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

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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Journal
Neurocritical Care
Published
2026-08-20
DOI
https://doi.org/10.1007/s12028-026-02595-z
Primary Topic
Traumatic Brain Injury and Neurovascular Disturbances
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article
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article

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

Luzius A. Steiner, András Czigler, Erta Beqiri, Miriam Weiss et al.
Neurocritical Care
Traumatic Brain Injury and Neurovascular Disturbances
article

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

Luzius A. Steiner, András Czigler, Erta Beqiri, Miriam Weiss, Celeste Dias, Ramani Balu, Geert Meyfroidt, Lucia Rivera‐Lara, Andrea Lavinio, Mypinder S. Sekhon, Per Enblad, Josef Škola, Nicolás de Riva, Jennifer K. Lee, Frederick Zeiler, Teodor Svedung Wettervik, Wendy Ziai, Matthew Kirschen, Marcel Aries, Celina Brunsch, Karol Budohoski, Martin U. Schuhmann, Brandon Foreman, Shirin Frisvold, Bart Depreitere, David K. Menon, David Nelson, Adel Helmy, Brian Appavu, Nils Petersen, Shirin K. Frisvold, Victoria Mccredie, Anthony Figaji, Francisco Abecasis, Chiara Robba, Peter Smielewski, Andreas Kramer, Soojin Park, Shruti Agrawal, Donald Griesdale, Peter J. Toth, Stefan Wolf, Gerrit Schubert, Ari Ercole, Ken Brady, Elisabeth Kooi, Fabio S. Taccone, Cornelia Hoedemaekers, Clare Gallagher, Raimund Helbok
article en

Abstract

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.

Neurocritical Care
Northwestern University (US), University of Bern (CH), Johannes Kepler University of Linz (AT), Uppsala University (SE), University Hospital of North Norway (NO), Université Libre de Bruxelles (BE), University Medical Center Groningen (NL), Karolinska University Hospital (SE), Children's Hospital of Philadelphia (US), NewYork–Presbyterian Hospital (US), Uppsala University Hospital (SE), University of Arizona (US), Johns Hopkins University (US), Radboud University Nijmegen (NL), University of Calgary (CA), Palo Alto University (US), University of Toronto (CA), University of Utah (US), University of Cambridge (GB), New York Times (US), Johns Hopkins Medicine (US), New York Hospital Queens (US), Society of Critical Care Medicine (US), Groote Schuur Hospital (ZA), Cambridge University Hospitals NHS Foundation Trust (GB), University Hospital of Basel (CH), Radboud University Medical Center (NL), Hospital de São João (PT), Yale University (US), Maastricht University (NL), Cambridge School (PT), Bridge University (SS), Centre Hospitalier Universitaire Brugmann (BE), Department of Medical Sciences (RU), Hospital Clínic de Barcelona (ES), Kepler Universitätsklinikum (AT), Universitätsklinikum Aachen (DE), Stanford Medicine (US), Ospedale Policlinico San Martino (IT), Hospital de Santa Maria (PT), Oncology Hematology Care (US), Addenbrooke's Hospital (GB), Kantonsspital Aarau (CH), Czech Technical University in Prague (CZ), University of Manitoba (CA), University of Cincinnati (US), Universitat de Barcelona (ES), UiT The Arctic University of Norway (NO), Columbia University (US), University of Pecs (HU), University of Tübingen (DE), RWTH Aachen University (DE), University of Cincinnati Medical Center (US), Stanford University (US), KU Leuven (BE)
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Traumatic Brain Injury and Neurovascular Disturbances
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