Critical care evidence--new directions.

During the past decades, intensivists have learned how to care for critically ill patients and enable many to survive illnesses that previously would have been fatal. For example, the mortality rates associated with acute respiratory distress syndrome (ARDS) and with sepsis have both declined markedly during this interval. 1 Improved short-term survival has resulted not only from better understanding of individual diseases but also (and perhaps more importantly) from optimizing intensive care unit (ICU) organization, standardizing best practices, and improving processes of care delivery. Even though this decline in short-term mortality is a major achievement, it has spawned new challenges. Increasingly, patients who survive serious illness experience " chronic critical illness " that continues well beyond ICU discharge and often culminates in long-term morbidity and mortality. For example, about 3 of 5 sep-sis survivors exhibit persistent cognitive decline or disability after hospital discharge. 2 Prevention of such disability , with its attendant emotional and economic costs for patient, family, and society, has become a therapeutic priority. Earlier interventions to prevent the need for ICU admission and to avoid the adverse consequences of ICU care are beginning to receive justified emphasis. Achieving further improvements in survival and quality of life for patients with critical illness may require different approaches to understanding disease processes, conducting research, and developing new therapies. In March 2014, a group of 24 experts in critical care research and practice held a meeting (the 2014 Brus-sels Round Table) at the 34th International Symposium on Intensive Care and Emergency Medicine (Brussels, Belgium). As described in this Viewpoint, the purpose of the round table was to share ideas regarding the potential for recent advances in biophysiology and molecular medicine and for newly developed biological, analytical , and statistical approaches to advance the science and practice of critical care medicine. The need to per-sonalize critical care according to physiologic responses to disease and treatment was emphasized in the context of the patient's innate physiology, chronobiol-ogy, immunology, and attempts to adapt. Scientific Methods The scientific methods on which intensivists currently rely to gather evidence may not be sufficient to guide practice and improve outcomes. Population heteroge-neity, complexity of interventions and disease, time dependence of disease characteristics, disrupted diurnal physiology and control mechanisms, variations in sensitivity to treatment, and adaptive biological responses complicate therapeutic endeavors. Although diversity of disease expression and requirements to personalize care are not unique to critical illnesses, these factors …