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Management of moderate to severe traumatic brain injury: an update for the intensivist

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A Correction to this article was published on 20 June 2022

This article has been updated

Abstract

Traumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary insults and optimizing the balance between substrate delivery and consumption. Over the past decades, multimodality monitoring has become more widely available, and clinical management protocols have been published that recommend potential interventions to correct pathophysiological derangements. Even while evidence from randomized clinical trials is still lacking for many of the recommended interventions, these protocols and algorithms can be useful to define a clear standard of therapy where novel interventions can be added or be compared to. Over the past decade, more attention has been paid to holistic management, in which hemodynamic, respiratory, inflammatory or coagulation disturbances are detected and treated accordingly. Considerable variability with regards to the trajectories of recovery exists. Even while most of the recovery occurs in the first months after TBI, substantial changes may still occur in a later phase. Neuroprognostication is challenging in these patients, where a risk of self-fulfilling prophecies is a matter of concern. The present article provides a comprehensive and practical review of the current best practice in clinical management and long-term outcomes of moderate to severe TBI in adult patients admitted to the intensive care unit.

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Fig. 1

(modified from The Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)). In patients with ICP monitoring (with/without additional brain oxygen monitoring) the four represent the starting points for deciding a treatment strategy. Tier 0, i.e. basic strategies (not included in the flowchart), apply to TBI patients who are admitted to an intensive care unit (ICU) for whom the decision to monitor ICP has been made. The goal of tier‐zero is to establish a stable, neuroprotective physiologic baseline regardless of eventual ICP readings. Tier-zero sedatives and analgesics target comfort and ventilator tolerance, temperature management targets the avoidance of fever and CPP > 60 mm Hg. Lower tier treatments are viewed as having a more favorable side effect profile than higher tiers and generally should be employed first. Treatments in any given tier are considered equivalent, with the selection of one treatment over another based on individual patient characteristics and physician discretion and multiple items from a single tier can be trialed individually or in combination with the goal of a rapid response. The provider should consider moving to more aggressive interventions in a higher tier quickly if the patient is not responding. Panel A Patients with ICP below the threshold usually do not need treatment except for conditions in which a high intracranial pressure–time burden is present because this condition is associated with worse outcomes. Refer to [1] for details. Therefore, in this setting, treatment could be considered also below the classical threshold of 22 mmHg. Panel B Consensus-based algorithm for the management of severe traumatic brain injury with brain hypoxia and normal intracranial pressure. Panel C Consensus-based algorithm for the management of severe traumatic brain injury with intracranial hypertension and brain hypoxia. Panel D Consensus-based algorithm for the management of severe traumatic brain injury with intracranial hypertension and normal brain oxygenation. Inter-tier recommendations encourage patient reassessment for remediable causes of treatment resistance. Stepping to a higher tier is a potential indicator of increased disease severity. As higher tiers represent interventions with increased associated risks, we recommend reassessing the patient’s basic intra-and extra-cranial physiologic status and reconsidering the surgical status of intracranial mass lesions not previously considered operative

Fig. 2

Change history

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Funding

No specific funding was obtained for this manuscript. Geert Meyfroidt is supported Flemish Government (Research Foundation–Flanders (FWO)), as Senior Clinical Researcher (1843118 N) and has project funding from the KU Leuven (C24/17/072).

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All authors have contributed to sections of the text. GM has written the first draft and drafted the final manuscript. First editing was done by GC. All authors have proofread the first draft and made corrections. All authors have read and approved the final draft.

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MPC receives funding from the Research Foundation Flanders (FWO) (Grant No. 1832817N) and Onderzoeksraad, KU Leuven (Grant No. C24/17/070) and from the Private Charity Organization “Help Brandwonden Kids”. AIRM declares receiving institutional support for CENTER-TBI from the European Union seventh Framework Program (grant 602150), and additional support from the Hannelore Kohl Stiftung (Germany), from OneMind (USA), from Integra LifeSciences Corporation (USA) and from NeuroTrauma Sciences (USA). Personal fees were received from PresuuraNeuro (DSMB) and NeuroTrauma Sciences, outside the scope of this work. DKM reports grants, consultancy fees, or payment for educational activity, from NeuroTrauma Sciences LLC, Lantmannen AB, GlaxoSmithKline Ltd, Calico LLC, Cortirio Ltd, all outside the submitted work. VFJN hold a grant from Roche Pharmaceuticals related to blood biomarkers and TBI. MO is consultant and member of Scientific Advisory Board of Neuroptics. MS is Editor-in-Chief of the Journal of Neurosurgical Anesthesiology. FST received lecture fees from INTEGRA and is Advisory Board Member from Neuroptics, all outside the submitted work. GC reports grants, personal fees as Speakers’ Bureau Member and Advisory Board Member from Integra and Neuroptics, all outside the submitted work. The other authors declare no conflicts of interest.

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Meyfroidt, G., Bouzat, P., Casaer, M.P. et al. Management of moderate to severe traumatic brain injury: an update for the intensivist. Intensive Care Med 48, 649–666 (2022). https://doi.org/10.1007/s00134-022-06702-4

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