The grades of evidence (I-III) and levels of recommendations (I-III) are defined at the end of the "Major Recommendations" field.
Level I
There are insufficient data to support a Level I recommendation for this topic.
Level II
Prophylactic administration of barbiturates to induce burst suppression electroencephalography (EEG) is not recommended.
High-dose barbiturate administration is recommended to control elevated intracranial pressure (ICP) refractory to maximum standard medical and surgical treatment. Hemodynamic stability is essential before and during barbiturate therapy.
Propofol is recommended for the control of ICP, but not for improvement in mortality or 6 month outcome. High-dose propofol can produce significant morbidity.
Summary
Analgesics and sedatives are a common management strategy for ICP control, although there is no evidence to support their efficacy in this regard and they have not been shown to positively affect outcome. When utilized, attention must be paid to potential undesirable side effects that might contribute to secondary injury.
High dose barbiturate therapy can result in control of ICP when all other medical and surgical treatments have failed. However it has shown no clear benefit in improving outcome. The potential complications of this form of therapy mandate that its use be limited to critical care providers; that patients be hemodynamically stable before its introduction; and that appropriate, continuous systemic monitoring be available to avoid or treat any hemodynamic instability. Utilization of barbiturates for the prophylactic treatment of ICP is not indicated
Definitions:
Grades of Evidence
Class I - Good quality randomized controlled trial (RCT)
Class II - Moderate quality RCT, good quality cohort, or good quality case-control,
Class III - Poor quality RCT; moderate or poor quality cohort; moderate or poor case-control; or case series, databases, or registries
Levels of Recommendation
Levels of recommendation are Level I, II, and III, derived from Class I, II, and III evidence, respectively.
Level I - Recommendations are based on the strongest evidence for effectiveness, and represent principles of patient management that reflect a high degree of clinical certainty.
Level II - Recommendations reflect a moderate degree of clinical certainty.
Level III - Recommendations for which the degree of clinical certainty is not established.
