Neurocritical Care

, Volume 18, Issue 1, pp 131–142 | Cite as

Protocol Management of Severe Traumatic Brain Injury in Intensive Care Units: A Systematic Review

  • Shane W. English
  • Alexis F. Turgeon
  • Elliott Owen
  • Steve Doucette
  • Giuseppe Pagliarello
  • Lauralyn McIntyre
Review Article

Abstract

To examine clinical trials and observational studies that compared use of management protocols (MPs) versus usual care for adult intensive care unit (ICU) patients with acute severe traumatic brain injury (TBI) on 6-month neurologic outcome (Glasgow Outcome Scale, GOS) and mortality, major electronic databases were searched from 1950 to April 18, 2011. Abstracts from major international meetings were searched to identify gray literature. A total of 6,151 articles were identified; 488 were reviewed in full and 13 studies were included. Data on patient and MP characteristics, outcomes and methodological quality were extracted. All 13 included studies were observational. A random effects model showed that use of MPs was associated with a favorable neurologic outcome (GOS 4 or 5) at 6 months (odds ratio [OR] and 95 % confidence interval [CI] 3.84 (2.47–5.96)) but not 12 months (OR, 95 % CI 0.87 (0.56–1.36)). Use of MPs was associated with reduced mortality at hospital discharge and 6 months (OR and 95 % CI 0.72 (0.45–1.14) and 0.33 (0.13–0.82) respectively), but not 12 months (OR, 95 % CI 0.79 (0.5–1.24)). Sources of heterogeneity included variation in study design, methodological quality, MP design, MP neurophysiologic endpoints, and type of ICU. MPs for severe TBI were associated with reductions in death and improved neurologic outcome. Although no definitive conclusions about the efficacy of MPs for severe TBI can be drawn from our study, these results should encourage the conduct of randomized controlled trials to more rigorously examine the efficacy of MPs for severe TBI.

Keywords

Clinical protocols Brain injuries Intensive care units Critical care Evidence-based medicine 

Supplementary material

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Supplementary material 1 (DOCX 14 kb)
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Supplementary material 2 (DOCX 25 kb)
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Supplementary material 3 (DOCX 32 kb)

References

  1. 1.
    Hesdorffer DC, Ghajar J. Marked improvement in adherence to traumatic brain injury guidelines in United States trauma centers. J Trauma. 2007;63:841–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Faul M, Wald MM, Rutland-Brown W, et al. Using a cost-benefit analysis to estimate outcomes of a clinical treatment guideline: testing the Brain Trauma Foundation guidelines for the treatment of severe traumatic brain injury. J Trauma. 2007;63:1271–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.Google Scholar
  4. 4.
    CIHI. Head injuries in Canada: a decade of change (1994–1995 to 2003–2004) analysis in brief. August 2006 (Online), https://secure.cihi.ca/free_products/ntr_head_injuries_2006_e.pdf.
  5. 5.
    Bullock R, Chestnut RM, Clifton GL, et al. Guidelines for the management of severe head injury: Brain Trauma Foundation, American Association of Neurological Surgeons Joint Section on Neurotrauma and Critical Care. J Neurotrauma. 1996;13:641–734.CrossRefGoogle Scholar
  6. 6.
    Bullock R, Chestnut RM, Clifton GL, et al. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2000;17:449–554.Google Scholar
  7. 7.
    Bullock MR, Povlishock JT, et al. Guidelines for the management of severe traumatic brain injury, 3rd edition. J Neurotrauma. 2007;24:S1–106.CrossRefGoogle Scholar
  8. 8.
    Bulger EM, Nathens AB, Rivara FP, et al. Management of severe head injury: institutional variations in care and effect on outcome. Crit Care Med. 2002;30:1870–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Hesdorffer DC, Ghajar J, Iacono L. Predictors of compliance with the evidence-based guidelines for traumatic brain injury care: a survey of United States trauma centers. J Trauma. 2002;52:1202–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Turgeon A, Lauzier F, Scales D, et al. Practice variation in the management and treatment of increased intracranial pressure in severe traumatic brain injury in Canada: a Canadian multicentre retrospective cohort study. Crit Care Med. 2009;37:A435.Google Scholar
  11. 11.
    Blackwood B, Alderdice F, Burns KEA, et al. Protocolized vs. non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients: Cochrane review protocol. J Adv Nurs. 2009;65:957–64.PubMedCrossRefGoogle Scholar
  12. 12.
    Quigley PA, Smith SW, Strugar J. Successful experienced with clinical pathways in rehabilitation. J Rehabil. 1998;64:29–32.Google Scholar
  13. 13.
    Teasdale GM, Pettigrew LEL, Wilson JTL, et al. Analyzing outcome of treatment of severe head injury: a review and update on advancing the use of the Glasgow outcome scale. J Neurotrauma. 1998;15:587–97.PubMedCrossRefGoogle Scholar
  14. 14.
    Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52:377–84.PubMedCrossRefGoogle Scholar
  15. 15.
    Deeks J, Dinnes J, D’Amico R, et al. Evaluating non-randomised intervention studies. Health Technol Assess. 2003;7(27):iii–x, 1–173.Google Scholar
  16. 16.
    Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions, Version 5.0.2. 2009 (Online). http://www.cochrane.org/training/cochrane-handbook/.
  17. 17.
    McKinley BA, Parmley CL, Tonneson AS. Standardized management of intracranial pressure: a preliminary clinical trial. J Trauma. 1999;46:271–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Cremer OL, Van Dijk GW, Van Wensen E, et al. Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med. 2005;33:2207–13.PubMedCrossRefGoogle Scholar
  19. 19.
    Fakhry SM, Trask AL, Waller MA, et al. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma. 2004;56:492–500.PubMedCrossRefGoogle Scholar
  20. 20.
    Elf K, Nilsson P, Enblad P. Outcome after traumatic brain injury improved by an organized secondary insult program and standardized neurointensive care. Crit Care Med. 2002;30:2129–34.PubMedCrossRefGoogle Scholar
  21. 21.
    McIlvoy L, Spain DA, Raque G, et al. Successful incorporation of the severe head injury guidelines into a phased-outcome clinical pathway. J Neurosci Nurs. 2001;33:72–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Eker C, Asgeirsson B, Grande PO, et al. Improved outcome after severe head injury with a new therapy based on principle for brain volume regulation and preserved microcirculation. Crit Care Med. 1998;26:1881–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Vitaz TW, McIlvoy L, Raque GH, et al. Development and implementation of a clinical pathway for severe traumatic brain injury. J Trauma. 2001;51:369–75.PubMedCrossRefGoogle Scholar
  24. 24.
    Vukic M, Negovetic L, Kovac D, et al. The effect of implementation of guidelines for the management of severe head injury on patient treatment and outcome. Acta Neurochir. 1999;141:1203–8.CrossRefGoogle Scholar
  25. 25.
    Patel HC, Menon DK, Tebbs S, et al. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28:547–53.PubMedCrossRefGoogle Scholar
  26. 26.
    Bader MK, Rosete J, Palmer S, et al. Implementation of the Brain Trauma Foundation (BTF) traumatic brain injury (TBI) guidelines and brain oxygen monitoring—the lessons learned in a ten-year experience. Neurocritical Care Society 6th Annual Meeting, Miami, Florida, 23–25 October, 2008. doi:10.1007/s12028-008-9141-4.
  27. 27.
    Palmer S, Bader MK, Qureshi A, et al. The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. J Trauma. 2001;50:657–64.PubMedCrossRefGoogle Scholar
  28. 28.
    Clayton TJ, Nelson RJ, Manara AR. Reduction in mortality from severe head injury following introduction of a protocol for intensive care management. Br J Anaesth. 2004;93:761–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Arabi YM, Haddad S, Tamim HM, et al. Mortality reduction after implementing a clinical practice guidelines-based management protocol for severe traumatic brain injury. J Crit Care. 2010;25:190–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Baker SP, O’Neill B, Haddon WJ, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–96.PubMedCrossRefGoogle Scholar
  31. 31.
    Maas AI, Dearden M, Teasdale GM, et al. EBIC-guidelines for management of severe head injury in adults: European brain injury consortium. Acta Neurochir (Wien). 1997;139:286–94.CrossRefGoogle Scholar
  32. 32.
    Asgeirsson B, Grande PO, Nordstrom C. A new therapy of post-trauma brain oedema based on haemodynamic principles for brain volume regulation. Intensive Care Med. 1994;20:260–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Hainsworth DS, Lockwood-Cook E, Pond M, et al. Development and implementation of clinical pathways for stroke on a multihospital basis. J Neurosci Nurs. 1997;29:156–62.PubMedCrossRefGoogle Scholar
  34. 34.
    Delaney CP, Fazio VW, Senagore AJ, et al. Fast track postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg. 2001;88:1533–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Kallet RH, Jasmer RM, Pittet J, et al. Clinical implementation of the ARDS network protocol is associated with reduced hospital mortality compared with historical controls. Crit Care Med. 2005;33:925–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Marelich GP, Murin S, Battistella F, et al. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses. Chest. 2000;118:459–67.PubMedCrossRefGoogle Scholar
  37. 37.
    Goldberg PA, Siegel MD, Sherwin RS, et al. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care. 2004;27:461–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27:2609–15.PubMedCrossRefGoogle Scholar
  39. 39.
    O’Keeffe T, Refaai M, Tchorz K, et al. A massive transfusion protocol to decrease blood component use and costs. Arch Surg. 2008;143:686–91.PubMedCrossRefGoogle Scholar
  40. 40.
    Holcomb BW, Wheeler AP, Ely EW. New ways to reduce unnecessary variation and improve outcomes in the intensive care unit. Curr Opin Crit Care. 2001;7:304–11.PubMedCrossRefGoogle Scholar
  41. 41.
    Hammond JJ. Protocols and guidelines in critical care: development and implementation. Curr Opin Crit Care. 2001;7:464–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Helmy A, Vizcaychipi M, Gupta AK. Traumatic brain injury: intensive care management. Br J Anaesth. 2007;99:32–42.PubMedCrossRefGoogle Scholar
  43. 43.
    March A. Facilitating implementation of evidence-based guidelines in hospital settings: learning from trauma centers. The Commonwealth Fund, 2006.Google Scholar
  44. 44.
    Mallen C, Peat G, Croft P. Quality assessment of observational studies is not commonplace in systematic reviews. J Clin Epidemiol. 2006;59:765–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA. 2000;283:2008–12.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Shane W. English
    • 1
  • Alexis F. Turgeon
    • 2
  • Elliott Owen
    • 1
  • Steve Doucette
    • 3
  • Giuseppe Pagliarello
    • 4
  • Lauralyn McIntyre
    • 5
  1. 1.Department of Medicine (Critical Care)The Ottawa HospitalOttawaCanada
  2. 2.Department of Anesthesia (Critical Care)L’Enfant-JésusQuébec CityCanada
  3. 3.Clinical Epidemiology ProgramThe Ottawa Hospital Research InstituteOttawaCanada
  4. 4.Department of Surgery (Critical Care)The Ottawa HospitalOttawaCanada
  5. 5.Department of Medicine (Critical Care)The Ottawa Hospital, The Ottawa Hospital Research InstituteOttawaCanada

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