A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

Gregory W J Hawryluk¹, Sergio Aguilera^{2

3}, Andras Buki^{4

5}, Eileen Bulger⁶, Giuseppe Citerio^{7

8}, D Jamie Cooper^{9

10}, Ramon Diaz Arrastia¹¹, Michael Diringer^{12

13}, Anthony Figaji¹⁴, Guoyi Gao¹⁵, Romergryko Geocadin¹⁶, Jamshid Ghajar¹⁷, Odette Harris¹⁸, Alan Hoffer¹⁹, Peter Hutchinson²⁰, Mathew Joseph²¹, Ryan Kitagawa²², Geoffrey Manley²³, Stephan Mayer²⁴, David K Menon²⁵, Geert Meyfroidt²⁶, Daniel B Michael²⁷, Mauro Oddo²⁸, David Okonkwo²⁹, Mayur Patel³⁰, Claudia Robertson³¹, Jeffrey V Rosenfeld^{32

33}, Andres M Rubiano^{34

35}, Juan Sahuquillo³⁶, Franco Servadei³⁷, Lori Shutter³⁸, Deborah Stein³⁹, Nino Stocchetti^{40

41}, Fabio Silvio Taccone⁴², Shelly Timmons⁴³, Eve Tsai⁴⁴, Jamie S Ullman⁴⁵, Paul Vespa^{46

47

48

49}, Walter Videtta⁵⁰, David W Wright⁵¹, Christopher Zammit⁵², Randall M Chesnut^{53

54

55

56}

Affiliations

¹ Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
² Almirante Nef Naval Hospital, Valparaiso University, Viña Del Mar, Chile.
³ Valparaiso University, Valparaiso, Chile.
⁴ Department of Neurosurgery, Medical School and Szentágothai Research Centre, Ifjúság Útja 20, Pécs, 7624, Hungary.
⁵ University of Pécs, Pécs, Hungary.
⁶ Department of Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Seattle, WA, 98104-2499, USA.
⁷ School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
⁸ Anaesthesia and Intensive Care, San Gerardo and Desio Hospitals, ASST-Monza, Monza, Italy.
⁹ Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.
¹⁰ Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia.
¹¹ Department of Neurology, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, 51 North 39th Street, Philadelphia, PA, 19104, USA.
¹² Department of Neurology, Washington University School of Medicine, St. Louis, USA.
¹³ Department of Neurology, Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza Suite 10400, St. Louis, MO, 63110, USA.
¹⁴ Division of Neurosurgery and Neuroscience Institute, Groote Schuur Hospital¸University of Cape Town, H53 Old Main Building, Main Road, Observatory, 7925, South Africa.
¹⁵ Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, 1630 Dongfang Road, Shanghai, 200127, China.
¹⁶ Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
¹⁷ Department of Neurosurgery, Stanford Neuroscience Health Center, 213 Quarry Rd 4th Fl, MC 5958, Palo Alto, CA, 94304, USA.
¹⁸ Department of Neurosurgery, 300 Pasteur Drive, Room R205, Edward's Building, MC: 5327, Stanford, CA, 94305, USA.
¹⁹ Department of Neurological Surgery, School of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 5042, Cleveland, OH, 44106, USA.
²⁰ Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge and Cambridge Biomedical Campus, Cambridge, CB20QQ, UK.
²¹ Department of Neurological Sciences, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India.
²² Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, 6400 Fannin St, Suite 2800, Houston, TX, 77030, USA.
²³ Department of Neurosurgery, San Francisco General Hospital and Trauma Center, University of California San Francisco, 1001 Potrero Ave., Bldg 1, Room 101, San Francisco, CA, 94110, USA.
²⁴ Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Neurology, K-11, Detroit, MI, 48202, USA.
²⁵ Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge and Addenbrooke's Hospital, Hills Road, Box 93, Cambridge, CB2 0QQ, UK.
²⁶ Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Herestraat 49, Box 7003 63, 3000, Leuven, Belgium.
²⁷ Department of Neurosurgery, Beaumont Health, Michigan Head and Spine Institute, Oakland University William Beaumont School of Medicine, Southfield, MI, USA.
²⁸ Department of Intensive Care Medicine, Faculty of Biology and Medicine, CHUV-Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.
²⁹ Department of Neurosurgery, University of Pittsburgh Medical Center Presbyterian, Suite B-400 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
³⁰ Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 MAB, Nashville, TN, 37212, USA.
³¹ Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
³² Department of Neurosurgery, Alfred Hospital, Melbourne, Australia.
³³ Department of Surgery, Monash University, Melbourne, Australia.
³⁴ INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia.
³⁵ MEDITECH Foundation, Clinical Research, Calle 7-A # 44-95, Cali, 760036, Colombia.
³⁶ Department of Neurosurgery, University Hospital Vall d'Hebron, Barcelona, Spain.
³⁷ Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy.
³⁸ Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh Medical Center, 3550 Terrace St, Room 646, Pittsburgh, PA, 15261, USA.
³⁹ Department of Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Ave., Ward 3A, San Francisco, CA, 94110, USA.
⁴⁰ Department of Physiopathology and Transplantation, Milan University, Milan, Italy.
⁴¹ Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
⁴² Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
⁴³ Department of Neurological Surgery, GH 5100 SNEU, Indianapolis, IN, 46202, USA.
⁴⁴ Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, The Ottawa Hospital, Department of Surgery, Division of Neurosurgery, University of Ottawa, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
⁴⁵ Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, 9 Tower, Manhasset, NY, USA.
⁴⁶ Gary L. Brinderson Family Chair in Neurocritical Care, UCLA School of Medicine, Los Angeles, USA.
⁴⁷ Critical Care Medicine Research, UCLA School of Medicine, Santa Monica, USA.
⁴⁸ Neurosurgery and Neurology, UCLA School of Medicine, Santa Monica, USA.
⁴⁹ Neurocritical Care, Ronald Reagan UCLA Medical Center, Santa Monica, USA.
⁵⁰ Intensive Care, Posadas Hospital, Buenos Aires, Argentina.
⁵¹ Department of Emergency Medicine, Emory University School of Medicine, 49 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA.
⁵² Department of Emergency Medicine, University of Rochester Medical Center, 265 Crittenden Blvd, Suite 2100, Box 655C, Rochester, NY, 14642, USA.
⁵³ Department of Neurological Surgery, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104-2499, USA. chesnutr@uw.edu.
⁵⁴ Department of Orthopaedic Surgery, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104-2499, USA. chesnutr@uw.edu.
⁵⁵ School of Global Health, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104-2499, USA. chesnutr@uw.edu.
⁵⁶ Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, WA, 98104-2499, USA. chesnutr@uw.edu.

PMID: 31659383
PMCID: PMC6863785
DOI: 10.1007/s00134-019-05805-9

A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

Gregory W J Hawryluk et al. Intensive Care Med. 2019 Dec.

. 2019 Dec;45(12):1783-1794.

doi: 10.1007/s00134-019-05805-9. Epub 2019 Oct 28.

Authors

Affiliations

¹ Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
² Almirante Nef Naval Hospital, Valparaiso University, Viña Del Mar, Chile.
³ Valparaiso University, Valparaiso, Chile.
⁴ Department of Neurosurgery, Medical School and Szentágothai Research Centre, Ifjúság Útja 20, Pécs, 7624, Hungary.
⁵ University of Pécs, Pécs, Hungary.
⁶ Department of Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Seattle, WA, 98104-2499, USA.
⁷ School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
⁸ Anaesthesia and Intensive Care, San Gerardo and Desio Hospitals, ASST-Monza, Monza, Italy.
⁹ Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.
¹⁰ Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia.
¹¹ Department of Neurology, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, 51 North 39th Street, Philadelphia, PA, 19104, USA.
¹² Department of Neurology, Washington University School of Medicine, St. Louis, USA.
¹³ Department of Neurology, Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza Suite 10400, St. Louis, MO, 63110, USA.
¹⁴ Division of Neurosurgery and Neuroscience Institute, Groote Schuur Hospital¸University of Cape Town, H53 Old Main Building, Main Road, Observatory, 7925, South Africa.
¹⁵ Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, 1630 Dongfang Road, Shanghai, 200127, China.
¹⁶ Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
¹⁷ Department of Neurosurgery, Stanford Neuroscience Health Center, 213 Quarry Rd 4th Fl, MC 5958, Palo Alto, CA, 94304, USA.
¹⁸ Department of Neurosurgery, 300 Pasteur Drive, Room R205, Edward's Building, MC: 5327, Stanford, CA, 94305, USA.
¹⁹ Department of Neurological Surgery, School of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 5042, Cleveland, OH, 44106, USA.
²⁰ Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge and Cambridge Biomedical Campus, Cambridge, CB20QQ, UK.
²¹ Department of Neurological Sciences, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India.
²² Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, 6400 Fannin St, Suite 2800, Houston, TX, 77030, USA.
²³ Department of Neurosurgery, San Francisco General Hospital and Trauma Center, University of California San Francisco, 1001 Potrero Ave., Bldg 1, Room 101, San Francisco, CA, 94110, USA.
²⁴ Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Neurology, K-11, Detroit, MI, 48202, USA.
²⁵ Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge and Addenbrooke's Hospital, Hills Road, Box 93, Cambridge, CB2 0QQ, UK.
²⁶ Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Herestraat 49, Box 7003 63, 3000, Leuven, Belgium.
²⁷ Department of Neurosurgery, Beaumont Health, Michigan Head and Spine Institute, Oakland University William Beaumont School of Medicine, Southfield, MI, USA.
²⁸ Department of Intensive Care Medicine, Faculty of Biology and Medicine, CHUV-Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.
²⁹ Department of Neurosurgery, University of Pittsburgh Medical Center Presbyterian, Suite B-400 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
³⁰ Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 MAB, Nashville, TN, 37212, USA.
³¹ Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
³² Department of Neurosurgery, Alfred Hospital, Melbourne, Australia.
³³ Department of Surgery, Monash University, Melbourne, Australia.
³⁴ INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia.
³⁵ MEDITECH Foundation, Clinical Research, Calle 7-A # 44-95, Cali, 760036, Colombia.
³⁶ Department of Neurosurgery, University Hospital Vall d'Hebron, Barcelona, Spain.
³⁷ Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy.
³⁸ Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh Medical Center, 3550 Terrace St, Room 646, Pittsburgh, PA, 15261, USA.
³⁹ Department of Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Ave., Ward 3A, San Francisco, CA, 94110, USA.
⁴⁰ Department of Physiopathology and Transplantation, Milan University, Milan, Italy.
⁴¹ Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
⁴² Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
⁴³ Department of Neurological Surgery, GH 5100 SNEU, Indianapolis, IN, 46202, USA.
⁴⁴ Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, The Ottawa Hospital, Department of Surgery, Division of Neurosurgery, University of Ottawa, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
⁴⁵ Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, 9 Tower, Manhasset, NY, USA.
⁴⁶ Gary L. Brinderson Family Chair in Neurocritical Care, UCLA School of Medicine, Los Angeles, USA.
⁴⁷ Critical Care Medicine Research, UCLA School of Medicine, Santa Monica, USA.
⁴⁸ Neurosurgery and Neurology, UCLA School of Medicine, Santa Monica, USA.
⁴⁹ Neurocritical Care, Ronald Reagan UCLA Medical Center, Santa Monica, USA.
⁵⁰ Intensive Care, Posadas Hospital, Buenos Aires, Argentina.
⁵¹ Department of Emergency Medicine, Emory University School of Medicine, 49 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA.
⁵² Department of Emergency Medicine, University of Rochester Medical Center, 265 Crittenden Blvd, Suite 2100, Box 655C, Rochester, NY, 14642, USA.
⁵³ Department of Neurological Surgery, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104-2499, USA. chesnutr@uw.edu.
⁵⁴ Department of Orthopaedic Surgery, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104-2499, USA. chesnutr@uw.edu.
⁵⁵ School of Global Health, University of Washington, Mailstop 359766, 325 Ninth Ave, Seattle, WA, 98104-2499, USA. chesnutr@uw.edu.
⁵⁶ Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, WA, 98104-2499, USA. chesnutr@uw.edu.

PMID: 31659383
PMCID: PMC6863785
DOI: 10.1007/s00134-019-05805-9

Abstract

Background: Management algorithms for adult severe traumatic brain injury (sTBI) were omitted in later editions of the Brain Trauma Foundation's sTBI Management Guidelines, as they were not evidence-based.

Methods: We used a Delphi-method-based consensus approach to address management of sTBI patients undergoing intracranial pressure (ICP) monitoring. Forty-two experienced, clinically active sTBI specialists from six continents comprised the panel. Eight surveys iterated queries and comments. An in-person meeting included whole- and small-group discussions and blinded voting. Consensus required 80% agreement. We developed heatmaps based on a traffic-light model where panelists' decision tendencies were the focus of recommendations.

Results: We provide comprehensive algorithms for ICP-monitor-based adult sTBI management. Consensus established 18 interventions as fundamental and ten treatments not to be used. We provide a three-tier algorithm for treating elevated ICP. Treatments within a tier are considered empirically equivalent. Higher tiers involve higher risk therapies. Tiers 1, 2, and 3 include 10, 4, and 3 interventions, respectively. We include inter-tier considerations, and recommendations for critical neuroworsening to assist the recognition and treatment of declining patients. Novel elements include guidance for autoregulation-based ICP treatment based on MAP Challenge results, and two heatmaps to guide (1) ICP-monitor removal and (2) consideration of sedation holidays for neurological examination.

Conclusions: Our modern and comprehensive sTBI-management protocol is designed to assist clinicians managing sTBI patients monitored with ICP-monitors alone. Consensus-based (class III evidence), it provides management recommendations based on combined expert opinion. It reflects neither a standard-of-care nor a substitute for thoughtful individualized management.

Keywords: Algorithm; Brain injury; Consensus; Head trauma; Intracranial pressure; Protocol; SIBICC; Seattle; Tiers.

PubMed Disclaimer

Conflict of interest statement

No conflicts of interest relevant to this project were identified amongst the authorship group.

Figures

**Fig. 1**
Consensus-based basic severe traumatic brain injury care for patients with an ICP monitor in situ. These are basic treatments recommended as fundamental to the care of patients with sTBI, to be initiated (“Expected interventions”) or considered (“Recommended interventions”) upon ICU admission of a patient with an ICP monitor, regardless of the monitored pressure. CO₂ carbon dioxide, *CPP* cerebral perfusion pressure, Hg hemoglobin, *HOB* head of bed, *ICP* intracranial pressure, *ICU* intensive care unit, *spO*₂ arterial oxygen saturation

**Fig. 2**
Consensus-based algorithm for the management of severe traumatic brain injury guided by intracranial pressure measurements. Upper right box presents the principles for navigating through the treatments and tiers. Lower tier treatments are viewed as having a more favorable side effect profile than higher tiers and generally should be employed first. Inter-tier recommendations encourage patient reassessment for remediable causes of treatment resistance. See text for details. *CPP* cerebral perfusion pressure, *EEG* electroencephalogram, *EVD* external ventricular drain, *ICP* intracranial pressure, *kPa* kiloPascals, *MAP* mean arterial pressure, P_aCO₂ arterial partial pressure of carbon dioxide

**Fig. 3**
Critical neuroworsening and its management. SIBICC definition (upper box), response (middle box) and a list of suggested differential diagnoses (bottom) surrounding critical neurological deterioration (critical neuroworsening). *CNS* central nervous system, *GCS* Glasgow Coma Scale, *ICP* intracranial pressure

**Fig. 4**
Consensus views on the safety of intracranial pressure monitor removal in patients with acceptable ICP (no longer requiring active ICP management). The heatmap represents a summary analysis of the likelihood of each CWG member to remove the ICP monitor under differing conditions of stable pupillary status, GCS [20] motor score, modified CT classification (see “Methods”), duration of acceptable ICP, and degree of treatment previously required for any intracranial hypertension (none, Tier 1, or Tier 2 or 3). Green, yellow, and red indicate “safe to proceed”, “consider proceeding with caution” and “do not proceed”, respectively, with transitional shades reflecting intermediate trends. To use, choose the heatmap representing the ICP treatment history, then the appropriate status cell reflecting categorization of the patient in terms of the variables presented. The color in the relevant cell reflects the tendency of the CWG to withdraw the ICP monitor in that circumstance. It is up to the treating physician to consider the value of that tendency in making the final decision. AP abnormal pupils, CT computed tomography, DI diffuse injury as defined in the Marshall CT Head Score, *GCS* Glasgow Coma Scale, *EML* evacuated mass lesion as defined in the Marshall CT Head Score, *ICP* intracranial pressure, NP normal pupils

**Fig. 5**
Consensus views on the safety of performing a sedation holiday aimed at obtaining an accurate neurological examination in patients whose ICP is controlled under different degrees of active management. The heatmap represents a summary analysis of the likelihood of each panelist to halt sedation to get an optimized neurological exam under differing conditions of stable pupillary status, GCS [20] motor score, modified CT classification (see “Methods”), duration of acceptable ICP with ongoing treatment, and degree of treatment previously required for any intracranial hypertension (none, Tier 1, or Tier 2 or 3). Green, yellow, and red indicate “safe to proceed”, “consider proceeding with caution” and “do not proceed”, respectively, with transitional shades reflecting intermediate trends. To use, choose the heatmap representing the ICP treatment history, then the appropriate status cell reflecting categorization of the patient in terms of the variables presented. The color in the relevant cell reflects the tendency of the CWG to perform a sedation holiday in that circumstance. It is up to the treating physician to consider the value of that tendency in making the final decision. AP abnormal pupils, CT computed tomography; DI diffuse injury as defined in the Marshall CT Head Score, *GCS* Glasgow Coma Scale, *EML* evacuated mass lesion as defined in the Marshall CT Head Score, *ICP* intracranial pressure, NP normal pupils

See this image and copyright information in PMC

Comment in

An algorithm for patients with intracranial pressure monitoring: filling the gap between evidence and practice.
Smith M, Maas AIR. Smith M, et al. Intensive Care Med. 2019 Dec;45(12):1819-1821. doi: 10.1007/s00134-019-05818-4. Epub 2019 Oct 15. Intensive Care Med. 2019. PMID: 31616963 No abstract available.

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A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

Affiliations

A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

Comment in

References

MeSH terms

LinkOut - more resources

Full Text Sources

Medical