Mortality and prehospital blood pressure in patients with major traumatic brain injury: Implications for the hypotension threshold

Daniel W Spaite, Chengcheng Hu, Bentley J Bobrow, Vatsal Chikani, Duane L Sherrill, Bruce Barnhart, Joshua B Gaither, Kurt R Denninghoff, Chad D Viscusi, Terry Mullins, P. David Adelson

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32 Citations (Scopus)

Abstract

IMPORTANCE Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90mmHg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence. OBJECTIVE To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists. DESIGN, SETTING, AND PARTICIPANTS Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119mmHg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders. MAIN OUTCOMES AND MEASURES The main outcome measurewas in-hospital mortality. RESULTS Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119mmHg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95%CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100mmHg as for a drop from 90 to 80mmHg, and so on throughout the range. CONCLUSIONS AND RELEVANCE We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119mmHg. Thus, in patients with traumatic brain injury, the concept that 90mmHg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90mmHg are needed.

Original languageEnglish (US)
Pages (from-to)360-368
Number of pages9
JournalJAMA Surgery
Volume152
Issue number4
DOIs
StatePublished - Apr 1 2017

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Hypotension
Blood Pressure
Mortality
Guidelines
Head
Abbreviated Injury Scale
Traumatic Brain Injury
International Classification of Diseases
Hospital Mortality
Logistic Models
Odds Ratio
Databases
Wounds and Injuries

ASJC Scopus subject areas

  • Surgery

Cite this

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title = "Mortality and prehospital blood pressure in patients with major traumatic brain injury: Implications for the hypotension threshold",
abstract = "IMPORTANCE Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90mmHg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence. OBJECTIVE To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists. DESIGN, SETTING, AND PARTICIPANTS Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119mmHg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders. MAIN OUTCOMES AND MEASURES The main outcome measurewas in-hospital mortality. RESULTS Among the 3844 included patients, 2565 (66.7{\%}) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119mmHg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8{\%} (adjusted odds ratio, 0.812; 95{\%}CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100mmHg as for a drop from 90 to 80mmHg, and so on throughout the range. CONCLUSIONS AND RELEVANCE We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119mmHg. Thus, in patients with traumatic brain injury, the concept that 90mmHg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90mmHg are needed.",
author = "Spaite, {Daniel W} and Chengcheng Hu and Bobrow, {Bentley J} and Vatsal Chikani and Sherrill, {Duane L} and Bruce Barnhart and Gaither, {Joshua B} and Denninghoff, {Kurt R} and Viscusi, {Chad D} and Terry Mullins and Adelson, {P. David}",
year = "2017",
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doi = "10.1001/jamasurg.2016.4686",
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T1 - Mortality and prehospital blood pressure in patients with major traumatic brain injury

T2 - Implications for the hypotension threshold

AU - Spaite, Daniel W

AU - Hu, Chengcheng

AU - Bobrow, Bentley J

AU - Chikani, Vatsal

AU - Sherrill, Duane L

AU - Barnhart, Bruce

AU - Gaither, Joshua B

AU - Denninghoff, Kurt R

AU - Viscusi, Chad D

AU - Mullins, Terry

AU - Adelson, P. David

PY - 2017/4/1

Y1 - 2017/4/1

N2 - IMPORTANCE Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90mmHg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence. OBJECTIVE To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists. DESIGN, SETTING, AND PARTICIPANTS Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119mmHg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders. MAIN OUTCOMES AND MEASURES The main outcome measurewas in-hospital mortality. RESULTS Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119mmHg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95%CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100mmHg as for a drop from 90 to 80mmHg, and so on throughout the range. CONCLUSIONS AND RELEVANCE We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119mmHg. Thus, in patients with traumatic brain injury, the concept that 90mmHg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90mmHg are needed.

AB - IMPORTANCE Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90mmHg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence. OBJECTIVE To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists. DESIGN, SETTING, AND PARTICIPANTS Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119mmHg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders. MAIN OUTCOMES AND MEASURES The main outcome measurewas in-hospital mortality. RESULTS Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119mmHg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95%CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100mmHg as for a drop from 90 to 80mmHg, and so on throughout the range. CONCLUSIONS AND RELEVANCE We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119mmHg. Thus, in patients with traumatic brain injury, the concept that 90mmHg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90mmHg are needed.

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