Update on Guidelines for Traumatic Brain Injury Current TBI Guidelines Shirley I. Stiver MD, PhD Department of Neurosurgery Guidelines for the management of traumatic brain injury Journal of Neurotrauma 24(S), May 2007 Impact of TBI Guidelines Impact of TBI Guidelines 277 trauma centers Routine ICP monitoring 1995 28% 2005 78% Ghajar Crit Care Med 23: 560 (1995) Hesdorffer J Trauma 52: 1202 (2002) Predictors of Guideline Compliance 1. Neurosurgical residency program (OR 5.0) 2. State / American College Surgeons Accreditation (OR 5.0) 3. Treatment protocols (OR 3.6) 1994-1999 93 patients Pre-TBI Guidelines N = 37 Post-TBI Guidelines N = 56 GOS=1 Died GOS=2&3 Severe Disability GOS=4&5 Good Outcome 16(43%) 11(30%) 10 (27%) 9(16%) 8(14%) 39 (70%) Post- versus pre- : 9.1 times higher odds ratio of a good outcome Palmer et al J Trauma 50: 657-64 (2001) Guidelines Central Concept Primary Injury Mechanical Vascular Secondary Injury Not all neurological damage from TBI occurs at the moment of impact New Classification I Must do II III Can do s of Evidence Standard Guideline Option Evidence Good quality RCT Moderate quality RCT Good quality cohort, case-control study Poor RCT Moderate/poor cohort, case-control Case series, Databases 1
Topic I II Blood pressure and oxygenation - Hyperosmolar therapy - Prophylactic hypothermia - - Infection prophylaxis - DVT prophylaxis - - Indications for ICP monitoring - ICP monitoring technology ICP thresholds - CPP thresholds - Brain oxygen monitoring and thresholds - - Anesthetics, analgesics, and sedatives - Nutrition - Anti-seizure prophylaxis - Hyperventilation - Steroids - - III Unchanged Guidelines I Must Do Steroids are NOT recommended for improving outcome or reducing ICP in patients with moderate or severe CRASH TBI Outcome High dose @6mo methylprednisolone is Dead associated with increased mortality and is contraindicated Steroid 1248 (26%) Placebo 1075 (22%) Crash Lancet 364: 1321 (2004); Lancet 365: 1957 (2005) Blood Pressure Avoid hypotension sbp < 90 mmhg Hyperventilation Prophylactic (PaCO2 < 25mmHg) not recommended ICP Monitoring Technology ICP Monitoring All severe TBI with GCS < 8 & abnormal CT Intracranial Pressure Thresholds Treat for ICP > 20 mmhg Pressure Volume Curve Ventricular catheter connected to external gauge is most accurate, low-cost & reliable Accuracy : 2mmHg in range 0-20mmHg 10% in range 20-100mmHg 2
Seizures Anticonvulsants recommended to decrease the incidence of early seizures, < 7days) (early seizures not associated with worse outcome) Prophylactic use of dilantin or valproate to prevent onset of Late post-traumatic seizures is NOT recommended Nutrition Feed beginning the first 72 hours to attain a full caloric replacement by post-injury day 7 I Can do Hypoxia Avoid PaO2 < 60mmHg or O2 sat< 90% Hyperventilation Temporizing measure for raised ICP Avoid first 24 hours after injury If used, augment with SjVO2 / PBrO2 Update TBI Guidelines Brain oxygen monitoring and thresholds Prophylactic Hypothermia Infection Prophylaxis Deep Vein thrombosis prophylaxis NEW Brain Oxygen Monitoring and Thresholds New Background ICP gives limited information about cerebral blood flow, oxygen delivery, metabolism Jugular venous saturation and brain tissue oxygen monitoring useful for detecting cerebral ischemia in patients with severe TBI Jugular venous saturation Brain oxygen tension (PBrO2) Treatment Threshold < 50% < 15 mmhg Prophylactic Hypothermia New Hypothermia slows cerebral metabolism ; 5-7% decrease in CMR02 for every C Control of intracranial hypertension Subgroup analysis duration, target temp, re-warm rate III can do Prophylactic hypothermia: NOT associated with decreased all cause mortality when compared with normothermic controls Lower risk of mortality if hypothermia maintained >48 hours (RR 0.51) Associated with higher GOS scores ; 32-35 C Good outcome 3
Infection Prophylaxis New Background ICP monitoring infections as high as 27% CSF cultures 8% infection rate EVD catheter tips 14% infection rate Duration of monitoring > 5 days Other concurrent systemic infections Ivh or SAH Open skull fracture, basilar skull # with CSF leak Leakage around catheter Infection Prophylaxis New Prophylactic antibiotics Not recommended for ventricular catheter placement Routine catheter exchange offers no benefit Flushing of the ventricular catheter not recommended Bacitracin flushes : 18% infection rate vs 6% controls Aucoin Am J Med 80: 369 (1986) Infection Prophylaxis Preliminary Antibiotic impregnated catheters safe and effective 288 patients (37 TBI) minocycline & rifampin impregnated catheters Infection rate Colonization rate Impregnanted 1% 18% Nonimpregnanted 9% 37% Zambramski Neurosurgery 98: 725(2003) Deep Venous Thrombosis New Without prophylaxis, Incidence of DVT in severe TBI 20% Mechanical Prophylaxis Graduated compression stocking or intermittent pneumatic compression recommended until ambulatory Pharmacological Prophylaxis Low MW /unfractionated heparin in combination with mechanical prophylaxis ; risk of expansion of ICH Three Revised Topics Hyperosmolar therapy (previously Mannitol ) Anesthesia, analgesics, and sedatives (previously Barbiturates ) Cerebral Perfusion Thresholds Revised Hyperosmolar Therapy Revised Mannitol II Mannitol (0.25-1.0 gm/kg) for ICP control ; avoid arterial hypotension Prior to ICP monitoring, Restrict mannitol use to patients with signs of impending cerebral herniation 4
Anesthetics, Analgesics, and Sedation Revised Propofol Infusion Syndrome II Should follow Propofol is recommended for ICP control, (but does not improve mortality or 6mo outcome) Barbiturates-prophylactic administration to induce burst suppression EEG is NOT recommended High-dose barbiturate administration recommended for ICP control, refractory to maximum medical and surgical therapy ; maintain hemodynamic stability Children, but also adults Clinical features: Hyperkalemia Hepatomegaly Lipemia Metabolic acidosis Myocardial failure Rhabdomyolysis Renal failure death Cerebral Perfusion Thresholds Revised Optimal CPP remains unanswered Cerebral Perfusion Thresholds II Should follow Avoid aggressive attempts to maintain CPP > 70 mmhg with fluids and pressors; increased risk of ARDS Geoffrey T. Manley, Chief of Neurotrauma SFGH, UCSF Kia Shahlaie, Neurosurgery, UC Davis 5