{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,5,6]],"date-time":"2025-05-06T10:12:31Z","timestamp":1746526351091},"reference-count":27,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","license":[{"start":{"date-parts":[[2024,1,26]],"date-time":"2024-01-26T00:00:00Z","timestamp":1706227200000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"<jats:sec>\n            <jats:title>BACKGROUND<\/jats:title>\n            <jats:p>In patients with acute brain injury (ABI) and refractory intracranial hypertension, the so-called \u2018tier three therapies\u2019 (TTT) (hypothermia, metabolic suppression with barbiturates, and decompressive craniectomy) may be used.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>OBJECTIVE<\/jats:title>\n            <jats:p>We aimed to describe the incidence of use of TTT, and to assess their effect on outcome.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>DESIGN<\/jats:title>\n            <jats:p>A secondary analysis of the ENIO observational study.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>SETTING<\/jats:title>\n            <jats:p>Seventy-three intensive care units (ICUs) in 18 countries worldwide between June 2018 and November 2020.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>PATIENTS<\/jats:title>\n            <jats:p>One thousand five hundred and twelve adult patients admitted to an intensive care unit (ICU) with ABI were included and categorised according to use or not of one or more TTT.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>RESULTS<\/jats:title>\n            <jats:p>Three hundred and ninety-six patients (26.2%) received at least one TTT during the ICU stay. Five patients (0.3%) received all three TTT. TTT patients were younger (<jats:italic toggle=\"yes\">P<\/jats:italic>\u200a&lt;\u200a0.0001), less likely to have a preinjury history of hypertension (<jats:italic toggle=\"yes\">P<\/jats:italic>\u200a=\u200a0.0008), and less frequently anisocoric within 24\u200ah from ICU admission (<jats:italic toggle=\"yes\">P<\/jats:italic>\u200a&lt;\u200a0.0001) than those with no tier three therapy. TTT were used less frequently in high-income countries than in upper income and lower middle-income countries (no TTT in 78% of patients in high-income countries, in 60.6% of patients in upper middle-income countries, and in 56.6% of patients in lower middle-income countries; <jats:italic toggle=\"yes\">P<\/jats:italic>\u200a&lt;\u200a0.0001). TTT were more frequent in patients with traumatic brain injury (TBI) compared with other types of ABI and in patients with invasive intracranial pressure (ICP) monitoring (<jats:italic toggle=\"yes\">P<\/jats:italic>\u200a&lt;\u200a0.0001). TTT use was associated with a higher incidence of ventilator-associated pneumonia (<jats:italic toggle=\"yes\">P<\/jats:italic>\u200a&lt;\u200a0.0001), need for tracheostomy (<jats:italic toggle=\"yes\">P<\/jats:italic>\u200a=\u200a0.0194), and prolonged ICU length of stay (LOS; <jats:italic toggle=\"yes\">P<\/jats:italic>\u200a&lt;\u200a0.0001) but not with increased ICU or hospital mortality (<jats:italic toggle=\"yes\">P<\/jats:italic>\u200a=\u200a0.999).<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>CONCLUSION<\/jats:title>\n            <jats:p>Patients with ABI are frequently managed using at least one TTT. Their use varies according to a country's economic resources, the type of ABI, and ICP monitoring and is associated with a higher risk of complications but not with ICU or hospital mortality.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1097\/ea9.0000000000000043","type":"journal-article","created":{"date-parts":[[2024,1,30]],"date-time":"2024-01-30T08:00:25Z","timestamp":1706601625000},"page":"e0043","update-policy":"http:\/\/dx.doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":1,"title":["The use of tier three therapies in acute brain injured 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