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SAN FRANCISCO – Complications developed with 3% of 298 intracranial pressure monitors inserted by trauma surgeons and with 0.8% of 112 monitors placed by neurosurgeons in patients with traumatic brain injury, a statistically insignificant difference.
Mortality rates were 37% for patients in the trauma surgeon group and 30% for patients in the neurosurgeon group, a difference that also was not significant, Dr. Sadia Ilyas and her associates reported at the annual meeting of the American Association for the Surgery of Trauma.
They retrospectively studied data for patients with traumatic brain injury (TBI) who received intracranial pressure monitors in 2006 through 2011 at one Level I trauma center. The trauma surgeons there had undergone training and credentialing in 2005 by neurosurgeons at the same facility for insertion of the monitors because neurosurgery coverage is not always available, explained Dr. Ilyas of Wright State University, Dayton, Ohio.
Complications in this series consisted of device malfunction or dislodgement, with no major or life-threatening complications.
Trauma surgeons in the training program each viewed two 10-minute instructional videos, were proctored by a neurosurgeon in a cadaver lab, and placed three monitors in patients under proctoring by a neurosurgeon. General surgery residents received similar training but were not credentialed to place intracranial pressure monitors without direct supervision.
Guidelines from the Brain Trauma Foundation recommend intracranial pressure monitoring in patients with severe TBI who have a Glasgow Coma Scale score of 8 or lower and an abnormal CT scan. Monitoring typically involves placement of a ventriculostomy or an intracranial pressure intraparenchymal monitor (bolt monitor).
In the study, 97% of all monitors placed were parenchymal monitors. Among those placed by neurosurgeons, 12% were ventriculostomies, which have the added advantage of therapeutic use but are more challenging to insert. "It is our view that placement of ICP parenchymal monitors is a more reasonable alternative for non-neurosurgeons," she said.
Six previous studies of 904 intracranial pressure monitors inserted by non-neurosurgeons found complication rates of 0%-8% with parenchymal monitors and 15% with ventriculostomy.
Each year in the United States approximately 200,000 people are hospitalized for TBI and 50,000 die from TBI. In 2010, an estimated 4,400 neurosurgeons were actively practicing in the United States (1.4 for every 100,000 residents), not all practiced trauma care, and a third were older than 55 years, she said.
Dr. Ilyas reported having no financial disclosures.
On Twitter @sherryboschert
These results have essentially been published before in other studies, and this paper doesn’t break any new ground.
I want to drive home the point that it is important, at least in my practice, to try to use ventriculostomy as the first line of monitoring because you can use it as a therapeutic tool to drain cerebrospinal fluid as well as just monitor. I do use parenchymal monitors but I can’t cannulate the ventricle.
A bigger issue is what to do with the information that you get from these monitors. Regardless of who puts these things in, someone needs to know how to treat the patients. Personally, I’ve been dismayed by the trend in recent years for so-called neuro critical care doctors to focus on things like temperature and serum sodium. It seems like very few intensivists who care for TBI patients really understand cerebral metabolism, cerebral blood flow, cerebral pathophysiology, and related processes.
As Dr. Ilyas and her colleagues have shown, the technical insertion of these devices is really not that difficult, but knowing the indications for when to put them in and when not to put them in, knowing how to interpret the data, and integrating the care of these patients into the neuro service are much more difficult things to do.
One problem with this paper is that it describes only short-term periprocedural complications. The real standard for measuring efficacy of interventions in TBI patients is long-term follow-up, which historically has been 6 months from injury and now more recent trials are using 12 months or even longer.
Dr. Alex B. Valadka is a neurosurgeon at the Seton Brain and Spine Institute, Austin, Tex. These are excerpts of his remarks as discussant of the study at the meeting. He reported having no financial disclosures.
These results have essentially been published before in other studies, and this paper doesn’t break any new ground.
I want to drive home the point that it is important, at least in my practice, to try to use ventriculostomy as the first line of monitoring because you can use it as a therapeutic tool to drain cerebrospinal fluid as well as just monitor. I do use parenchymal monitors but I can’t cannulate the ventricle.
A bigger issue is what to do with the information that you get from these monitors. Regardless of who puts these things in, someone needs to know how to treat the patients. Personally, I’ve been dismayed by the trend in recent years for so-called neuro critical care doctors to focus on things like temperature and serum sodium. It seems like very few intensivists who care for TBI patients really understand cerebral metabolism, cerebral blood flow, cerebral pathophysiology, and related processes.
As Dr. Ilyas and her colleagues have shown, the technical insertion of these devices is really not that difficult, but knowing the indications for when to put them in and when not to put them in, knowing how to interpret the data, and integrating the care of these patients into the neuro service are much more difficult things to do.
One problem with this paper is that it describes only short-term periprocedural complications. The real standard for measuring efficacy of interventions in TBI patients is long-term follow-up, which historically has been 6 months from injury and now more recent trials are using 12 months or even longer.
Dr. Alex B. Valadka is a neurosurgeon at the Seton Brain and Spine Institute, Austin, Tex. These are excerpts of his remarks as discussant of the study at the meeting. He reported having no financial disclosures.
These results have essentially been published before in other studies, and this paper doesn’t break any new ground.
I want to drive home the point that it is important, at least in my practice, to try to use ventriculostomy as the first line of monitoring because you can use it as a therapeutic tool to drain cerebrospinal fluid as well as just monitor. I do use parenchymal monitors but I can’t cannulate the ventricle.
A bigger issue is what to do with the information that you get from these monitors. Regardless of who puts these things in, someone needs to know how to treat the patients. Personally, I’ve been dismayed by the trend in recent years for so-called neuro critical care doctors to focus on things like temperature and serum sodium. It seems like very few intensivists who care for TBI patients really understand cerebral metabolism, cerebral blood flow, cerebral pathophysiology, and related processes.
As Dr. Ilyas and her colleagues have shown, the technical insertion of these devices is really not that difficult, but knowing the indications for when to put them in and when not to put them in, knowing how to interpret the data, and integrating the care of these patients into the neuro service are much more difficult things to do.
One problem with this paper is that it describes only short-term periprocedural complications. The real standard for measuring efficacy of interventions in TBI patients is long-term follow-up, which historically has been 6 months from injury and now more recent trials are using 12 months or even longer.
Dr. Alex B. Valadka is a neurosurgeon at the Seton Brain and Spine Institute, Austin, Tex. These are excerpts of his remarks as discussant of the study at the meeting. He reported having no financial disclosures.
SAN FRANCISCO – Complications developed with 3% of 298 intracranial pressure monitors inserted by trauma surgeons and with 0.8% of 112 monitors placed by neurosurgeons in patients with traumatic brain injury, a statistically insignificant difference.
Mortality rates were 37% for patients in the trauma surgeon group and 30% for patients in the neurosurgeon group, a difference that also was not significant, Dr. Sadia Ilyas and her associates reported at the annual meeting of the American Association for the Surgery of Trauma.
They retrospectively studied data for patients with traumatic brain injury (TBI) who received intracranial pressure monitors in 2006 through 2011 at one Level I trauma center. The trauma surgeons there had undergone training and credentialing in 2005 by neurosurgeons at the same facility for insertion of the monitors because neurosurgery coverage is not always available, explained Dr. Ilyas of Wright State University, Dayton, Ohio.
Complications in this series consisted of device malfunction or dislodgement, with no major or life-threatening complications.
Trauma surgeons in the training program each viewed two 10-minute instructional videos, were proctored by a neurosurgeon in a cadaver lab, and placed three monitors in patients under proctoring by a neurosurgeon. General surgery residents received similar training but were not credentialed to place intracranial pressure monitors without direct supervision.
Guidelines from the Brain Trauma Foundation recommend intracranial pressure monitoring in patients with severe TBI who have a Glasgow Coma Scale score of 8 or lower and an abnormal CT scan. Monitoring typically involves placement of a ventriculostomy or an intracranial pressure intraparenchymal monitor (bolt monitor).
In the study, 97% of all monitors placed were parenchymal monitors. Among those placed by neurosurgeons, 12% were ventriculostomies, which have the added advantage of therapeutic use but are more challenging to insert. "It is our view that placement of ICP parenchymal monitors is a more reasonable alternative for non-neurosurgeons," she said.
Six previous studies of 904 intracranial pressure monitors inserted by non-neurosurgeons found complication rates of 0%-8% with parenchymal monitors and 15% with ventriculostomy.
Each year in the United States approximately 200,000 people are hospitalized for TBI and 50,000 die from TBI. In 2010, an estimated 4,400 neurosurgeons were actively practicing in the United States (1.4 for every 100,000 residents), not all practiced trauma care, and a third were older than 55 years, she said.
Dr. Ilyas reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Complications developed with 3% of 298 intracranial pressure monitors inserted by trauma surgeons and with 0.8% of 112 monitors placed by neurosurgeons in patients with traumatic brain injury, a statistically insignificant difference.
Mortality rates were 37% for patients in the trauma surgeon group and 30% for patients in the neurosurgeon group, a difference that also was not significant, Dr. Sadia Ilyas and her associates reported at the annual meeting of the American Association for the Surgery of Trauma.
They retrospectively studied data for patients with traumatic brain injury (TBI) who received intracranial pressure monitors in 2006 through 2011 at one Level I trauma center. The trauma surgeons there had undergone training and credentialing in 2005 by neurosurgeons at the same facility for insertion of the monitors because neurosurgery coverage is not always available, explained Dr. Ilyas of Wright State University, Dayton, Ohio.
Complications in this series consisted of device malfunction or dislodgement, with no major or life-threatening complications.
Trauma surgeons in the training program each viewed two 10-minute instructional videos, were proctored by a neurosurgeon in a cadaver lab, and placed three monitors in patients under proctoring by a neurosurgeon. General surgery residents received similar training but were not credentialed to place intracranial pressure monitors without direct supervision.
Guidelines from the Brain Trauma Foundation recommend intracranial pressure monitoring in patients with severe TBI who have a Glasgow Coma Scale score of 8 or lower and an abnormal CT scan. Monitoring typically involves placement of a ventriculostomy or an intracranial pressure intraparenchymal monitor (bolt monitor).
In the study, 97% of all monitors placed were parenchymal monitors. Among those placed by neurosurgeons, 12% were ventriculostomies, which have the added advantage of therapeutic use but are more challenging to insert. "It is our view that placement of ICP parenchymal monitors is a more reasonable alternative for non-neurosurgeons," she said.
Six previous studies of 904 intracranial pressure monitors inserted by non-neurosurgeons found complication rates of 0%-8% with parenchymal monitors and 15% with ventriculostomy.
Each year in the United States approximately 200,000 people are hospitalized for TBI and 50,000 die from TBI. In 2010, an estimated 4,400 neurosurgeons were actively practicing in the United States (1.4 for every 100,000 residents), not all practiced trauma care, and a third were older than 55 years, she said.
Dr. Ilyas reported having no financial disclosures.
On Twitter @sherryboschert
AT THE AAST ANNUAL MEETING
Major finding: Complications developed with 3% of monitors placed by trauma surgeons and 0.8% placed by neurosurgeons.
Data source: Retrospective review of 410 patients with TBI who received intracranial pressure monitors in 2006-2011.
Disclosures: Dr. Ilyas reported having no financial disclosures.