Intermittent versus continuous cerebrospinal fluid drainage management in adult severe traumatic brain injury: assessment of intracranial pressure burden.
BACKGROUND
There is clinical equipoise regarding whether neurointensive care unit management of external ventricular drains (EVD) in severe traumatic brain injury (TBI) should involve an open EVD, with continuous drainage of cerebrospinal fluid (CSF), versus a closed EVD, with intermittent opening as necessary to drain CSF. In a matched cohort design, we assessed the relative impact of continuous versus intermittent CSF drainage on intracranial pressure in the management of adult severe TBI.


METHODS
Sixty-two severe TBI patients were assessed. Thirty-one patients managed by open EVD drainage were matched by age, sex, and injury severity (initial Glasgow Coma Scale (GCS) score) to 31 patients treated with a closed EVD drainage. Patients in the open EVD group also had a parenchymal intracranial pressure (ICP) monitor placed through an adjacent burr hole, allowing real-time recording of ICP. Hourly ICP and other pertinent data, such as length of stay in intensive care unit (LOS-ICU), Injury Severity Score, and survival status, were extracted from our prospective database.


RESULTS
With age, injury severity (initial GCS score), and neurosurgical intervention adjusted for, there was a statistically significant difference of 5.66 mmHg in mean ICP (p < 0.0001) between the open and the closed EVD groups, with the closed EVD group exhibiting greater mean ICP. ICP burden (ICP ≥ 20 mmHg) was shown to be significantly higher in the intermittent EVD group (p = 0.0002) in comparison with the continuous EVD group.


CONCLUSIONS
Continuous CSF drainage via an open EVD seemed to be associated with more effective ICP control in the management of adult severe TBI.
Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA, 15213, USA.
Enyinna L
EL
Nwachuku
Ava M
AM
Puccio
Anita
A
Fetzick
Bobby
B
Scruggs
Yue-Fang
YF
Chang
Lori A
LA
Shutter
David O
DO
Okonkwo
D000328:Adult; D001930:Brain Injuries / Q000134:cerebrospinal fluid* / Q000601:surgery; D004322:Drainage / Q000295:instrumentation / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D019586:Intracranial Hypertension / Q000134:cerebrospinal fluid / Q000601:surgery; D007427:Intracranial Pressure / Q000502:physiology*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000295:instrumentation / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome