Page 6

eMag_264548_NCS Currents_December2016_3

The fourth edition of the “Brain Trauma Foundation’s Guidelines for the Management of Severe Traumatic Brain Injury” recently published in Neurosurgery (2016 Sep 20) represents several important updates over the 2007 edition and is an important reference tool for clinicians involved in the management of traumatic brain injury. It reviewed 189 publications to report on five Class 1, 46 Class 2, 136 Class 3 studies, and two meta-analyses. The complete Guideline document is available online at https://braintrauma.org/ coma/guidelines. While several changes to recommendations represent updates in the literature since 2007, persistent gaps in evidence and methodologic errors have made these advances challenging. The quality of evidence was assessed on four domains: aggregate quality of studies, Christian B Ricks, MD consistency of results, whether evidence provided is direct or indirect, and precision of evidence. In addition, the number of studies and subjects were considered. Overall 28 evidence-based recommendations were issued, which included one level I, seven level IIA, ten level IIB, and ten level III recommendations. This article will focus on summarizing the 14 new or updated recommendations, and point out key differences compared to the 2007 guidelines. It should be noted that the 4th Edition is transitional, as there will not be a 5th edition. Instead, the guidelines are moving to a model of continuous monitoring of literature, rapid updates to evidence review, and revisions to recommendations as evidence warrants. The concept of a “Living Guideline” reflects advances in technology, increasing volume of available information, and the change in expectations among clinicians and other stakeholders. A static document updated every few years no longer serves the demands of the community. TREATMENTS Decompressive Craniectomy: Bifrontal DC is not recommended to improve outcomes as measured by the GOS-E score at 6 months post-injury in severe TBI patients with diffuse injury (without mass lesions), and with ICP elevation to values >20 mm Hg for more than 15 minutes within a 1-hour period that are refractory to first-tier therapies. However, this procedure has been demonstrated to reduce ICP and to minimize days in the intensive care unit (ICU) (Level II A). A large frontotemporoparietal DC (not less than 12 x 15 cm or 15 cm diameter) is recommended over a small frontotemporoparietal DC for reduced mortality and improved neurologic outcomes (Level II A). This is a new topic. Of note, this recommendation may be modified soon based on the recent RESCUEicp trial that showed better ICP control and lower mortality in surgically decompressed patients, but with higher rates of vegetative states and severe disability. Prophylactic Hypothermia: Early (within 2.5 hours), short-term (48 hours post-injury) prophylactic hypothermia is not recommended to improve outcomes in patients with diffuse injury (Level II B). Utility of hypothermia is still under investigation for refractory ICP control, and must be balanced with the risks of coagulopathy, immunosuppression, and cardiac dysrhythmias. This is a stronger recommendation than the prior edition that was based on subgroups from a meta-analysis, which no longer met current standards for inclusion. Cerebrospinal Fluid Drainage: An EVD system zeroed at the midbrain with continuous drainage of CSF may be considered to lower ICP burden more effectively than intermittent use (Level III). Use of CSF drainage to lower ICP in patients with an initial Glasgow Coma Scale (GCS) <6 during the first 12 hours after injury may be considered (Level III). While these guidelines support the use of an EVD to lower ICP, the effect of this on mortality and morbidity remains unknown. This is a new topic. Nutrition: Feeding patients to attain basal caloric replacement at least by the 5th day and at most by the 7th day post-injury is recommended to decrease mortality (Level II A). Transgastric jejunal feeding is recommended to reduce the incidence of ventilator-associated pneumonia (Level II B). Differences in intermittent vs continuous feedings, enteral vs parenteral routes, vitamins/supplements, and glycemic controls did not alter outcomes. These recommendations are based on additional evidence and introduce an earlier time point for attaining basal caloric replacement as well as a comment on the route of feeding. Infection Prophylaxis: The use of povidone-iodine (PI) oral care is not recommended to reduce ventilator-associated pneumonia (VAP) and may cause an increased risk of acute respiratory distress syndrome (Level II A). Antimicrobial-impregnated catheters may be considered to prevent catheter-related infections during external ventricular drainage (EVD) (Level III). In the TBI population, VAP can be as high as 40% and EVD infections 27%, and are associated with worse neurological outcomes. These were independent of early vs late tracheostomy, prophylactic antibiotics, or PI oral care. Early tracheostomy is still given a Level II A recommendation. The revision adds a recommendation regarding VAP, modifies the prior recommendation regarding EVDs, and removes prior comments regarding periprocedural use of antibiotics. Seizure Prophylaxis: At the present time there is insufficient evidence to recommend LEV over PTN regarding efficacy in preventing early PTS and toxicity (No level). Prior recommendations regarding prophylactic use of other anti-seizure medications remain in the new edition. The new statement was added based on variability in clinical practices and conflicting studies. MONITORING ICP Monitoring: Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality (Level II B). Level 1 evidence is lacking mainly because of routine use of ICP monitoring in developed nations and lack of equipoise, although basing treatment on radiographic and clinical data may be equally effective. This statement was felt to best represent current data. Some prior recommendations were restated in the current version with the acknowledgement that they are not supported by currents standards for evidence. CPP Monitoring: Management of severe TBI patients using guidelines-based recommendations for CPP monitoring is recommended to decrease 2-week mortality (Level II B). Monitoring ICP and CPP does not change outcomes, only using these measurements in addition to clinical assessment for treatment decisions. CPP monitoring and threshold recommendations have been separated in this edition. Lori Shutter, MD 6


eMag_264548_NCS Currents_December2016_3
To see the actual publication please follow the link above