New TBI management guidelines lacking answers

There’s a list of 18 topics in the new Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition, by Nancy Carney, PhD, of Oregon Health and Science University in Portland.

The new guidelines, which include 189 publications that provided 28 recommendations on the 18 topics, still lack answers to many key clinical questions, according to an article in Med Page Today.

“Endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, the guidelines include 14 new or changed recommendations and 14 unchanged recommendations. Evidence to support seven previous recommendations did not meet current standards, the article reads. “Despite major developments in the management of severe TBI, however, the guidelines do not include recommendations in many key areas because of a lack of evidence. As a result, the guidelines should not be considered a complete protocol for clinical use, the authors said.”

For example, there is insufficient evidence to support the use of  hyperosmolar agents  to improve outcomes for TBI patients, yet many clinicians have observed their value in daily practice.

“Until there is evidence for or against this treatment approach, the neurosurgeon or critical care physician needs to make the call,” the article reads. “The CDC estimates that following the treatment recommendations in these guidelines could double the chances of survival for U.S. patients with severe TBI, increase the proportion of good outcomes for survivors from 35 percent to 66 percent, and decrease the proportion of poor outcomes from 34 percent to 19 percent.”

An estimated 80 percent adherence to the new guidelines across the nation will save the U.S. approximately $4.08 billion annually.

“The research needs to be conducted consistent with the highest standards in order for the results to be used as evidence,” the article reads. “Critical evidence gaps need to be identified, study designs improved, and state-of-the-art methods used for synthesizing and assessing evidence. In lieu of waiting for better clinical evidence to be produced, a formal consortium could focus on comparative effectiveness research that strictly adheres to evidence-based protocols rather than randomized controlled trials and observational studies, the authors proposed.”