Risk Factors for Withdrawal of Life-Sustaining Treatment in Severe Traumatic Brain Injury

Studies demonstrate a significant variation in decision-making regarding withdrawal of life-sustaining treatment (WLST) practices for patients with severe traumatic brain injury (TBI). We investigated risk factors associated with WLST in severe TBI. We hypothesized age ≥65 years would be an independent risk factor. In addition, we compared survivors with patients who died in hospital after WLST to identify potential factors associated with in-hospital mortality. The Trauma Quality Improvement Program (2010–2016) was queried for patients with severe TBI of the head. Patients were compared by age (age < 65 and age ≥ 65 years) and survival after WLST (survivors versus non-survivors) at hospitalization discharge. A multivariable logistic regression model was used for analysis. From 1,403,466 trauma admissions, 328,588 (23.4%) patients had severe TBI. Age ≥ 65 years was associated with increased WLST (odds ratio: 1.76, confidence interval: 1.59–1.94, P < 0.001), whereas nonwhite race was associated with decreased WLST (odds ratio: 0.60, confidence interval: 0.55–0.65, P < 0.001). Compared with non-survivors of WLST, survivors were older (74 vs 61 years, P < 0.001) and more likely to have comorbidities such as hypertension (57% vs 38.5%, P < 0.001). Age ≥ 65 years was an independent risk factor for WLST, and nonwhite race was associated with decreased WLST. Patients surviving until discharge after WLST decision were older (≥74 years) and had multiple comorbidities.

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Risk Factors for Conversion to Permanent Ventricular Shunt in Patients Receiving Therapeutic Ventriculostomy for Traumatic Brain Injury

Neurosurgery ◽

10.1227/neu.0b013e3181fd85f4 ◽

2011 ◽

Vol 68 (1) ◽

pp. 85-88 ◽

Cited By ~ 14

Author(s):

David F. Bauer ◽

Gerald. McGwin ◽

Sherry M. Melton ◽

Richard L. George ◽

James M. Markert

Keyword(s):

Risk Factors ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Length Of Stay ◽

Confidence Interval ◽

Odds Ratio ◽

Average Length ◽

Discharge Disposition ◽

Csf Diversion ◽

History Of Culture

Abstract BACKGROUND: Intracranial pressure is routinely monitored in patients with severe traumatic brain injury (TBI). Patients with TBI sometimes develop hydrocephalus, requiring permanent cerebrospinal fluid (CSF) diversion. OBJECTIVE: To quantify the need for permanent CSF diversion in patients with TBI. METHODS: Patients who received a ventriculostomy after TBI between June 2007 and July 2008 were identified, and their medical records were abstracted to a database. RESULTS: Sixteen of 71 patients (22.5%) receiving a ventriculostomy required a ventriculoperitoneal or ventriculoatrial shunt before discharge from the hospital. The average number of days between ventriculostomy and shunt was 18.3. Characteristics that predispose these patients to require permanent CSF diversion include the need for craniotomy within 48 hours of admission (odds ratio, 5.20; 95% confidence interval, 1.48-18.35) and history of culture-positive CSF (odds ratio, 5.52; 95% confidence interval, 1.19-25.52). Length of stay was increased in patients receiving permanent CSF diversion (average length of stay, 61 vs 31 days; P = .04). Patient discharge disposition was similar between shunted and nonshunted patients. CONCLUSION: In this retrospective study, 22% of TBI patients who required a ventriculostomy eventually needed permanent CSF diversion. Patients with TBI should be assessed for the need for permanent CSF diversion before discharge from the hospital. Care must be taken to prevent ventriculitis. Future studies are needed to evaluate more thoroughly the risk factors for the need for permanent CSF diversion in this patient population.

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Risk of Surgery and Anesthesia for Ischemic Stroke

Anesthesiology ◽

10.1097/00000542-200002000-00024 ◽

2000 ◽

Vol 92 (2) ◽

pp. 425-425 ◽

Cited By ~ 46

Author(s):

Gilbert Y. Wong ◽

David O. Warner ◽

Darrell R. Schroeder ◽

Kenneth P. Offord ◽

Mark A. Warner ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Ischemic Stroke ◽

High Risk ◽

Confidence Interval ◽

Odds Ratio ◽

Independent Risk Factor ◽

Index Date ◽

Stroke Index ◽

Increased Risk

Background The goal of this study was to determine if the combination of surgery and anesthesia is an independent risk factor for the development of incident (first-time) ischemic stroke. Methods All residents of Rochester, MN, with incident ischemic stroke from 1960 through 1984 (1,455 cases and 1,455 age- and gender-matched controls) were used to identify risk factors associated with ischemic stroke. Cases and controls undergoing surgery involving general anesthesia or central neuroaxis blockade before their stroke/index date of diagnosis were identified. A conditional logistic regression model was used to estimate the odds ratio of surgery and anesthesia for ischemic stroke while adjusting for other known risk factors. Results There were 59 cases and 17 controls having surgery within 30 days before their stroke/index date. After adjusting for previously identified risk factors, surgery within 30 days before the stroke/index date (perioperative period) was found to be an independent risk factor for stroke (P<0.001; odds ratio, 3.9; 95% confidence interval, 2.1-7.4). In an analysis that excluded matched pairs where the case and/or control underwent surgery considered "high risk" for stroke (cardiac, neurologic, or vascular procedures), "non-high-risk surgery" was also found to be an independent risk factor for perioperative stroke (P = 0.002; odds ratio, 2.9; 95% confidence interval, 1.5-5.7). Conclusion Our results suggest that there is an increased risk of ischemic stroke in the 30 days after surgery and anesthesia. This risk remains elevated even after excluding surgeries (cardiac, neurologic, and vascular surgeries) considered to be high risk for ischemic stroke.

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Does Health Care Insurance Affect Outcomes after Traumatic Brain Injury? Analysis of the National Trauma Databank

The American Surgeon ◽

10.1177/000313481007601019 ◽

2010 ◽

Vol 76 (10) ◽

pp. 1108-1111 ◽

Cited By ~ 15

Author(s):

Rodrigo F. Alban ◽

Cherisse Berry ◽

Eric Ley ◽

James Mirocha ◽

Daniel R. Margulies ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Confidence Interval ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Injury Severity ◽

Unit Length ◽

Multivariate Logistic Regression Analysis ◽

National Trauma ◽

Severe Tbi

Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. Multivariate logistic regression analysis was used to determine independent risk factors for mortality. Of 52,344 moderate to severe TBI patients, 41,711 (79.7%) were insured. Compared with the uninsured, insured TBI patients were older (46.1 ± 22.4 vs 37.3 ± 16.3 years, P < 0.0001), more severely injured (ISS > 16: 78.4% vs 74.4%, P < 0.0001), had longer intensive care unit length of stay (6.0 ± 9.4 vs 5.1 ± 7.6, P < 0.0001) and had higher mortality (9.3% vs 8.0%, P < 0.0001). However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.

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Young Age as a Risk Factor for Impaired Cerebral Autoregulation after Moderate to Severe Pediatric Traumatic Brain Injury

Anesthesiology ◽

10.1097/aln.0b013e31816725d7 ◽

2008 ◽

Vol 108 (4) ◽

pp. 588-595 ◽

Cited By ~ 66

Author(s):

Serena S. Freeman ◽

Yuthana Udomphorn ◽

William M. Armstead ◽

Dana M. Fisk ◽

Monica S. Vavilala

Keyword(s):

Traumatic Brain Injury ◽

Risk Factor ◽

Brain Injury ◽

Confidence Interval ◽

Glasgow Coma Scale ◽

Glasgow Coma Scale Score ◽

Cerebral Autoregulation ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Coma Scale

Background Little is known about age and cerebral autoregulation in children with traumatic brain injury (TBI). The authors compared cerebral autoregulation between young (aged <4 yr) and older (aged > or =4 yr) children with TBI. Methods After University of Washington's institutional review board approval, a retrospective analysis of prospectively collected data (May 2002 and June 2007) was performed. Eligibility criteria included age 16 yr or younger, moderate to severe (admission Glasgow Coma Scale score <13) TBI, TBI on computed tomography scan, and tracheal intubation. Cerebral autoregulation testing was performed within 72 h after TBI, and autoregulation was quantified using the autoregulatory index. An autoregulatory index less than 0.4 represents impaired cerebral autoregulation. The 12-month Glasgow outcome score was measured. Data are presented as mean +/- SD or range. Results Thirty-seven children (8.9 +/- 5.1 yr; 0.8-16 yr) were enrolled. Children younger than 4 yr had a higher incidence of impaired cerebral autoregulation (8 of 10 vs. 7 of 27; P = 0.006) and worse 12-month outcome (Glasgow outcome score 3.0 +/- 1.0 vs. 4.0 +/- 1.0; P = 0.02) than older children. Age less than 4 yr (adjusted odds ratio, 12.2; 95% confidence interval, 1.5-98.5) and low Glasgow Coma Scale score (adjusted odds ratio for higher Glasgow Coma Scale, 0.53; 95% confidence interval, 0.30-0.96) were independently associated with impaired cerebral autoregulation. Conclusions Age less than 4 yr was a risk factor for impaired cerebral autoregulation, independent of TBI severity. Age-related factors may play a role in the mechanisms maintaining or worsening cerebral autoregulation in children after TBI.

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Comparison of Outcomes in Level I vs Level II Trauma Centers in Patients Undergoing Craniotomy or Craniectomy for Severe Traumatic Brain Injury

Neurosurgery ◽

10.1093/neuros/nyy634 ◽

2019 ◽

Vol 86 (1) ◽

pp. 107-111 ◽

Cited By ~ 5

Author(s):

Nohra Chalouhi ◽

Nikolaos Mouchtouris ◽

Fadi Al Saiegh ◽

Robert M Starke ◽

Thana Theofanis ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Confidence Interval ◽

Hospital Mortality ◽

Odds Ratio ◽

Functional Independence ◽

Trauma Centers ◽

Level Ii ◽

Severe Tbi ◽

Level I

ABSTRACTBACKGROUNDTraumatic brain injury (TBI) carries a devastatingly high rate of morbidity and mortality.OBJECTIVETo assess whether patients undergoing craniotomy/craniectomy for severe TBI fare better at level I than level II trauma centers in a mature trauma system.METHODSThe data were extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients > 18 yr with severe TBI (Glasgow Coma Scale [GCS] score less than 9) undergoing craniotomy or craniectomy in the state of Pennsylvania from January 1, 2002 through September 30, 2017.RESULTSOf 3980 patients, 2568 (64.5%) were treated at level I trauma centers and 1412 (35.5%) at level II centers. Baseline characteristics were similar between the 2 groups except for significantly worse GCS scores at admission in level I centers (P = .002). The rate of in-hospital mortality was 37.6% in level I centers vs 40.4% in level II centers (P = .08). Mean Functional Independence Measure (FIM) scores at discharge were significantly higher in level I (10.9 ± 5.5) than level II centers (9.8 ± 5.3; P < .005). In multivariate analysis, treatment at level II trauma centers was significantly associated with in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.03-1.37; P = .01) and worse FIM scores (odds ratio, 1.4; 95% confidence interval, 1.1-1.7; P = .001). Mean hospital and ICU length of stay were significantly longer in level I centers (P < .005).CONCLUSIONThis study showed superior functional outcomes and lower mortality rates in patients undergoing a neurosurgical procedure for severe TBI in level I trauma centers.

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A-126 Clinical Utility of Risk Factors to Predict Self-reported Neurobehavioral Outcome Following Traumatic Brain Injury: PTSD, Sleep, Resilience, and Lifetime Blast Exposure

Archives of Clinical Neuropsychology ◽

10.1093/arclin/acaa068.126 ◽

2020 ◽

Vol 35 (6) ◽

pp. 919-919

Author(s):

Lange R ◽

Lippa S ◽

Hungerford L ◽

Bailie J ◽

French L ◽

...

Keyword(s):

Risk Factors ◽

Traumatic Brain Injury ◽

Risk Factor ◽

Brain Injury ◽

Clinical Utility ◽

Poor Sleep ◽

Post Injury ◽

Poor Outcome ◽

Blast Exposure ◽

Neurobehavioral Outcome

Abstract Objective To examine the clinical utility of PTSD, Sleep, Resilience, and Lifetime Blast Exposure as ‘Risk Factors’ for predicting poor neurobehavioral outcome following traumatic brain injury (TBI). Methods Participants were 993 service members/veterans evaluated following an uncomplicated mild TBI (MTBI), moderate–severe TBI (ModSevTBI), or injury without TBI (Injured Controls; IC); divided into three cohorts: (1) < 12 months post-injury, n = 237 [107 MTBI, 71 ModSevTBI, 59 IC]; (2) 3-years post-injury, n = 370 [162 MTBI, 80 ModSevTBI, 128 IC]; and (3) 10-years post-injury, n = 386 [182 MTBI, 85 ModSevTBI, 119 IC]. Participants completed a 2-hour neurobehavioral test battery. Odds Ratios (OR) were calculated to determine whether the ‘Risk Factors’ could predict ‘Poor Outcome’ in each cohort separately. Sixteen Risk Factors were examined using all possible combinations of the four risk factor variables. Poor Outcome was defined as three or more low scores (< 1SD) on five TBI-QOL scales (e.g., Fatigue, Depression). Results In all cohorts, the vast majority of risk factor combinations resulted in ORs that were ‘clinically meaningful’ (ORs > 3.00; range = 3.15 to 32.63, all p’s < .001). Risk factor combinations with the highest ORs in each cohort were PTSD (Cohort 1 & 2, ORs = 17.76 and 25.31), PTSD+Sleep (Cohort 1 & 2, ORs = 18.44 and 21.18), PTSD+Sleep+Resilience (Cohort 1, 2, & 3, ORs = 13.56, 14.04, and 20.08), Resilience (Cohort 3, OR = 32.63), and PTSD+Resilience (Cohort 3, OR = 24.74). Conclusions Singularly, or in combination, PTSD, Poor Sleep, and Low Resilience were strong predictors of poor outcome following TBI of all severities and injury without TBI. These variables may be valuable risk factors for targeted early interventions following injury.

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Demographic and clinical risk factors associated with hospital mortality after isolated severe traumatic brain injury: a cohort study

Journal of Intensive Care ◽

10.1186/s40560-015-0113-4 ◽

2015 ◽

Vol 3 (1) ◽

Cited By ~ 13

Author(s):

Vijay Krishnamoorthy ◽

Monica S. Vavilala ◽

Brianna Mills ◽

Ali Rowhani-Rahbar

Keyword(s):

Risk Factors ◽

Traumatic Brain Injury ◽

Cohort Study ◽

Brain Injury ◽

Hospital Mortality ◽

Severe Traumatic Brain Injury ◽

Clinical Risk Factors ◽

Factors Associated ◽

Clinical Risk

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Risk factors associated with sleep disturbance following traumatic brain injury

Sleep Medicine ◽

10.1016/j.sleep.2013.11.238 ◽

2013 ◽

Vol 14 ◽

pp. e109

Author(s):

Y. Dong ◽

P. Sheng ◽

W. Tong ◽

Z. Li ◽

D. Xu ◽

...

Keyword(s):

Risk Factors ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Sleep Disturbance ◽

Factors Associated

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Influence of Concomitant Polypharmacy on Docetaxel-induced Febrile Neutropenia

Cancer Diagnosis & Prognosis ◽

10.21873/cdp.10018 ◽

2021 ◽

Vol 1 (3) ◽

pp. 135-141

Author(s):

KATSUYA MAKIHARA ◽

YUKA SHIMEDA ◽

TOMOKAZU MATSUMURA

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Febrile Neutropenia ◽

Confidence Interval ◽

Cytochromes P450 ◽

Cyp3a4 Activity ◽

Factors Associated ◽

Cyp3a4 Inhibitors ◽

Concomitant Medications ◽

Main Factor

Background/Aim: Docetaxel (DTX) is metabolized by liver cytochromes P450 (CYP) 3A4 (CYP3A4) and 3A5 (CYP3A5) CYP3A4 activity is considered the main factor affecting the effectiveness in DTX clearance. We, therefore, explored the association between DTX-induced febrile neutropenia (FN) and concomitant polypharmacy involving CYP3A4 inhibitors in cancer patients. Patients and Methods: Among patients who received docetaxel, we compared the number of concomitant medications between patients with and without FN, and risk factors associated with FN were identified. Results: The total number of concomitant CYP3A4 inhibitors and substrates used was significantly higher in patients with FN [mean: 2.1 (95% confidence interval (CI)=1.5-2.9)] than in those without FN [mean: 1.4 (95% CI=1.0-1.8)] (p=0.01). The only risk factor for FN was the use of ≥2 concomitant CYP3A4 inhibitors and substrates in total (OR=4.82, 95% CI=1.77-14.1; p=0.002). Conclusion: Polypharmacy involving CYP3A4 inhibitors and substrates increases the risk of DTX-induced FN.

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