Variation in the Use of Intracranial-Pressure Monitoring and Mortality in Critically Ill Children With Meningitis in the United States

ODETOLA ET AL1 have studied the effect of using intracranial-pressure (ICP) monitoring in critically ill children with meningitis. They used the Kids’ Inpatient Database and studied children from 0 to 17 years of age who were hospitalized with meningitis and required mechanical ventilation in 1997 and 2000. Among their findings was that the use of ICP monitoring had no effect on the mortality rate when compared with a balanced sample of patients without ICP monitoring. This study is consistent with a study by Odetola and Bratton,2 who used a different database. They studied 559 patients from 15 US PICUs. There was significant variation in the use of ICP monitors among the various units, but there was no difference in survival of patients between the centers that had high a utilization rate compared with those with low or nonuse of ICP monitors. The results of these 2 studies are somewhat discouraging and do not demonstrate benefit as was achieved by the use of ventilatory support, which reduced mortality by 50%.3 These studies are in contrast to others such as the one by Lindvall et al,4 which suggested that reducing ICP may increase survival among patients with bacterial meningitis. Their study included 15 patients who underwent continuous ICP monitoring. Ten patients survived. Among the survivors, the ICP was reduced gradually. The mean ICP was significantly higher and the cerebral perfusion pressure was markedly decreased in nonsurvivors compared with survivors. The initial ICP was 46.4 8.6 mm Hg in the nonsurvivors versus 20.3 4.6 mm Hg in the survivors. Thus, the 2 groups were distinctly different from the onset. Thus, the effect of ICP monitoring is difficult to assess. Grande et al5 studied 12 patients who had elevated ICP above 20 mm Hg. Pressure was reduced in 10 patients who survived. The 2 patients who did not survive had low cerebral perfusion pressures and dilated pupils and were thought to be beyond recovery. Again, it is difficult to assess whether the survival rate was influenced by the use of monitoring. Thus, the benefit of using ICP monitoring is not clearly proven in these 2 studies. Conflicting experiences regarding the value of ICP monitoring in reducing mortality in patients with meningitis makes its use controversial. Despite using 2 large databases, the negative studies have some drawbacks.1,2 Both were retrospective. The exact indications for placing the ICP monitor were unknown. There were no uniform treatment protocols, and most importantly, there are no data regarding the effectiveness of treatment in reducing intracranial hypertension. Also, there is no information regarding the status of the surviving patients who underwent ICP monitoring. We do not know if monitoring had any effect on reducing sequelae from meningitis. As Odetola et al note, the results cannot be used to definitively recommend for or against the use of ICP monitors in the clinical setting.1 As they suggest, a prospective randomized clinical trial may be necessary to answer some of these questions, and as they indicated, such a trial would be ethically challenging to design. This is an important issue to resolve because length of