Placement of intracranial pressure monitors by non-neurosurgeons

Maintaining adequate cerebral perfusion is important in the treatment of patients with closed head injury. Placement of an intracranial pressure (ICP) monitor is necessary to determine both ICP and the cerebral perfusion pressure and serves as a guide to the contemporary management of traumatic brain injury. Insertion of such monitoring devices historically has been performed by neurosurgeons, but others including general (trauma) surgeons have successfully inserted simple ICP monitors. The purpose of this study was to assess the efficacy of ICP monitor placement and to compare the complication rates for ICP monitor placement by general surgery residents, trauma surgeons, and staff neurosurgeons. We retrospectively reviewed the medical records of trauma patients with cerebral injury who required insertion of parenchymal ICP monitors from January 1994 to January 1999. Monitor placement was performed by staff neurosurgeons, general surgical residents, and trauma surgeons. Surgical residents received appropriate training in the placement of ICP monitors from attending trauma surgeons and neurosurgeons. Records were examined for demographic variables such as age, gender, mechanism of injury, admission Glasgow Coma Score, and Injury Severity Score. Records were also reviewed for duration of ICP monitoring and for complications (i.e., intracranial hemorrhage after monitor placement, monitor-related infection, monitor malfunction, and monitor displacement). One hundred fifty-seven monitors were placed in 146 patients with intracranial injury. Surgical residents placed 87 ICP monitors without neurosurgical or trauma attending surgeons at the bedside and 43 with immediate supervision by general surgeons or neurosurgeons. Neurosurgeons placed 26 monitors without the participation of residents, and an attending trauma surgeon placed one monitor without the involvement of a resident or a neurosurgeon. There were no major technical complications, no episodes of catheter-induced intracranial hemorrhage, and no infectious complications. These data suggest that simple ICP monitors may be inserted by non-neurosurgeons without significant problems or complications. The low complication rate associated with this procedure was similar for neurosurgeons and non-neurosurgeons. We believe that insertion of simple parenchymal ICP monitors should be considered a core skill for trauma surgeons and should be included in surgical residency training. Insertion of ICP monitors by non-neurosurgeons is a potential method of improving the care of patients with brain injury in geographic areas that are underserved by neurosurgeons.