As Dr Trauner points out, the origin of Reye's syndrome is unknown, so that its treatment is necessarily empiric. Mild cases should be observed closely in the hospital and treated with 10% to 15% hypertonic glucose solutions, which may prevent progression.1
Given the high mortality (33% ), an aggressive therapeutic approach seems justified, and both Dr Trauner and Dr Shaywitz and colleagues agree on intensive care, mechanical ventilation, correction of metabolic abnormalities, and treatment of intracranial pressure (ICP). The differences arise in the management of intracranial pressure. The Yale protocol calls for invasive monitoring and the use of barbiturates. Intracranial pressure monitoring is controversial2-4 but seems justified for the short term in a grave but potentially remediable condition. The benefits of barbiturate therapy, however, may be negated quickly by their aggravation of the metabolic disorder and by decreasing the patient's ability to fight infection, a common complication. Dexamethasone is