Neurocritical Care in Germany: Need for Guidance

Excerpt

One of the essential dilemmas in (neuro-)critical care is the low level of evidence for or against certain therapeutic approaches. A specific neurocritical care feature—that may complicate further generation of evidence—is its interdisciplinary patient-centered care, i.e., an overlapping patient collective that in Germany is treated either in neurological, neurosurgical, or interdisciplinarily in anesthesiological-directed neuro-intensive care units (NICU). For instance, patients with subarachnoidal hemorrhage (SAH) can be treated by neurologists or neurosurgeons as well as anesthesiologists or other specialities. No wonder that the individual guidelines can differ in their recommendations regarding monitoring and treatment [1‐3]. Another aspect for the lack of evidence is that large randomized controlled trials generating the highest levels of evidence are less frequent as in general critical care. For the critical care management of stroke, only decompressive surgery is established as a level 1 evidence today [4] whereas many urging problems like management of basilar artery thrombosis or cerebellar stroke reach only weak levels of evidence. Besides practical problems such as randomizing severely ill patients who cannot consent, there is also a lack of industry-sponsored trials in the field of (neuro) critical care, possibly as the severity of diseases undermines the chances for positive clinical end-points [5]. Moreover, high-quality papers funded by public authorities are rare and rather help to guide when there is uncertainty in specific therapeutic options such as whether or not surgery should be performed in ICH or malignant middle cerebral infarction [6‐8]. Yet, the majority of basic treatment in daily neurocritical care is supported by lower levels of evidence, if any at all, and studies are often of retrospective and single-center design. …