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

Intensive Care Med, 2020 · DOI: https://doi.org/10.1007/s00134-019-05900-x · Published: January 21, 2020

Simple Explanation

Current guidelines for treating severe traumatic brain injury (sTBI) lack management protocols to bridge the gap between research and patient care. This study aimed to create a modern sTBI protocol for adult patients monitored for both intracranial pressure (ICP) and brain oxygen levels. A consensus group of 42 experts developed three treatment protocols using a Delphi-method approach, finalized at an in-person meeting. These protocols address managing ICP elevation with normal brain oxygen, brain hypoxia with normal ICP, and both intracranial hypertension and brain hypoxia. The protocols offer a tiered approach, with higher tiers involving therapies with greater risk. They also consider blood transfusion and ventilator management. The goal is to assist clinicians but not replace individualised management.

Study Duration

Not specified

Participants

42 experienced and actively practicing sTBI opinion leaders

Evidence Level

Class III evidence

Key Findings

1
Established three distinct treatment protocols for managing sTBI patients with combined ICP and brain oxygen monitoring: one for ICP elevation with normal brain oxygenation, one for brain hypoxia with normal ICP, and one for both conditions present.
2
Developed a list of interventions considered fundamental to sTBI care, to be initiated or considered upon ICU admission, regardless of measured values.
3
Identified treatments NOT recommended for use in managing severe traumatic brain injury when both ICP and PbtO2 are monitored, except in special circumstances.

Research Summary

This study established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management.

Practical Implications

Clinical Decision Support

The protocols provide a framework for clinicians to manage sTBI patients with combined ICP and brain oxygen monitoring, aiding in treatment decisions based on the patient's condition.

Standardization of Care

The algorithms can assist in standardizing care approaches, particularly in centers less specialized in sTBI management, potentially improving patient outcomes.

Further Research

The protocols serve as a foundation for future research, allowing for the evaluation and refinement of treatment strategies for sTBI patients with multi-modality monitoring.

Study Limitations

1
The protocols are based on expert consensus and represent Class III evidence, indicating a lack of proven superiority over other methods.
2
The algorithms are not legally binding and should not replace thoughtful clinical judgment, as variability within patients may necessitate local adaptation.
3
The panel acknowledged that higher monitor readings may not always parallel improved oxygen availability when FiO2 or PaO2 are pushed very high.

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