Treatment of patients with severe traumatic brain injury: a 7-year single institution experience

Abstract

Background This study was designed to compare the efficacy of multimodality monitoring and goal-directed therapy protocol (MM&GDTP), in patients with Glasgow Coma Scale (GCS) scores ≤8 with the conventional intracranial pressure (ICP)-cerebral perfusion pressure (CPP) treatment. Methods The study was divided into two time periods, a 2-year historic period in which severe traumatic brain injury (sTBI) patients were treated with an ICP-CPP targeted strategy and a 5-year intervention period during which MM&GDTP was utilized. Patients with unsurvivable brain injuries were excluded. Variables of interest included mechanism of injury, age, sex, hemodynamics, GCS score, abbreviated injury score–head (AIS-H), Marshall Class, injury severity score, decompressive craniectomy, ventilator/intensive care unit days, length of stay, predicted mortality by corticosteroid randomization after significant head injury model, functional outcome, and mortality. Results The study group comprised 810 sTBI patients, aged 14–93 years, admitted during a 7-year period; of these patients, 67 and 99 AIS-H≥4 and Marshall Class ≥III were included in control and intervention groups, respectively. The control group was treated with an ICP-CPP targeted approach, while the intervention group with an MM&GDTP. At presentation and after resuscitation, patients in the intervention group required a higher CPP to reach the endpoints of therapy. The MM&GDTP decreased mortality from 34.3% to 23.2%, yielding a 32.3% improvement in overall survival and improved functional outcome as measured by GOS >3 (MM&GDTP vs. ICP-CPP: 50/99 vs. 15/67, P=0.003). Conclusion Institution of MM&GDTP targeted to threshold-defined values improves functional outcomes and may reduce mortality among patients with sTBI compared to that of patients receiving an ICP-CPP–based treatment.

Keywords

• traumatic brain injuries
• severe
• treatment
• multimodality monitoring and goal-directed therapy protocol
• mortality