Must Read Paper: Vincent – 10 BIG mistakes in ICM

Happened upon this commentary written by the venerable Jean-Louis Vincent in Intensive Care Medicine, and it’s a MUST read.  Below is his “Top 10 list,” but there is a lot more discussion in the paper worth reading.  Below are a few of my thoughts, but I’d love to hear what everyone else thinks….

1. We focus too much on syndromes/phenotypes (ARDS, sepsis, AKI, etc.) over specific cellular alterations.
2. We jump to prospective RCTs before identifying the right patient population then struggle to interpret the results.
   • Shock 2? PACMAN? Are their subgroups that benefit from these interventions or evaluations (example: Pre-operative IABP) ? Should we be throwing the baby out with the bath water?
   • At the 2015 SCCM CC Congress, Luciano Gattinoni said it best, “Physiology is the basis of medical reasoning, not statistics.  Statistics are a tool.”
3. We continue to allow the walls of the ICU to define critical illness & pre-emptive intervention.
   • Peter Safar defined the continuum of critical illness decades ago… why are we still struggling with this concept?
4. We have failed to appreciate the path to post-ICU recovery.
   • If you aren’t reading publications by Dale Needham, Giora Netzer, and others about post-ICU sydrome, start… NOW.
5. We’ve failed to optimize the path to recovery.
6. Protocols are good, but sometimes get in the way of good patient care.
   • Protocols standardize treatment goals, but lets be honest, all patients are different and may require subtle differences in management during their resuscitation!
   • The classic example would be EGDT – It wasn’t the protocol that saved lives, it was the concept – early, aggressive sepsis management.
7. We are too aggressive with normalizing physiology.
   • The list of physiologic variables we struggle to normalize (SpO2, BP, pH, INR, etc.) go on and on, but do they actually need to be normal?
   • Chris Nickson highlights an interesting twist on this concept in his Euboxia talk
8. We are poor communicators with patients, families, nursing, and other support staff.
   • I think this is likely true across all specialties – whether in critical care, emergency medicine, or as an out patient.  We ALL can do better.
9. We have failed to appropriate goals of treatment based on pre-ICU quality of health.
10. We have not adequately addressed the ethical aspects of care – specifically end-of-life decisions.

Hopefully this list will wet your palate enough to go on and read this thought provoking editorial.  Are Vincent, Hall, & Slutsky spot on? or are they way off base?  What should they have included in this list?

Don’t be selfish,  leave your thoughts below!

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