Meyfroidt and colleagues recently published a commentary in Intensive Care Medicine addressing ten tenets in neurocritical care that merit debate. The article deals with the following ten statements:
1. Only neurointensivists should care about the brain.
2. Clinical examination of neurocritically ill patients is impossible.
3. We should no longer monitor ICP in traumatic brain injury (TBI).
4. The threshold to treat ICP is 20 or 22mmHg.
5. Ketamine increases the ICP.
6. Subarachnoid haemorrhage (SAH) patients should get ‘triple H’ therapy.
7. There is no need to control the temperature after cardiac arrest (CA).
8. Hypoglycaemia is harmful for the brain, hyperglycaemia is not.
9. In acute ischemic stroke (AIS), revascularization should be done within 3h of symptom onset.
10. Blood pressure control in intracerebral haemorrhage (ICH): contradictory trials.
The article is well written and argues convincingly against clinging to firmly held beliefs that aren’t necessarily founded on strong evidence. It’s well worth a read and highlights a number of important controversies and discussions that need more attention.
While I agree with almost all of the points the authors are making, I would like to address one small issue:
The matter of general anaesthesia vs. conscious sedation for endovascular procedures in occlusive stroke turns up as an aside under statement nr. 9. The authors mention in passing that GA is not recommended. I find this to be a a somewhat sweeping statement that warrants a bit of nuance. In the article one refers to the Campbell review of 2018, where GA was found on aggregate to be associated with worse outcomes. However, when newer RCTs are seen in isolation from less robust studies (retrospective, non-randomised or randomised, but designed to assess other interventions), the conclusion is more equivocal. For more detail please see our article on this matter. Briefly put, the issue can hardly be said to be convincingly laid to rest. Thus, if sound clinical judgment indicates that GA is the appropriate technique then one should not be deterred from choosing it based on the current evidence.
EMCrit’s Josh Farkas has followed up on the Meyfroidt article by expanding on the list of false neurointensive care beliefs in this commentary. Also definitely worth checking out.