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Development of a Severe Traumatic Brain Injury Consensus-Based Treatment Protocol Conference in Latin America.

ABSTRACT: BACKGROUND:Severe traumatic brain injury (sTBI) is a significant global health problem disproportionately affecting low- and middle-income countries (LMICs). Management of intracranial hypertension in sTBI is crucial to survival and optimal recovery. Practitioners in high-income countries routinely use intracranial pressure (ICP) monitors although their usefulness has been questioned. ICP monitors are usually unavailable in LMICs. No consensus-based/tested protocols or literature exists for sTBI treatment without ICP monitoring. METHODS:Investigators developed serial SurveyMonkey surveys for Latin American neurointensivists and neurosurgeons to determine current practice. These clinicians had extensive routine ongoing experience in sTBI without ICP monitoring. Surveys were administered and analyzed before/during/after a 2015 Buenos Aires consensus conference. Investigators identified areas of convergence blinded from colleagues' responses. A 47-clinician task force, representing 15 countries, who routinely manage patients with sTBI without monitors developed consensus-based treatment guidelines during a 3-day facilitated conference. RESULTS:Elements were added to the protocol at an 80% agreement threshold. Follow-on surveys resolved remaining elements to 97% agreement. The protocol addresses both tapering (on improvement) and neuroworsening. Staged treatment options were identified, plus unique clinical practice issues. This process introduced a research method to a large multidisciplinary group of LMIC clinicians. This report describes the process used to develop an LMIC-specific protocol that is transferable to other diseases/injuries. The protocol is being tested in 5 LMICs. CONCLUSIONS:We derived consensus-based guidelines for sTBI treatment without ICP monitoring, and introduced a research method to a large multidisciplinary group of LMIC clinicians naive to such methods.

SUBMITTER: Hendrickson P

PROVIDER: S-EPMC6214355 | biostudies-literature | 2018 Feb

REPOSITORIES: biostudies-literature

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Development of a Severe Traumatic Brain Injury Consensus-Based Treatment Protocol Conference in Latin America.

Hendrickson Peter P Pridgeon James J Temkin Nancy R NR Videtta Walter W Petroni Gustavo G Lujan Silvia S Guadagnoli Nahuel N Urbina Zulma Z Pahnke Perla Blanca PB Godoy Daniel D Pinero Gustavo G Lora Freddy Sandi FS Aguilera Sergio S Rubiano Andres M AM Morejon Caridad Soler CS Jibaja Manuel M Lopez Hubiel H Romero Ricardo R Dikmen Sureyya S Chaddock Kelley K Chesnut Randall M RM

World neurosurgery 20171205

<h4>Background</h4>Severe traumatic brain injury (sTBI) is a significant global health problem disproportionately affecting low- and middle-income countries (LMICs). Management of intracranial hypertension in sTBI is crucial to survival and optimal recovery. Practitioners in high-income countries routinely use intracranial pressure (ICP) monitors although their usefulness has been questioned. ICP monitors are usually unavailable in LMICs. No consensus-based/tested protocols or literature exists ...[more]

PMID: 29203307

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Project description:BackgroundSeveral methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty.AimTo formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities.MethodsA group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants.ResultsConsensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence.ConclusionThe Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.

Dataset Information

Development of a Severe Traumatic Brain Injury Consensus-Based Treatment Protocol Conference in Latin America.

Publications

Development of a Severe Traumatic Brain Injury Consensus-Based Treatment Protocol Conference in Latin America.

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