Which therapeutic interventions in critical care medicine have been shown to reduce mortality in prospective, randomized, clinical trials? A survey of candidates for the Belgian Board Examination in Intensive Care Medicine

Multicenter, randomized, controlled trials evaluating mortality in intensive care: doomed to fail?

OBJECTIVES

To determine how many multicenter, randomized controlled trials have been published that assess mortality as a primary outcome in the adult intensive care unit population, and to evaluate their methodologic quality.

DATA SOURCE

A sensitive search strategy for randomized controlled trials was conducted in the Cochrane Central Register of Controlled Trials and in MedLine using the PubMed interface.

STUDY SELECTION

All publications of adult, multicenter randomized controlled trials carried out in the intensive care unit, with mortality as a primary outcome, and including >50 patients were selected.

DATA EXTRACTION

Seventy-two randomized controlled trials were retrieved and were classified according to their effect on mortality: beneficial, detrimental, or neutral.

DATA SYNTHESIS

Ten of the studies reported a positive impact of the studied intervention on mortality, seven studies reported a detrimental effect of the intervention, and 55 studies showed no effect on mortality.

CONCLUSIONS

This literature search demonstrates that relatively few of the randomized controlled trials conducted in intensive care units and using mortality as a primary outcome show a beneficial impact of the intervention on the survival of critically ill patients. Methodological limitations of some of the randomized controlled trials may have prevented positive results. Other forms of evidence and end points other than mortality need to be considered when evaluating interventions in critically ill patients.

Evidence-based medicine in the ICU: important advances and limitations

Evidence-based medicine (EBM) is an important strategy for assessing the vast amounts of published data and applying them appropriately to our patients. However, in intensive care medicine, there is a shortage of "gold standard" randomized controlled trial evidence to support (or not support) therapeutic decisions. In addition, even when well-conducted randomized trials have been performed, we are still left with unanswered questions. In the last 5 years, several clinical trials have yielded positive results with a number of interventions being shown to improve outcomes. Here, we will outline the limitations and advances of EBM in intensive care medicine, by discussing the key findings in the last few years from studies of therapeutic agents for ICU patients.