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CRITICAL CARE AND TRAUMA

Evidence-Based Management of Critically Ill Patients: Analysis and Implementation

Department of Anesthesia and Perioperative Care and Cardiovascular Research Institute, University of California, San Francisco

Address correspondence and reprint requests to Michael A. Gropper, MD, PhD, Critical Care Medicine, 505 Parnassus Ave., Room M917, University of California San Francisco, San Francisco, CA 94143-0624. Address e-mail to gropperm{at}anesthesia.ucsf.edu

A number of important clinical trials focusing on critically ill patients have been completed in the last few years. These trials have been among the first critical care clinical trials to demonstrate mortality reduction in the critically ill. As in any adaptation of evidence-based medicine, it is essential to closely examine the trials and to determine whether the demonstrated benefits can be translated to the individual patient. In addition to the primary outcome, usually survival benefit, it is also important to examine cost-effectiveness. All of the trials examined in this review were able to demonstrate mortality reduction. Most focused on patients with severe sepsis, because this population has been associated with both frequent mortality and increased hospital costs. Some of the interventions, such as small tidal volume mechanical ventilation in patients with acute lung injury or the administration of low-dose corticosteroids for patients with septic shock, are cost-effective and relatively simple to implement. Others, such as use of activated protein C in patients with severe sepsis or "tight" glycemic control in patients with hyperglycemia, require either significant pharmaceutical expenditure or, possibly, additional health care personnel. Nevertheless, the trials discussed represent significant advances in the field of critical care medicine and should at least be considered for implementation in all intensive care units.