. 2020 May;46(5):919-929.

doi: 10.1007/s00134-019-05900-x. Epub 2020 Jan 21.

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

Randall Chesnut^{1

2}, Sergio Aguilera^{3

4}, Andras Buki^{5

6}, Eileen Bulger⁷, Giuseppe Citerio^{8

9}, D Jamie Cooper^{10

11}, Ramon Diaz Arrastia¹², Michael Diringer¹³, Anthony Figaji¹⁴, Guoyi Gao¹⁵, Romer 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 Servadei^{37

38}, Lori Shutter³⁹, Deborah Stein⁴⁰, Nino Stocchetti^{41

42}, Fabio Silvio Taccone⁴³, Shelly Timmons⁴⁴, Eve Tsai⁴⁵, Jamie S Ullman⁴⁶, Paul Vespa⁴⁷, Walter Videtta⁴⁸, David W Wright⁴⁹, Christopher Zammit⁵⁰, Gregory W J Hawryluk⁵¹

Affiliations

¹ Department of Neurological Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, Washington, 98104-2499, USA.
² Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, Washington, 98104-2499, USA.
³ Almirante Nef Naval Hospital, Viña del Mar, Chile.
⁴ Valparaiso University, Valparaiso, Chile.
⁵ Department of Neurosurgery, Medical School and Szentágothai Research Centre, Ifjúság útja 20, 7624, Pécs, Hungary.
⁶ University of Pécs, Pécs, Hungary.
⁷ Department of Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Seattle, WA, 98104-2499, USA.
⁸ School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
⁹ Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy.
¹⁰ Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Monash, Australia.
¹¹ Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia.
¹² University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, 51 North 39th Street, Philadelphia, PA, 19104, USA.
¹³ Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, 1 Barnes-Jewish Hospital Plaza, St. Louis, MO, 63110, USA.
¹⁴ Division of Neurosurgery and Neuroscience Institute, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, 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 Johns Hopkins University School of Medicine, 1800 Orleans St. Sheikh Zayed Tower, Baltimore, MD, 21287, USA.
¹⁷ Stanford Neuroscience Health Center, 213 Quarry Rd 4th Fl MC 5958, Palo Alto, CA, 94304, USA.
¹⁸ Department of Neurosurgery, 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, HAN 5042, Cleveland, OH, 44106, USA.
²⁰ Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, 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 University of California San Francisco, San Francisco General Hospital and Trauma Center, 1001 Potrero Ave., Bldg 1, Room 101, San Francisco, CA, 94110, USA.
²⁴ Neurology, K-11, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA.
²⁵ Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, 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 Oakland University William Beaumont School of Medicine, Beaumont Health, Michigan Head and Spine Institute, Southfield, MI, USA.
²⁸ Department of Intensive Care Medicine, CHUV-Lausanne University Hospital, University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland.
²⁹ Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
³⁰ Vanderbilt University Medical Center, Nashville, USA.
³¹ 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, 760036, Cali, Colombia.
³⁶ University Hospital Vall D'Hebron, Barcelona, Spain.
³⁷ Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy.
³⁸ World Federation of Neurosurgical Societies, Nyon, Switzerland.
³⁹ University of Pittsburgh Medical Center, 3550 Terrace St, Room 646, Pittsburgh, PA, 15261, USA.
⁴⁰ Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, 1001 Potrero Ave., Ward 3A, San Francisco, CA, 94110, USA.
⁴¹ Department of Physiopathology and Transplantation, Milan University, Milan, Italy.
⁴² Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
⁴³ Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
⁴⁴ Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, 30 Hope Dr., Suite 1200 | Building B, Hershey, PA, 17033, USA.
⁴⁵ Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, University of Ottawa, The Ottawa Hospital, C2 Neurosciences Unit, The Ottawa Hosptial, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
⁴⁶ 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.
⁴⁷ Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, Santa Monica, USA.
⁴⁸ Posadas Hospital, Buenos Aires, Argentina.
⁴⁹ Emory University School of Medicine, 49 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA.
⁵⁰ School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 655C, Rochester, NY, 14642, USA.
⁵¹ Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada. ghawryluk@hsc.mb.ca.

PMID: 31965267
PMCID: PMC7210240
DOI: 10.1007/s00134-019-05900-x

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

Randall Chesnut et al. Intensive Care Med. 2020 May.

. 2020 May;46(5):919-929.

doi: 10.1007/s00134-019-05900-x. Epub 2020 Jan 21.

Authors

Affiliations

¹ Department of Neurological Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, Washington, 98104-2499, USA.
² Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, Washington, 98104-2499, USA.
³ Almirante Nef Naval Hospital, Viña del Mar, Chile.
⁴ Valparaiso University, Valparaiso, Chile.
⁵ Department of Neurosurgery, Medical School and Szentágothai Research Centre, Ifjúság útja 20, 7624, Pécs, Hungary.
⁶ University of Pécs, Pécs, Hungary.
⁷ Department of Surgery, Harborview Medical Center, University of Washington, 325 Ninth Ave, Seattle, WA, 98104-2499, USA.
⁸ School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
⁹ Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy.
¹⁰ Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Monash, Australia.
¹¹ Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia.
¹² University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, 51 North 39th Street, Philadelphia, PA, 19104, USA.
¹³ Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, 1 Barnes-Jewish Hospital Plaza, St. Louis, MO, 63110, USA.
¹⁴ Division of Neurosurgery and Neuroscience Institute, University of Cape Town, H53 Old Main Building, Groote Schuur Hospital, 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 Johns Hopkins University School of Medicine, 1800 Orleans St. Sheikh Zayed Tower, Baltimore, MD, 21287, USA.
¹⁷ Stanford Neuroscience Health Center, 213 Quarry Rd 4th Fl MC 5958, Palo Alto, CA, 94304, USA.
¹⁸ Department of Neurosurgery, 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, HAN 5042, Cleveland, OH, 44106, USA.
²⁰ Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, 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 University of California San Francisco, San Francisco General Hospital and Trauma Center, 1001 Potrero Ave., Bldg 1, Room 101, San Francisco, CA, 94110, USA.
²⁴ Neurology, K-11, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA.
²⁵ Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, 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 Oakland University William Beaumont School of Medicine, Beaumont Health, Michigan Head and Spine Institute, Southfield, MI, USA.
²⁸ Department of Intensive Care Medicine, CHUV-Lausanne University Hospital, University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland.
²⁹ Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
³⁰ Vanderbilt University Medical Center, Nashville, USA.
³¹ 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, 760036, Cali, Colombia.
³⁶ University Hospital Vall D'Hebron, Barcelona, Spain.
³⁷ Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy.
³⁸ World Federation of Neurosurgical Societies, Nyon, Switzerland.
³⁹ University of Pittsburgh Medical Center, 3550 Terrace St, Room 646, Pittsburgh, PA, 15261, USA.
⁴⁰ Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, 1001 Potrero Ave., Ward 3A, San Francisco, CA, 94110, USA.
⁴¹ Department of Physiopathology and Transplantation, Milan University, Milan, Italy.
⁴² Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
⁴³ Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
⁴⁴ Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, 30 Hope Dr., Suite 1200 | Building B, Hershey, PA, 17033, USA.
⁴⁵ Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, University of Ottawa, The Ottawa Hospital, C2 Neurosciences Unit, The Ottawa Hosptial, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
⁴⁶ 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.
⁴⁷ Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, Santa Monica, USA.
⁴⁸ Posadas Hospital, Buenos Aires, Argentina.
⁴⁹ Emory University School of Medicine, 49 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA.
⁵⁰ School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 655C, Rochester, NY, 14642, USA.
⁵¹ Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada. ghawryluk@hsc.mb.ca.

PMID: 31965267
PMCID: PMC7210240
DOI: 10.1007/s00134-019-05900-x

Abstract

Background: Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place.

Methods: Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting.

Results: We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms.

Conclusions: These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference.

Keywords: Algorithm; Brain injury; Brain oxygen; Consensus; Head trauma; Intracranial pressure; PbtO2; Protocol; SIBICC; Seattle; Tiers.

PubMed Disclaimer

Conflict of interest statement

On behalf of all authors, the corresponding author states that there are no relevant conflicts of interest.

Figures

**Fig. 1**
Consensus-based basic severe traumatic brain injury care for patients with an ICP and brain oxygen 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 both an ICP and brain oxygen monitor, regardless of the measured values. 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**
This matrix provides the schema for the 4 clinical conditions encountered in patients with both ICP and brain oxygen monitors in situ. Type A reflects normal values for both monitors and does not require treatment. Type B involves ICP elevation but normal brain oxygen values; we propose a distinct treatment algorithm for such patients than in those with ICP elevation and unknown P_btO₂ values. Type C patients have hypoxic brains but normal ICP and Type D patients have both brain hypoxia and ICP elevation. An ICP of 22 mmHg discriminates normal (lower) and abnormal (higher) values while P_btO₂ values of 20 mmHg discriminates normal (higher) and abnormal (lower) values. ICP intracranial pressure, P_btO₂ partial pressure of brain oxygen

**Fig. 3**
Consensus-based algorithm for the management of severe traumatic brain injury with intracranial hypertension and normal brain oxygenation. 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. 4**
Consensus-based algorithm for the management of severe traumatic brain injury with brain hypoxia and normal intracranial pressure. 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. 5**
Consensus-based algorithm for the management of severe traumatic brain injury with intracranial hypertension and brain hypoxia. 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. 6**
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

See this image and copyright information in PMC

References

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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

MeSH terms

Substances

LinkOut - more resources

Full Text Sources

Medical

Miscellaneous