Staircase strategy, tier-three therapies, and effects on outcome in traumatic brain injured patients: the Triple-T TBI study

Purpose: To evaluate the clinical practice and timing of use of tier-three therapies (TTT) after traumatic brain injury (TBI), and to explore their association with intensive care unit (ICU) mortality and 3 months neurological outcome. Methods: International multicenter, retrospective, observational, cohort study performed in 16 ICUs including 408 adult TBI patients requiring at least one of the TTT [i.e. metabolic suppression with barbiturates, secondary decompressive craniectomy (DC), and mild hypothermia] for the control of intracranial hypertension during the ICU stay. Results: Among 408 adult TBI patients, secondary DC was the most frequent TTT utilized (n = 297, 72.8%), and was associated with reduced ICU mortality [Odds Ratio, OR 0.34 (95% Confidence Interval, CI 0.14-0.78) p = 0.012] and better neurological outcome (p = 0.047), whereas barbiturates were associated with increased ICU mortality [OR: 3.05 (95% CI 1.43-6.49); p = 0.004) and worse neurological outcome (p = 0.032). Two hundred and twenty-four (55%) patients received interventions in adherence to guidelines, which was associated with a non-significant trend towards better outcomes. Conclusions: The staircase approach before the use of TTT was not often utilized after severe TBI. Secondary DC was performed more often than other treatments and its use was associated with improved mortality and neurological outcome. The benefits of adherence to guidelines before TTT prescription should be further evaluated.