Guidelines for the Management of Severe Traumatic Brain Injury 4th Edition Nancy Carney, PhD Oregon Health & Science University, Portland, OR Annette M. Totten, PhD Oregon Health & Science University, Portland, OR Cindy O'Reilly, BS Oregon Health & Science University, Portland, OR Jamie S. Ullman, MD Hofstra North Shore-LIJ School of Medicine, Hempstead, NY Gregory W. J. Hawryluk, MD, PhD University of Utah, Salt Lake City, UT Michael J. Bell, MD University of Pittsburgh, Pittsburgh, PA Susan L. Bratton, MD University of Utah, Salt Lake City, UT Randall Chesnut, MD University of Washington, Seattle, WA Odette A. Harris, MD, MPH Stanford University, Stanford, CA Niranjan Kissoon, MD University of British Columbia, Vancouver, BC Andres M. Rubiano, MD El Bosque University, Bogota, Colombia; MEDITECH Foundation, Neiva, Colombia Lori Shutter, MD University of Pittsburgh, Pittsburgh, PA Robert C. Tasker, MBBS, MD Harvard Medical School & Boston Children’s Hospital, Boston, MA Monica S. Vavilala, MD University of Washington, Seattle, WA Jack Wilberger, MD Drexel University, Pittsburgh, PA David W. Wright, MD Emory University, Atlanta, GA Jamshid Ghajar, MD, PhD Stanford University, Stanford, CA Reviewed for evidence-based integrity and endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. September 2016 TABLE OF CONTENTS PREFACE ...................................................................................................................................... 5 ACKNOWLEDGEMENTS .............................................................................................................................................. 5 FUNDING SOURCE ...................................................................................................................................................... 6 DISCLAIMER OF LIABILITY ........................................................................................................................................ 6 CONFLICT OF INTEREST DISCLOSURE ........................................................................................................................ 7 AUTHORS’ PREFACE .................................................................................................................................................. 7 INTRODUCTION......................................................................................................................... 8 BRAIN TRAUMA RESEARCH: CURRENT CONDITIONS ................................................................................................. 8 THE BRAIN TRAUMA FOUNDATION’S POSITION ........................................................................................................ 9 THE BRAIN TRAUMA EVIDENCE-BASED CONSORTIUM ............................................................................................ 12 METHODS .................................................................................................................................. 14 SYSTEMATIC EVIDENCE REVIEW AND SYNTHESIS ................................................................................................... 14 DEVELOPMENT OF RECOMMENDATIONS .................................................................................................................. 22 EVIDENCE SYNTHESIS AND RECOMMENDATIONS, PART I: TREATMENTS ....... 25 1. DECOMPRESSIVE CRANIECTOMY ................................................................................................................... 26 2. PROPHYLACTIC HYPOTHERMIA ...................................................................................................................... 36 3. HYPEROSMOLAR THERAPY ............................................................................................................................ 49 4. CEREBROSPINAL FLUID DRAINAGE ................................................................................................................ 57 5. VENTILATION THERAPIES .............................................................................................................................. 62 6. ANESTHETICS, ANALGESICS, AND SEDATIVES ............................................................................................... 67 7. STEROIDS ....................................................................................................................................................... 76 8. NUTRITION ..................................................................................................................................................... 84 9. INFECTION PROPHYLAXIS............................................................................................................................... 99 10. DEEP VEIN THROMBOSIS PROPHYLAXIS ...................................................................................................... 111 11. SEIZURE PROPHYLAXIS ................................................................................................................................ 120 EVIDENCE SYNTHESIS AND RECOMMENDATIONS, PART II: MONITORING ... 130 12. INTRACRANIAL PRESSURE MONITORING ...................................................................................................... 132 13. CEREBRAL PERFUSION PRESSURE MONITORING .......................................................................................... 145 14. ADVANCED CEREBRAL MONITORING .......................................................................................................... 151 EVIDENCE SYNTHESIS AND RECOMMENDATIONS, PART III: THRESHOLDS .. 163 15. BLOOD PRESSURE THRESHOLDS .................................................................................................................. 164 16. INTRACRANIAL PRESSURE THRESHOLDS ...................................................................................................... 172 17. CEREBRAL PERFUSION PRESSURE THRESHOLDS .......................................................................................... 181 18. ADVANCED CEREBRAL MONITORING THRESHOLDS..................................................................................... 191 FUTURE RESEARCH ............................................................................................................. 201 TOPIC SELECTION AND REFINEMENT ..................................................................................................................... 201 METHODS—INDIVIDUAL STUDIES ......................................................................................................................... 202 METHODS—SYSTEMATIC REVIEWS AND GUIDELINES DEVELOPMENT .................................................................. 203 CONCLUSION ......................................................................................................................... 205 2 TABLES TABLE 1-1. QUALITY OF THE BODY OF EVIDENCE (DEPRESSIVE CRANIECTOMY) ................................................... 28 TABLE 1-2. SUMMARY OF EVIDENCE – CLASS 1 AND 2 STUDIES (DEPRESSIVE CRANIECTOMY) .............................. 29 TABLE 1-3. SUMMARY OF EVIDENCE – CLASS 3 STUDIES (DEPRESSIVE CRANIECTOMY) ........................................ 31 TABLE 2-1. QUALITY OF THE BODY OF EVIDENCE (PROPHYLACTIC HYPOTHERMIA) .............................................. 37 TABLE 2-2. SUMMARY OF EVIDENCE – CLASS 1 AND 2 STUDIES (PROPHYLACTIC HYPOTHERMIA) ......................... 39 TABLE 2-3. SUMMARY OF EVIDENCE–CLASS 3 STUDIES (PROPHYLACTIC HYPOTHERMIA) ..................................... 44 TABLE 3-1. QUALITY OF THE BODY OF EVIDENCE (HYPEROSMOLAR THERAPY) ..................................................... 51 TABLE 3-2. SUMMARY OF EVIDENCE - CLASS 2 (HYPEROSMOLAR THERAPY) ......................................................... 52 TABLE 3-3. SUMMARY OF EVIDENCE–CLASS 3 STUDIES (HYPEROSMOLAR THERAPY) ........................................... 54 TABLE 4-1. QUALITY OF THE BODY OF EVIDENCE (CEREBROSPINAL FLUID DRAINAGE)......................................... 58 TABLE 4-2. SUMMARY OF EVIDENCE – CLASS 3 STUDIES (CEREBROSPINAL FLUID DRAINAGE) ............................. 59 TABLE 5-1. QUALITY OF THE BODY OF EVIDENCE (VENTILATION THERAPIES) ....................................................... 64 TABLE 5-2. SUMMARY OF EVIDENCE (VENTILATION THERAPIES) ........................................................................... 65 TABLE 6-1. QUALITY OF THE BODY OF EVIDENCE (ANESTHETICS, ANALGESICS, AND SEDATIVES) ........................ 69 TABLE 6-2. SUMMARY OF EVIDENCE: CLASS 2 STUDIES (ANESTHETICS, ANALGESICS, AND SEDATIVES) ............... 70 TABLE 6-3. SUMMARY OF EVIDENCE: CLASS 3 STUDIES (ANESTHETICS, ANALGESICS, AND SEDATIVES) ............... 72 TABLE 7-1. QUALITY OF THE BODY OF EVIDENCE (STEROIDS) ................................................................................ 77 TABLE 7-2. SUMMARY OF EVIDENCE: CLASS 1 AND 2 STUDIES (STEROIDS) ............................................................ 78 TABLE 7-3. SUMMARY OF EVIDENCE: CLASS 3 STUDIES (STEROIDS) ...................................................................... 81 TABLE 8-1. QUALITY OF THE BODY OF EVIDENCE (NUTRITION) ............................................................................. 86 TABLE 8-2. SUMMARY OF EVIDENCE: CLASS 2 STUDIES (NUTRITION) .................................................................... 87 TABLE 8-3. SUMMARY OF EVIDENCE: CLASS 3 STUDIES (NUTRITION) ...................................................................