Abstract
The Brain Trauma Foundation guidelines recommend intracranial pressure (ICP) monitoring for the majority of patients with severe traumatic brain injury. ICP monitors have therefore become an integral part of the intensive care management of these patients however such invasive devices are not without risk. Following a critical incident in which an intraparenchymal cerebral perfusion catheter was inserted significantly further than intended, we undertook a retrospective audit of the depth of intraparenchymal brain monitoring devices in patients with traumatic brain injury and subarachnoid haemorrhage. The majority of intraparenchymal monitoring devices were ICP catheters and the majority of these were inserted beyond the manufacturers' recommendations despite most of these catheters having an integral depth indicator. Extreme care should be taken when inserting monitors that do not have a depth indicator.