A Harmonised Protocol for the Use of PRx in Adult and Paediatric TBI Patients with ICP Monitoring: CLINICCA Workgroup Output

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INTRODUCTION: A survey of 44 worldwide clinical experts in continuous monitoring of cerebral autoregulation (CCA) revealed that while half used a CCA index in clinical decision making, only 39% were using it as part of a local clinical protocol (CLINICCA survey, 2023). We aimed to distil common elements from existing protocols, focusing on the intracranial pressure (ICP) derived pressure reactivity index (PRx) in traumatic brain injury (TBI). METHODOLOGY: A template for a protocol followed the structure of the original CLINICCA survey which included five components: (1) PRx value triggering further clinical review, (2) PRx value informing approach to intracranial hypertension management, (3) derived CPP targets used to 'optimise' brain physiology, (4) derived CPP targets used to decrease the burden of therapy and (5) use of PRx and derived CPP targets in a stepwise approach within a multimodality protocol. Each component included four contingencies: 'what', 'when', 'advantages' and 'reservations'. Respondents using PRx and/or derived CPP targets in adult or paediatric TBI were invited to edit the template, submit local protocols, and provide clinical practice examples. Feedback was harmonised into a final protocol. RESULTS: Contributors from nine centres edited the template, and two centres submitted written protocols. Most centres expanded components related to PRx status prompting clinical review and informing intracranial hypertension management. Variability existed in the use of derived CPP targets and neuromonitoring modalities incorporated into implementation of multimodality monitoring based practice. A supplement for technical advice regarding PRx use was created. CONCLUSIONS: Creating a harmonised protocol on the basis of common themes amongst currently used clinical protocols and approaches might facilitate broader implementation of CCA-guided therapy and inform future clinical trial design. Sharing protocols and identifying variability may promote discussion regarding advantages and limitations of PRx use in TBI.

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