The authors try to make the point that without scientifically rigorous evidence, consensus guidelines are of no value. In fact, because data is lacking, much of the practice of medicine is based on consensus. This consensus defines “standard of care.” We agree that the science behind the management of tricyclic overdose is limited. However, this is exactly the clinical setting in which consensus guidelines are of greatest value.
Consensus guidelines standardize management approach but do not limit approaches required in unique clinical situations. Consensus is based on available evidence that is weighted. Greater weight is placed on studies of greater scientific rigor. The experience of coming to consensus is good as scientists are brought together to interpret existing data and delineate areas of controversy.
Guidelines are of little value if they don't go through an appropriate evidence‐based process. The level of specificity of the guidelines is determined by the rigor of the evidence. Take the example of serum alkalinization in TCA overdose. It is difficult to argue that pH should not be monitored when the serum is being alkalinized. However, this is rarely done. A consensus guideline may state that pH be monitored and suggest the frequency of obtaining a pH. This would standardize approach and change medical practice.
Consensus guidelines should change over time as more information becomes available. However, if we wait for proper scientific evidence, we will continue with what we have, which is a marked variability in clinical management of sick patients. It is extremely difficult to do large multicenter overdose studies due to the number of variables, time requirements, and funding limitations. Little if any financial support is currently directed toward multicenter overdose studies. It is unlikely that will change, but the process of developing consensus guidelines may highlight the areas that most need further research.
Current therapy for TCA overdose is based on “experience, intuition, and limited experimental data.” This basis of treatment causes a marked variability in recommendations and treatment approaches. It is this variability in treatment approaches that compromises patient care, not consensus guidelines.
Donna Seger
Christina Hantsch
Keith Wrenn
E‐mail: [email protected]