Traumatic Brain edema

A comprehensive online search for guidelines and articles was undertaken to identify the most relevant articles to be reviewed and guidelines to consider for adaptation.

Inclusion/exclusion criteria followed in the search were:

▪️  Selecting only national and/or international guidelines.

▪️   Specific range of dates for publication (using Guidelines published or updated 2005 and later)

▪️    A large series none controlled, prospective clinical trials of treatment using surgical versus nonsurgical management have been reviewed.

▪️     Selecting peer reviewed publications only.

▪️    Selecting guidelines written in English language.

▪️    Papers with the following characteristics were also excluded: case series with less than 10 patients evaluated by CT scan and with incomplete outcome data (mortality or GOS (Glasgow outcome score)), case reports, operative series with operations occurring longer than 14 days from injury.

▪️   Excluding guidelines written by a single author, not on behalf of an organization to be valid and comprehensive, a guideline ideally requires multidisciplinary input

▪️     Excluding guidelines published without references

▪️  Selected articles were evaluated for design, prognostic significance, therapeutic efficacy, and overall outcome.

▪️  All retrieved Guidelines were screened and appraised using the AGREE II instrument (www.agreetrust.org) by at least two members. The panel decided on a cut-off point or ranked the guidelines (any guideline scoring above 50% on the rigour dimension was retained). We selected “Guidelines for the Management of Severe Traumatic Brain Injury 4th Edition: Brain Trauma Foundation: September 2016.⁶

➡️Evidence assessment:

According to the WHO Handbook for Guidelines, we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess the quality of a body of evidence, develop and report recommendations. GRADE methods represent internationally agreed standards for making transparent recommendations. Detailed GRADE information is available on the following sites:

■ GRADE working group: https://www.gradeworkinggroup.org/

■ GRADE online training modules: http://cebgrade.mcmaster.ca/

Table 1: Quality of evidence in GRADE

Table 2: Significance of the four levels of evidence

Table 3: Factors that determine How to upgrade or downgrade the quality of Evidence

➡️The strength of the recommendation:

The strength of a recommendation communicates the importance of adherence to the recommendation.

➡️Strong recommendations:

With strong recommendations, the guideline communicates the message that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted as policy.

➡️Conditional recommendations

These are made when there is greater uncertainty about the four factors above or if local adaptation has to account for a greater variety in values and preferences, or when resource use makes the intervention suitable for some, but not for other locations. This means that there is a need for substantial debate and involvement of stakeholders before this recommendation can be adopted as policy.

➡️When not to make recommendations

When there is lack of evidence on the effectiveness of an intervention, it may be appropriate not to make a recommendation.