Critical care evidence base-the role of research
Remember the days when urine output was driven by 'renal dose dopamine'? Hooray...the urine output went up...must be good?...wrong...in a well conducted RCT the patients did not benefit...and nor did the kidneys. Also remember the nitric oxide synthase inhibitor trials...the drug increased blood pressure in septic patients...except mortality went UP not DOWN...remember cooling patients with raised ICP or doing decompression...it reduced the ICP...must be good?...WRONG...led to WORSE outcomes. ...fresh blood MUST be better than 30 day old blood from the back of the shelf surely...WRONG...mortality went UP not DOWN. Think about the Canadian Critical Care Trials Group...did an HFO trial in oscillation that they led the world on...hooray they decreased mortality...BUT it was in the CONTROL arm. ..the HFO treatment they had been convinced was beneficial was actually harmful. The increase in PO2 seen with HFO was associated with INCREASED mortality. Tight glycaemic control must be good ....WRONG INCREASES mortality....for years we gave Volplex...must be good right...you give less volume and it more quickly expands the intravascular space...WRONG.,in the trial there was a dose-dependent INCREASE in mortality in the COLLOID arm. Look at the old sepsis trials...hundreds of thousands of patients got methyl pred...reduced the white count and fever and increased the BP...must be good right...WRONG...very significant INCREASE in mortality...OK what about methyl pred in TBI...tens of thousands of patients got this...must be good surely to reduce swelling and secondary brain injury from inflammation...CRASH trial...WRONG...INCREASED mortality...thousands of neurosurgeons were WRONG. They were actually killing patients. They swore blind it was good...they had 'seen it work'...THEY WERE WRONG. Remember the Supra-normalised DO2 trials...surely putting a PA catheter in and improving oxygen delivery with fluids and pressors will be good in critically ill patients? Clever ICU doctors swore blind that they were saving patients WRONG...they were actually killing them (Michelle Hayes/Luciano gattinoni di proper RCTs...and got the OPPOSITE result to the one they themselves expected).