Table 1 List of consensus recommendations
N | Recommendation | Level |
|---|---|---|
1 | We recommend that all salvageable (i.e., patients who may recover, at least to some extent, with appropriate treatment) severe isolated TBI patients needing or at risk of needing neurosurgery [i.e., for surgical mass lesion and/or ICP monitoring] admitted to a spoke center should be rapidly transferred to a hub center after hemodynamic and respiratory stabilization | Strong recommendation |
2 | We recommend the utilization of a telemedicine service for rapid digital image transfer from the spoke to the hub center | Strong recommendation |
3 | We recommend, before and during transfer from the spoke to the hub center, a continuous and clear collaboration/communication (i.e., check for availability of ICU bed/OR, significant clinical deterioration during transfer, etc.) between different medical specialties (anesthesiology/intensive care/neurocritical care, neurosurgery, neuroradiology, trauma surgery, etc.) | Strong recommendation |
4 | We recommend sedation, intubation and mechanical ventilation for the transfer of all severe TBI patients | Strong recommendation |
5 | We recommend that the transfer of severe TBI patients should be performed by appropriately trained and certified critical care transport personnel with experience in advanced airway management/life support strategies and basic knowledge of neurocritical care (i.e., medical management of cerebral swelling, herniation) | Weak recommendation |
6 | We recommend that severe salvageable TBI patients with signs/elevated risk of herniation and need for neurosurgery (brain CT scan already done in spoke hospital with neurosurgical consultation) should be directly transported form the spoke center to the OR at the hub center | Strong recommendation |
7 | We recommend, in severe TBI patients needing transfer to the hub center, an invasive monitoring of ABP in addition to the standard cardiorespiratory monitoring (ECG, HR, SpO2 and ETCO2) | Weak recommendation |
8 | We recommend maintaining SAP > 110 mmHg or mean arterial pressure MAP > 80 mmHg* in severe isolated TBI patients *In the case of invasive ABP monitoring, the arterial transducer should be zeroed at the level of the tragus | Strong recommendation |
9 | We recommend maintaining PLT count > 75.000/mm3 in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring) | Strong recommendation |
10 | We recommend maintaining PT/aPTT value < 1.5 the normal control in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring) | Strong recommendation |
11 | We recommend early reversal of anticoagulant/antiplatelets agents, in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring) | Strong recommendation |
12 | We recommend utilization of POC tests (i.e., TEG and ROTEM), if available, to optimize coagulation function in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring) | Weak recommendation |
13 | We are unable to recommend the routine use of specific anti-seizure drugs in salvageable severe TBI patients presenting with seizure observed clinically and/or with EEG | No recommendation |
14 | We recommend performing serial neurologic evaluations (GCS + pupil examination) in the spoke center and during transfer to the hub center to detect neurologic deterioration in patients without signs of intracranial hypertension | Strong recommendation |
15 | We recommend against discontinuation of sedation to obtain a reliable neurological evaluation in patients with radiological signs of intracranial hypertension (i.e., midline shift, compression of the basal cisterns, sulcal effacement, etc.). In this scenario, only pupil examination, especially during the transfer, would be useful | Strong recommendation |
16 | We are unable to recommend use of brain ultrasonography (i.e., optic nerve sheath diameter, cerebral blood flow waveform analysis, etc.), in the presence of skilled operators, as a reliable screening non-invasive tool for detection of intracranial hypertension in the spoke center | No recommendation |
17 | We are unable to recommend use of automated pupillometry, if available, as a reliable screening non-invasive tool for detection of intracranial hypertension in the spoke center | No recommendation |
18 | We recommend that performance of brain ultrasonography and/or automated pupillometry, if utilized in the spoke center, should not significantly delay the patient’s transfer | Strong recommendation |
19 | We recommend that severe isolated TBI patients should be maintained with a head of the bed elevated at 30°–45° to facilitate brain venous drainage in the spoke center and during transfer to the hub center | Strong recommendation |
20 | We recommend that in severe TBI patients, the head should be maintained in the midline avoiding compression of the neck veins in the spoke center and during transfer to the hub center | Strong recommendation |
21 | We recommend avoiding core body temperature > 37.5 °C and to aim for normothermia in severe TBI patients | Strong recommendation |
22 | We recommend maintaining Hb level > 7 g/dl in severe TBI patients | Strong recommendation |
23 | We recommend maintaining SpO2 > 94% in severe TBI patients | Strong recommendation |
24 | We recommend maintaining a PaCO2 of 35–38 mmHg in severe TBI patients | Strong recommendation |
25 | We recommend maintaining a serum Na level of 140–145 mEq/l in severe TBI patients | Strong recommendation |
26 | We recommend osmotherapy as a therapeutic maneuver to be utilized in patients with signs of intracranial hypertension/brain herniation awaiting emergent neurosurgery | Strong recommendation |
27 | We recommend short-term hyperventilation as a therapeutic maneuver that should be utilized only in patients with signs of brain herniation awaiting emergent neurosurgery | Strong recommendation |
28 | We recommend an increase in sedation, while maintaining an acceptable ABP, as a therapeutic maneuver that should be utilized in the management of patients with signs of brain herniation awaiting emergent neurosurgery | Strong recommendation |