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Determining neurological prognosis in patients with severe traumatic brain injury: a survey of Canadian intensivists

Introduction

Current prognostic information following severe traumatic brain injury (TBI) is of limited clinical utility. We hypothesized that wide practice variation exists in determining prognosis in this population. We conducted a survey of Canadian intensivists to better understand prognosis determination and decisions regarding level of care following severe TBI.

Methods

Survey items were generated to assess the perceived utilization and utility of different tests for prognosis determination, and the perception of prognosis and decision on the level of care. We used direct questions and scenario-based questions (five-point Likert scales). We pretested the questionnaire to assess its clinical sensibility, and conducted test–retest reliability. Canadian intensivists were identified at all level I and level II trauma centers. The survey was administered electronically. Nonrespondents were sent a paper questionnaire.

Results

The response rate was 73% (180/215). Most respondents worked in teaching hospitals (95%), mixed medical/surgical ICUs (87%) with more than 40 severe TBI cases/year (65%). Poor neurological prognosis at 1 year was defined as Glasgow outcome scale 1, 2 or 3 for 69% of respondents. More than 60% considered that accurate prognosis determination would be most helpful within 7 days following severe TBI. Most respondents cited monitoring (>70%), clinical examination (>85%) and CT scan (>90%) as being the most frequently used source of information for evaluating prognosis, as opposed to MRI (30%) or somatosensory evoked potentials (15%). When asked if a 25-year-old male with severe TBI had a poor neurological prognosis at 1 year, 40% of respondents disagreed/strongly disagreed, 30% had no opinion and 30% agreed/strongly agreed. When asked how comfortable they would be to recommend withdrawal of life-support measures, 82% reported being uncomfortable/very uncomfortable, 9% had no opinion and 9% were comfortable/very comfortable.

Conclusion

We observed significant variation in perceptions of neurological prognosis and in decisions regarding level of care among Canadian intensivists. Considering the importance of such prognostic information in clinical practice, a better understanding of prognosis determination in TBI is warranted.

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Turgeon, A., Lauzier, F., Burns, K. et al. Determining neurological prognosis in patients with severe traumatic brain injury: a survey of Canadian intensivists. Crit Care 13, P88 (2009). https://doi.org/10.1186/cc7252

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Keywords

  • Traumatic Brain Injury
  • Prognostic Information
  • Trauma Center
  • Survey Item
  • Severe Traumatic Brain Injury