Patrick M Kochanek1, Robert C Tasker2, Nancy Carney3, Annette M Totten4, P David Adelson5, Nathan R Selden6, Cynthia Davis-O'Reilly7, Erica L Hart8, Michael J Bell9, Susan L Bratton10, Gerald A Grant11, Niranjan Kissoon12, Karin E Reuter-Rice13, Monica S Vavilala14, Mark S Wainwright15. 1. Ake N. Grenvik Professor of Critical Care Medicine, Vice Chair, Department of Critical Care Medicine, Professor of Anesthesiology, Pediatrics, Bioengineering, and Clinical and Translational Science, Director, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA. 2. Department of Neurology and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA. 3. Professor, Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR. 4. Associate Professor, Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland OR. 5. Diane and Bruce Halle Endowed Chair in Pediatric Neurosciences, Chief, Pediatric Neurosurgery, Director, BARROW Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ. 6. Chair, Department of Neurological Surgery, Oregon Health & Science University, Portland, OR. 7. Research Associate, Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland OR. 8. Research Assistant, Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland OR. 9. Professor and Chief, Critical Care Medicine, Children's National Medical Center, Washington, DC. 10. Emeritus Professor of Pediatrics, University of Utah, Salt Lake City, UT. 11. Department of Neurosurgery, Stanford University, Stanford, CA. 12. Department of Pediatrics, British Columbia's Children's Hospital, Clinical Investigator, Child and Family Research Institute, University of British Columbia, Vancouver, BC. Canada. 13. School of Nursing/School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University, Durham, NC. 14. Professor & Vice Chair Strategic Affairs, Anesthesiology & Pain Medicine, Professor, Pediatrics, Director, Harborview Injury Prevention and Research Center (HIPRC), University of Washington, Seattle, WA. 15. Herman and Faye Sarkowsky Endowed Chair, Head, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, WA.
Abstract
OBJECTIVES: The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. METHODS AND MAIN RESULTS: This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. CONCLUSIONS: New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
OBJECTIVES: The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. METHODS AND MAIN RESULTS: This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. CONCLUSIONS: New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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