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      A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

      case-report
      1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ,
      Intensive Care Medicine
      Springer Berlin Heidelberg
      Brain injury, Head trauma, Algorithm, Protocol, Consensus, Intracranial pressure, Tiers, Seattle, SIBICC

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          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.

          Electronic supplementary material

          The online version of this article (10.1007/s00134-019-05805-9) contains supplementary material, which is available to authorized users.

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          Most cited references21

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          • Abstract: found
          • Article: not found

          Decompressive craniectomy in diffuse traumatic brain injury.

          It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure. From December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final primary outcome was the score on the Extended Glasgow Outcome Scale at 6 months. Patients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P=0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P=0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%). In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617.).
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            Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension.

            Background The effect of decompressive craniectomy on clinical outcomes in patients with refractory traumatic intracranial hypertension remains unclear. Methods From 2004 through 2014, we randomly assigned 408 patients, 10 to 65 years of age, with traumatic brain injury and refractory elevated intracranial pressure (>25 mm Hg) to undergo decompressive craniectomy or receive ongoing medical care. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOS-E) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 6 months. The primary-outcome measure was analyzed with an ordinal method based on the proportional-odds model. If the model was rejected, that would indicate a significant difference in the GOS-E distribution, and results would be reported descriptively. Results The GOS-E distribution differed between the two groups (P<0.001). The proportional-odds assumption was rejected, and therefore results are reported descriptively. At 6 months, the GOS-E distributions were as follows: death, 26.9% among 201 patients in the surgical group versus 48.9% among 188 patients in the medical group; vegetative state, 8.5% versus 2.1%; lower severe disability (dependent on others for care), 21.9% versus 14.4%; upper severe disability (independent at home), 15.4% versus 8.0%; moderate disability, 23.4% versus 19.7%; and good recovery, 4.0% versus 6.9%. At 12 months, the GOS-E distributions were as follows: death, 30.4% among 194 surgical patients versus 52.0% among 179 medical patients; vegetative state, 6.2% versus 1.7%; lower severe disability, 18.0% versus 14.0%; upper severe disability, 13.4% versus 3.9%; moderate disability, 22.2% versus 20.1%; and good recovery, 9.8% versus 8.4%. Surgical patients had fewer hours than medical patients with intracranial pressure above 25 mm Hg after randomization (median, 5.0 vs. 17.0 hours; P<0.001) but had a higher rate of adverse events (16.3% vs. 9.2%, P=0.03). Conclusions At 6 months, decompressive craniectomy in patients with traumatic brain injury and refractory intracranial hypertension resulted in lower mortality and higher rates of vegetative state, lower severe disability, and upper severe disability than medical care. The rates of moderate disability and good recovery were similar in the two groups. (Funded by the Medical Research Council and others; RESCUEicp Current Controlled Trials number, ISRCTN66202560 .).
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              A trial of intracranial-pressure monitoring in traumatic brain injury.

              Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed. We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging-clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance). There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging-clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups. For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01068522.).
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                Author and article information

                Contributors
                ghawryluk@hsc.mb.ca
                aguilera71@gmail.com
                buki.andras@pte.hu
                ebulger@uw.edu
                giuseppe.citerio@unimib.it
                Jamie.Cooper@monash.edu
                Ramon.Diaz-Arrastia@uphs.upenn.edu
                diringerm@neuro.wustl.edu
                anthony.figaji@uct.ac.za
                guoyigao@gmail.com
                rgeocad1@jhmi.edu
                jghajar@stanford.edu
                odette@stanford.edu
                SAlan.Hoffer@UHhospitals.org
                pjah2@cam.ac.uk
                mjoseph@cmcvellore.ac.in
                Ryan.S.Kitagawa@uth.tmc.edu
                manleyg@ucsf.edu
                stephanamayer@gmail.com
                dkm13@cam.ac.uk
                geert.meyfroidt@uzleuven.be
                danielm@mhsi.us
                mauro.oddo@chuv.ch
                okonkwodo@upmc.edu
                mayur.b.patel@vumc.org
                claudiar@bcm.edu
                j.rosenfeld@alfred.org.au
                andresrubiano@aol.com
                sahuquillo@neurotrauma.net
                franco.servadei@hunimed.eu
                shutterla@upmc.edu
                deborah.stein@ucsf.edu
                nino.stocchetti@policlinico.mi.it
                ftaccone@ulb.ac.be
                stimmons@mac.com
                etsai@toh.ca
                jullman1@northwell.edu
                pvespa@mednet.ucla.edu
                wvidetta@yahoo.com.ar
                dwwrigh@emory.edu
                Christopher_Zammit@URMC.Rochester.edu
                chesnutr@uw.edu
                Journal
                Intensive Care Med
                Intensive Care Med
                Intensive Care Medicine
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0342-4642
                1432-1238
                28 October 2019
                28 October 2019
                2019
                : 45
                : 12
                : 1783-1794
                Affiliations
                [1 ]GRID grid.21613.37, ISNI 0000 0004 1936 9609, Section of Neurosurgery, , University of Manitoba, ; GB1, 820 Sherbrook Street, Winnipeg, MB R3A 1R9 Canada
                [2 ]GRID grid.414892.2, Almirante Nef Naval Hospital, Valparaiso University, ; Viña Del Mar, Chile
                [3 ]GRID grid.412185.b, ISNI 0000 0000 8912 4050, Valparaiso University, ; Valparaiso, Chile
                [4 ]GRID grid.9679.1, ISNI 0000 0001 0663 9479, Department of Neurosurgery, , Medical School and Szentágothai Research Centre, ; Ifjúság Útja 20, Pécs, 7624 Hungary
                [5 ]GRID grid.9679.1, ISNI 0000 0001 0663 9479, University of Pécs, ; Pécs, Hungary
                [6 ]GRID grid.34477.33, ISNI 0000000122986657, Department of Surgery, Harborview Medical Center, , University of Washington, ; 325 Ninth Ave, Seattle, WA 98104-2499 USA
                [7 ]GRID grid.7563.7, ISNI 0000 0001 2174 1754, School of Medicine and Surgery, , University of Milan-Bicocca, ; Milan, Italy
                [8 ]GRID grid.415025.7, ISNI 0000 0004 1756 8604, Anaesthesia and Intensive Care, , San Gerardo and Desio Hospitals, ASST-Monza, ; Monza, Italy
                [9 ]GRID grid.1002.3, ISNI 0000 0004 1936 7857, Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, , Monash University, ; Melbourne, Australia
                [10 ]GRID grid.1623.6, ISNI 0000 0004 0432 511X, Department of Intensive Care and Hyperbaric Medicine, , The Alfred Hospital, ; Melbourne, VIC Australia
                [11 ]GRID grid.25879.31, ISNI 0000 0004 1936 8972, Department of Neurology, Penn Presbyterian Medical Center, , University of Pennsylvania Perelman School of Medicine, ; 51 North 39th Street, Philadelphia, PA 19104 USA
                [12 ]GRID grid.4367.6, ISNI 0000 0001 2355 7002, Department of Neurology, , Washington University School of Medicine, ; St. Louis, USA
                [13 ]GRID grid.239359.7, ISNI 0000 0001 0503 2990, Department of Neurology, , Barnes-Jewish Hospital, ; 1 Barnes Jewish Hospital Plaza Suite 10400, St. Louis, MO 63110 USA
                [14 ]GRID grid.7836.a, ISNI 0000 0004 1937 1151, Division of Neurosurgery and Neuroscience Institute, , Groote Schuur Hospital¸University of Cape Town, ; H53 Old Main Building, Main Road, Observatory, 7925 South Africa
                [15 ]GRID grid.16821.3c, ISNI 0000 0004 0368 8293, Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, , Shanghai Jiaotong University School of Medicine, ; 1630 Dongfang Road, Shanghai, 200127 China
                [16 ]GRID grid.21107.35, ISNI 0000 0001 2171 9311, Department of Neurology, , Johns Hopkins University School of Medicine, ; 600 N. Wolfe Street, Phipps 455, Baltimore, MD 21287 USA
                [17 ]Department of Neurosurgery, Stanford Neuroscience Health Center, 213 Quarry Rd 4th Fl, MC 5958, Palo Alto, CA 94304 USA
                [18 ]GRID grid.240952.8, ISNI 0000000087342732, Department of Neurosurgery, ; 300 Pasteur Drive, Room R205, Edward’s Building, MC: 5327, Stanford, CA 94305 USA
                [19 ]GRID grid.67105.35, ISNI 0000 0001 2164 3847, Department of Neurological Surgery, School of Medicine, , Case Western Reserve University, ; 11100 Euclid Avenue, 5042, Cleveland, OH 44106 USA
                [20 ]GRID grid.120073.7, ISNI 0000 0004 0622 5016, Division of Neurosurgery, Department of Clinical Neurosciences, , Addenbrooke’s Hospital, University of Cambridge and Cambridge Biomedical Campus, ; Cambridge, CB20QQ UK
                [21 ]GRID grid.11586.3b, ISNI 0000 0004 1767 8969, Department of Neurological Sciences, , Christian Medical College, ; Ida Scudder Road, Vellore, Tamil Nadu India
                [22 ]Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, 6400 Fannin St, Suite 2800, Houston, TX 77030 USA
                [23 ]GRID grid.266102.1, ISNI 0000 0001 2297 6811, Department of Neurosurgery, San Francisco General Hospital and Trauma Center, , University of California San Francisco, ; 1001 Potrero Ave., Bldg 1, Room 101, San Francisco, CA 94110 USA
                [24 ]GRID grid.413103.4, ISNI 0000 0001 2160 8953, Department of Neurology, , Henry Ford Hospital, ; 2799 W Grand Blvd, Neurology, K-11, Detroit, MI 48202 USA
                [25 ]GRID grid.5335.0, ISNI 0000000121885934, Division of Anaesthesia, Addenbrooke’s Hospital, , University of Cambridge and Addenbrooke’s Hospital, ; Hills Road, Box 93, Cambridge, CB2 0QQ UK
                [26 ]GRID grid.410569.f, ISNI 0000 0004 0626 3338, Department and Laboratory of Intensive Care Medicine, , University Hospitals Leuven and KU Leuven, ; Herestraat 49, Box 7003 63, 3000 Leuven, Belgium
                [27 ]GRID grid.261277.7, ISNI 0000 0001 2219 916X, Department of Neurosurgery, Beaumont Health, Michigan Head and Spine Institute, , Oakland University William Beaumont School of Medicine, ; Southfield, MI USA
                [28 ]GRID grid.9851.5, ISNI 0000 0001 2165 4204, Department of Intensive Care Medicine, Faculty of Biology and Medicine, CHUV-Lausanne University Hospital, , University of Lausanne, ; Lausanne, Switzerland
                [29 ]GRID grid.461860.d, ISNI 0000 0004 0462 9068, Department of Neurosurgery, , University of Pittsburgh Medical Center Presbyterian, ; Suite B-400 200 Lothrop Street, Pittsburgh, PA 15213 USA
                [30 ]GRID grid.412807.8, ISNI 0000 0004 1936 9916, Department of Surgery, , Vanderbilt University Medical Center, ; 1211 21st Avenue South, 404 MAB, Nashville, TN 37212 USA
                [31 ]GRID grid.39382.33, ISNI 0000 0001 2160 926X, Department of Neurosurgery, , Baylor College of Medicine, ; One Baylor Plaza, Houston, TX 77030 USA
                [32 ]GRID grid.1623.6, ISNI 0000 0004 0432 511X, Department of Neurosurgery, , Alfred Hospital, ; Melbourne, Australia
                [33 ]GRID grid.1002.3, ISNI 0000 0004 1936 7857, Department of Surgery, , Monash University, ; Melbourne, Australia
                [34 ]GRID grid.412195.a, ISNI 0000 0004 1761 4447, INUB/MEDITECH Research Group, Neurosciences Institute, , El Bosque University, ; Bogotá, Colombia
                [35 ]MEDITECH Foundation, Clinical Research, Calle 7-A # 44-95, Cali, 760036 Colombia
                [36 ]GRID grid.411083.f, ISNI 0000 0001 0675 8654, Department of Neurosurgery, , University Hospital Vall d’Hebron, ; Barcelona, Spain
                [37 ]Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
                [38 ]GRID grid.412689.0, ISNI 0000 0001 0650 7433, Department of Critical Care Medicine, Neurology and Neurosurgery, , University of Pittsburgh Medical Center, ; 3550 Terrace St, Room 646, Pittsburgh, PA 15261 USA
                [39 ]GRID grid.266102.1, ISNI 0000 0001 2297 6811, Department of Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, , University of California, ; 1001 Potrero Ave., Ward 3A, San Francisco, CA 94110 USA
                [40 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, Department of Physiopathology and Transplantation, , Milan University, ; Milan, Italy
                [41 ]GRID grid.414818.0, ISNI 0000 0004 1757 8749, Neuroscience Intensive Care Unit, , Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, ; Milan, Italy
                [42 ]GRID grid.4989.c, ISNI 0000 0001 2348 0746, Department of Intensive Care, Hospital Erasme, , Université Libre de Bruxelles (ULB), ; Brussels, Belgium
                [43 ]Department of Neurological Surgery, GH 5100 SNEU, Indianapolis, IN 46202 USA
                [44 ]GRID grid.28046.38, ISNI 0000 0001 2182 2255, Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, The Ottawa Hospital, Department of Surgery, Division of Neurosurgery, , University of Ottawa, ; Civic Campus, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
                [45 ]GRID grid.240382.f, ISNI 0000 0001 0490 6107, Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, , North Shore University Hospital, ; 300 Community Drive, 9 Tower, Manhasset, NY USA
                [46 ]GRID grid.19006.3e, ISNI 0000 0000 9632 6718, Gary L. Brinderson Family Chair in Neurocritical Care, , UCLA School of Medicine, ; Los Angeles, USA
                [47 ]GRID grid.19006.3e, ISNI 0000 0000 9632 6718, Critical Care Medicine Research, , UCLA School of Medicine, ; Santa Monica, USA
                [48 ]GRID grid.19006.3e, ISNI 0000 0000 9632 6718, Neurosurgery and Neurology, , UCLA School of Medicine, ; Santa Monica, USA
                [49 ]GRID grid.413083.d, ISNI 0000 0000 9142 8600, Neurocritical Care, , Ronald Reagan UCLA Medical Center, ; Santa Monica, USA
                [50 ]Intensive Care, Posadas Hospital, Buenos Aires, Argentina
                [51 ]GRID grid.189967.8, ISNI 0000 0001 0941 6502, Department of Emergency Medicine, , Emory University School of Medicine, ; 49 Jesse Hill Jr Dr, Atlanta, GA 30303 USA
                [52 ]GRID grid.412750.5, ISNI 0000 0004 1936 9166, Department of Emergency Medicine, , University of Rochester Medical Center, ; 265 Crittenden Blvd, Suite 2100, Box 655C, Rochester, NY 14642 USA
                [53 ]GRID grid.34477.33, ISNI 0000000122986657, Department of Neurological Surgery, , University of Washington, ; Mailstop 359766, 325 Ninth Ave, Seattle, WA 98104-2499 USA
                [54 ]GRID grid.34477.33, ISNI 0000000122986657, Department of Orthopaedic Surgery, , University of Washington, ; Mailstop 359766, 325 Ninth Ave, Seattle, WA 98104-2499 USA
                [55 ]GRID grid.34477.33, ISNI 0000000122986657, School of Global Health, , University of Washington, ; Mailstop 359766, 325 Ninth Ave, Seattle, WA 98104-2499 USA
                [56 ]GRID grid.34477.33, ISNI 0000000122986657, Harborview Medical Center, , University of Washington, ; 325 Ninth Ave, Mailstop 359766, Seattle, WA 98104-2499 USA
                Author information
                http://orcid.org/0000-0002-5604-7057
                http://orcid.org/0000-0001-6377-3666
                Article
                5805
                10.1007/s00134-019-05805-9
                6863785
                31659383
                b66dbbcf-c0d2-4ac0-8cdb-51e00ebd310f
                © The Author(s) 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 19 July 2019
                : 25 September 2019
                Categories
                Conference Reports and Expert Panel
                Custom metadata
                © Springer-Verlag GmbH Germany, part of Springer Nature 2019

                Emergency medicine & Trauma
                brain injury,head trauma,algorithm,protocol,consensus,intracranial pressure,tiers,seattle,sibicc

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