Association with Mortality Following Severe Traumatic Brain Injury

Abstract

Background:The aim of this study was to describe the utilization patterns of brain tissue oxygen (PbtO 2 ) monitoring following severe traumatic brain injury (TBI) and determine associations with mortality, health care use, and pulmonary toxicity. Methods:We conducted a retrospective cohort study of patients from United States trauma centers participating in the American College of Surgeons National Trauma Databank between 2008 and 2016. We examined patients with severe TBI (defined by admission Glasgow Coma Scale score ≤ 8) over the age of 18 years who survived more than 24 h from admission and required intracranial pressure (ICP) monitoring. The primary exposure was PbtO 2 monitor placement. The primary outcome was hospital mortality, defined as death during the hospitalization or discharge to hospice. Secondary outcomes were examined to determine the association of PbtO 2 monitoring with health care use and pulmonary toxicity and included the following: (1) intensive care unit length of stay, (2) hospital length of stay, and (3) development of acute respiratory distress syndrome (ARDS). Regression analysis was used to assess differences in outcomes between patients exposed to PbtO 2 monitor placement and those without exposure by using propensity weighting to address selection bias due to the nonrandom allocation of treatment groups and patient dropout.Results: A total of 35,501 patients underwent placement of an ICP monitor. There were 1,346 (3.8%) patients who also underwent PbtO 2 monitor placement, with significant variation regarding calendar year and hospital. Patients who underwent placement of a PbtO 2 monitor had a crude in-hospital mortality of 31.1%, compared with 33.5% in patients who only underwent placement of an ICP monitor (adjusted risk ratio 0.84, 95% confidence interval 0.76-0.93). The development of the ARDS was comparable between patients who underwent placement of a PbtO 2 monitor and patients who only underwent placement of an ICP monitor (9.2% vs. 9.8%, adjusted risk ratio 0.89, 95% confidence interval 0.73-1.09).Conclusions: PbtO 2 monitor utilization varied widely throughout the study period by calendar year and hospital. PbtO 2 monitoring in addition to ICP monitoring, compared with ICP monitoring alone, was associated with a decreased in-hospital mortality, a longer length of stay, and a similar risk of ARDS. These findings provide further guidance for clinicians caring for patients with severe TBI while awaiting completion of further randomized controlled trials.

Multimodal and autoregulation monitoring in the neurointensive care unit

“…PbtO 2 represents the second most commonly used invasive neuromonitor after ICP and the two together are the most widely published MMM combination (4). Bundling PbtO 2 and ICP/CPP compared to managing ICP/CPP in isolation has been explored in multiple retrospective analyses, both in TBI and SAH populations, and found improved mortality and functional outcomes associated with combined therapy with no increase in length of stay or serious adverse events including ARDS (95,99,(120)(121)(122)(123). Though large prospective trial data is lacking, a 2015 small multicenter study found that PbtO 2 and ICP/CPP guided therapy was associated with more aggressive ICP control and higher CPP with a trend toward improved functional outcomes at 6 months compared to ICP management alone (124).…”

Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs

“…97 Similar trends have been observed with large observational studies, but the results of the BOOST-3 trial (NCT03754114) are eagerly anticipated. 98 DC, which is non-permanent removal of a skull bone flap, can be used as a primary procedure when performed for evacuation of a mass lesion to control postoperative ICP. This is particularly attractive for acute subdural hematomas (ASDHs) due to the high incidence of cerebral edema and IHT.…”

“… 97 Similar trends have been observed with large observational studies, but the results of the BOOST-3 trial (NCT03754114) are eagerly anticipated. 98 …”

Initial neurocritical care of severe traumatic brain injury: New paradigms and old challenges

“…[ 73 ] Although promising results have also been demonstrated in large observational studies, routine adoption of B tp O 2 monitoring will likely be influenced by the anticipated BOOST-3 trial (NCT03754114). [ 42 , 49 ]…”