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

Antecedentes La lesión cerebral traumática grave (TCE) es un importante problema de salud mundial que afecta de manera desproporcionada a los países de ingresos bajos y medios (PIBM). El manejo de la hipertensión intracraneal en la sTBI es crucial para la supervivencia y la recuperación óptima. Los médicos de los países de ingresos altos utilizan habitualmente monitores de presión intracraneal (PIC), aunque se ha cuestionado su utilidad. Los monitores ICP generalmente no están disponibles en los países de ingresos bajos y medianos. No existen protocolos o literatura probados / basados ​​en consenso para el tratamiento de la sTBI sin monitoreo de la PIC. Métodos Los investigadores desarrollaron encuestas en serie de SurveyMonkey para neurointensivistas y neurocirujanos latinoamericanos para determinar la práctica actual. Estos médicos tenían una amplia experiencia continua de rutina en sTBI sin monitorización de la PIC. Las encuestas se administraron y analizaron antes / durante / después de una conferencia de consenso en Buenos Aires de 2015. Los investigadores identificaron áreas de convergencia cegadas a las respuestas de los colegas. Un grupo de trabajo de 47 médicos, que representa a 15 países, que trata de forma rutinaria a pacientes con TCE sin monitores, desarrolló pautas de tratamiento basadas en consenso durante una conferencia facilitada de 3 días. Resultados Se agregaron elementos al protocolo a un umbral de acuerdo del 80%. Las encuestas de seguimiento resolvieron los elementos restantes con un 97% de acuerdo. El protocolo aborda tanto la disminución gradual (en la mejora) como el empeoramiento neurológico. Se identificaron opciones de tratamiento por etapas, además de problemas únicos de práctica clínica. Este proceso introdujo un método de investigación a un gran grupo multidisciplinario de médicos de LMIC. Este informe describe el proceso utilizado para desarrollar un protocolo específico de LMIC que es transferible a otras enfermedades / lesiones. El protocolo se está probando en 5 LMIC. Conclusiones Derivamos pautas consensuadas para el tratamiento de la sTBI sin monitorización de la PIC, e introdujimos un método de investigación a un gran grupo multidisciplinario de médicos de LMIC sin experiencia en tales métodos.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 method

Development of a severe traumatic brain injury consensus-based treatment protocol conference in Latin America

Antecedentes La lesión cerebral traumática grave (TCE) es un importante problema de salud mundial que afecta de manera desproporcionada a los países de ingresos bajos y medios (PIBM). El manejo de la hipertensión intracraneal en la sTBI es crucial para la supervivencia y la recuperación óptima. Los médicos de los países de ingresos altos utilizan habitualmente monitores de presión intracraneal (PIC), aunque se ha cuestionado su utilidad. Los monitores ICP generalmente no están disponibles en los países de ingresos bajos y medianos. No existen protocolos o literatura probados / basados ​​en consenso para el tratamiento de la sTBI sin monitoreo de la PIC. Métodos Los investigadores desarrollaron encuestas en serie de SurveyMonkey para neurointensivistas y neurocirujanos latinoamericanos para determinar la práctica actual. Estos médicos tenían una amplia experiencia continua de rutina en sTBI sin monitorización de la PIC. Las encuestas se administraron y analizaron antes / durante / después de una conferencia de consenso en Buenos Aires de 2015. Los investigadores identificaron áreas de convergencia cegadas a las respuestas de los colegas. Un grupo de trabajo de 47 médicos, que representa a 15 países, que trata de forma rutinaria a pacientes con TCE sin monitores, desarrolló pautas de tratamiento basadas en consenso durante una conferencia facilitada de 3 días. Resultados Se agregaron elementos al protocolo a un umbral de acuerdo del 80%. Las encuestas de seguimiento resolvieron los elementos restantes con un 97% de acuerdo. El protocolo aborda tanto la disminución gradual (en la mejora) como el empeoramiento neurológico. Se identificaron opciones de tratamiento por etapas, además de problemas únicos de práctica clínica. Este proceso introdujo un método de investigación a un gran grupo multidisciplinario de médicos de LMIC. Este informe describe el proceso utilizado para desarrollar un protocolo específico de LMIC que es transferible a otras enfermedades / lesiones. El protocolo se está probando en 5 LMIC. Conclusiones Derivamos pautas consensuadas para el tratamiento de la sTBI sin monitorización de la PIC, e introdujimos un método de investigación a un gran grupo multidisciplinario de médicos de LMIC sin experiencia en tales métodos.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 method

Consensus-based management protocol (CREVICE protocol) for the treatment of severe traumatic brain injury based on imaging and clinical examination for use when intracranial pressure monitoring is not employed

Globally, intracranial pressure (ICP) monitoring use in severe traumatic brain injury (sTBI) is inconsistent and susceptible to resource limitations and clinical philosophies. For situations without monitoring, there is no published comprehensive management algorithm specific to identifying and treating suspected intracranial hypertension (SICH) outside of the one ad hoc Imaging and Clinical Examination (ICE) protocol in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST:TRIP) trial. As part of an ongoing National Institutes of Health (NIH)-supported project, a consensus conference involving 43 experienced Latin American Intensivists and Neurosurgeons who routinely care for sTBI patients without ICP monitoring, refined, revised, and augmented the original BEST:TRIP algorithm. Based on BEST:TRIP trial data and pre-meeting polling, 11 issues were targeted for development. We used Delphi-based methodology to codify individual statements and the final algorithm, using a group agreement threshold of 80%. The resulting CREVICE (Consensus REVised ICE) algorithm defines SICH and addresses both general management and specific treatment. SICH treatment modalities are organized into tiers to guide treatment escalation and tapering. Treatment schedules were developed to facilitate targeted management of disease severity. A decision-support model, based on the group's combined practices, is provided to guide this process. This algorithm provides the first comprehensive management algorithm for treating sTBI patients when ICP monitoring is not available. It is intended to provide a framework to guide clinical care and direct future research toward sTBI management. Because of the dearth of relevant literature, it is explicitly consensus based, and is provided solely as a resource (a “consensus-based curbside consult”) to assist in treating sTBI in general intensive care units in resource-limited environments