From indication to initiation of invasive intracranial pressure monitoring time differences between neurosurgeons and intensive care physicians: can intracranial hypertension dose be reduced? TIMING-ICP, a multicenter, observational, prospective study

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BACKGROUND: The duration of episodes of intracranial hypertension is related to poor outcome, hence the need for prompt diagnosis. Numerous issues can lead to delays in the implementation of invasive intracranial pressure (ICP) monitoring, thereby increasing the dose of intracranial hypertension to which the patient is exposed. The aim of this prospective, observational, multicenter study was to assess the magnitude of this delay, evaluating the time required for initiation of invasive ICP monitoring, from indication (T1) to initiation of the maneuver (T2) when performed by neurosurgeons compared to intensive care physicians. METHODS: We evaluated the impact of the operator performing the maneuver (neurosurgeon vs. intensivist) on the T2-T1 time interval, where T1 represents the time at which indication for invasive ICP monitoring is declared, and T2 the time at which the maneuver starts, defined as the skin incision. The effect of the operator performing the maneuver was evaluated through a parametric survival model. Both intraparenchymal catheters (IPCs) and external ventricular drains (EVDs) were considered as invasive ICP monitoring devices. Invasive monitoring could be performed in intensive care unit (ICU) or in operating room (OR). RESULTS: A total of 112 patients were included into the final analysis; 39 IPCs were placed by intensivists within the ICU, and a total of 73 IPCs and EVDs by neurosurgeons both within the ICU and OR settings. The mean difference in T2-T1 time for IPCs placement in the ICU was 69 min (CI 50.1-94.8) in the intensivist group and 145 min (CI 103.4-202.9) in neurosurgeon group. The mean difference between these groups, 76 min, was found to be statistically significant (p-value = 0.0021). In the group treated by neurosurgeons, no statistically significant differences were found in timing between the ICU and the OR. CONCLUSIONS: Invasive ICP monitoring performed with IPCs in ICU begins earlier when performed by intensivists rather than neurosurgeons. This finding suggests the possibility to obtain a prompt diagnosis of intracranial hypertension when intensivists intervein directly at patient's bedside. Further studies are needed to confirm these findings and investigate their effect on outcome.

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