Intracranial pressure monitoring among children with severe traumatic brain injury.
OBJECT Well-designed studies linking intracranial pressure (ICP) monitoring with improved outcomes among children with severe traumatic brain injury (TBI) are lacking. The main objective of this study was to examine the relationship between ICP monitoring in children and in-hospital mortality following severe TBI. METHODS An observational study was conducted using data derived from 153 adult or mixed (adult and pediatric) trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and 29 pediatric trauma centers participating in the pediatric pilot TQIP between 2010 and 2012. Random-intercept multilevel modeling was used to examine the association between ICP monitoring and in-hospital mortality among children with severe TBI ≤16 years of age after adjusting for important confounders. This association was evaluated at the patient level and at the hospital level. In a sensitivity analysis, this association was reexamined in a propensity-matched cohort. RESULTS A total of 1705 children with severe TBI were included in the study cohort. The overall in-hospital mortality was 14.3% of patients (n = 243), whereas the mortality of the 273 patients (16%) who underwent invasive ICP monitoring was 11% (n = 30). After adjusting for patient- and hospital-level characteristics, ICP monitoring was associated with lower in-hospital mortality (adjusted OR 0.50; 95% CI 0.30-0.85; p = 0.01). It is possible that patients who were managed with ICP monitoring were selected because of an anticipated favorable or unfavorable outcome. To further address this potential selection bias, the analysis was repeated with the hospital-specific rate of ICP monitoring use as the exposure. The adjusted OR for death of children treated at high ICP-use hospitals was 0.49 compared with those treated at low ICP-use hospitals (95% CI 0.31-0.78; p = 0.003). Variations in ICP monitoring use accounted for 15.9% of the interhospital variation in mortality among children with severe TBI. Similar results were obtained after analyzing the data using propensity score-matching methods. CONCLUSIONS In this observational study, ICP monitoring use was associated with lower hospital mortality at both the patient and hospital levels. However, the contribution of variable ICP monitoring rates to interhospital variation in pediatric TBI mortality was modest.
Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto.|Division of Neurosurgery, University of Ottawa.|Department of Surgery, University of Toronto.
Aziz S
AS
Alali
Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto.|Department of Surgery, University of Toronto.
David
D
Gomez
Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto.|Department of Surgery, University of Toronto.|Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.
Chethan
C
Sathya
Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC.
Randall S
RS
Burd
Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Ontario, Canada.
Todd G
TG
Mainprize
Division of Neurosurgery, University of Ottawa.
Richard
R
Moulton
Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and.
Richard A
RA
Falcone
Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto.|Department of Surgery, University of Toronto.
Charles
C
de Mestral
Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto.|Department of Surgery, University of Toronto.|Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.|Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
Avery
A
Nathens
ACS = American College of Surgeons; AIS = Abbreviated Injury Scale; GCS = Glasgow Coma Scale; ICC = intraclass correlation coefficient; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; ICP = intracranial pressure; MOR = median odds ratio; PCV = proportional change in variance; TBI = traumatic brain injury; TQIP = Trauma Quality Improvement Program; head injury; intracranial pressure; multilevel analysis; propensity score; trauma; traumatic brain injury