Controversies and Evolving Concepts in Critical Care

Wassim H. Fares, MD, MSc

Mark D. Siegel, MD

Finding appropriately designed clinical trials to guide critical care practice can be daunting. The intensive care unit (ICU) environment poses logistic obstacles to performing studies, including narrow time windows to enroll patients, difficulties obtaining consent for patient enrollment, and a mandate to collaborate across institutions to generate results. Lacking robust evidence, critical care guidelines are often based on expert opinion, spawning many controversies, which we explore in this issue of Seminars in Respiratory and Critical Care Medicine. Evidence is building to address these controversies, and we have been fortunate to recruit an impressive cadre of experts to address many of the challenges intensivists face each day.

This issue starts with an elegant summary by Drs. Ahasic and Christiani of progress being made toward realizing the potential of personalized critical care medicine. Subsequent articles review new evidence driving the treatment of severe ARDS by Dr. O'Gara et al and pulmonary emboli by Dr. Marshall et al. Then Dr. Bice et al address growing concerns about chronic critical illness and our approach to discussing the burdens and benefits of tracheostomy with patients and families.

Drs. Holdorf and Lilly as well as Drs. Chong and Ward, respectively, address evolving concerns about staffing and resource utilization in critical care, focusing on the e-ICU (or tele-ICU), nighttime staffing, and the role of intensivist “extenders,” while also wrestling with ICU bed expansion and the common practice of offering critical care to dying patients. This issue also presents two comprehensive reviews of invasive and noninvasive hemodynamic monitoring tools while exploring their value and limitations in the “post-Swan-Ganz” era, one focusing on the right heart failure syndrome by Dr. Kholdani et al and another focusing on overall hemodynamic monitoring in the ICU by Drs. Suess and Pinsky.

Multiple critical care practices are gaining momentum, including the implementation of protocols to standardize treatment and the use of bedside-focused ultrasound. The quality of evidence supporting this momentum is thoroughly discussed. Drs. Siner and Connors consider the criteria required to deem a protocol successful, while Drs. Brown and Kasal explore sources of error in ultrasound-guided clinical management as well as accumulating evidence to support bedside ultrasonography.

We are also updated by Drs. Honiden and Inzucchi on current approaches to optimizing nutritional support and managing hyperglycemia. Another review by Dr. Jutte et al explores evolving concerns about physical, cognitive, and psychological disabilities in ICU survivors, including the barriers to improving long-term outcomes.

An issue devoted to current controversies would be incomplete without discussing rapidly evolving priorities related to sedation and end-of-life care. Dr. Debiasi et al beautifully present a comprehensive review of new approaches to preventing and managing agitation, highlighting recent efforts to keep ICU patients more awake. We also include a state-of-the art review by Dr. Akgun et al of palliative care in the ICU, which is gaining traction as we seek to improve care for dying patients.

We are enormously grateful to our expert authors. If this issue succeeds, it is because of their thoroughness, novel insights, and lucid writing. Finally, we deeply appreciate the patience and support of Dr. Lynch and his staff and the opportunity given to us to assemble this exciting collection.