背景:脑水肿是一种常见的,急性脑损伤危重患者可能危及生命的并发症。然而,关于最佳监测和治疗策略的不确定性仍然存在,这可能会导致广泛的实践差异。
方法:在2022年7月至2023年5月期间,向管理脑水肿的临床医生分发了一项关于监测和管理实践的20个问题的数字调查。这项调查是通过电子邮件进行的,社交媒体,医学会议,和神经危重症护理协会网站。我们用χ2检验,费希尔的精确检验,方差分析,和逻辑回归来报告与实践变化相关的因素,诊断监测方法,以及基于从业者和机构特征的治疗触发因素。
结果:来自30个国家160个机构的321名参与者,65%来自大学附属中心,74%的人是主治医生,38%是女性,38%的人接受过神经病学培训,55%来自美国。84%的人观察到他们机构的实践变化,引用最多的是“提供者偏好”(87%)。与变异相关的因素包括性别,经验,大学隶属关系,在美国以外的地方练习。大学附属机构倾向于使用更多的测试(中位数为3.87vs.3.43,p=0.01)以监测脑水肿。关于管理实践,20%的受访者首选去骨瓣减压术时间是在48小时后,37%的人表示,影像学检查结果仅足以触发手术。50%的受访者报告根据放射学适应症或预防性开始渗透治疗。管理策略与受访者或中心特征之间没有显着关联。27%的受访者表示他们以24小时或更短的间隔获得了神经影像学检查。在这个群体中,主治医生更有可能遵循这种做法(65.5%vs.34.5%,p=0.04)。
结论:脑水肿的监测和治疗策略各不相同。与实践变化相关的特征包括从业者和机构特征。我们为理解实践模式提供了基础,这些实践模式对于告知教育计划至关重要,规范准则,并进行未来的试验。
BACKGROUND: Cerebral edema is a common, potentially life-threatening complication in critically ill patients with acute brain injury. However, uncertainty remains regarding best monitoring and treatment strategies, which may result in wide practice variations.
METHODS: A 20-question digital survey on monitoring and management practices was disseminated between July 2022 and May 2023 to clinicians who manage cerebral edema. The survey was promoted through email, social media, medical conferences, and the Neurocritical Care Society Web site. We used the χ2 test, Fisher\'s exact test, analysis of variance, and logistic regression to report factors associated with practice variation, diagnostic monitoring methods, and therapeutic triggers based on practitioner and institutional characteristics.
RESULTS: Of 321 participants from 160 institutions in 30 countries, 65% were from university-affiliated centers, 74% were attending physicians, 38% were woman, 38% had neurology training, and 55% were US-based. Eighty-four percent observed practice variations at their institutions, with \"provider preference\" being cited most (87%). Factors linked to variation included gender, experience, university affiliation, and practicing outside the United States. University affiliates tended to use more tests (median 3.87 vs. 3.43, p = 0.01) to monitor cerebral edema. Regarding management practices, 20% of respondents\' preferred timing for decompressive hemicraniectomy was after 48 h, and 37% stated that radiographic findings only would be sufficient to trigger surgery. Fifty percent of respondents reported initiating osmotic therapy based on radiographic indications or prophylactically. There were no significant associations between management strategies and respondent or center characteristics. Twenty-seven percent of respondents indicated that they acquired neuroimaging at intervals of 24 h or less. Within this group, attending physicians were more likely to follow this practice (65.5% vs. 34.5%, p = 0.04).
CONCLUSIONS: Cerebral edema monitoring and management strategies vary. Features associated with practice variations include both practitioner and institutional characteristics. We provide a foundation for understanding practice patterns that is crucial for informing educational initiatives, standardizing guidelines, and conducting future trials.