JAMA Surgery: Neurosurgery Topic Collection

Association Between Early Hyperoxia and Worse Outcomes After Traumatic Brain Injury Early Hyperoxia Worsens Outcomes After TBI

Brenner M, Stein D, Hu P, et al. — Thu, 01 Nov 2012 00:00:00 GMT

Objective

To investigate the relationship between oxygenation and short-term outcomes in patients with traumatic brain injury (TBI).

Design

Logistic regression analysis was used to determine whether average high (>200 mm Hg) or low (<100 mm Hg) PaO₂ levels within the first 24 hours of hospital admission correlated with patient outcomes relative to patients with average PaO₂ levels between 100 and 200 mm Hg.

Setting

Level 1 trauma center.

Patients

We retrospectively reviewed 1547 consecutive patients with severe TBI who survived past 12 hours after hospital admission.

Main Outcome Measures

We measured mortality, intensive care unit length of stay, hospital length of stay, and discharge Glasgow Coma Scale (GCS) score.

Results

Of the 1547 patients, 77% were male and 89% sustained blunt trauma. Mean (SD) age, admission GCS score, and Injury Severity Score were 41.3 (20.6) years, 8.3 (4.7), and 31.9 (12.5), respectively. Mean (SD) intensive care unit length of stay and hospital length of stay were 8.7 (10.5) days and 13.8 (13.7) days, respectively. Mean (SD) discharge GCS score was 10.1 (4.7). The mortality rate was 28%. After controlling for age, sex, Injury Severity Score, mechanism of injury, and admission GCS score, patients with high PaO₂ levels had significantly higher mortality and lower discharge GCS scores than patients with a normal PaO₂ (P < .05). Patients with low PaO₂ levels also had increased mortality (P < .05).

Conclusions

Hyperoxia within the first 24 hours of hospitalization is associated with worse short-term functional outcomes and higher mortality after TBI. Although the mechanism for this has not been completely elucidated, it may involve hyperoxia-induced oxygen-free radical toxicity with or without vasoconstriction. Hyperoxia and hypoxia were found to be equally detrimental to short-term outcomes in patients with TBI. A narrower therapeutic window for oxygenation may improve mortality and functional outcomes.

Hyperoxia and Traumatic Brain Injury Comment on “Early Hyperoxia Worsens Outcomes After Traumatic Brain Injury” Hyperoxia and Traumatic Brain Injury

Cryer H. — Thu, 01 Nov 2012 00:00:00 GMT

Brenner and colleagues have nicely shown that average PaO₂ levels of less than 100 mm Hg or greater than 200 mm Hg are independently associated with higher mortality and worse discharge Glasgow Coma Scale scores in 1547 patients with a brain Abbreviated Injury Score of 3 or greater after risk adjusting for mechanism of injury, age, Injury Severity Score, sex, and admission Glasgow Coma Scale score. It has been well established that hypoxia is detrimental to outcome in brain injury. Because of this, there may be a tendency to give higher levels of oxygen to prevent hypoxia. Indeed, the authors found that 43% of their patients had PaO₂ values greater than 200 mm Hg in the first 24 hours of care. Unfortunately, this hyperoxia appears to be detrimental to outcome compared with normoxia and is just as bad as hypoxia. If true, these are important findings that could change the way we approach patients with traumatic brain injury.

Is Insurance Status a Modifiable Factor in Brain Tumor Treatment Outcomes? Comment on “Postoperative Mortality After Surgery for Brain Tumors by Patient Insurance Status in the United States” Insurance Status

Hervey-Jumper SL, Maher CO. — Thu, 01 Nov 2012 00:00:00 GMT

Despite advancements in surgical technique and in our understanding of tumor biology, the survival of patients with brain tumors has not vastly improved during the past 2 decades. Exploration of factors that can be changed in individual patients deserves attention. Inequalities in the delivery and implementation of health care in the United States have been well documented. Using the Nationwide Inpatient Sample (NIS), Momin et al provide an excellent analysis of uninsured, Medicaid, and privately insured adult patients who underwent craniotomy for a brain tumor. They analyzed International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes collected for 10 years for the surgical treatment of brain tumors from 28 582 patients in 37 states. Their aim was to determine whether insurance status was associated with a higher early in-hospital postoperative mortality rate. They concluded that uninsured (as opposed to Medicaid and privately insured) patients experienced the highest mortality even after exclusion of patients with comorbid illness.

Postoperative Mortality After Surgery for Brain Tumors by Patient Insurance Status in the United States Insurance Status and Craniotomy

Momin EN, Adams H, Shinohara RT, et al. — Thu, 01 Nov 2012 00:00:00 GMT

Objective

To examine whether being uninsured is associated with higher in-hospital postoperative mortality when undergoing surgery in the United States for a brain tumor.

Design

Retrospective cohort study using the Nationwide Inpatient Sample, January 1, 1999, through December 31, 2008.

Setting

The Nationwide Inpatient Sample contains all inpatient records from a stratified sample of 20% of hospitals in 37 states.

Patients

A total of 28 581 patients, aged 18 to 65 years, who underwent craniotomy for a brain tumor. Three groups were studied: Medicaid recipients and privately insured and uninsured patients.

Main Outcome Measure

The main outcome measure was in-hospital postoperative death. Associations between this outcome and insurance status were examined within the full cohort and within the subset of patients with no comorbidity using Cox proportional hazards models. These models were stratified by hospital to control for any clustering effects that could arise from differing access to care.

Results

In the unadjusted analysis, the mortality rate for privately insured patients was 1.3% (95% CI, 1.1%-1.4%) compared with 2.6% for uninsured patients (95% CI, 1.9%-3.3%; P < .001) and 2.3% for Medicaid recipients (95% CI, 1.8%-2.8%; P < .001). After adjusting for patient characteristics and stratifying by hospital in patients with no comorbidity, uninsured patients still had a higher risk of experiencing in-hospital death (hazard ratio, 2.62; 95% CI, 1.11-6.14; P = .03) compared with privately insured patients. In this adjusted analysis, the disparity was not conclusively present in Medicaid recipients (hazard ratio, 2.03; 95% CI, 0.97-4.23; P = .06).

Conclusions

Uninsured patients who underwent craniotomy for a brain tumor experienced the highest in-hospital mortality. Differences in overall health do not fully account for this disparity.