title: Intracranial pressure monitor in patients with traumatic brain injury.
abstract: BACKGROUND
  Brain Trauma Foundation (BTF) guidelines recommend intracranial pressure (ICP) monitoring for traumatic brain injury (TBI) patients with a Glasgow Coma Scale score of 8 or less with an abnormal head computed tomography, or a normal head computed tomography scan with systolic blood pressure ≤90 mm Hg, posturing, or in patients of age ≥40. The benefits of these guidelines on outcome remain unproven. We hypothesized that adherence to BTF guidelines for ICP monitoring does not improve outcomes in patients with TBI.
  
  
  METHODS
  All TBI patients with an admission Glasgow Coma Scale ≤8 admitted to our level I trauma center over a 3-y period were identified. Adherence to the individual components of our institutional TBI Bundle (ICP monitoring, SpO2 ≥95%, PaCO2 30-39 mm Hg, systolic blood pressure ≥90 mm Hg, cerebral perfusion pressure ≥60 mm Hg, ICP ≤25 mm Hg, and temperature 36°C-37°C) was assessed. Patients were stratified into two groups as follows: patients with ICP monitoring (ICP) and patients without ICP monitoring (no-ICP). Outcome measures were survival and discharge disposition. Multivariate regression analysis was performed.
  
  
  RESULTS
  We identified 2618 TBI patients, 261 of whom met the BTF criteria for ICP monitoring. After excluding those with nonsurvivable injuries (n = 67), 194 patients were available for analysis. The two groups were similar in demographics and severity of head injury. Survival rate was higher in the no-ICP group compared with that in the ICP group (98% versus 76%, P < 0.004). Non-monitored patients were discharged with higher levels of function per discharge location (28% home versus 4% home; P < 0.001). Patients without ICP monitoring were 1.21 times more likely to survive compared with that of patients with ICP monitoring (odds ratio: 1.21, 95% confidence interval [1.1-1.9], P = 0.01). In the ICP group, the overall compliance rate to the ICP and cerebral perfusion pressure goals as required by the BTF guidelines was poor.
  
  
  CONCLUSIONS
  Our data suggest that there is a subset of patients meeting BTF criteria for ICP monitoring that do well without ICP monitoring. This finding should provoke reevaluation of the indication and utility of ICP monitoring in TBI patients.
authors.affiliation: Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona. Electronic address: atang@surgery.arizona.edu.
authors.forename: Andrew
authors.initials: A
authors.lastname: Tang
authors.affiliation: Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
authors.forename: Viraj
authors.initials: V
authors.lastname: Pandit
authors.affiliation: Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
authors.forename: Vernard
authors.initials: V
authors.lastname: Fennell
authors.affiliation: Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
authors.forename: Trevor
authors.initials: T
authors.lastname: Jones
authors.affiliation: Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
authors.forename: Bellal
authors.initials: B
authors.lastname: Joseph
authors.affiliation: Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
authors.forename: Terence
authors.initials: T
authors.lastname: O'Keeffe
authors.affiliation: Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
authors.forename: Randall S
authors.initials: RS
authors.lastname: Friese
authors.affiliation: Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.
authors.forename: Peter
authors.initials: P
authors.lastname: Rhee
mesh_terms: D000328:Adult; D001130:Arizona / Q000453:epidemiology; D001930:Brain Injuries / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007427:Intracranial Pressure; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D055815:Young Adult
keywords: Brain trauma foundation; Intracranial pressure monitoring; Mortality after traumatic brain injury; Traumatic brain injury