BEST-TRIP

Key points

• how ICP monitor use may affect care in a resource-limited environment
• Two strategies of care, one triggered by an ICP monitor and the other by clinical and CT findings, for severe TBI and not ICP per se were compared
• Outcomes were similar
• Most patients, however, did not develop increased ICP, so whether treatment of increased ICP makes a difference was not answered.
• Use of an ICP monitor was associated with more efficient care
• placement of Pbto₂ monitors in brain that appears normal on the admission head CT and ipsilateral to the worst pathology

BEST-TRIP Trial Summary

Objective

The BEST-TRIP (Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure) trial aimed to determine whether intracranial pressure (ICP) monitoring improves outcomes in patients with severe traumatic brain injury.

Methods

• Design: Multicenter, randomized controlled trial.
• Participants: 324 patients aged 13 years or older with severe traumatic brain injury and treated in ICUs in Bolivia or Ecuador.
• Interventions: Patients were randomized to either ICP monitoring with a protocol to maintain pressure below 20 mm Hg (pressure-monitoring group) or a protocol based on imaging and clinical examination (imaging–clinical examination group).
• Outcome Measures: The primary outcome was a composite measure including survival time, level of consciousness, functional status at 3 and 6 months, and neuropsychological status at 6 months.

Results

• Primary Outcome: No significant difference in composite scores between the pressure-monitoring group and the imaging–clinical examination group (score, 56 vs. 53; P = 0.49).
• Mortality Rates: Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging–clinical examination group (P = 0.60).
• ICU Stay: The median length of stay in the ICU was similar between the groups (12 days for pressure-monitoring vs. 9 days for imaging–clinical examination; P = 0.25).
• Brain-Specific Treatments: Patients in the imaging–clinical examination group received more brain-specific treatments compared to the pressure-monitoring group (4.8 vs. 3.4 days; P = 0.002).

Conclusion

For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less did not show superiority over care based on imaging and clinical examination. These findings suggest that routine intracranial pressure monitoring may not provide additional benefits in improving patient outcomes in this context.

Weaknesses

• Composite primary outcome with mortality equally weighted with 20 other variables such as motor dexterity
• Not powered for mortality
• Differences in treatment strategies between intervention and control groups e.g. in intervention group drainage of CSF was 1st option for raised ICP, where as this was not an option in control group
• Study performed in Bolivia and Ecuador. There are significant differences between the health care provided, particularly pre-hospital resuscitation, between Bolivia/Ecuador and Western European countries. Therefore these results may not be valid in other settings.

Reference

Chesnut RM, Temkin N, Carney N, et al. A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury. N Engl J Med 2012; 367:2471-2481. File:BEST-TRIP.pdf