Sedation Intensity in Patients with Moderate to Severe Traumatic Brain Injury in the Intensive Care Unit: A TRACK-TBI Cohort Study

Rianne G F Dolmans; Jason Barber; Brandon Foreman; Nancy R Temkin; David O Okonkwo; Claudia S Robertson; Geoffrey T Manley; Eric S Rosenthal

doi:10.1007/s12028-024-02054-7

Sedation Intensity in Patients with Moderate to Severe Traumatic Brain Injury in the Intensive Care Unit: A TRACK-TBI Cohort Study

Neurocrit Care. 2024 Aug 13. doi: 10.1007/s12028-024-02054-7. Online ahead of print.

Authors

Rianne G F Dolmans¹, Jason Barber², Brandon Foreman³, Nancy R Temkin^{2

4}, David O Okonkwo⁵, Claudia S Robertson⁶, Geoffrey T Manley⁷, Eric S Rosenthal⁸

Affiliations

¹ Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA. rianne.dolmans@freeler.nl.
² Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
³ Department of Neurology and Rehabilitation Medicine, University of Cincinnati and, University of Cincinnati Medical Center, Cincinnati, OH, USA.
⁴ Department of Biostatistics, University of Washington, Seattle, WA, USA.
⁵ Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
⁶ Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
⁷ Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA.
⁸ Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.

PMID: 39138718
DOI: 10.1007/s12028-024-02054-7

Abstract

Background: Interventions to reduce intracranial pressure (ICP) in patients with traumatic brain injury (TBI) are multimodal but variable, including sedation-dosing strategies. This article quantifies the different sedation intensities administered in patients with moderate to severe TBI (msTBI) using the therapy intensity level (TIL) across different intensive care units (ICUs), including the use of additional ICP-lowering therapies.

Methods: Within the prospective Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, we performed a retrospective analysis of adult patients with msTBI admitted to an ICU for a least 5 days from seven US level 1 trauma centers who received invasive ICP monitoring and intravenous sedation. Sedation intensity was classified prospectively as one of three ordinal levels as part of the validated TIL score, which were collected at least once a day.

Results: A total of 127 patients met inclusion criteria (mean age 41.6 ± 17.7 years; 20% female). The median Injury Severity Score was 27 (interquartile range 17-33), with a median admission Glasgow Coma Score of 3 (interquartile range 3-7); 104 patients had severe TBI (82%), and 23 patients had moderate TBI (18%). The sedation intensity score was highest on the first ICU day (2.69 ± 1.78), independent of patient severity. Time to reaching each sedation intensity level varied by site. Sedation level I was reached within 24 h for all sites, but sedation levels II and III were reached variably between days 1 and 3. Sedation level III was never reached by two of seven sites. The total TIL score was highest on the first ICU day, with a modest decrease for each subsequent ICU day, but there was high site-specific practice-pattern variation.

Conclusions: Intensity of sedation and other therapies for elevated ICP for patients with msTBI demonstrate large practice-pattern variation across level 1 trauma centers within the TRACK-TBI cohort study, independent of patient severity. Optimizing sedation strategies using patient-specific physiologic and pathoanatomic information may optimize patient outcomes.

Keywords: Neurocritical care; Neurotrauma; Sedation; Therapy intensity level; Traumatic brain injury.

Grants and funding

U01 NS086090/NS/NINDS NIH HHS/United States