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National Variability in Intracranial Pressure Monitoring and Craniotomy for Children With Moderate to Severe Traumatic Brain Injury

Van Cleve, William MD, MPH*; Kernic, Mary A. PhD, MPH; Ellenbogen, Richard G. MD§; Wang, Jin PhD; Zatzick, Douglas F. MD; Bell, Michael J. MD#; Wainwright, Mark S. MD, PhD**; Groner, Jonathan I. MD‡‡; Mink, Richard B. MD, MACM§§; Giza, Christopher C. MD¶¶; Boyle, Linda Ng PhD‖‖; Mitchell, Pamela H. PhD##; Rivara, Frederick P. MD, MPH; Vavilala, Monica S. MD*; for the PEGASUS (Pediatric Guideline Adherence and Outcomes) Project

doi: 10.1227/NEU.0000000000000097
Research-Human-Clinical Studies: Editor's Choice
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BACKGROUND: Traumatic brain injury (TBI) is a significant cause of mortality and disability in children. Intracranial pressure monitoring (ICPM) and craniotomy/craniectomy (CRANI) may affect outcomes. Sources of variability in the use of these interventions remain incompletely understood.

OBJECTIVE: To analyze sources of variability in the use of ICPM and CRANI.

METHODS: Retrospective cross-sectional study of patients with moderate/severe pediatric TBI with the use of data submitted to the American College of Surgeons National Trauma Databank.

RESULTS: We analyzed data from 7140 children at 156 US hospitals during 7 continuous years. Of the children, 27.4% had ICPM, whereas 11.7% had a CRANI. Infants had lower rates of ICPM and CRANI than older children. A lower rate of ICPM was observed among children hospitalized at combined pediatric/adult trauma centers than among children treated at adult-only trauma centers (relative risk = 0.80; 95% confidence interval 0.66-0.97). For ICPM and CRANI, 18.5% and 11.6%, respectively, of residual model variance was explained by between-hospital variation in care delivery, but almost no correlation was observed between within-hospital tendency toward performing these procedures.

CONCLUSION: Infants received less ICPM than older children, and children hospitalized at pediatric trauma centers received less ICPM than children at adult-only trauma centers. In addition, significant between-hospital variability existed in the delivery of ICPM and CRANI to children with moderate-severe TBI.

ABBREVIATIONS: AIS, Abbreviated Injury Score

CRANI, craniotomy/craniectomy

GCS, Glasgow Coma Score

ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification

ICP, intracranial pressure

ICPM, intracranial pressure monitoring

ISS, Injury Severity Score

NTDB, National Trauma Databank

TBI, traumatic brain injury

*Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington;

Department of Epidemiology, University of Washington, Seattle, Washington;

§Departments of Neurological Surgery and Global Health Medicine, University of Washington, Seattle, Washington;

Harborview Injury Prevention and Research Center, Seattle, Washington;

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington;

#Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania;

**Department of Pediatrics, Northwestern University, Chicago, Illinois;

‡‡Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio;

§§Harbor-UCLA Medical Center, Los Angeles BioMedical Research Institute and David Geffen School of Medicine at UCLA, Los Angeles, California;

¶¶Divisions of Neurosurgery and Pediatric Neurology, UCLA, Los Angeles, California;

‖‖College of Engineering, University of Washington, Seattle, Washington;

##School of Nursing, University of Washington, Seattle, Washington

Correspondence: Monica S. Vavilala, MD, Professor of Anesthesiology and Pediatrics, Adjunct Professor of Neurological Surgery and Radiology, University of Washington and Harborview Injury Prevention and Research Center, Harborview Medical Center, 325 Ninth Ave, Box 359724, Seattle, WA 98104. E-mail:

Received February 14, 2013

Accepted July 10, 2013

Copyright © by the Congress of Neurological Surgeons