Traumatic brain injury: intensive care, monitoring, threshold target values

L.A. Maltseva, V.I. Grishin, D.V. Bazylenko, S.O. Pshenko


In September 2016, an updated guidelines for severe head injury were published, “Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition”, which include the following parts: 1) intensive care; 2) monitoring; 3) threshold values. Part 1 summarizes the evidence and re­commendations for 11 intensive care methods which are ­either specific for the treatment of severe traumatic brain injury (TBI) in hospital or are associated with risks that threaten patients with TBI. This part does not include the procedures or therapies used in the general practice of intensive care. The intensive care methods included in part 1 reflect the principles of current clinical practice, but they can change as new research data on intensive care options are available that can replace or supplement existing recommendations. Part II “Monito­ring” emphasizes the importance of using information obtained in monitoring directly for the correction of ongoing intensive care, which can provide better results than therapy based solely on clinical trial data. This part of the guidelines includes re­commendations related to the impact of monitoring intracranial pressure (ICP), cerebral perfusion pressure, and advanced cerebral monitoring on patient outcomes. It should be emphasized that in the clinical practice of developed countries, multimodal monitoring is used. While, limited resources in low- and middle-income countries often do not allow exten­ded monitoring, and medical decisions can only come from one clinical assessment. Thus, the monitoring will vary depen­ding on the technological provision. In the third edition of the manual, in contrast to the previous version, which had three sections on ICP monitoring (indications, technologies and target values), the section “Indications for ICP monitoring” discusses the following questions: who should monitor, the usefulness of the information received, and its impact on the outcome of treatment. H.M. Eisenberg et al. (1988) conduc­ted a randomized clinical trial to study ICP-directed treatment with barbiturates. S. Palmer et al. (2001) compared 2 groups of patients who received treatment: 1) before the introduction of recommendations; 2) after the introduction of recommendations. All patients underwent ICP monitoring, the study did not have a comparison group without ICP monitoring, and therefore it was excluded in this publication, since an evaluation of the impact of monitoring as a guide to the therapy and its effect on outcome was not evaluated. The influence of the information received from the ICP monitoring on the outcome was considered in the 4th edition of the manual. The section “ICP monitoring technologies” in the 3rd edition included description and ranking of available ICP monitoring technologies. The technology assessment used methods and standards different from those used for systematic review of evidence and development of treatment guidelines. For this reason, the technology section was not included in the ma­nual. The section “Target values of intracranial pressure” from the 3rd edition was expanded and in the 4th edition was moved to the “Target values” section, which includes target values for the blood pressure, cerebral perfusion pressure, advanced cerebral monitoring and ICP. Part III “Threshold values” includes data and recommendations related to threshold values of parameters monitored during hospital treatment in patients with TBI. This part is limited to those parameters that are specific for TBI. Attention is focused on measures that have de­monstrated a positive impact on outcome. The 4th edition includes threshold values for blood pressure, ICP, and advanced cerebral monitoring. The threshold value may be the value at which it is possible to avoid or reduce the risk of negative outcomes or values to be sought in order to increase the likelihood of positive outcomes of ongoing intensive care.


traumatic brain injury; intensive care; monitoring


Bratton S.L., Chestnut R.M., Ghajar J., McConnell Hammond F.F., Harris O.A., Hartl R., Manley G.T., Neme­cek A., Newell D.W., Rosenthal G., Schouten J., Shutter L., Timmons S.D., Ullman J.S., Videtta W., Wilberger J.E., Wright D.W.; Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma Critical Care — AANS CNS. Guidelines for the management of severe traumatic brain injury // J. Neurotrauma. — 2007. — 24(Suppl. 1). — S1-106. — PMID: 17511554.

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