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232747_NCS Currents_December_2_eMag

EDITOR’S MEMORANDUM Coming Up in Neurocritical Care Eelco F.M.Wijdicks, MD, PhD, FNCS, Editor-in-Chief The year 2016 will open with a bang—three The second guideline involves reversal of anticoagulation in new guidelines published by the NCS in the intracranial hemorrhages. In conjunction with the Society Neurocritical Care journal. of Critical Care Medicine, an international committee with a diverse group of experts provided recommendations for the The journal is of course the perfect vehicle reversal of warfarin, direct factor Xa antagonists, direct thrombin for publication of guidelines and scientific inhibitors, unfractionated heparin, low molecular weight statements with several published in the heparin, thrombolytics, and also antiplatelet agents. Apparently past and easily assessable for subscribers. resumption of anticoagulation — a much more nebulous area — When we publish the first issue of 2016, will be addressed in a future guideline. we will keep the papers open access for a week to facilitate communication and distribution. These new guidelines demand A third guideline is on prophylaxis of venous thrombosis. The attention because the topics are on common complex decisions goal of this guideline is to provide an evidence-based manuscript and a comprehensive critical review perusing all relevant papers to address the appropriate administration of thromboprophylaxis had not been comprehensively addressed before. (pharmacological and mechanical prophylaxis) in patients with neurologic illness and thus the paper specifically addresses These guidelines also demonstrate a continuous advancement decisions in patient with ischemic stroke, intracranial and in vetting of the literature, consensus building, and writing intraventricular hemorrhage, aneurysmal subarachnoid by the NCS Guidelines Committee. Guidelines are difficult hemorrhage, traumatic brain injury, spinal cord injury, brain to produce because they must provide fair and reliable tumors, acute neuromuscular disorders, and patients undergoing recommendations and eventually allow evidence-based neurosurgical and neurovascular interventions. decision-making during patient care. The Institute of Medicine has set standards for trustworthy In each of these guidelines, a “committee of experts” was recruited guidelines. These standards demand the most up-to-date from within the NCS. For each guideline, clinical questions literature, expert consensus, and public input. The standards were generated and divided into four components based on include establishing transparency, management of conflict the so-called Oxford PICO questions (P: population/patient, I: of interest, guideline development group composition, intervention/indicator, C: comparator/control, and O: outcome). clinical practice guideline–systematic review intersection, establishing evidence-based foundations for rating strength of The committees utilized GRADE methodology to adjudicate the recommendations, articulation of recommendations, external quality of evidence as high, moderate, low, or very low based on review, and updating (iom.nationalacademies.org). their confidence that the estimate of effect was close to the true effect. They generated recommendations only after considering The membership should be proud of the NCS Guideline quality of evidence, relative risks and benefits, patient values and Committee for meeting these standards and keeping us informed. preferences, and resource allocation. It is hard and frustrating work but the end result will impact our practice and certainly for some individualists. Changing practice The committees faced a common concern: the paucity of evidence. based on good evidence is the new norm. There is nothing better Nonetheless, recommendations could be distilled from a large than that. body of literature sometimes with personal opinion seeping through in conclusions such as “strong recommendation, low quality evidence.” One guideline involves the insertion and management of ventriculostomy drains. There are considerable differences in management between providers and concerns over the rate of complications such as infection, malposition, and hemorrhage. The paper provides statements about thromboembolism prophylaxis, antimicrobial impregnated catheters, and how to best adhere to a bundle of care. 25


232747_NCS Currents_December_2_eMag
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