Is intracranial pressure monitoring still required in the management of severe traumatic brain injury? Ethical and methodological considerations on conducting clinical research in poor and low-income countries

Long-term disabilities suffered by patients with severe traumatic brain injury (TBI) are a continuous challenge for health care systems and a burden for patients, their families, and the community in terms of suffering, disability, and monetary cost. [13,19]Approximately 50% of TBI comatose patients with an abnormal computed tomography (CT) scan also have high intracranial pressure (ICP). [22]Death, vegetative state, and severe disability are the expected outcomes in patients with persistent high ICP not controlled by medical and/or surgical treatment.As high ICP cannot be estimated reliably by clinical examination or even sequential imaging, ICP monitoring has been considered a necessary tool for its diagnosis and management.After decades of ongoing debate about how and when to monitor ICP, a consensus was finally reached in 1995 with the publication of the first evidence-based guidelines (EBGs) for the management of severe TBI in adults, developed under the sponsorship of the Brain Trauma Foundation (BTF). [3]Three consecutive versions of these guidelines have established-as a level II recommendation-that ICP should be monitored in "all salvageable patients with a severe TBI and an abnormal CT scan". [3,30]BTF guidelines are endorsed by most scientific societies worldwide and they have been translated into many languages and disseminated and applied in the United States, Europe, South America, China, and Japan, thus defining the core principles for managing severe TBI.In keeping with the guidelines, care centered on ICP management is the standard for patients with severe TBI in both developed countries and those developing countries that can afford their costly management.A few studies have shown that good adherence to the BTF guidelines improve outcomes and reduce the cost of the acute care. [12,16,24,26]his article may be cited as: