2021 Trauma/Critical Care Presentations

MSS14: DOES PLACEMENT OF INTRACRANIAL PRESSURE MONITORS CHANGE CLINICAL OUTCOMES IN PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY ADMITTED TO A LEVEL 1 TRAUMA CENTER?
Joshua Lane, CPT, PAC; Jordan Guice, MAJ, MD; Alexander Mills, CPT, DO; Valerie Sams, LtCol, MD; Remealle How, Maj, MD; Samuel Williams, Maj, AGACNPBC; San Antonio Military Medical Center

Objectives: Traumatic Brain Injury (TBI) is a leading cause of morbidity and mortality and is a prevalent diagnosis among military and civilian trauma patients.  In 2016, the Brain Trauma Foundation (BTF) released updated guidelines for managing patients with severe TBI that recommended intracranial pressure (ICP) monitoring (Level IIB).  At our institution, a large proportion of patients meeting severe TBI criteria do not receive ICP monitoring for various reasons.  Consequently, we sought to compare outcomes in patients who received invasive ICP monitoring versus those who did not. We hypothesized that ICP monitoring did not significantly improve outcomes in our patients with severe TBI.

Methods: We identified patients with severe TBI admitted to our institution between January 2016 and May 2019. Patient demographics, admission physiology, neurosurgical intervention (excluding ICP monitoring), hospital procedures, and outcomes were compared between patients who underwent invasive ICP monitoring and those who did not.  Descriptive statistics were calculated and comparisons between the two groups were performed using Chi-Squared test, Fisher’s exact test, and t-test.

Results:  Of the 222 severe TBI patients in this study, 60 patients (27%) underwent invasive ICP monitoring compared to 162 patients (73%) who did not. Demographics, neurosurgical interventions, admission vitals, and admission Glasgow Coma Scale were not significantly different between groups.  The non-monitored group had significantly fewer days in the ICU (mean 8.2 vs 16.7; p<0.0001), on mechanical ventilation (mean 4.9 vs 11.6;p<0.0001), and in the hospital (mean 19.8 vs 36.2; p=0.0005). It also had lower incidence of tracheostomy (12.4% vs 50%; p<0.0001), gastrostomy tube placement (16.67% vs 46.67%; p<0.0001), and IVC filter placement (1.85% vs 15%;p=0.0004). In-hospital mortality in the monitored group was significantly higher (25% vs 9.88%; p=0.0059). Notably, the ICP monitor group had significantly higher ISS (28.8 vs 24.9; p=0.0163) and lower TRISS (0.49 vs 0.61; p= 0.003). Multivariable logistic regression analysis on mortality was performed adjusting for ISS and TRISS, which continued to demonstrate significantly higher mortality in the ICP monitor group.

Conclusion: At our institution, the majority of patients with severe TBI did not have invasive ICP monitoring, but had more favorable outcomes than those patients who had invasive ICP monitors.  These findings suggest a need to re-evaluate indications for ICP monitoring in severe TBI patients in our institution and further studies to analyze patient characteristics that may aid in selection of those who will maximally benefit from invasive ICP monitoring.