Page 7

eMag_264548_NCS Currents_December2016_3

THRESHOLDS Blood Pressure Thresholds: Maintaining systolic blood pressure (SBP) at ≥100 mm Hg for patients 50 to 69 years old or at ≥110 mm Hg or above for patients 15 to 49 or over 70 years old may be considered to decrease mortality and improve outcomes (Level III). This recommendation based on new literature is a change from the previous edition that recommended avoidance of a SBP of less than 90mm Hg (Level II). ICP Thresholds: Treating ICP above 22 mm Hg is recommended because values above this level are associated with increased mortality (Level II B). Borderline ICP values should be interpreted in the context of CPP, PbtO2, and SjvO2 values. If these are normal a higher ICP may be acceptable. The prior recommendation to treat an ICP above 20 mm Hg was revised based on new literature and downward re-classification of older literature. CPP Thresholds: The recommended target cerebral perfusion pressure (CPP) value for survival and favorable outcomes is between 60 and 70 mm Hg. Whether 60 or 70 mm Hg is the minimum optimal CPP threshold is unclear and may depend upon the patient’s autoregulatory status (Level II B). CPP requires the monitoring of ICP, and levels greater than 70 mm Hg were associated with respiratory complications and worse outcomes. Increasingly the “ideal” CPP appears to be different for each patient, with those with intact pressure autoregulation tolerating higher CPP than those with dysfunctional pressure autoregulation. The previous recommendation to target CPP between 50 – 70 mm Hg was revised based on new literature and downward re-classification of prior evidence. The prior recommendation to avoid aggressive treatment to maintain CPP above 70 mm Hg has been retained as a Level III recommendation. Advanced Cerebral Monitoring & Thresholds: This is now separated into two sections addressing monitoring modalities and treatment thresholds individually. No new recommendations have been added, but the previous Level III recommendation regarding brain tissue oxygen thresholds has been removed based on conflicting evidence. As predicted, while some clarity has been shed on select areas of TBI management, the majority of decision making lacks high quality evidence-based recommendations. More disheartening is the continued utilization of study designs and protocols which will not produce strong evidence. It is our hope that these guidelines not only guide the decision making of clinicians, but also the topics and methods of future research. 7


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