Implementation of a neurocritical care program is associated with improved neurologic outcomes in severe traumatic brain injury: A quasi-experimental uncontrolled before-and-after study
CCCF ePoster library. Hu V. Nov 2, 2016; 150995
Ms. Vivien Hu
Ms. Vivien Hu
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Abstract
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Topic: Retrospective or Prospective Cohort Study

Implementation of a neurocritical care program is associated with improved neurologic outcomes in severe traumatic brain injury: A quasi-experimental uncontrolled before-and-after study


Vivien Hu BSc(Pharm)1, Mypinder S Sekhon MD2,3, Navid Kherzi MD3, Dean R Chittock MD MPH2,
Peter Gooderham MD3, Brian Toyota MD3, Vinay K Dhingra MD2, Morad S Hameed MD MPH2,4 and Donald E Griesdale MD MPH2,5,6

1Faculty of Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, Canada, V5Z 1M9.
2Department of Medicine, Division of Critical Care Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, Canada, V5Z 1M9.
3Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, Canada, V5Z 1M9.
4Division of Trauma Surgery, Department of Surgery, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, Canada, V5Z 1M9.
5Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, Canada, V5Z 1M9.
6Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute,899 West 12th Avenue, University of British Columbia, Vancouver, BC, Canada, V5Z 1M9.


Grant acknowledgements:
Dr. Griesdale is funded by the VGH & UBC Hospital Foundation Best of Health Fund.

Abstract:

Introduction
Neurocritical care (NCC) is a subspecialty of critical care medicine that focuses on the management of central nervous system diseases, including traumatic brain injury (TBI)1. The most common model, a stand-alone NCC unit, has been associated with improved outcomes in patients with TBI. However, a stand-alone NCC may also increase mortality for patients admitted with non-neurological illnesses2. In 2014, we developed a consultancy based NCC service implemented within a closed mixed medical-surgical intensive care unit (ICU) at Vancouver General Hospital. As part of this service, we also implemented multimodal neuromonitoring consisting of brain tissue oxygen (PbO2) and autoregulation monitoring.
 
Objectives
Evaluate the neurologic outcomes and process measures of patients admitted with a severe TBI after the introduction of a consultancy-based NCC service.
 
Methods
Patients with severe TBI (GCS ≤8) were included if they underwent intracranial pressure (ICP) monitoring. Prior to November 2014, neuromonitoring consisted exclusively of external ventricular drains (EVD) and jugular venous oximetry. Post-NCC service implementation in November 2014, patient management consisted of consultation with a NCC neurointensivist and the implementation of multimodal monitoring: Licox® PbO2 monitoring, Camino® parenchymal ICP monitoring, and ICM+® brain autoregulation monitoring. ICM+® calculates the pressure-reactivity index (PRx) in real-time, which is a Pearson correlation coefficient between 10-sec averaged values of mean arterial pressure (MAP) and corresponding ICP signals. PRx allows identification of the zone of autoregulation to determine the optimal CPP for each individual patient. Multivariable ordinal logistic regression was used to model the association between NCC service implementation and Glasgow Outcome Scale (GOS) at 6 months.
 
Results
Database search identified 113 patients: 76 pre-NCC (Feb 2010 – Oct 2014) and 37 post-NCC (Nov 2014 – May 2016) implementation. The cohort had a mean age of 39 years (SD 2) and 87 of 113 (87%) were male. The median admission GCS motor score was 3 (IQR 1 – 4). Daily MAP was maintained at a higher level post-NCC (95 mmHg [10]) than pre-NCC (88 mmHg [10], p<0.001). Post-NCC was associated with lower mean temperature (36.6 ⁰C [0.90]) compared to pre-NCC (37.2 ⁰C [1.0], p=0.001). EVDs were used in all patients Pre-NCC and in 14 of 37 (41%) Post-NCC (p<0.0001). Compared to pre-NCC, patients post-NCC had fewer days of mechanical ventilation (9 [6 – 9] vs, 12 [7 – 17], p=0.029), fewer days of intravenous sedation (5 [3 – 6] vs. 7 [4 – 11], p=0.0008) and fewer days of ICP monitoring (5 [3 – 6] vs. 7 [4 – 7], p=0.0001). There was no difference before or after NCC program implementation in duration of intensive care or hospitalization. After adjustment for age, admission GCS motor score, pupillary abnormalities, gender, and Rotterdam CT head score, implementation of the NCC program was associated with a 2.5 increased odds (OR 2.5, 95% CI: 1.1 – 5.3, p=0.022) of an improved GOS at 6 months.
 
Conclusion
Implementation of an NCC program consisting of NCC consultation and multimodal neuromonitoring was independently associated with improvement in 6 month neurologic outcomes in patients admitted with severe TBI. The NCC program was also associated with fewer days of intravenous sedation, mechanical ventilation and invasive neuromonitoring.  
 


References:
  1. Kramer AH, Zygun DA. Do neurocritical care units save lives? Measuring the impact of specialized ICUs. Neurocrit Care 2011;14:329–33.
  2. Lott JP, Iwashyna TJ, Christie JD, Asch DA, Kramer AA, Kahn JM. Critical illness outcomes in specialty versus general intensive care units. Am J Respir Crit Care Med 2009;179:676–83. 
     


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