Monitoring and sedation differences in the management of severe head injury and subarachnoid hemorrhage among neurocritical care centers.
BACKGROUND
The emergence of specialized neurocritical care (NCC) centers has been associated with an improved survival of patients with severe traumatic brain injury or subarachnoid hemorrhage. However, there are no established guidelines on sedation strategy or the frequency of evaluating the level of consciousness using the neurological wake-up test (NWT) in sedated NCC patients.


OBJECTIVE
The aim was to compare the (1) monitoring techniques, (2) sedation principles, and (3) the use of the NWT in patients with severe traumatic brain injury or subarachnoid hemorrhage in 16 NCC centers.


METHODS
A systematic survey of all 16 centers providing NCC in Scandinavia was performed using a questionnaire regarding the routine primary choice of sedative and analgesic compounds, monitoring techniques, and the frequency of the NWT, sent to the director of each center during 1999, 2004, and 2009.


RESULTS
The response rate was 100%. Except for one center in 1999, all included centers routinely used monitoring of intracranial and cerebral perfusion pressure. In contrast, newer monitoring techniques such as microdialysis, jugular bulb oximetry, and brain tissue oxygenation were infrequently used throughout the survey period. Approximately half of the NCC centers used propofol infusion as the primary sedative, whereas the remaining centers used midazolam infusion, and there was a marked variation in the choice of analgesia in each evaluated year. The NWT was never used in 50% of centers and ≥six times daily in one center from 1999 to 2009. Most differences among the NCC centers remained unchanged over the evaluated 10-year period.


CONCLUSIONS
Although Scandinavian countries have similar healthcare systems, there were marked differences among the participating NCC centers in the choice of monitoring tools and sedatives and the routine use of the NWT. These differences likely reflect different clinical management traditions and a lack of evidence-based guidelines in routine NCC.
Questions or comments about this article may be directed to Karin Skoglund, RN ICN PhD, at karin.skoglund@neuro.uu.se. She is an Assistant Professor at the School of Health, Care and Social Welfare, Mälardalen University, Eskilstuna, Sweden. Per Enblad, PhD, is a Professor at the Department of Neuroscience, Neurosurgery, Uppsala University Hospital, Uppsala University, Uppsala, Sweden. Niklas Marklund, PhD, is an Associate Professor at the Department of Neuroscience, Neurosurgery, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
Karin
K
Skoglund
Per
P
Enblad
Niklas
N
Marklund
D015924:Blood Pressure Monitors; D001930:Brain Injuries / Q000188:drug therapy* / Q000451:nursing; D018925:Chemokines; D003422:Critical Care / Q000379:methods*; D064648:Critical Care Nursing / Q000379:methods; D004569:Electroencephalography; D015600:Glasgow Coma Scale; D019538:Health Care Surveys; D006785:Hospitals, University; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D017551:Microdialysis; D008991:Monitoring, Physiologic / Q000379:methods* / Q000451:nursing; D010092:Oximetry; D012537:Scandinavian and Nordic Countries; D013345:Subarachnoid Hemorrhage / Q000188:drug therapy* / Q000451:nursing; D011795:Surveys and Questionnaires
D018925:Chemokines; D006993:Hypnotics and Sedatives