Traumatic brain injury management in the intensive care unit

Target Parameters:

^ Parameter ^ Target Value ^
| ICP        | < 20 mmHg        |
| CPP        | 60–70 mmHg       |
| SpO₂       | > 94%            |
| SBP        | > 100–110 mmHg   |
| PaCO₂      | 35–40 mmHg       |

Monitoring:

• Invasive ICP (if GCS ≤ 8 + abnormal CT)
• Serial CT imaging
• Repeated neurological exams
• Labs: glucose, sodium, coagulation, osmolality

Neuroprotection:

• Avoid hypoxia, hypotension, fever, seizures
• Maintain normoglycemia
• Anticonvulsants (e.g., levetiracetam for 7 days)

In a narrative review Robba et al. ¹⁾ describe current standards of care in the management of traumatic brain injury (TBI) in the intensive care unit (ICU), and to identify major knowledge gaps and areas of clinical heterogeneity—especially regarding the use of neuromonitoring, treatment of complications, prognostic tools, and emerging technologies (such as biomarkers and artificial intelligence)— in order to offer a pragmatic reference for clinicians treating TBI patients in critical care settings.

This article presents itself as a comprehensive review of TBI management in the ICU but ultimately delivers little more than a superficial aggregation of known facts and buzzwords, wrapped in a veneer of academic consensus that is neither bold nor original.

🧱 1. Lack of Structure, No Systematic Review Despite addressing a critical topic, the article fails from the outset to clearly define its methodology. It is not a systematic review, nor a guideline, nor a meta-analysis. It is instead a loosely structured narrative overview, which means it lacks methodological rigor, selection criteria, and reproducibility. This makes its conclusions soft, vague, and potentially misleading for policy-making or bedside application.

📉 2. Low-Evidence Echo Chamber The authors themselves acknowledge that “most recommendations are based on low levels of evidence”, yet proceed to build the review upon them with surprisingly little critique. This turns the article into an echo chamber of established dogmas and institutional inertia rather than a courageous re-evaluation of what actually works in TBI ICU care. For example:

The role of ICP monitoring is still portrayed as foundational, despite mounting evidence questioning its universal applicability.

The section on neuromonitoring techniques reads like a device manufacturer’s brochure, with no solid discussion on cost-effectiveness, inter-center variability, or external validation.

⚙️ 3. Artificial Intelligence and Biomarkers: Token Mentions AI and biomarkers are brought up as if to satisfy a checklist of trending topics, not as genuinely integrated or critically evaluated components of TBI care. No specific algorithms, validation studies, or real-world implementation barriers are mentioned. It’s a throwaway paragraph masquerading as a research frontier.

“Further research is needed” — the most overused and intellectually lazy sentence in contemporary academic publishing makes a predictable appearance here, as a way to sidestep specificity or bold positions.

🧪 4. Heterogeneity: The Cop-Out The authors repeatedly cite “heterogeneity of clinical practice” as a problem, but do not attempt to offer decisive, evidence-backed pathways for harmonization. There is no structured comparison between regional protocols, no proposed stratification by injury severity, and no attempt to produce actionable algorithms. Instead, we are left with:

“Clinicians should adapt to local resources and expertise.” Which is the same as saying: “Do what you can and hope for the best.”

🛑 5. Pragmatism Without Precision Although the authors claim to offer a “pragmatic approach,” the article remains frustratingly vague in key areas:

Prognostic tools: mentioned, but with no framework for integrating them into daily practice.

Sedation, ventilation, osmotherapy: discussed generically, without risk-benefit ratios or patient-specific guidance.

Outcome metrics: not clearly stratified by age, GCS, or ICU infrastructure.

A true pragmatic guide would provide decision trees, real-world case scenarios, or at least level-of-evidence annotations. None are included.

🧊 6. Missed Opportunity for Leadership Given the credentials of the author group—which includes some of the biggest names in neurocritical care—this article could have been a seminal update. Instead, it settles for playing it safe, stating the obvious, and perpetuating clinical ambiguity rather than resolving it.

It is not provocative. It is not visionary. It is not even particularly educational.

🔚 Conclusion This review adds little of substance to the field of neurocritical care. It is too vague to guide practice, too generic to influence policy, and too passive to drive innovation. What could have been a landmark in redefining standards and confronting the inertia of TBI management is instead a padded consensus document dressed up as a state-of-the-art review.

Verdict:

❌ Ambitious in scope, disappointing in execution. A missed opportunity to lead. Ultimately forgettable.