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Surgical Intensive care, University Hospital, Geneva, Switzerland
Address correspondence and reprint requests to Peter M. Suter, MD, Surgical Intensive Care, University Hospital, CH-1211, Genève, Switzerland.
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Introduction |
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What are the major advances in this field during the last 10 years? There are certainly too many to be mentioned here, so I feel obliged to make an arbitrary selection, retaining educational and organizational achievements, ventilation-induced lung injury, and new therapies for sepsis and septic shock.
By whom should the critically ill be treated today? The 1990s have clearly confirmed the survival advantage provided for the patient by a professional approach in intensive care medicine. As in the majority of the other medical specialities, full time intensive care unit physicians with the appropriate, officially recognized training and board certification, seem not only to treat patients more efficiently, reducing mortality, but are also more cost efficient than other professionals (1,2). In addition, the resulting team approach and responsibility improve organization and management significantly.
In the presence of so much strong evidence for this professional scheme, it is surprising that, in many European countries, such official training and certification guidelines still do not exist, and that full time intensivists are often not available. Less surprisingly, research and scientific publications continue to be of lower quality in countries in which a speciality formation/training and separate board for intensive care medicine are not recognized.
Certainly, there has been a renewed interest in respiratory mechanics and "adapted" modes of mechanical ventilation during the last few years based on convincing animal data. The first clinical studies suggest evidence for the clinical reality of ventilator-induced lung injury, and, more importantly, its potential influence on outcome (1a,3–7).
These data have already profoundly changed the management of respiratory failure and mechanical ventilation during the last decade. Outcome studies suggest that mortality in one of the severest forms of acute respiratory failure, i.e., acute respiratory distress syndrome, has markedly declined since the 1980s, possibly as the consequence of lung protective strategies of ventilation and an improvement in general intensive care (8). These results are an occasion for some optimism in the field.
The last decade has not provided much reason for optimism, however, for the therapy of sepsis and septic shock. Despite important advances in our understanding of the mechanisms leading to the clinical picture and the often dismal outcome in this disease, the identification of important mediators and neutralizing proteins, all specific therapeutic interventions have failed so far to improve prognosis, even though many new therapies have been tested in appropriate randomized, double-blinded trials, including early corticosteroids and other antiinflammatory drugs, mediator neutralizing drugs, such as antitumor necrosis factor antibodies, antiinterleukins, and augmentation of systemic oxygen transport (9–13).
Thus, although many important advances have been made in the field of intensive care medicine during the last decade of the 20th century, there remain vast areas in which understanding and management must be improved; these include acute central nervous system diseases, cost-effectiveness analysis, and ethical questions overall related to end-of-life issues (14,15). These and other domains remain to be addressed, not only by the specialists in intensive care medicine, but also by large interdisciplinary discussion groups, including citizens and patient associations.
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