Tellen D Bennett1,2,3, Peter E DeWitt4, Tom H Greene5, Rajendu Srivastava6,7, Jay Riva-Cambrin8, Michael L Nance9, Susan L Bratton10, Desmond K Runyan11, J Michael Dean10, Heather T Keenan10. 1. Pediatric Critical Care, University of Colorado School of Medicine, Aurora. 2. Children's Hospital Colorado, Aurora. 3. Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora. 4. Bioinformatics and Biostatistics, Colorado School of Public Health, Aurora. 5. Division of Biostatistics, University of Utah School of Medicine, Salt Lake City. 6. Pediatric Inpatient Medicine, University of Utah School of Medicine, Salt Lake City. 7. Office of Research, Intermountain Healthcare, Salt Lake City, Utah. 8. Division of Pediatric Neurosurgery, Department of Clinical Neurosciences, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada. 9. Department of Pediatric Surgery, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia. 10. Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City. 11. Department of Pediatrics, Kempe Center, University of Colorado School of Medicine, Aurora.
Abstract
Importance: Intracranial pressure (ICP) monitoring is a mainstay of therapy for children with traumatic brain injury (TBI), but its overall association with patient outcome is unclear. Objective: To test the hypothesis that ICP monitoring is associated with improved functional survival of children with severe TBI. Design, Setting, and Participants: A propensity-weighted effectiveness analysis was conducted using 2 linked national databases with data from 30 US children's hospitals from January 1, 2007, to December 31, 2012, on 3084 children with severe TBI. Clinical events including neurosurgical procedures were identified using validated computable phenotypes. Data analysis was conducted from September 1, 2016, to March 1, 2017. Exposure: Placement of an ICP monitor. Main Outcomes and Measures: A composite of hospital mortality, discharge to hospice, or survival with placement of new tracheostomy and gastrostomy tubes. Results: Of the 3084 children in the study (1128 girls and 1956 boys; mean [SD] age, 7.03 [5.44] years), 1002 (32.4%) underwent ICP monitoring, with substantial hospital variation (6% to 50% by hospital). Overall, 484 children (15.7%) experienced the primary composite outcome. A propensity approach using matching weights generated good covariate balance between those who did and those who did not undergo ICP monitoring. Using a propensity-weighted logistic regression model clustered by hospital, no statistically significant difference was found in functional survival between monitored and unmonitored patients (odds ratio of poor outcome among those who underwent ICP monitoring, 1.31; 95% CI, 0.99-1.74). In a prespecified secondary analysis, no difference in mortality was found (odds ratio, 1.16; 95% CI, 0.89-1.50). Prespecified subgroup analyses of children younger and older than 2 years of age and among those with unintentional and inflicted (intentional) injuries also showed no difference in outcome with ICP monitoring. Conclusions and Relevance: With the use of linked national data and validated computable phenotypes, no evidence was found of a benefit from ICP monitoring on functional survival of children with severe TBI. Intracranial pressure monitoring is a widely but inconsistently used technology with incompletely demonstrated effectiveness. A large prospective cohort study or randomized trial is needed.
Importance: Intracranial pressure (ICP) monitoring is a mainstay of therapy for children with traumatic brain injury (TBI), but its overall association with patient outcome is unclear. Objective: To test the hypothesis that ICP monitoring is associated with improved functional survival of children with severe TBI. Design, Setting, and Participants: A propensity-weighted effectiveness analysis was conducted using 2 linked national databases with data from 30 US children's hospitals from January 1, 2007, to December 31, 2012, on 3084 children with severe TBI. Clinical events including neurosurgical procedures were identified using validated computable phenotypes. Data analysis was conducted from September 1, 2016, to March 1, 2017. Exposure: Placement of an ICP monitor. Main Outcomes and Measures: A composite of hospital mortality, discharge to hospice, or survival with placement of new tracheostomy and gastrostomy tubes. Results: Of the 3084 children in the study (1128 girls and 1956 boys; mean [SD] age, 7.03 [5.44] years), 1002 (32.4%) underwent ICP monitoring, with substantial hospital variation (6% to 50% by hospital). Overall, 484 children (15.7%) experienced the primary composite outcome. A propensity approach using matching weights generated good covariate balance between those who did and those who did not undergo ICP monitoring. Using a propensity-weighted logistic regression model clustered by hospital, no statistically significant difference was found in functional survival between monitored and unmonitored patients (odds ratio of poor outcome among those who underwent ICP monitoring, 1.31; 95% CI, 0.99-1.74). In a prespecified secondary analysis, no difference in mortality was found (odds ratio, 1.16; 95% CI, 0.89-1.50). Prespecified subgroup analyses of children younger and older than 2 years of age and among those with unintentional and inflicted (intentional) injuries also showed no difference in outcome with ICP monitoring. Conclusions and Relevance: With the use of linked national data and validated computable phenotypes, no evidence was found of a benefit from ICP monitoring on functional survival of children with severe TBI. Intracranial pressure monitoring is a widely but inconsistently used technology with incompletely demonstrated effectiveness. A large prospective cohort study or randomized trial is needed.
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Authors: Patrick M Kochanek; Travis C Jackson; Ruchira M Jha; Robert S B Clark; David O Okonkwo; Hülya Bayır; Samuel M Poloyac; Amy K Wagner; Philip E Empey; Yvette P Conley; Michael J Bell; Anthony E Kline; Corina O Bondi; Dennis W Simon; Shaun W Carlson; Ava M Puccio; Christopher M Horvat; Alicia K Au; Jonathan Elmer; Amery Treble-Barna; Milos D Ikonomovic; Lori A Shutter; D Lansing Taylor; Andrew M Stern; Steven H Graham; Valerian E Kagan; Edwin K Jackson; Stephen R Wisniewski; C Edward Dixon Journal: J Neurotrauma Date: 2019-02-01 Impact factor: 5.269