Published in:
Open Access
01-12-2019 | Central Nervous System Trauma | Conference Reports and Expert Panel
A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)
Authors:
Gregory W. J. Hawryluk, Sergio Aguilera, Andras Buki, Eileen Bulger, Giuseppe Citerio, D. Jamie Cooper, Ramon Diaz Arrastia, Michael Diringer, Anthony Figaji, Guoyi Gao, Romergryko Geocadin, Jamshid Ghajar, Odette Harris, Alan Hoffer, Peter Hutchinson, Mathew Joseph, Ryan Kitagawa, Geoffrey Manley, Stephan Mayer, David K. Menon, Geert Meyfroidt, Daniel B. Michael, Mauro Oddo, David Okonkwo, Mayur Patel, Claudia Robertson, Jeffrey V. Rosenfeld, Andres M. Rubiano, Juan Sahuquillo, Franco Servadei, Lori Shutter, Deborah Stein, Nino Stocchetti, Fabio Silvio Taccone, Shelly Timmons, Eve Tsai, Jamie S. Ullman, Paul Vespa, Walter Videtta, David W. Wright, Christopher Zammit, Randall M. Chesnut
Published in:
Intensive Care Medicine
|
Issue 12/2019
Login to get access
Abstract
Background
Management algorithms for adult severe traumatic brain injury (sTBI) were omitted in later editions of the Brain Trauma Foundation’s sTBI Management Guidelines, as they were not evidence-based.
Methods
We used a Delphi-method-based consensus approach to address management of sTBI patients undergoing intracranial pressure (ICP) monitoring. Forty-two experienced, clinically active sTBI specialists from six continents comprised the panel. Eight surveys iterated queries and comments. An in-person meeting included whole- and small-group discussions and blinded voting. Consensus required 80% agreement. We developed heatmaps based on a traffic-light model where panelists’ decision tendencies were the focus of recommendations.
Results
We provide comprehensive algorithms for ICP-monitor-based adult sTBI management. Consensus established 18 interventions as fundamental and ten treatments not to be used. We provide a three-tier algorithm for treating elevated ICP. Treatments within a tier are considered empirically equivalent. Higher tiers involve higher risk therapies. Tiers 1, 2, and 3 include 10, 4, and 3 interventions, respectively. We include inter-tier considerations, and recommendations for critical neuroworsening to assist the recognition and treatment of declining patients. Novel elements include guidance for autoregulation-based ICP treatment based on MAP Challenge results, and two heatmaps to guide (1) ICP-monitor removal and (2) consideration of sedation holidays for neurological examination.
Conclusions
Our modern and comprehensive sTBI-management protocol is designed to assist clinicians managing sTBI patients monitored with ICP-monitors alone. Consensus-based (class III evidence), it provides management recommendations based on combined expert opinion. It reflects neither a standard-of-care nor a substitute for thoughtful individualized management.