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      Traumatic brain injury (TBI) outcomes in an LMIC tertiary care centre and performance of trauma scores

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          Abstract

          Background

          This study evaluates post-ICU outcomes of patients admitted with moderate and severe Traumatic Brain Injury (TBI) in a tertiary neurocritical care unit in an low middle income country and the performance of trauma scores: A Severity Characterization of Trauma, Trauma and Injury Severity Score, Injury Severity Score and Revised Trauma Score in this setting.

          Methods

          Adult patients directly admitted to the neurosurgical intensive care units of the National Hospital of Sri Lanka between 21st July 2014 and 1st October 2014 with moderate or severe TBI were recruited.

          A telephone administered questionnaire based on the Glasgow Outcome Scale Extended (GOSE) was used to assess functional outcome of patients at 3 and 6 months after injury. The economic impact of the injury was assessed before injury, and at 3 and 6 months after injury.

          Results

          One hundred and one patients were included in the study. Survival at ICU discharge, 3 and 6 months after injury was 68.3%, 49.5% and 45.5% respectively. Of the survivors at 3 months after injury, 43 (86%) were living at home. Only 19 (38%) patients had a good recovery (as defined by GOSE 7 and 8). Three months and six months after injury, respectively 25 (50%) and 14 (30.4%) patients had become “economically dependent”. Selected trauma scores had poor discriminatory ability in predicting mortality.

          Conclusions

          This observational study of patients sustaining moderate or severe TBI in Sri Lanka (a LMIC) reveals only 46% of patients were alive at 6 months after ICU discharge and only 20% overall attained a good (GOSE 7 or 8) recovery. The social and economic consequences of TBI were long lasting in this setting. Injury Severity Score, Revised Trauma Score, A Severity Characterization of Trauma and Trauma and Injury Severity Score, all performed poorly in predicting mortality in this setting and illustrate the need for setting adapted tools.

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          Most cited references22

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          Clinical trials in head injury.

          Raj Narayan, Mary Ellen Michel, Beth Ansell … (2002)
          Traumatic brain injury (TBI) remains a major public health problem globally. In the United States the incidence of closed head injuries admitted to hospitals is conservatively estimated to be 200 per 100,000 population, and the incidence of penetrating head injury is estimated to be 12 per 100,000, the highest of any developed country in the world. This yields an approximate number of 500,000 new cases each year, a sizeable proportion of which demonstrate significant long-term disabilities. Unfortunately, there is a paucity of proven therapies for this disease. For a variety of reasons, clinical trials for this condition have been difficult to design and perform. Despite promising pre-clinical data, most of the trials that have been performed in recent years have failed to demonstrate any significant improvement in outcomes. The reasons for these failures have not always been apparent and any insights gained were not always shared. It was therefore feared that we were running the risk of repeating our mistakes. Recognizing the importance of TBI, the National Institute of Neurological Disorders and Stroke (NINDS) sponsored a workshop that brought together experts from clinical, research, and pharmaceutical backgrounds. This workshop proved to be very informative and yielded many insights into previous and future TBI trials. This paper is an attempt to summarize the key points made at the workshop. It is hoped that these lessons will enhance the planning and design of future efforts in this important field of research.
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            Patient outcome after traumatic brain injury in high-, middle- and low-income countries: analysis of data on 8927 patients in 46 countries.

            Michael Kenward, Haleema Shakur, J. Silva … (2009)
            Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide. The burden of TBI is greatest in low- and middle-income countries (LAMIC), yet little is known about patient outcomes in these settings. Complete data on 8927 patients from 46 countries from the corticosteroid randomization after significant head injury (CRASH) trial were analysed to explore whether outcomes 6 months after TBI differed between high-income countries and LAMIC. Just under half of patients experienced a good recovery, one-third moderate or severe disability and one-quarter died within 6 months of their injury. Univariate analyses showed that patients in LAMIC were more likely to die following severe TBI, but were less likely to be disabled following mild and moderate TBI. These results were confirmed in multivariate analyses. Compared to patients in high-income countries, patients in LAMIC have over twice the odds of dying following severe TBI (OR 2.23, 95% CI 1.51-3.30) but half the odds of disability following mild (OR 0.41, 95% CI 0.23-0.72) and moderate TBI (OR 0.53, 95% CI 0.35-0.81). There were no differences between settings in the odds of death following either mild or moderate TBI. Reduced death rates following severe TBI in patients from high-income countries may be due to differences in medical care which may result in a higher proportion of patients surviving with a disability. Socio-cultural factors may explain the lower levels of disability after mild and moderate TBI in LAMIC.
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              Outcome measures for traumatic brain injury.

              Amit Agrawal, B Devi, Dhaval Shukla (2011)
              Traumatic brain injury (TBI) is a major public health problem resulting in death and disabilities of young and productive people. Though the mortality of TBI has decreased substantially in recent years the disability due to TBI has not appreciably reduced. Various outcome scales have been proposed and used to assess disability after TBI. A few, commonly used are Glasgow Outcome Scale (GOS) with or without extended scores, Disability Rating Scale (DRS), Functional Independence Measure (FIM), Community Integration Questionnaire (CIQ), and the Functional Status Examination (FSE). These scales assess disability resulting from physical and cognitive impairments. For patients with good physical recovery a cognitive and neuropsychological outcome measure is required. Such measures include Neurobehavioural Function Inventory and specific neuropsychological tests like Rey Complex Figure for visuoconstruction and memory, Controlled Oral Word Association for verbal fluency, Symbol Digit Modalities (verbal) for sustained attention and Grooved Pegboard for fine motor dexterity. A more holistic and complete outcome measure is Quality of Life (QOL). Disease specific QOL measure for TBI, Quality of Life after Brain Injury (QOLIBRI) has also been recently proposed. The problems with outcome measures include poor operational definitions, lack of sensitivity or low ceiling effects, inability to evaluate patients who cannot report, lack of integration of morbidity and mortality categories, and limited domains of functioning assessed. GOSE-E satisfies most of the criteria of good outcome scale and in combination with neuropsychological tests is a near complete instrument for assessment of outcome after TBI. Copyright © 2011 Elsevier B.V. All rights reserved.
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                Author and article information

                Contributors
                Samitha Samanamalee: samanmalisamitha@gmail.com
                Ponsuge Chathurani Sigera: chaturani@nicslk.com
                Ambepitiyawaduge Pubudu De Silva: pubudu@nicslk.com
                Kaushila Thilakasiri: kaushila@gmail.com
                Aasiyah Rashan: aasiyah@nicslk.com
                Saman Wadanambi: samanwadanamby@hotmail.com
                Kosala Saroj Amarasiri Jayasinghe: sarojoffice@yahoo.com
                Arjen M. Dondorp: arjen@tropmedres.ac
                Rashan Haniffa:
                ORCID: http://orcid.org/0000-0002-7192-0598
                rashan@nicslk.com
                Journal
                Journal ID (nlm-ta): BMC Anesthesiol
                Journal ID (iso-abbrev): BMC Anesthesiol
                Title: BMC Anesthesiology
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2253
                Publication date (Electronic): 8 January 2018
                Publication date PMC-release: 8 January 2018
                Publication date Collection: 2018
                Volume: 18
                Electronic Location Identifier: 4
                Affiliations
                [1 ]Health Education Bureaue, No.2, Kynsey Road, Colombo, 08 Sri Lanka
                [2 ]Network for Improving Critical Care Systems and Training, 2nd Floor, YMBA Building, Colombo, 08 Sri Lanka
                [3 ]National Intensive Care Surveillance, Quality Secretariat Building, Castle Street Hospital for Women, Colombo, 08 Sri Lanka
                [4 ]ISNI 0000 0004 0381 1861, GRID grid.450885.4, Intensive Care National Audit & Research Centre, ; No. 24, High Holborn, London, WC1V 6AZ UK
                [5 ]ISNI 0000 0004 0556 2133, GRID grid.415398.2, National Hospital of Sri Lanka, ; Colombo, 10 Sri Lanka
                [6 ]ISNI 0000000121828067, GRID grid.8065.b, Faculty of Medicine, University of Colombo, ; No. 25,Kynsey Rd, Colombo, 08 Sri Lanka
                [7 ]ISNI 0000 0004 1937 0490, GRID grid.10223.32, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, , Mahidol University, ; 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok, 10400 Thailand
                Author information
                http://orcid.org/0000-0002-7192-0598
                Article
                Publisher ID: 463
                DOI: 10.1186/s12871-017-0463-7
                PMC ID: 5759275
                PubMed ID: 29298664
                SO-VID: 6f56db24-ca5b-4ff6-85d2-ad18b7ba8edd
                Copyright © © The Author(s). 2018
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 12 July 2017
                Date accepted : 18 December 2017
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2018

                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: traumatic brain injury,low middle income country,economic outcome,social outcome,functional outcome,icu mortality
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: traumatic brain injury, low middle income country, economic outcome, social outcome, functional outcome, icu mortality

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