SEVERE HEAD-INJURY IN THE UNITED-KINGDOM AND IRELAND - A SURVEY OF PRACTICE AND IMPLICATIONS FOR MANAGEMENT

Objective: To study the current intensive care management of patients with severe head injury (defined as a Glasgow Coma Scale score of less than or equal to 8) in neurosurgical referral centers in the United K ingdom (UK) and Ireland.Data Collection: A questionnaire was sent to t he directors of the 44 neurosurgical referral units identified from th e UK Medical Directory. After 4 wks, a copy of the questionnaire was s ent to all nonresponders, with a cover letter urging them to respond. The aim was to collect data regarding the characteristics of the inten sive care units (ICU), sedation, monitoring modalities used, the treat ment of intracranial hypertension, and general care of severely head-i njured patients. Data Extraction: Forty completed questionnaires were returned. Only 35 (88%) centers provided care for the severely head-in jured as defined in the questionnaire. Patients were managed in specia lized neurosurgical ICUs in 66% of centers and in general ICUs in the remainder of the centers. The ICUs were coordinated by an anesthesiolo gist in 66% of instances and by a neurosurgeon in 23%. The mean number of beds per units was 7.9 (range 4 to 16), with 1:1 nurse/bed ratio a nd 5.5 nurses per bed (total number of nursing staff per bed) (range 2 .75 to 8). Annual caseload varied between units with the majority of u nits (49%) receiving between 25 and 50 patients with severe head injur y, 23% receiving between 50 and 100 patients with severe head injury, and 29% receiving >100 patients with severe head injury. There was con siderable variability in both the nature of monitoring and therapy bet ween centers. Although blood and central venous pressures were invasiv ely monitored in >50% of the patients in 94% and 77% of the centers, r espectively, intracranial pressure was only monitored routinely in 57% of the centers. Jugular venous bulb oximetry, transcranial Doppler ul trasonography, electroencephalography, and near-infrared spectroscopy were rarely used. Nearly all centers used propofol and midazolam for s edation, with morphine, fentanyl, and alfentanil as the main analgesic s. Muscle relaxation was commonly used, with 40% of the centers employ ing it in 100% of their patients. Atracurium and vecuronium were the m ost commonly used agents. Only 68% of the centers had a protocol for t he treatment of intracranial hypertension. Although hyperventilation t o a PaCO2 of 26 to 30 torr (3.5 to 4.0 kPa) was the norm in the majori ty of centers (56%), two centers aimed for PaCO2 values (26 torr ((3.5 kPa). A quarter of the units did not aim for a cerebral perfusion pre ssure of >60 mm Hg. Mild hypothermia was rarely used and 14% of the ce nters continued to use corticosteroids for the treatment of intracrani al hypertension as a result of head trauma. Conclusion: We conclude th at there are wide variations in the management of the severely head in jured patient in the UK and Ireland. Some of the therapies employed ar e not supported by available research findings. Rationalization (using rational management, i.e., based on good evidence) of the intensive c are management of severe head injury with the development of widely ac cepted guidelines may result in an improvement in the quality of care of the head-injured patient.