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

  • Hawryluk, Gregory WJ;
  • Aguilera, Sergio;
  • Buki, Andras;
  • Bulger, Eileen;
  • Citerio, Giuseppe;
  • Cooper, D Jamie;
  • Arrastia, Ramon Diaz;
  • Diringer, Michael;
  • Figaji, Anthony;
  • Gao, Guoyi;
  • Geocadin, Romergryko;
  • Ghajar, Jamshid;
  • Harris, Odette;
  • Hoffer, Alan;
  • Hutchinson, Peter;
  • Joseph, Mathew;
  • Kitagawa, Ryan;
  • Manley, Geoffrey;
  • Mayer, Stephan;
  • Menon, David K;
  • And 22 more
Publication Date
Oct 28, 2019
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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. / status: published

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