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

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.

Keywords: Algorithm; Brain injury; Consensus; Head trauma; Intracranial pressure; Protocol; SIBICC; Seattle; Tiers.

Conflict of interest statement

No conflicts of interest relevant to this project were identified amongst the authorship group.

Figures

Fig. 1

Consensus-based basic severe traumatic brain injury care for patients with an ICP monitor in situ. These are basic treatments recommended as fundamental to the care of patients with sTBI, to be initiated (“Expected interventions”) or considered (“Recommended interventions”) upon ICU admission of a patient with an ICP monitor, regardless of the monitored pressure. CO2 carbon dioxide, CPP cerebral perfusion pressure, Hg hemoglobin, HOB head of bed, ICP intracranial pressure, ICU intensive care unit, spO2 arterial oxygen saturation

Fig. 2

Consensus-based algorithm for the management of severe traumatic brain injury guided by intracranial pressure measurements. Upper right box presents the principles for navigating through the treatments and tiers. Lower tier treatments are viewed as having a more favorable side effect profile than higher tiers and generally should be employed first. Inter-tier recommendations encourage patient reassessment for remediable causes of treatment resistance. See text for details. CPP cerebral perfusion pressure, EEG electroencephalogram, EVD external ventricular drain, ICP intracranial pressure, kPa kiloPascals, MAP mean arterial pressure, PaCO2 arterial partial pressure of carbon dioxide

Fig. 3

Critical neuroworsening and its management. SIBICC definition (upper box), response (middle box) and a list of suggested differential diagnoses (bottom) surrounding critical neurological deterioration (critical neuroworsening). CNS central nervous system, GCS Glasgow Coma Scale, ICP intracranial pressure

Fig. 4

Consensus views on the safety of intracranial pressure monitor removal in patients with acceptable ICP (no longer requiring active ICP management). The heatmap represents a summary analysis of the likelihood of each CWG member to remove the ICP monitor under differing conditions of stable pupillary status, GCS [20] motor score, modified CT classification (see “Methods”), duration of acceptable ICP, and degree of treatment previously required for any intracranial hypertension (none, Tier 1, or Tier 2 or 3). Green, yellow, and red indicate “safe to proceed”, “consider proceeding with caution” and “do not proceed”, respectively, with transitional shades reflecting intermediate trends. To use, choose the heatmap representing the ICP treatment history, then the appropriate status cell reflecting categorization of the patient in terms of the variables presented. The color in the relevant cell reflects the tendency of the CWG to withdraw the ICP monitor in that circumstance. It is up to the treating physician to consider the value of that tendency in making the final decision. AP abnormal pupils, CT computed tomography, DI diffuse injury as defined in the Marshall CT Head Score, GCS Glasgow Coma Scale, EML evacuated mass lesion as defined in the Marshall CT Head Score, ICP intracranial pressure, NP normal pupils

Fig. 5

Consensus views on the safety of performing a sedation holiday aimed at obtaining an accurate neurological examination in patients whose ICP is controlled under different degrees of active management. The heatmap represents a summary analysis of the likelihood of each panelist to halt sedation to get an optimized neurological exam under differing conditions of stable pupillary status, GCS [20] motor score, modified CT classification (see “Methods”), duration of acceptable ICP with ongoing treatment, and degree of treatment previously required for any intracranial hypertension (none, Tier 1, or Tier 2 or 3). Green, yellow, and red indicate “safe to proceed”, “consider proceeding with caution” and “do not proceed”, respectively, with transitional shades reflecting intermediate trends. To use, choose the heatmap representing the ICP treatment history, then the appropriate status cell reflecting categorization of the patient in terms of the variables presented. The color in the relevant cell reflects the tendency of the CWG to perform a sedation holiday in that circumstance. It is up to the treating physician to consider the value of that tendency in making the final decision. AP abnormal pupils, CT computed tomography; DI diffuse injury as defined in the Marshall CT Head Score, GCS Glasgow Coma Scale, EML evacuated mass lesion as defined in the Marshall CT Head Score, ICP intracranial pressure, NP normal pupils