Peter Hendrickson1, James Pridgeon1, Nancy R Temkin1, Walter Videtta2, Gustavo Petroni3, Silvia Lujan3, Nahuel Guadagnoli4, Zulma Urbina5, Perla Blanca Pahnke6, Daniel Godoy7, Gustavo Pinero8, Freddy Sandi Lora9, Sergio Aguilera10, Andres M Rubiano11, Caridad Soler Morejon12, Manuel Jibaja13, Hubiel Lopez14, Ricardo Romero15, Sureyya Dikmen1, Kelley Chaddock1, Randall M Chesnut16. 1. Harborview Medical Center, University of Washington, Seattle, Washington, USA. 2. Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina. 3. Hospital Emergencia, Dr. Clemente Alvarez, Rosario, Argentina. 4. Hospital Emergencia, Hospital Privado de Rosario, Rosario, Argentina. 5. Hospital Erasmo Meoz ICU #1, Cucuta, Colombia. 6. Hospital Municipal de Urgencias, Cordoba, Argentina. 7. Sanatorio Pasteur, Catamarca, Argentina. 8. Leonidas, Lucero Hospital, Bahia Blanca, Argentina. 9. Hospital Obrero No 1 de La Paz, La Paz, Bolivia. 10. Hospital Regional, Inquique, Chile. 11. Meditech Foundation, El Bosque University, Neiva, Colombia. 12. Ameijeiras Hospital, La Habana, Cuba. 13. Hospital Eugenio Espejo, Quito, Ecuador. 14. Hospital General de la Plaza de la Salud, Santo Domingo, Dominican Republic. 15. Fundación Clinica Campbell, Barranquilla, Colombia. 16. Harborview Medical Center, University of Washington, Seattle, Washington, USA. Electronic address: chesnutr@uw.edu.
Abstract
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 methods.
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 methods.
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