Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the 07/09/2019 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3oaxD/vH2r76VBJLc78Tw9i0ooXPDln19rdUVr3qDoxk= by https://journals.lww.com/pccmjournal from Downloaded Brain Trauma Foundation Guidelines Downloaded Patrick M. Kochanek, MD, MCCM1; Robert C. Tasker, MA, MD, FRCP2; Nancy Carney, PhD3; from Annette M. Totten, PhD4; P. David Adelson, MD, FACS, FAAP, FAANS5; https://journals.lww.com/pccmjournal Nathan R. Selden, MD, PhD, FACS, FAAP6; Cynthia Davis-O’Reilly, BS7; Erica L. Hart, MST8; Michael J. Bell, MD9; Susan L. Bratton, MD, MPH, FAAP10; Gerald A. Grant, MD11; Niranjan Kissoon, MD, FRCP(C), FAAP, MCCM, FACPE12; Karin E. Reuter-Rice, PhD, CPNP-AC, FCCM, FAAN13; Monica S. Vavilala, MD14; by 15 BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3oaxD/vH2r76VBJLc78Tw9i0ooXPDln19rdUVr3qDoxk= Mark S. Wainwright, MD, PhD 1Ake N. Grenvik Professor of Critical Care Medicine, Vice Chair, Depart- 15Herman and Faye Sarkowsky Endowed Chair, Head, Division of Pediatric Neu- ment of Critical Care Medicine, Professor of Anesthesiology, Pediatrics, rology, University of Washington, Seattle Children's Hospital, Seattle, WA. Bioengineering, and Clinical and Translational Science, Director, Safar This document was endorsed by the American Association of Neurologi- Center for Resuscitation Research, University of Pittsburgh School of cal Surgeons/Congress of Neurological Surgeons. Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA. Any opinions, findings, and conclusions or recommendations expressed 2 Department of Neurology and Department of Anesthesiology, Critical in this material are those of the authors and do not necessarily reflect the Care and Pain Medicine, Boston Children's Hospital, Harvard Medical views of the U.S. Army Contracting Command, Aberdeen Proving Ground, School, Boston, MA. Natick Contracting Division, Stanford University, or the Brain Trauma 3Professor, Pacific Northwest Evidence-based Practice Center, Depart- Foundation. The information contained in the Guidelines for the Manage- ment of Medical Informatics and Clinical Epidemiology, Oregon Health & ment of Pediatric Severe Traumatic Brain Injury reflects the current state of Science University, Portland, OR. knowledge at the time of publication. The Brain Trauma Foundation, Ameri- 4Associate Professor, Pacific Northwest Evidence-based Practice Cen- can Association of Neurological Surgeons, Congress of Neurological Sur- ter, Department of Medical Informatics and Clinical Epidemiology, Ore- geons, and other collaborating organizations are not engaged in rendering gon Health & Science University, Portland, OR. professional medical services and assume no responsibility for patient outcomes resulting from application of these general recommendations 5Diane and Bruce Halle Endowed Chair in Pediatric Neurosciences, in specific patient circumstances. Accordingly, the Brain Trauma Foun- Chief, Pediatric Neurosurgery, Director, BARROW Neurological Insti- dation, American Association of Neurological Surgeons, and Congress tute at Phoenix Children's Hospital, Phoenix, AZ. of Neurological Surgeons consider adherence to these clinical practice 6Chair, Department of Neurological Surgery, Oregon Health & Science guidelines will not necessarily assure a successful medical outcome. The University, Portland, OR. information contained in these guidelines reflects published scientific evi- 7Research Associate, Pacific Northwest Evidence-based Practice Cen- dence at the time of completion of the guidelines and cannot anticipate ter, Department of Medical Informatics and Clinical Epidemiology, Oregon subsequent findings and/or additional evidence, and therefore should not Health & Science University, Portland, OR. be considered inclusive of all proper procedures and tests or exclusive of on 8Research Assistant, Pacific Northwest Evidence-based Practice Center, other procedures and tests that are reasonably directed to obtaining the 07/09/2019 Department of Medical Informatics and Clinical Epidemiology, Oregon same result. Medical advice and decisions are appropriately made only Health & Science University, Portland, OR. by a competent and licensed physician who must make decisions in light 9 of all the facts and circumstances in each individual and particular case Professor and Chief, Critical Care Medicine, Children’s National Medical and on the basis of availability of resources and expertise. Guidelines are Center, Washington, DC. not intended to supplant physician judgment with respect to particular 10Emeritus Professor of Pediatrics, University of Utah, Salt Lake City, UT. patients or special clinical situations and are not a substitute for physician- 11Department of Neurosurgery, Stanford University, Stanford, CA. patient consultation. Accordingly, the Brain Trauma Foundation, American Association of Neurological Surgeons, and Congress of Neurological 12Department of Pediatrics, British Columbia’s Children’s Hospital, Clini- Surgeons consider adherence to these guidelines to be voluntary, with cal Investigator, Child and Family Research Institute, University of British the ultimate determination regarding their application to be made by the Columbia, Vancouver, BC. Canada. physician in light of each patient’s individual circumstances. 13School of Nursing/School of Medicine, Department of Pediatrics, Divi- sion of Pediatric Critical Care Medicine, Duke University, Durham, NC. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of 14 Professor & Vice Chair Strategic Affairs, Anesthesiology & Pain Medi- this article on the journal’s website (http://journals.lww.com/pccmjournal). cine, Professor, Pediatrics, Director, Harborview Injury Prevention and Research Center (HIPRC), University of Washington, Seattle, WA. Supported, in part, by the U.S. Army Contracting Command, Aberdeen Prov- ing Ground, and Natick Contracting Division, through a contract awarded 20 Copyright © 2019 by the Society of Critical Care Medicine and the World to Stanford University (W911 QY-14-C-0086), a subcontract awarded to Federation of Pediatric Intensive and Critical Care Societies Oregon Health & Science University. Previous editions were supported by DOI: 10.1097/PCC.0000000000001735 funding from multiple sources through the Brain Trauma Foundation. Pediatric Critical Care Medicine www.pccmjournal.org S1 Copyright © 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Unauthorized reproduction of this article is prohibited Kochanek et al Dr. Kochanek received funding from the Society of Critical Care Medicine that presents a “Critical Pathway” algorithm of care for both (Editor-in-Chief of Pediatric Critical Care Medicine), from serving as an first-tier and second-tier (refractory intracranial hypertension) expert witness on cases in pediatric critical care. Drs. Carney and Tot- ten’s, Ms. Davis-O’Reilly’s, and Ms. Hart’s institutions received funding approaches. The algorithm reflects both the evidence-based from Stanford University. Dr. Selden disclosed that he has stock options recommendations from these guidelines and consensus-based (current $0 value) in Cerebrotech for scientific advisory board service (this device is not clinically available and is not referenced in the work). expert opinion, vetted by the clinical investigators, where evi- Dr. Reuter-Rice received funding from textbook royalties and curriculum dence was not available. An algorithm was provided in the First content, and she received support for article research from Robert Wood but not Second Editions of the guidelines, and we believe that Johnson Foundation funding 2013–2016. Dr. Wainwright received fund- ing from Sage Therapeutics. The remaining authors have disclosed that given the new reports available, along with the existing gaps in they do not have any potential conflicts of interest. evidence, a combination of evidence-based and consensus-based Hector R. Wong, MD, is a Guest Editor. recommendations provides additional and much-needed guid- For information regarding this article, E-mail: [email protected]. ance for clinicians at the bedside. The algorithm also addresses edu (Pediatr Crit Care Med 2019; 20:S1–S82) a number of issues that are important but were not previously Key Words: critical care; evidence-based medicine; guidelines; covered in the guidelines, given the lack of research and the focus pediatrics; systematic review; traumatic brain injury on evidence-based recommendations. This includes addressing issues such as a stepwise approach to elevated ICP, differences in tempo of therapy in different types of patients, scenarios with a rapidly escalating need for ICP-directed therapy in the setting of Severe Traumatic Brain Injury in Infants, Children, impending herniation, integration of multiple monitoring tar- and Adolescents in 2019: Some Overdue Progress, gets, and other complex issues such as minimal versus optimal Many Remaining Questions, and Exciting Ongoing therapeutic targets and approaches to weaning therapies. We Work in the Field of Traumatic Brain Injury Research hope that the readership finds the algorithm document helpful, In this Supplement to Pediatric Critical Care Medicine, we are recognizing that it represents a challenging albeit important step. pleased to present the Third