Evidence lost to treatment of critically-ill patients?

Treatment strategies for critically-ill patients can and should never be excluded from grading processes that classify the evidence and provide decision support for health care workers involved in the care of these patients. Along with grading the available evidence, implementing new therapies and strategies in daily practice is another important but frequently forgotten step in improving care for critically-ill patients. Explanations for why some trials show benefit while other trials do not or even show harm include differences in the timing and the dose of the studied interventions, differences and heterogeneity of study populations and differences in trial protocols. Potential factors that may hamper the implementation of new therapies and strategies include translational problems, potentially biased expert opinions, concerns about side-effects and costs and problems with the recognition of critically-ill patients who might actually benefit from a new therapy or strategy. We discuss difficulties with grading the evidence for and the implementation of lung-protective mechanical ventilation in acute respiratory distress syndrome, glucocorticosteroid therapy in refractory septic shock, glucocorticosteroid therapy in acute respiratory distress syndrome, goal-directed fluid therapy in shock, activated protein C in severe sepsis and intensive insulin therapy in critical illness.