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 Glasgow Outcome Scale >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.