Critical Care Medicine: Major Changes in Dogma of the Past Decade

Critical care medicine is a young specialty that has e-uperi-enced an expansion of research efforts in the last decade. hlany physiologic and therapeutic principles or ”dogmas” have been challenged, resulting in major ‘shifts ” and minor “drifts ” in thinking. This article reviews the available litera-ture about some of these important and sometimes contro-versial changes, with emphasis on the practical implications of the concepts. Specific areas discussed include supply-dependent oxygen consumption in critical illness, manipula-tion of the cytokine cascade in sepsis, ventilation in the acute respintory distress syndrome (ARDS), blood transfusion in the critically ill, the concept of the niultiple organ dysfunc-tion syndrome (hIODS), the need for nutritional support in the critically ill, and others. hlany of the changes discussed involve the recognition that the host response to a severe insult is exceedingly complex, and the understanding of this response and the effects of it at a tissue and cellular level are incomplete. As a result, the ability to impact the outcome of sepsis and AIODS has tlius far been disappointing, with the possible exception of ‘lung-protective ” ventilation. The final challenge in critical care medicine is to gain information that will allom the practitioner to better understand, prevent, and treat the complex events that result in organ and cellulnr dysfunction. Future changes in dogma are welcome if they help achieve these goals