Thompson HJ, Rivara FP, Jurkovich GJ et al.
In: Crit Care Med 2008, 36; 282-290

 

BEWERTUNGSSYSTEM

*****    = hervorragende Arbeit
****    = gute grundlagenwissenschaftliche Arbeit/klinische Studie/Übersichtsarbeit
***    = geringer Neuheitswert oder nur für Spezialisten geeignet
**    = weniger interessant, leichte formale oder methodische Mängel
*    = erhebliche Mängel

 

NIMA_1-2009


Bewertung: ****





Zielstellung:

Mrs. Thompson and collaborators present an analysis of the mortality after traumatic brain injury. Data of 1776 patients was extracted from a prospective multicenter cohort study on the effect of trauma center care on mortality published earlier by MacKenzie et al. to specifically identify the effect of intensive care on age and mortality. The purpose of this study was to "evaluate the effect of age on intensity of care provided and on mortality at discharge". The age groups distinguished were 25 to 54, 55 to 64, 65 to 74 and 75 to 84 years. The intensity of care was viewed by the number of measures taken by the attending physicians such as ICU treatment, intubation, ICP recording, use of mannitol barbiturate coma, decompressive craniectomy, number of consults, number of "do not resuscitate orders", withdrawal of treatment and others.
Several factors were associated with an increased risk of in hospital death: Age, pulmonary artery catheter, intubation, the presence of a "do not resuscitate" order, withdrawal of treatment. These factors plus the use of mannitol were also associated with death within 12 months after discharge from hospital.
It is concluded there had been a lower intensity of care provided to older patients. The higher the number of surgical or medical consults, the lower was the risk of death.

Kommentar:

This is an analysis of a large number of patients with intensive care treatment after head injury. There are many noteworthy details: Of 1235 patients admitted to the ICU, 868 were intubated and 281 received intracranial pressure monitoring. 220 patients received a pulmonary artery catheter, 70 patients underwent decompressive craniectomy and 59 were treated with a barbiturate coma. A number of issues of this analysis raise questions:
The severity of the brain injury was based on the motor component of the Glasgow Coma Score (GCS). While this is common practice, it is contrary to common sense. In 1984, ten years after the GCS had been recommended, Ropper et al. (Neurology 34, 1089-92) had reported on spontaneous movements in brain dead patients. Obviously a GCS of 6 is compatible with brain death. The prognostic value of the GCS in the first days after injury has lately been seriously questioned ( Moskopp et al. Problems of the Glasgow Coma Scale with early intubated patients. Neurosurg. Rev 18, 253-7, 1995, Balestreri et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry 75, 161-2, 2004) and the motor score is clearly no measure of the severity of a brain injury. The duration of coma has been found related with outcome (Frowein, Firsching: Classification of head injury, Handbook of neurology, Elsevier, Amsterdam, 1990) and may be considered a good yardstick for the severity of head injury. In addition, the authors correctly used the pupillary response as a measure of the severity of brain injury because of its high predictive value.
The amount of intensive care includes some very controversial measures, which are obviouly not applied to the older patients to the same extent as to the younger age groups. There is no scientific evidence for the beneficial effect of ICP recording, jugular bulb or pulmonary artery catheter, barbiturate coma, decompressive craniectomy. Withholding elderly patients these measures does not mean the older patients are deprived of the necessary intensive care treatment.
Intubation in this paper is valued among these measures on a par with ICP recording, barbiturate coma and certain catheters. Intubation, however, is not an optional and controversial measure without scientific evidence of its benefit for the patient but a lifesaving precautionary measure in comatose patients to ensure adequate ventilation which to the best of my knowledge has received universal acceptance and is listed as a must in comatose patients (see Leitlinien Schädel-Hirntrauma, Deutsche Gesellschaft für Neurochirurgie AWMF, 2007). As it is predominantly the comatose patient, who is intubated, and the study obviously includes non comatose patients, it is only logical, that intubated patients have a less favorable prognosis than non- intubated ones.
The "do not resuscitate" orders or the withdrawal of treatment can of course only be justified with the certain prediction of a fatal outcome despite all efforts in the first place. It is of course not an unexpected observation that these patients carried a higher risk of death.
The numbers of medical and surgical consults are also difficult to interpret, as they obviously applied to those patients with a reasonable prospect of survival.
The conclusion to include "multidisciplinary decision making" in intensive care medicine is an honorable and selfevident attitude, but difficult to be based on the data provided by this detailed and informative study.

(R. Firsching)