成人重型颅脑损伤管理中的脑血管自动调节监测：临床医生的德尔菲共识
Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians.
作者信息
Depreitere B, Citerio G, Smith M, Adelson P David, Aries M J, Bleck T P, Bouzat P, Chesnut R, De Sloovere V, Diringer M, Dureanteau J, Ercole A, Hawryluk G, Hawthorne C, Helbok R, Klein S P, Neumann J O, Robba C, Steiner L, Stocchetti N, Taccone F S, Valadka A, Wolf S, Zeiler F A, Meyfroidt G
机构信息
Neurosurgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
Intensive Care Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
出版信息
Neurocrit Care. 2021 Jun;34(3):731-738. doi: 10.1007/s12028-020-01185-x. Epub 2021 Jan 25.
BACKGROUND
Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty.
AIM
To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities.
METHODS
A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants.
RESULTS
Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence.
CONCLUSION
The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.
背景
已经提出了几种方法来测量创伤性脑损伤（TBI）中的脑血管自动调节（CA），但缺乏金标准以及关于CA指导管理的风险、对护理的影响和实施结果的前瞻性临床数据导致了不确定性。
目的
采用德尔菲共识方法，由一组专家临床医生制定声明，以反映CA的当前知识、可在TBI管理中实施的方面以及CA研究重点。
方法
一组25名在成人重型TBI患者管理方面具有临床专业知识的国际学术专家参与了这一共识过程。在两次在线调查中向该组提交了77项声明和多项选择题，随后进行了一次面对面会议和第三次在线调查。参与者收到了关于平均得分以及重新提交或重新表述声明的理由的反馈。声明达成共识的定义为超过75%的参与者达成一致。
结果
参与者就CA状态在成人重型TBI病理生理学中的重要性、CA损伤的动态非二元性质、其与结局的关联以及采用通用和绝对脑灌注压目标的不可取性达成了共识。对于任何当前CA评估方法的准确性、可靠性和验证，无法达成共识。关于如何在临床管理方案中实施CA信息也没有达成共识，这反映了临床证据不足。
结论
德尔菲过程产生了25项共识声明，涉及受损CA的病理生理学及其对脑灌注压目标和结局的影响。提出了一项研究议程，强调需要更好地验证CA评估方法，以及使用前瞻性安全性、可行性和有效性研究重点调查CA指导管理在临床护理中的应用。
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