Updated Guidelines for Management of Severe Traumatic Brain Injury

Authors: Dorothea S. Rosenberger, M.D., Ph.D. et al

ASA Monitor 12 2017, Vol.81, 38-40.

The Brain Trauma Foundation published its updated guidelines for the management of severe traumatic brain injury (sTBI) in fall 2016 on its website braintrauma.org, followed by an executive summary published in Neurosurgery in January 2017. The fourth edition of guidelines of sTBI is based on systematic review of Class 1 and Class 2/3 grade research studies, resulting in Level I, IIa/IIb and III recommendations.

The new guidelines include 28 evidence-based recommendations, of which 14 are new (e.g., cerebrospinal fluid drainage) or updated (e.g., hypothermia, nutrition and seizure prophylaxis) and 14 remain unchanged. The guideline chapters are treatment, monitoring and thresholds in the active management of sTBI. Summarized below are recommendations important for in-hospital care and related to risks for patients with severe TBI.

Interestingly, overall recommendations for anesthetic medications have not changed; it was reiterated that propofol at high doses can increase morbidity and it should therefore be used cautiously for lowering intracranial pressure (ICP). Despite proving effective for this indication, its use should not be expected to improve either mortality or outcome at six months after injury.

Recommendations for treatment, monitoring and thresholds relevant for all anesthesiologists who take care of patients with sTBI for trauma, orthopedic or any other procedures in the emergency room, O.R. and ICU are as follows:

• Hypothermia

Early (within 2.5 hours), short-term (48 hours post-injury), prophylactic (preceding elevation of intracranial pressure) hypothermia is not recommended to improve outcome in patients with diffuse injury. Therapeutic hypothermia is effective in reducing intracranial pressure but it does not improve outcome from sTBI.

• Management of ICP, cerebral perfusion pressure (CPP) and cerebrospinal fluid (CSF) drainage

• • 1) Treating ICP >22 mmHg is recommended to reduce mortality.
  • 2) The recommendations from the previous (2007) edition of the TBI guidelines pertaining to ICP monitoring are merely re-stated, acknowledging lack of evidence meeting current standards for a formal recommendation, while affirming that treatment of intracranial hypertension is an important element of optimal patient care. Therefore, “early ICP monitoring with external drainage (EVD) is recommended in all salvageable patients with severe TBI (GCS 3-8 after resuscitation) with imaging revealing hematoma, swelling, contusion, herniation or compressed basal cisterns, and especially if over 40 years of age, unilateral/bilateral motor posturing or SBP <90 mmHg.”
  • 3) CPP measurement is recommended as favorable out comes have been demonstrated with CPP 60-70 mmHg. Aggressive CPP increase >70 with vasopressors or fluids should be avoided, however. Determination of accurate measurement reference (heart versus tragus level) needs to be clearly communicated between anesthesiologist and surgical team. CPP measurement requires ICP monitoring.
  • 4) CSF drainage to lower ICP in patients with an initial GCS <6 during the first 12 hours after injury may be considered. External ventricular drainage systems should be zeroed at midbrain when continuous drainage is implemented (see also reference by SNACC Task Force for Developing Guidelines for Perioperative Management of Adult Patients with External Ventricular and Lumbar Drains snacc.societyhq.com/wp-content/uploads/2016/11/SNACC_EVD_LD_Manuscript.pdf).

• Mannitol: The current guidelines merely re-state the text of its previous edition, due to the lack of quality evidence

• • 1) Mannitol is effective in controlling ICP at a dose of 0.25-1 g/kg of body weight when ICP is >22 mmHg while monitoring plasma sodium levels. Arterial hypotension with systolic blood pressure <90 mmHg should be avoided.
  • 2) Prior to initiation of ICP monitoring, restrict empiric mannitol use to patients with signs of transtentorial herniation or progressive neurologic deterioration not attributable to extracranial causes.

• Blood pressure and ventilation management

• • 1) Systolic blood pressure >100 mmHg for patients 50-69 years old and >110 mmHg for both younger (15-49) and older (>70) patients is recommended.
  • 2) The third edition statement: “Avoid hyperventilation in the first 24 hours in the absence of SjO₂ or BtpO₂ monitoring; prolonged prophylactic hyperventilation with PaCO₂ <25 mmHg is NOT recommended” remains included in the current guidelines, recognizing, however, that it is not supported by evidence that meets current standards.

• Anesthetic drugs and other medications

• • 1) Propofol at high dose is not recommended, although propofol decreases ICP and is still included in the guidelines for this purpose.
  • 2) Barbiturates should be used only to control ICP after maximum surgical and medical therapy showed to be ineffective; they are reserved for the critical care setting provided hemodynamics are stable both before and after initiation of therapy.
  • 3) No high-dose steroids: High-dose methylprednisolone was associated with increased mortality.
  • 4) Seizure prophylaxis for preventing late post-traumatic seizures is not recommended. Selection of levetiracetam versus phenytoin (which is beneficial for seizures occurring soon after injury) is not supported by sufficient evidence

• Procedures

• • 1) Early basic caloric replacement, best via trans-gastric jejunal (post-pyloric) feeding tube by the fifth and no later than seventh day, is recommended to decrease mortality.
  • 2) Early tracheostomy is recommended to reduce mechanical ventilation days (provided ICP and other intracranial neurophysiologic measurements are congruent with a safe anesthetic).

Summary

Recommendations and guidelines as well as clinical, basic and translational science are in flux. The practical implementation of guidelines should be based on various data sources to improve outcome in sTBI. The authors acknowledge that sTBI might have in itself randomization bias for clinical studies and therefore give little guidance directed to intraoperative management. In the future, large-scale observational comparative effectiveness research (CER) studies might receive higher grading than in the past and could be considered in generation of guidelines supporting clinical decision-making. Guidelines are intended to serve as a starting point for individualized patient care protocols, and limitations in guidelines are an inspiration for future studies.

Bibliography:

Carney N, Totten AM, O’Reilly C, et al; for Brain Trauma Foundation. Guidelines for Management of Severe Traumatic Brain Injury. 4th ed. https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/. Published August 14, 2016. Last accessed October 6, 2017.

Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;80(1):6–15.

Volovici V, Haitsma IK, Dirven CMF, Steyerberg EW, Lingsma HF, Maas AIR . Letter: guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;81(2):E21.

Hawryluk GWJ, Ullman JS, Totten AM, Ghajar J . In reply: guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;81(1):E3–E4.

Kosty JA, Kofke WA . On a not-dead horse: CPP deserves more respect. J Neurosurg Anesthesiol. 2012;24(1):1–2.

Lele AV, Hoefnagel AL, Schloemerkemper N, et al; for SNACC Task Force for Developing Guidelines for Perioperative Mgmt. of External Ventricular and Lumbar Drains. Perioperative management of adult patients with external ventricular and lumbar drains: guidelines from the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol. 2017;29(3):191–210.