Does no one working on brain injuries understand that protocols are needed, NOT guidelines. Guidelines are lazy and an effective way not to take responsibility for patient recovery.
Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition
Update of the Brain Trauma Foundation Guidelines
Pediatric Critical Care Medicine:
March 2019 - Volume 20 - Issue 3S -
p S1–S82
doi: 10.1097/PCC.0000000000001735
Supplement
Free
Severe Traumatic Brain Injury in Infants, Children, and Adolescents in 2019: Some Overdue Progress, Many Remaining Questions, and Exciting Ongoing Work in the Field of Traumatic Brain Injury Research
In this Supplement to Pediatric Critical Care Medicine, we are pleased to present the Third Edition of the Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (TBI). This body of work updates the Second Edition of the guidelines that was published in 2012 (1).
It represents a substantial effort by a multidisciplinary group of
individuals assembled to reflect the team approach to the treatment of
these complex, critically ill patients that is essential to optimizing critical care
and improving outcomes. This work also represents the strong and
always-evolving partnership between investigators from the medical and
research communities, forged in Chicago in 2000, from which the first
pediatric TBI guidelines
were developed. The mutual trust and respect we share have been the
foundation of our commitment to bringing evidence-based care to children
with TBI.
Updating these guidelines
was particularly exciting to the individuals who have participated in
the previous two editions because several new studies have been
published which begin to address a number of major gaps in the pediatric
TBI literature—gaps that were specifically identified as targets for
future research in earlier editions. For example, we are now able to
include reports on the effects of commonly used sedatives and analgesics
on intracranial pressure (ICP). Similarly, initial head-to-head
comparisons of the influence of agents in routine “real world” use such
as hypertonic saline (HTS), fentanyl, and others now inform these guidelines (2 , 3).
A total of 48 new studies were included in this Third Edition. Although
some progress has been made and should be celebrated, overall the level
of evidence informing these guidelines
remains low. High-quality randomized studies that could support level I
recommendations remain absent; the available evidence produced only
three level II recommendations, whereas most recommendations are level
III, supported by low-quality evidence.
Based in part on a number of requests from the
readership to individual clinical investigators, we have included a
companion article in the regular pages of Pediatric Critical Care Medicine
that presents a “Critical Pathway” algorithm of care for both
first-tier and second-tier (refractory intracranial hypertension)
approaches. The algorithm reflects both the evidence-based
recommendations from these guidelines
and consensus-based expert opinion, vetted by the clinical
investigators, where evidence was not available. An algorithm was
provided in the First but not Second Editions of the guidelines,
and we believe that given the new reports available, along with the
existing gaps in evidence, a combination of evidence-based and
consensus-based recommendations provides additional and much-needed
guidance for clinicians at the bedside. The algorithm also addresses a
number of issues that are important but were not previously covered in
the guidelines,
given the lack of research and the focus 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 impending herniation, integration
of multiple monitoring targets, and other complex issues such as
minimal versus optimal therapeutic targets and approaches to weaning
therapies. We hope that the readership finds the algorithm document
helpful, recognizing that it represents a challenging albeit important
step.
Designing and developing this pediatric TBI evidence-based guidelines
document required an expert administrative management team, and to that
end, we are extremely grateful to the staff of the Pacific Northwest
Evidence-based Practice Center, Oregon Health & Science University,
for their vital contribution to this work. We are also grateful to the
Brain Trauma Foundation and the Department of Defense for supporting the
development and publication of these guidelines
documents. We are grateful to the endorsing societies for recognizing
the importance of this work and for the considerable work of the
clinical investigators in constructing the final document. We are also
pleased to have collaborated with the Congress of Neurological Surgeons
and the journal Neurosurgery that is copublishing the Executive Summary document of these guidelines
for its readership. We are also grateful to Hector Wong for serving as
Guest Editor, along with the external reviewers of this final document.
Finally, we thank each of the clinical investigators and coauthors on
this project. We believe that the considerable uncompensated time and
effort devoted to this important project will help to educate clinicians
worldwide and enhance the outcomes of children with severe TBI.
Clinical investigators provided Conflict of Interest Disclosures at the
beginning of the process, which were re-reviewed at the time of
publication. No clinical investigator made inclusion decisions or
provided assessments on publications for which they were an author.
Looking forward, it is important to recognize that these guidelines were written as the Approaches and Decisions in Acute Pediatric TBI Trial (ADAPT) (4–6),
one of the most important in the field of pediatric TBI, was coming to a
close. The ADAPT completed enrollment of 1,000 cases of severe
pediatric TBI and is one example of the recent heightened general
interest in TBI as a disease. This new interest in the importance of TBI
has emerged in part from the recognition of the high prevalence of TBI
across the injury severity spectrum, particularly concussion, and from
the need for new classification systems and new trial design for TBI in
both children and adults (7 , 8).
In addition, the emerging links between TBI and a number of
neurodegenerative diseases have broadened the interest in TBI, have led
to additional support of TBI research, and have produced an
unprecedented level of research in TBI and a quest for new therapies (9–11).
We expect that the results of ADAPT, along with those of other ongoing
and recently completed research in the field, will help provide new
insight and clarity into the acute medical management (MM) of infants,
children, and adolescents with severe TBI, and mandate further
refinement of the recommendations in these documents. We know that we
speak for the entire team of clinical investigators in welcoming the
opportunity to incorporate additional high-level evidence into future
updates of these guidelines.
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