Evidence‐based critical care medicine: seeing through a glass darkly

Emergency surgery in the elderly patient: a quality improvement approach

“…To undertake a randomised controlled trial for this group of patients is therefore likely to be very difficult. These problems have been discussed recently in relation to critical care research [15]. An alternative method is to use a quality improvement approach, with data displayed as 'run charts' using statistical process control techniques and small samples paired with repeated small tests of change using 'plan-do-study-act' (PDSA) methods [16,17].…”

The role of steroids in treating septic shock

“…This not only applies to steroids but also to a panoply of ICU therapies [17]. Narrowing the patient populations may prove more fruitful.…”

“…Is it naïve to expect studies in critically ill patients with heterogenous pathologies to produce definitive conclusions? This not only applies to steroids but also to a panoply of ICU therapies [17]. Narrowing the patient populations may prove more fruitful.…”

Oesophageal Doppler monitoring, doubt and equipoise: evidence based medicine means change

“…Many clinicians ‘got it wrong’ with activated protein C, steroids in sepsis and head injury, colloids, peri‐operative beta blockade and routine epidural analgesia, to name but a few. Clinicians’ desire to improve care , compounded by publication bias, means it is perhaps inevitable that one might encounter examples of definitive negative studies that ultimately curb enthusiasm for ineffective therapies following smaller (and erroneously positive) initial studies; often the ‘truth’ around a therapy depends upon how far along this path we have progressed . Recent experience with activated protein C in sepsis is a case in point: the initial PROWESS paper suggested impressive benefit but was essentially a post‐hoc subgroup analysis .…”