title: Struggle for implementation of new strategies in intensive care medicine: anticoagulation, insulin, and lower tidal volumes.
abstract: The management of intensive care patients have changed dramatically in the last years: from merely supportive care, it has moved to evidence-based strategies that have been demonstrated to reduce mortality of the severely ill patients. Clinical research have brought numerous positive clinical trials offering intensive care physicians specific therapies to improve outcome of intensive care patients. Among them were the trials that tested the infusion of activated protein C in patients with severe sepsis, tight glycemic control in surgical intensive care patients, and use of lung protective mechanical ventilation by using small tidal volumes in patients with acute lung injury. Although results of these trials were sufficiently strong to, at least, consider implementation of these strategies in critical care medicine, published and yet unpublished reports show that there is significant struggle with implementation of these therapies. This manuscript focuses on the potential reasons that underlie this problem.
authors.affiliation: Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands. m.j.schultz@amc.uva.nl
authors.forename: Marcus J
authors.initials: MJ
authors.lastname: Schultz
authors.forename: Esther K
authors.initials: EK
authors.lastname: Wolthuis
authors.forename: Hazra S
authors.initials: HS
authors.lastname: Moeniralam
authors.forename: Marcel
authors.initials: M
authors.lastname: Levi
mesh_terms: D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use*; D003422:Critical Care / Q000191:economics / Q000379:methods*; D016638:Critical Illness / Q000628:therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D006943:Hyperglycemia / Q000150:complications / Q000188:drug therapy; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D011182:Postoperative Care / Q000379:methods; D011486:Protein C / Q000191:economics / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D011994:Recombinant Proteins / Q000191:economics / Q000627:therapeutic use; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000628:therapy; D018746:Systemic Inflammatory Response Syndrome / Q000150:complications / Q000188:drug therapy; D013990:Tidal Volume
chemical_list: D000925:Anticoagulants; D007004:Hypoglycemic Agents; D007328:Insulin; D011486:Protein C; D011994:Recombinant Proteins; C421124:drotrecogin alfa activated