Where should patients with severe traumatic brain injury be managed?: Patients can be safely managed in a nonspecialist center.

Severe traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. Advances in the understanding of the pathophysiology of TBI, in association with advances in monitoring and imaging technologies, have led to significant improvements in its management. These include the introduction of protocol-driven therapies to manage intracranial pressure (ICP) and cerebral perfusion pressure (CPP) to optimize cerebral oxygen delivery and prevent or minimize secondary brain injury. Neuroscience units offer a high level of care for patients with TBI, including 24-hour access to neurosurgical intervention and neurointensive care units staffed by trained neurointensivists and specialist nursing staff. However, it is unclear whether improvements in outcome after TBI have occurred because of management in such highly specialized units or because of the introduction of, and adherence to, protocol-guided therapy. If the latter, then management of some patients with severe TBI in a general intensive care unit (ICU) would yield similar outcomes and free up specialist neurocritical care beds for more complex patients requiring specialist interventions. The use of protocol-driven therapy, or consensus guidance, to improve clinical outcome is employed successfully throughout all areas of medicine. Perhaps the most well known is the Surviving Sepsis Campaign which comprises a series of guidelines established in 2008 to reduce the morbidity and mortality associated with sepsis. Adherence to these guidelines is associated with significant improvements in patient outcome. Other guidelines relevant to intensive care medicine include pharmacological sedation protocols, central venous catheter placement guidelines, and ventilator weaning. There is a growing body of evidence that protocolguided therapy after TBI can also improve patient outcome. What is not clear is whether managing patients in a neuroscience center confers any additional benefit. In one US study, patients managed in level I trauma centers with direct neurosurgical access had improved outcomes compared with those managed in level II centers. However, outcome improved significantly in level II as well as level I centers after the introduction of treatment protocols for the management of TBI. A study from the Center for Disease Control Prevention in the United States also demonstrated that a greater proportion (66% vs. 35%) of patients with severe TBI have a good outcome when their management is based on Brain Trauma Foundation (BTF) guidelines. Extrapolation of these findings suggests that national implementation of BTF guidelines would lead to cost savings of US$250 million per year in the United States alone. In patients with severe TBI, Patel et al demonstrated that the establishment of an evidence-based management protocol aimed at control of ICP and CPP resulted in a significant reduction in mortality (from 59.6% to 40.4%), compared with historic controls. The proportion of favorable outcome was also high (66.6%) in those presenting with evidence of raised ICP in the absence of a mass lesion (60.0%) and in those that required complex interventions to optimize ICP and CPP. In a similar study Elf et al described a standardized treatment protocol incorporating an organized secondary insult program designed to avoid secondary brain damage and compared recent mortality rates to 2 previous periods; one before the availability of a neurocritical care unit and the other after the establishment of a basic neurocritical care unit without protocolized treatment strategies. Each time period showed a progressive decrease in mortality (from 40% to 27% to 2.8%) in association with an increase in the incidence of good functional outcome in survivors (from 40% to 68% to 84%). Clayton et al demonstrated that the introduction of protocol-guided management of severe TBI reduced ICU and hospital mortality, from 20% to 13.5% and 24.5% to 20.8%, respectively. The ICU mortality for those without head injury did not change significantly over the same period, strongly suggesting that the benefits to the head injured patients derived from the introduction of the protocol-driven management paradigm. In reality, critically ill patients with severe TBI are managed in 1 of 3 places; in a specialized neurocritical care unit, in a general ICU with full neurosurgical support, or in a District General Hospital (DGH) ICU without immediate access to such support. Limited Copyright r 2010 by Lippincott Williams & Wilkins From the *Department of Anesthesia; and wIntensive Care, Royal Berkshire Hospital, Reading, UK. Conflict of Interest: None. Reprints: Anna Petsas, MBBS, Department of Anaesthetic, Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK (e-mail: annapetsas@gmail.com). POINTS OF VIEW