为急性脑损伤(ABI)患者的机械通气和呼吸支持提供临床实践建议,并制定研究议程。
召集了一个国际共识小组,其中包括29名在重症监护医学领域具有急性呼吸衰竭专业知识的临床医生和科学家。神经重症监护,或者两者兼而有之,和两位无投票权的方法学家。小组分为七个小组,每个涉及与患有ABI的重症监护病房(ICU)患者相关的预定义临床实践领域,定义为急性创伤性脑或脑血管损伤。小组进行了系统的搜索和建议评估的分级,开发和评估(GRADE)方法用于评估证据和提出问题。实施了经过修改的德尔菲程序,进行了四轮投票,要求小组成员回答问题(第1-3轮),然后是建议声明(最后一轮)。强烈推荐,弱推荐,或者当>85%时没有定义推荐,75-85%,和<75%的小组成员,分别,同意一个声明。
等级等级较低,非常低,或跨域不存在。协商一致意见产生了36项声明(19项强有力的建议,6个薄弱的建议,11无建议)关于气道管理,无创呼吸支持,机械通气策略,呼吸衰竭的抢救干预措施,呼吸机解放,以及脑损伤患者的气管造口术。确定了几个知识空白,为未来的研究工作提供信息。
这一共识为ICU收治的ABI患者的护理提供了指导。证据不足或缺乏,需要研究来证明可行性,安全,以及不同管理方法的有效性。
To provide clinical practice recommendations and generate a research agenda on mechanical ventilation and respiratory support in patients with acute brain injury (ABI).
An international
consensus panel was convened including 29 clinician-scientists in intensive care medicine with expertise in acute respiratory failure, neurointensive care, or both, and two non-voting methodologists. The panel was divided into seven subgroups, each addressing a predefined clinical practice domain relevant to patients admitted to the intensive care unit (ICU) with ABI, defined as acute traumatic brain or cerebrovascular injury. The panel conducted systematic searches and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate evidence and formulate questions. A modified Delphi process was implemented with four rounds of voting in which panellists were asked to respond to questions (rounds 1-3) and then recommendation statements (final round). Strong recommendation, weak recommendation, or no recommendation were defined when > 85%, 75-85%, and < 75% of panellists, respectively, agreed with a statement.
The GRADE rating was low, very low, or absent across domains. The
consensus produced 36 statements (19 strong recommendations, 6 weak recommendations, 11 no recommendation) regarding airway management, non-invasive respiratory support, strategies for mechanical ventilation, rescue interventions for respiratory failure, ventilator liberation, and tracheostomy in brain-injured patients. Several knowledge gaps were identified to inform future research efforts.
This
consensus provides guidance for the care of patients admitted to the ICU with ABI. Evidence was generally insufficient or lacking, and research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches.