A Roquilly1, B Vigué2, M Boutonnet3, P Bouzat4, K Buffenoir5, E Cesareo6, A Chauvin7, C Court8, F Cook9, A C de Crouy10, P Denys11, J Duranteau2, S Fuentes12, T Gauss13, T Geeraerts14, C Laplace2, V Martinez15, J F Payen16, B Perrouin-Verbe17, A Rodrigues2, K Tazarourte18, B Prunet19, P Tropiano20, V Vermeersch21, L Velly22, H Quintard23. 1. Anaesthesiology and Intensive Care Unit, Hôtel-Dieu, Nantes University Hospital, Nantes, France. Electronic address: antoine.roquilly@chu-nantes.fr. 2. Anaesthesiology and Intensive Care Unit, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France. 3. Hôpital d'instruction des armées Percy, Clamart, France. 4. Grenoble Alps Trauma Centre, Department of Anaesthesia and Critical Care, Grenoble University Hospital, Grenoble, France. 5. Neurosurgery department, Nantes University Hospital, Nantes, France. 6. Edouard-Herriot University Hospital, Lyon, France. 7. Anaesthesiology and Intensive Care Unit, Lariboisière Hospital, AP-HP, Paris, France. 8. Orthopaedic Surgery Department, Spine and Bone Tumor Unit, Bicêtre University Hospital, Le Kremlin-Bicêtre, France. 9. Unité de réanimation chirurgicale polyvalente et de polytraumatologie, Albert-Chenevier-Henri-Mondor University Hospital, Créteil, France. 10. Unité SRPR/Réanimation chirurgicale, Bicêtre University Hospital, Le Kremlin-Bicêtre, France. 11. Orthopaedic department, Spine and Bone Tumor Unit. Bicêtre University Hospital, Le Kremlin Bicêtre, France. 12. Aix-Marseille University, AP-HM, Department of Neurosurgery, University Hospital Timone, Marseille, France. 13. Post-Intensive Care Rehabilitation Unit, Bicêtre University Hospital, Le Kremlin Bicêtre, France. 14. Anaesthesiology and Critical Care Department, Toulouse University Hospital, University of Toulouse 3-Paul Sabatier, Toulouse, France. 15. Neuro Urology Unit, Department of Physical Medicine and Rehabilitation. Raymond Poincaré University Hospital, Garches, France. 16. Department of Anaesthesia and Critical Care, Grenoble Alps University Hospital, 38000 Grenoble, France. 17. Department of Neurological Physical Medicine and Rehabilitation, Nantes University Hospital, Nantes, France. 18. Emergency department, Edouard-Herriot University Hospital, 69003 Lyon, France. 19. Department of Anaesthesia and Critical Care, Val-de-Grâce Hospital, Paris, France. 20. Aix-Marseille University, AP-HM, Orthopaedic and traumatic surgery, University Hospital Timone, Marseille, France. 21. Anaesthesiology and Intensive Care Unit, Brest University Hospital, Brest, France. 22. Aix Marseille University, AP-HM, Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Marseille, France. 23. Intensive Care Unit, Nice University Hospital, Pasteur 2 Hospital, Nice, France.
Abstract
OBJECTIVES: To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. DESIGN: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. RESULTS: The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS: There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.
OBJECTIVES: To update the French guidelines on the management of traumapatients with spinal cord injury or suspected spinal cord injury. DESIGN: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. RESULTS: The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS: There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.