National variability in intracranial pressure monitoring and craniotomy for children with moderate to severe traumatic brain injury

Van Cleve, W.; Kernic, M. A.; Ellenbogen, R. G.; Wang, J.; Zatzick, D. F.; Bell, M. J.; Wainwright, M. S.; Groner, J. I.; Mink, R. B.; Giza, C. C.; Boyle, L. N.; Mitchell, P. H.; Rivara, F. P.; Vavilala, M. S.

Neurosurgery. 2013 Jul 19; 73(5):746-52; discussion 752; quiz 752


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.

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