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ORIGINAL ARTICLE
Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 110-113

Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from rural setup of a developing country


1 Department of Neurosurgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, India
2 Department of Surgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, India
3 Department of Anesthesiology, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, India
4 Department of Community Medicine, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, India

Date of Web Publication12-Sep-2011

Correspondence Address:
Amit Agrawal
Department of Neurosurgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5151.84794

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   Abstract 

Introduction: Traumatic brain injuries (TBI) are steadily increasing and are a major cause of mortality and morbidity, particularly in the young population, leading to the loss of life and productivity in the developing countries. Providing critical care to these patients with TBI is a challenge even in well-advanced centers in major cities of India. In the present study, we describe our experience of resource utilization in the management of TBI in a critical care unit (CCU) from a rural setup.
Materials and Methods: All consecutive patients who were admitted from January 2007 to December 2009 in the CCU for the management of traumatic brain injury were included in the study. The case records of the patients were reviewed retrospectively, and data were collected on age, gender, severity of head injury, associated injuries, total CCU stay, total hospital stay, and outcome.
Results: The total duration (days) of hospital stay was 8.96±6.16 days and a median of 8 days, and CCU stay was 3.77±6.34 days with a median of 2 days. No deaths occurred with mild head injury. A total of 73 (19.16%) deaths occurred in 381 admitted subjects in CCU. The risk of death among both the sexes is not significantly different, that is, odds ratio (OR) 1.032 [95% confidence interval (CI) 0.351-3.03], so also the risk of death among the different age groups is also not significant having OR, 0.978 (95% CI, 0.954-1.00). The severity of head injury (mild, moderate, and severe) and CCU stay parameters had significant difference with risk of death [OR, 3.22 (95% CI, 2.49-4.16) and OR, 2.50 (95% CI, 1.9-3.2)].
Conclusions: Apparently it seems possible to use the existing health care structures in rural areas to improve trauma care. It becomes particularly relevant in poor resource, developing countries, where health care facilities and access to specialized care units are still far below the acceptable standard, there is a need to compare with the reference group to further support the evidence.

Keywords: Critical care, head injury, intensive care unit, rural, traumatic brain injury


How to cite this article:
Agrawal A, Gode D, Kakani A, Nagrale M, Quazi SZ, Gaidhane A, Shaikh P. Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from rural setup of a developing country. Int J Crit Illn Inj Sci 2011;1:110-3

How to cite this URL:
Agrawal A, Gode D, Kakani A, Nagrale M, Quazi SZ, Gaidhane A, Shaikh P. Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from rural setup of a developing country. Int J Crit Illn Inj Sci [serial online] 2011 [cited 2019 Dec 12];1:110-3. Available from: http://www.ijciis.org/text.asp?2011/1/2/110/84794


   Introduction Top


Traumatic brain injuries (TBI) is steadily increasing and is a major cause of mortality and morbidity, particularly in the young population, leading to the loss of life and productivity in the developing countries. [1],[2],[3],[4] Providing critical care to these patients with TBI is a challenge even in well-advanced centers in major cities of India. [4],[5],[6],[7],[8] In the present study, we describe our experience of critical care unit (CCU) resource utilization in the management of TBI from a rural setup.


   Materials and Methods Top


The present study was a retrospective review performed at Acharya Binova Bhave Rural Hospital (AVBRH), Sawangi (Meghe). AVBRH is a 900 bedded teaching hospital cum tertiary referral center situated in rural area of central India. The period of study was from January 2007 to December 2009. All consecutive patients who were admitted in the CCU for the management of traumatic brain injury were included in the study. The case records of the patients were reviewed retrospectively, and data were collected on age, gender, severity of head injury, associated injuries, total CCU stay, total hospital stay, and outcome. The biochemical investigations were performed only where and when necessary. Computerized tomography (CT) was performed in all the cases. Based on the neurologic status and status of the associated injuries, patients were managed conservatively and all the patients were managed as per the standard protocol and maximally aggressive therapy aimed at diminishing intracranial pressure and elevating cerebral perfusion pressure was pursued in every case. We did not have facility for the intracranial pressure monitoring. Indications for surgery were operable lesions on CT scan. Based on Glasgow Coma Scale (GCS), the severity of head injury was defined as mild (GCS: 13-15), moderate (GCS: 9-12), and severe (GCS: 3-8). [9]

All the patients with a GCS score of 8 or less, respiratory distress, or shock were intubated, ventilated, and sedated as necessary. Tracheostomy was performed where there was poor neurological status, prolonged intubation, ventilation, and facial injuries. Prophylactic anticonvulsant (pheytoin) was used in all high-risk cases. We do not use corticosteroids in head injury patients routinely. All patients were provided with supportive care and received regular physiotherapy for their physical disability and respiratory problems. The condition was noted at discharge and outcome was analyzed according to the GCS. [10]

Statistical analyses

All statistical analyses were carried out using SPSS software version 11.0 (SPSS Inc., Chicago IL). Continuous variables were expressed as mean ± SD. Chi-square test was used to compare categorical variables. Statistical significance was set at P < 0.05. Logistic regression analysis was used to identify risk factors associated with CCU mortality at various day and times of admission.


   Results Top


During the study period, a total 381 patients were admitted to the intensive care unit for the management of head injury. There were total 303 males and 78 females [Figure 1]. The majority of the patients were in their 3 rd , 4 th , and 5 th decade [Figure 2]. The mean age of the subjects was 37.78±16.99 years and median age was 36 years. The most common cause of the TBI was road traffic accidents (67%). The total duration (days) of hospital stay was 8.96±6.16 days and median of 8 days, CCU stay was 3.77±6.34 days with median of 2 days [Table 1]. The pattern of injuries is shown in [Table 2]. It was evident that majority of the death in Severe GCS was in less than 24 h, that is, 44 (100%), whereas those subjects who were in CCU for 2-7 days among them 14 (21.21%) died, whereas only 4 (11.43%) died in CCU who stayed for 8-14 days, out of the 62 deaths, which occurred among the severe GCS. No deaths occurred in CCU subjects who stayed for more than 15 days [Table 3]. The deaths which occurred in Moderate GCS were within 24 h among 11 (5.50%) subjects of the 200 subjects. No deaths occurred in Mild GCS subjects. A total 73 (19.16%) deaths occurred in 381 admitted subjects in CCU. The risk of death among both the sexes is not significantly different, that is, OR, 1.032 (95% CI, 0.351-3.03), so also the risk of death among the different age groups is also not significant having OR, 0.978 (95% CI, 0.954-1.00). While, the GCS (mild, moderate, and severe) and CCU stay parameters were having significant difference with risk of death having OR, 3.22 (95% CI, 2.49-4.16) and OR, 2.50 (95% CI, 1.9-3.2) [Table 4].
Table 1: Demographic profi le of study population

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Table 2: Pattern of injuries in patients admitted to CCU clinical traumatic brain injury (n=381)

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Table 3: Duration of stay in ICU, severity of head injury and outcome

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Table 4: Multiple logistic regression of outcome with sex, age, and duration of stay

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Figure 1: Sex distribution

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Figure 2: Age distribution

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   Discussion Top


As in any other injuries, the majority of victims of traumatic brain injury patients are male and in younger age groups; [11] and is explained by the fact that during this age, people, especially males are more mobile, go out for work and take risks, while elderly people, females, and children usually stay at home. Initial GCS and severity of brain injury was used to match TBI patients and lower initial GCS can be due to greater severity of brain injury and also possible because of decreased brain perfusion (perhaps reflecting inadequate resuscitation). [12] It has been concluded that the GCS score may be used to stratify and predict mortality risk in intensive care patients, but it may lack sensitivity. [13] Resource limitation in developing countries restricts the routine use of aggressive pre- and inhospital management strategies, such as intracranial pressure monitoring for patients with head injury, and many strategies have been developed to overcome these limitations and also to improve outcome in resource constrained environment. [4] Despite the limitations of our trauma care system and resource limitations, mortality among traumatic brain injury patients can be reduced if every caregiver, from the site of injury to the CCU, maintains hemodynamic stability (diastolic blood pressure > 70 mmHg and systolic BP > 90 mmHg) at all times. [4] As in the present study, prolonged CCU lengths of stay can have increased survival rates, acceptable mortality rates, and quality of life despite significant costs. [14],[15],[16] One of the limitations of this present study is that we do not know about patients who were injured and did not reach hospital [17] and those with nonfatal severe injuries in the city received hospital care. [18]


   Conclusion Top


Apparently it seems possible to use existing health care structures in rural areas to improve trauma care [19] and it becomes particularly relevant in poor resource, developing countries, where health care facilities and access to specialized care units are still far below the acceptable standard, [20] there is a need to compare with the reference group to further support the evidence. Although the present article may not change the way critical care is provided, we believe that it will give clinicians and their associates a fair idea of what to expect (and possibly to prepare families/survivors for) regarding the prognosis and path of critical care in the time to come, particularly in rural areas where the resources are limited.

 
   References Top

1.Oertel M, Kelly DF, McArthur D, Boscardin WJ, Glenn TC, Lee JH, et al. Progressive hemorrhage after head trauma: Predictors and consequences of the evolving injury. J Neurosurg 2002;96:109-16.  Back to cited text no. 1
    
2.Road traffic accidents in developing countries. Report of a WHO meeting. World Health Organ Tech Rep Ser 1984;703:1-29.  Back to cited text no. 2
    
3.Gururaj G. Epidemiology of traumatic brain injuries: Indian scenario. Neurol Res 2002;24:24-8.  Back to cited text no. 3
    
4.Santhanam R, Pillai SV, Kolluri SV, Rao UM. Intensive care management of head injury patients without routine intracranial pressure monitoring. Neurol India 2007;55:349-54.  Back to cited text no. 4
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5.Chintamani, Khanna J, Singh JP, Kulshreshtha P, Kalra P, Priyambada B, et al. Early tracheostomy in closed head injuries: Experience at a tertiary center in a developing country--a prospective study. BMC Emerg Med 2005;5:8.  Back to cited text no. 5
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6.Joseph M. Intracranial pressure monitoring in a resource-constrained environment: A technical note. Neurol India 2003;51:333-5.  Back to cited text no. 6
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7.Kannan S, Marudachalam KS, Puri GD, Chari P. Severe head injury patients in a multidisciplinary ICU: Are they a burden? Intensive Care Med 1999;25:855-8.  Back to cited text no. 7
    
8.Singh M, Vaishya S, Gupta S, Mehta VS. Economics of head injuries. Neurol India 2006;54:78-80.  Back to cited text no. 8
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9.Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81-4.  Back to cited text no. 9
    
10.Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1:480-4.  Back to cited text no. 10
    
11.Gururaj G. Road traffic deaths, injuries and disabilities in India: Current scenario. Natl Med J India 2008;21:14-20.  Back to cited text no. 11
    
12.Henzler D, Cooper DJ, Mason K. Factors contributing to fatal outcome of traumatic brain injury: A pilot case control study. Crit Care Resusc 2001;3:153-7.  Back to cited text no. 12
    
13.Bastos PG, Sun X, Wagner DP, Wu AW, Knaus WA. Glasgow Coma Scale score in the evaluation of outcome in the intensive care unit: Findings from the Acute Physiology and Chronic Health Evaluation III study. Crit Care Med 1993;21:1459-65.  Back to cited text no. 13
    
14.Ong AW, Omert LA, Vido D, Goodman BM, Protetch J, Rodriguez A, et al. Characteristics and outcomes of trauma patients with ICU lengths of stay 30 days and greater: A seven-year retrospective study. Crit Care 2009;13:R154.  Back to cited text no. 14
    
15.Combes A, Costa MA, Trouillet JL, Baudot J, Mokhtari M, Gibert C, et al. Morbidity, mortality, and quality-of-life outcomes of patients requiring ≥14 days of mechanical ventilation. Crit Care Med 2003;31:1373-81.  Back to cited text no. 15
    
16.Fakhry SM, Kercher KW, Rutledge R. Survival, quality of life, and charges in critically III surgical patients requiring prolonged ICU stays. J Trauma 1996;41:999-1007.  Back to cited text no. 16
    
17.Kobusingye OC, Guwatudde D, Owor G, Lett RR. Citywide trauma experience in Kampala, Uganda: A call for intervention. Inj Prev 2002;8:133-6.  Back to cited text no. 17
    
18.Mock CN, nii-Amon-Kotei D, Maier RV. Low utilization of formal medical services by injured persons in a developing nation: Health service data underestimate the importance of trauma. J Trauma 1997;42:504-11.  Back to cited text no. 18
    
19.Nafissi N, Saghafinia M, Balochi K. Improving trauma care in rural Iran by training existing treatment chains. Rural Remote Health 2008;8:881.  Back to cited text no. 19
    
20.Adudu OP, Ogunrin OA, Adudu OG. Morbidity and mortality patterns among ne urological patients in the intensive care unit of a tertiary health facility. Ann Afr Med 2007;6:174-9.  Back to cited text no. 20
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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