Low-value clinical practices in adult traumatic brain injury : an umbrella review

Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last 3 decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (Assessing the Methodological Quality of Systematic Reviews), reported effect sizes, and credibility of evidence (I to IV). The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: computed tomography (CT) in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality, and most included studies had a high risk of bias

Transfusion sanguine chez les patients en état critique suivant un traumatisme craniocérébral

Introduction: Le recours à une stratégie transfusionnelle restrictive est préconisé chez les patients en état critique. Une incertitude demeure toutefois quant aux seuils optimaux de transfusion pour les patients atteints de traumatisme craniocérébral considérant que le cerveau lésé est susceptible aux lésions hypoxémiques. Nous avons tenté d’identifier les croyances de pratique des cliniciens quant aux facteurs déterminant l’ordonnance d’une transfusion et les seuils de transfusion considérés comme optimaux dans cette population. Méthodologie: Nous avons développé une enquête de pratique destinée aux intensivistes et aux neurochirurgiens canadiens, australiens et britanniques responsables des soins des patients ayant subi un traumatisme craniocérébral. Le questionnaire a été élaboré par un groupe d’experts à l’aide d’un processus structuré (génération et réduction de domaines/items). Le questionnaire a été validé pour garantir sa sensibilité clinique, sa fiabilité et son contenu. Résultats: Le taux de réponse était de 28,7% (218/760). Lorsque nous avons soumis aux répondants le cas hypothétique d’un jeune adulte ayant subi un traumatisme craniocérébral, nous avons observé une hétérogénéité de pratiques transfusionnelles, 47% (intervalle de confiance [IC] à 95%, 41 à 54%) des répondants étant en faveur d’une transfusion à partir d’un taux d’hémoglobine ≤70 g·L–1 dans la phase aiguë de soins, alors que 73% (IC 95%, 67 à 79%) utiliseraient ce seuil dans la phase chronique. Les traumatismes multiples, les données de monitorage neurologique, un choc hémorragique et une chirurgie programmée constituaient les principaux facteurs influençant le besoin perçu de transfusion. L’absence de données probantes et de recommandations était responsable de l’incertitude concernant les stratégies de transfusion chez cette population. Conclusion: Dans notre étude, les cliniciens mentionnent que leur pratique transfusionnelle est influencée par l’acuité des soins, les caractéristiques des patients et le monitorage neurologique. L’incertitude clinique concernant la stratégie de transfusion optimale est principalement attribuable à l’absence de données probantes ou de recommandations. Des études randomisées contrôlées sont nécessaires afin de déterminer quelles stratégies de transfusion seraient optimales pour cette population.Introduction: Restrictive transfusion strategy has been advocated in critically ill patients. Nevertheless, considerable uncertainty exists regarding optimal transfusion thresholds in patients with traumatic brain injury because the injured brain is susceptible to hypoxemic damage. We aimed to identify the determinants of red blood cell transfusion and the perceived optimal transfusion thresholds in adult patients with moderate-to-severe traumatic brain injury. Methods: We conducted an electronic, self-administered survey targeting critical care specialists and neurosurgeons from Canada, Australia, and the United Kingdom caring for patients with traumatic brain injury. The questionnaire was initially developed by a panel of experts using a structured process (domains/items generation and reduction). The questionnaire was validated for clinical sensibility, reliability, and content. Results: Our response rate was 28.7% (218/760). When presented with the hypothetical scenario of a young adult patient with traumatic brain injury, a wide range of transfusion practices was observed, with 47% (95% confidence interval [CI], 41 to 54%) favoring red blood cell transfusion at a hemoglobin level of ≤70 g·L-1 in the acute phase of care, while 73% (95% CI, 67 to 79%) would use this trigger in the plateau phase of care. Multiple trauma, neuro-monitoring data, hemorrhagic shock, and planned surgery were the main factors that influenced the need for transfusion. The lack of clinical evidence and guidelines was responsible for uncertainty regarding red blood cell transfusion strategies in this patient population. Conclusion: In our survey about critically ill patients with traumatic brain injury, intensivists and neurosurgeons believed that transfusion practice is mainly influenced by the acuity of care, patient characteristics, and neuro-monitoring. Clinical equipoise regarding optimal transfusion strategy is believed to be mainly attributed to the lack of clear clinical evidence and guidelines. Appropriate randomized-controlled trials are required to determine the optimal transfusion strategies in critically ill patients with traumatic brain injur

Efficacy of antiseizure prophylaxis in chronic subdural hematoma: a cohort study on routinely collected health

OBJECTIVE Chronic subdural hematoma (CSDH) is a common neurosurgical condition that can result in significant morbidity. The incidence of epileptic events associated with CSDH reported in the literature varies considerably and could potentially increase morbidity and mortality rates. The effectiveness of antiepileptic prophylaxis for this indication remains unclear. The primary objective of this study was to assess the relevance of anticonvulsant prophylaxis in reducing seizure events in patients with CSDH. METHODS All consecutive cases of CSDH from January 1, 2005, to May 30, 2014, at the Hôpital de l’Enfant-Jésus in Quebec City were retrospectively reviewed. Sociodemographic data, antiepileptic prophylaxis use, incidence of ictal events, and clinical and radiological outcome data were collected. Univariate analyses were done to measure the effect of antiepileptic prophylaxis on ictal events and to identify potential confounding factors. Multivariate logistic regression was performed to evaluate factors associated with epileptic events. RESULTS Antiepileptic prophylaxis was administered in 28% of the patients, and seizures occurred in 11%. Univariate analyses showed an increase in the incidence of ictal events in patients receiving prophylaxis (OR 5.92). Four factors were identified as being associated with seizures: septations inside the hematoma, membranectomy, antiepileptic prophylaxis, and a new deficit postoperatively. Antiepileptic prophylaxis was not associated with seizures in multivariate analyses. CONCLUSIONS Antiepileptic prophylaxis does not seem to be effective in preventing seizures in patients with CSDH. However, due to the design of this study, it is difficult to conclude definitively about the usefulness of this prophylactic therapy that is widely prescribed for this conditio