Adherence to Brain Trauma Foundation guidelines for management of traumatic brain injury patients

• Author / Creator

  Khormi, Yahya

• Severe traumatic brain injury (TBI) is a significant cause of death and disability around the world. Management based on Brain Trauma Foundation (BTF) guidelines is widely accepted and thought to improve outcomes. The objectives of this thesis are to provide an overview of adherence to BTF guidelines as a whole and specifically for intracranial pressure (ICP) monitoring, to explore which factors influence adherence and to study the effects of guideline-based management on outcomes. Firstly, we conducted a search of relevant electronic bibliographic databases. Twenty articles met inclusion/exclusion criteria out of 666 papers screened. All were cohort studies. Wide variation of adherence to BTF guidelines was observed with a median of 60.7% (range 0-100%). The lowest median adherence was observed with surgical management (14%), while the highest was observed with oxygenation (100%), steroid (97.8%) and blood pressure recommendation (92.3%). Variability was primarily explained by the variation in strength of evidence of each recommendation. Treating patients with higher severity of injury and treatment in a level 1 trauma center positively influenced adherence. Adherence was not associated with improved crude mortality [OR: 0.82, (95% CI: 0.60-1.12) or adjusted mortality [OR: 0.95, (95% CI: 0.88-1.02). However, beneficial effects were observed in subgroup analysis through implementation of a guidelines-based protocol in terms of in-hospital crude mortality as well as adherence to specific recommendations; nutrition, Systolic Blood Pressure (SBP), oxygen (O2) and cerebral perfusion threshold, but low level of evidence and study heterogeneity limit the generalizability of the results. Secondly, We conducted a retrospective cohort study of patients with severe blunt TBI registered in Alberta Trauma Registry between 2000 to 2013. Patients who died in the emergency department and patients from provinces other than Alberta were excluded. Outcomes were adherence rate with 3rd edition of the BTF guidelines, overall in-hospital mortality, and length of stay in hospital and intensive care unit (ICU). In this cohort, the BTF guideline adherence rate for ICP monitoring was 30%. Adherence rates increased with younger age, high ISS score, lower Glasgow Coma Score (GCS), abnormal CT head, craniotomy, admission to neurocritical care unit, and absence of alcohol intoxication or cardiac arrest. After adjusting for potential confounders adherence was associated with higher mortality (OR 2.01, 95% CI: 1.56-2.59, p<0.001) and increase ICU and hospital length of stay (p<0.001). Overall, the literature indicate that adherence to BTF guidelines is variable and further study is required to strengthen the current evidence and identify factors related to adherence with guidelines include professional prospective. Adherence to BTF guidelines for ICP monitoring in severe TBI in Alberta was low, varied across centers and was associated with higher mortality and morbidity. ICP insertion may be an indicator of TBI severity, alternatively the current BTF criteria for ICP monitoring may fail to identify patients likely to benefit. Further study is required to refine the indications of ICP monitoring in TBI patients.

• Subjects / Keywords

  • Brain Trauma Foundation guidelines
  • TBI
  • Brain injury guidelines
  • Traumatic brain injury

• Graduation date

  Fall 2018

• Type of Item

  Thesis

• Degree

  Master of Science

• DOI

  https://doi.org/10.7939/R3JM23Z0K

• License

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