Timing of external ventricular drain placement and its effects on in-hospital outcomes in traumatic brain injury: A propensity score-matched analysis

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OBJECTIVE: Patients with traumatic brain injury (TBI) often develop elevated intracranial pressure (ICP) and require emergency external ventricular drain (EVD) placement to decompress the cerebral ventricles. In patients who are initially stable, elevated ICP may develop later during hospitalization, necessitating delayed EVD placement. In these patients, it is unclear if early empiric placement can help reduce mortality. The purpose of this study is to compare the differences in in-hospital outcomes between delayed and early EVD placement. METHODS: In this retrospective cohort study, the National Trauma Data Bank was queried from 2017 to 2019 for all adults with TBI who underwent EVD placement. Late placement was defined as placement longer than the 75 % percentile (13.8 h). Patients in the early and late groups were propensity-score matched based on patient demographics, comorbidities, injury severity, and hospital trauma level. Group differences were compared using t-tests and chi-squared tests. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality. RESULTS: A total of 6249 patients were included, of which 4686 underwent early and 1563 underwent late placement. Following matching, the late group had comparable rates of mortality (34.54 % vs. 32.91 %, P = .62) and length of stay (LOS; 23.62 vs. 20.85 days, P = .1), but longer intensive care unit LOS (15.72 vs. 13.33 days, P < .01) and ventilator duration (13.41 vs. 10.1 days, P < .01) and higher rates of stroke (6.13 % vs. 4.15 %, P < .01) and unplanned intubation (10.37 % vs. 4.87 %, P < .01). On multivariable regression analysis, EVD timing was not an independent predictor of in-hospital mortality (OR 1, CI 0.99-1.01). CONCLUSIONS: Given the comparable mortality rates between early and late EVD placement, a flexible, patient-centered approach to EVD timing that prioritizes individualized clinical indications may be superior to rigid timing protocols or empiric EVD placement in TBI.

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