BRAIN TRAUMA FOUNDATION GUIDELINE PPT (1).pptx

Brain trauma Foundation guidelines

1. BRAIN TRAUMA FOUNDATION GUIDELINE

2. Introduction 4th Edition of the BTF guidelines- Living Guidelines model Transitional Not intend to produce a 5th Edition A model of continuous monitoring of the literature, rapid updates to the evidence review Revisions to the recommendations as the evidence warrants

3. The Role of the BTF GUIDELINES A service organization dedicated to improving outcomes from TBI A evidence based guideline The Scope of the Guidelines Address treatment interventions Monitoring Treatment thresholds that are particular to TBI or That address a risk that is higher in TBI patients

4. Methods The development of guidelines encompasses two major activities: A systematic review and synthesis of evidence The derivation of recommendations 189 publications used for evidence- 5 Class 1, 46 Class 2, 136 Class 3 studies, and 2 meta-analyses

5. Class 1: Highest class and is limited to good-quality RCTs Class 2: Moderate-quality RCTs and good-quality cohort or case-control studies Class 3: Lowest class and is given to low-quality RCTs Moderate- to low-quality cohort or case control studies Case series and other non-comparative designs

6. Level of Recommendation Determined by the assessment of the quality of the body of evidence, rather than the class of the included studies Primarily based on the quality of the body of evidence Level I ( STANDARD) : high-quality - prospective RCTs Level II A ( GUIDELINE) : moderate-quality – well designed controlled trials without randomization Level II B (GUIDELINE): low-quality- well designed cohort or case controlled study Level III( OPTIONAL) : low-quality- case series, case reports, expert opinion

7. Topics Included in This Edition The topics are organized in three categories that are specific to severe TBI in adults: Treatments Monitoring Thresholds

8. Treatments Decompressive Craniectomy Prophylactic Hypothermia Hyperosmolar Therapy Cerebrospinal Fluid Drainage Ventilation Therapies Anesthetics , Analgesics, and Sedatives Steroids Nutrition Infection Prophylaxis Deep Vein Thrombosis Prophylaxis Seizure Prophylaxis Monitoring 12. Intracranial Pressure 13. Cerebral Perfusion Pressure 14. Advanced Cerebral Monitoring Thresholds 15. Blood Pressure 16. Intracranial Pressure 17. Cerebral Perfusion Pressure 18. Advanced Cerebral Monitoring

9. Major Changes for This Edition SUMMARY: • Cerebral Fluid Drainage (New topic) • Decompressive Craniectomy (New topic) • Deep Vein Thrombosis- For risks that are TBI-specific Direct evidence was not identified Indirect evidence was identified and included • Intracranial Pressure Technology- assessment is outside the scope of management guidelines and no longer included • Hyperventiliation -renamed “ Ventilation Therapies”

10. Continu …. Brain Oxygen Monitoring- renamed “ Advanced Cerebral Monitoring” Infection Prophylaxis Focus on Ventilator Associated Pneumonia (VAP) External Ventricular Drain infections Indirect evidence was identified and used Intracranial Pressure Monitoring, Cerebral Perfusion Pressure Monitoring, Advanced Cerebral Monitoring Divided into Benefits and risks of monitoring (Monitoring) Values to be targeted or avoided (Thresholds)

11. 1. Decompressive Craniectomy INTRODUCTION: Cerebral edema can result from a combination of several pathological mechanisms a/w primary and secondary injury patterns in TBI As pressure within the skull increases, brain tissue displacement can lead to cerebral herniation, resulting in disability or death Surgical removal of a “ portion of the skull” k/a decompressive craniectomy (DC) Performed for the purpose of relieving elevated ICP with outcome improvement in specific TBI patients

12. RECOMMENDATIONS Level I Insufficient evidence to support a Level I recommendation for this topic Level II A Bifrontal DC is not recommended to improve outcomes as measured by The Glasgow Outcome Scale–Extended (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)

13. Changes from Prior Edition DC is a new topic for this 4th Edition DC had been included in the surgical guidelines

14. 2. Prophylactic Hypothermia INTRODUCTION: Hypothermia is well recognized to preserve cells and tissue in the face of metabolic challenge Evidence supports the administration of hypothermia as standard of care for neuroprotection after cardiac arrest from acute coronary syndromes In addition to suggested neuroprotective effects, hypothermia is well known for its ability to reduce ICP Hypothermia bears risks, including coagulopathy and immunosuppression Profound hypothermia bears the additional risk of cardiac dysrhythmia and death

15. RECOMMENDATIONS Level I and II A Insufficient evidence to support a Level I or II A recommendation Level II B Early (within 2.5 hours), short-term (48 hours post-injury) prophylactic hypothermia is not recommended to improve outcomes in patients with diffuse injury

16. Changes from Prior Edition In the 3rd Edition The studies that compared hypothermia to normothermia were summarized in a meta-analysis For 4th Edition- Re-examined the underlying assumptions of our prior work in light of the current standards for meta-analysis and decided not to repeat the meta-analysis

17. 3. Hyperosmolar Therapy INTRODUCTION Mannitol was previously thought to reduce ICP through simple brain dehydration Both mannitol and hypertonic saline work to reduce ICP Reducing blood viscosity Improved microcirculatory flow of blood constituents and Consequent constriction of the pial arterioles

18. RECOMMENDATIONS Level I, II, and III Insufficient evidence about effects on clinical outcomes to support a specific recommendation, or To support use of any specific hyperosmolar agent, for patients with severe TBI

19. Changes from Prior Edition The Committee is universal in its belief that hyperosmolar agents are useful in the care of patients with severe TBI However, the literature does not currently support recommendations that meet the strict criteria for contemporary evidenced-based medicine approaches for guideline development

20. 4. Cerebrospinal Fluid Drainage INTRODUCTION: Management of external ventricular drainage (EVD) systems in patients with TBI remains a controversial topic EVD in a closed position allows for monitoring of ICP EVD in open position allows drainage of CSF can occur EVD should be maintained in a closed or open position vary widely based on a number of variables, including patient’s age, institutional resources, and physician preferences

21. A key variable in EVD management appears to be related to patient age. In the pediatric population continuous CSF drainage is a relatively common practice with evidence to support improvements in both ICP management and injury biomarkers.

22. RECOMMENDATIONS Level I and II There was insufficient evidence to support a Level I or II recommendation for this topic Level III An EVD system zeroed at the midbrain with continuous drainage of CSF may be considered to lower ICP burden more effectively than intermittent use Use of CSF drainage to lower ICP in patients with an initial GCS<6 6 during the first 12 hours after injury may be considered

23. Changes from Prior Edition New topic, added to the 4th Edition as CSF drainage Potential treatment to lower ICP

24. 5. Ventilation Therapies INTRODUCTION Patients with severe TBI require definitive airway protection They are at risk of pulmonary aspiration or compromised respiratory drive and function May also require transient hyperventilation to treat cerebral herniation Normal ventilation is currently the goal for severe TBI patients in the absence of cerebral herniation and normal PaCO2 ranges(35-45 mm Hg)

25. CBF is linearly responsive to PaCO2 Low PaCO2- results in low CBF and may result in cerebral ischemia High PaCO2- result in cerebral hyperemia and ICP Severe TBI patients receive mechanical ventilation, which can tightly regulate PaCO2 levels through rate and tidal volume adjustments

26. Older studies suggested- Cerebral hyperemia was more common than cerebral ischemia Hyperventilation was recommended in the care of patients with TBI More recent studies- after severe TBI, cerebral metabolic rate is not always low and can be variable In fact, cerebral ischemia has been documented in a number of studies after severe TBI Therefore, the high prevalence of cerebral ischemia in these patients suggests safety in providing normoventilation so as to prevent further cerebral ischemia and infarction

27. Level I and II A Isufficient evidence to support a Level I or II A recommendation f Level II B Prolonged prophylactic hyperventilation with PaCO2 of 25 mm Hg or less is not recommended

28. Recommendations from the Prior (3rd) Edition Not Supported by Evidence Meeting Current Standards Hyperventilation is recommended as a temporizing measure for the reduction of elevated ICP Hyperventilation should be avoided during the first 24 hours after injury when CBF is often critically reduced If hyperventilation is used, jugular venous oxygen saturation (SjO2) or brain tissue O2 partial pressure (BtpO2) measurements are recommended to monitor oxygen delivery

29. Changes from Prior Edition The title was changed from Hyperventilation to Ventilation Therapies.

30. 6. Anesthetics, Analgesics, and Sedatives INTRODUCTION Anesthetics, analgesics, and sedatives are important and commonly-used therapies in acute TBI for a variety of reasons Prophylaxis or control of IH and seizures To control ICP by preventing unnecessary movement, coughing, and straining against tubes Barbiturates, may also improve coupling of regional blood flow to metabolic demands resulting in higher brain oxygenation with lower CBF, and decreased ICP from decreased CBV Other brain protective mechanisms- inhibition of oxygen radical mediated lipid peroxidation

31. Side effects- Hypotension and decreased cardiac output, as well as increased intrapulmonary shunting, which may lead to hypoxia These may give rise to a paradoxical decrease in CPP which may negate the benefits of decreased ICP

32. RECOMMENDATIONS Level I and II A There was insufficient evidence to support a Level I or Level IIA recommendation Level II B Administration of barbiturates to induce burst suppression measured by EEG as prophylaxis against the development of IH is not recommended High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment Hemodynamic stability is essential before and during barbiturate therapy Propofol is recommended for the control of ICP and not recommended for improvement in mortality or 6-month outcomes Caution is required as high-dose propofol can produce significant morbidity

33. Changes from Prior Edition No content changes from the 3rd Edition to the recommendations

34. 7. Steroids INTRODUCTION Steroids were introduced in the early 1960s as a treatment for brain edema Experimental evidence accumulated that steroids were useful in the restoration of altered vascular permeability in brain edema- Reduction of CSF production Attenuation of free radical production Glucocorticoids were found to be beneficial to patients with brain tumors when administered in the perioperative period Based on this experience glucocorticoids became commonly administered to patients undergoing a variety of neurosurgical procedures and became commonplace in the treatment of severe TBI However, studies of severe TBI patients failed to find a benefit (CRASH trial)

35. RECOMMENDATIONS Level I The use of steroids is not recommended for improving outcome or reducing ICP In patients with severe TBI, high-dose methylprednisolone was associated with increased mortality and is contraindicated Changes from Prior Edition The body of evidence was updated to include the 6-month outcomes of the CRASH trial.14 There were no changes to the recommendations

36. Changes from Prior Edition The body of evidence was updated to include the 6-month outcomes of the CRASH trial No changes to the recommendations

37. 8. Nutrition INTRODUCTION Seminal work from the 1980s demonstrated that severe TBI was associated with increased energy expenditure early after injury TBI itself causes an intrinsic increase in metabolism and requirement for caloric support

38. RECOMMENDATIONS Level I There was insufficient evidence to support a Level I recommendation Level II A Feeding patients to attain basal caloric replacement at least by the fifth day and, at most, by the seventh day post-injury is recommended to decrease mortality Level II B Transgastric jejunal feeding is recommended to reduce the incidence of ventilator associated pneumonia

39. Changes from Prior Edition Additional evidence was identified and incorporated into revised recommendations that emphasize Early nutrition and Address the method of feeding

40. 9. Infection Prophylaxis INTRODUCTION Severe TBI can increase a patient’s susceptibility to infection- Necessary mechanical ventilation to prevent airway obstruction, aspiration Infection risks –VAP and central line-associated bacteremias are increased in all critically ill patients Patients undergoing ICP monitoring are reported to have related infection rates as high as 27%

41. RECOMMENDATIONS Level I There was insufficient evidence to support a Level I recommendation Level II A Early tracheostomy is recommended to reduce mechanical ventilation days when the overall benefit is felt to outweigh the complications associated with such a procedure However, there is no evidence that early tracheostomy reduces mortality or the rate of nosocomial pneumonia The use of povidone-iodine (PI) oral care is not recommended to reduce VAP and may cause an increased risk of acute respiratory distress syndrome Level III Antimicrobial-impregnated catheters may be considered to prevent catheter-related infections during EVD

42. Changes from Prior Edition The Level II recommendation from the 3rd Edition of these guidelines that stated “Periprocedural antibiotics for intubation should be administered to reduce the incidence of pneumonia” has not been carried forward

43. 10. Deep Vein Thrombosis Prophylaxis INTRODUCTION Patients with TBI are at significant risk for developing venous thromboembolism (VTE) TBI has been a/w up to 54% incidence of deep venous thrombosis without prophylactic treatment 25% incidence in patients with isolated TBI treated with sequential compression devices Reiff et al. demonstrated a three-to-four-fold increase in the DVT risk in TBI despite use of mechanical and chemoprophylaxis

44. Severe TBI patients can be at significant risk for VTE due to hypercoagulability resulting from the primary brain injury, prolonged periods of immobilization, and focal motor deficits If untreated, DVT can result in potentially debilitating or fatal pulmonary embolism

45. RECOMMENDATIONS Level I and II There was insufficient evidence to support a Level I or II recommendation Level III Low molecular weight heparin (LMWH) or low-dose unfractioned heparin may be used in combination with mechanical prophylaxis However, there is an increased risk for expansion of intracranial hemorrhage

46. Changes from Prior Edition The Level 3 recommendation supporting use of compression stockings has been incorporated in the recommendation about pharmacologic prophylaxis, as mechanical treatments such as stockings are the general standard of care and there is not a body of evidence or issues that are TBI-specific

47. 11. Seizure Prophylaxis INTRODUCTION Acute symptomatic seizures may occur as a result of severe TBI Such post-traumatic seizures (PTS) are classified- Early within 7 days of injury Late after 7 days following injury Post-traumatic epilepsy (PTE) is defined as recurrent seizures more than 7 days following injury In patients with severe TBI, the rate of clinical PTS may be as high as 12%, while that of subclinical seizures detected on electroencephalography may be as high as 20% to 25%

48. The risk factors for early PTS include GCS score of ≤10 Immediate seizures Post-traumatic amnesia lasting longer than 30 minutes Linear or depressed skull fracture Penetrating head injury Subdural, epidural, or intracerebral hematoma Cortical contusion Age ≤65 years Chronic alcoholism

49. RECOMMENDATIONS Level I There was insufficient evidence to support a Level I recommendation for this topic Level II A Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS Phenytoin is recommended to decrease the incidence of early PTS (within 7 days of injury), when the overall benefit is felt to outweigh the complications associated with such treatment However, early PTS have not been associated with worse outcomes At the present time there is insufficient evidence to recommend levetiracetam over phenytoin regarding efficacy in preventing early post-traumatic seizures and toxicity

50. Changes from Prior Edition The recommendations have not changed for this update from the 3rd Edition

51. 12. Intracranial Pressure Monitoring INTRODUCTION A mainstay of the care of the patients with the most severe brain injuries has been the monitoring treatment of ICP Because of its fundamental place in the care of patients with severe TBI and its relationship to overall outcomes, ICP monitoring has been included in every guideline for severe TBI published by the BTF

52. RECOMMENDATIONS Level I and II A There was insufficient evidence to support a Level I or II A recommendation for ICP monitoring Level II B Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality

53. Recommendations from the Prior (3rd) Edition Not Supported by Evidence Meeting Current Standards Recommendations from the Prior (3rd) Edition Not Supported by Evidence Meeting Current Standards ICP should be monitored in all salvageable patients with a severe TBI (GCS 3-8 after resuscitation) and an abnormal CT scan An abnormal CT scan of the head is one that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns ICP monitoring is indicated in patients with severe TBI with a normal CT scan if two or more of the following features are noted at admission: Age over 40 years, Unilateral or bilateral motor posturing SBP< 90 mm Hg

54. Changes from Prior Edition New Class 2 studies provide evidence for recommendations that replace those of the 3rd Edition of these guidelines

55. 13. Cerebral Perfusion Pressure Monitoring INTRODUCTION