Critical care--an all-encompassing specialty.

The August 29 issue of the Journal will include the first in a series of review articles on critical care. Critical care is a young specialty that is generally considered to have developed from the successful use of invasive ventilation during the 1952 polio epidemic in Copenhagen. In his report of the response to that epidemic, Ibsen described much more than the use of invasive ventilation; he also described collaborative, multidisciplinary care that can serve as a model for critical care services to this day.1 He described managing severe infections and respiratory failure, providing cardiovascular support with resuscitation fluids and vasopressors, monitoring ventilation by measuring carbon dioxide, placing nasogastric tubes to feed patients, and conducting daily multidisciplinary rounds. He also described the importance of backup systems when patients’ lives are so dependent on technology that even brief technical failures will prove fatal.1 From these beginnings, critical care has spread to most countries in the world. In many developed societies, the number of critical care beds is increasing while total number of acute care hospital beds is decreasing; the proportion of acute care hospital beds that are intensive care unit (ICU) beds is increasing substantially.2 Critical care services consume a high proportion of health care budgets. In 2005, critical care services in the United States were estimated to cost $81.7 billion, or 0.66% of the gross domestic product.3 Although the organization of critical care services varies from country to country, it is clear that taken at its broadest definition, critical care is an all-encompassing specialty with almost limitless boundaries. Critical care involves the use of life-sustaining, high-technology medicine catering to a patient population that extends to both extremes of age. In adult ICUs, the average age is increasing and is now commonly well over 60 years. Although ICUs admitting patients for preplanned brief stays after planned major surgery have very low mortality rates, the rates in adult ICUs among patients admitted “for cause” are generally around 15% in developed countries. In a recent study of Medicare beneficiaries in the United States, 29.2% of patients had been treated in an ICU during the last month of their lives.4 Currently, most deaths in ICUs are expected, and ICU clinicians regularly face the decision of when to change the focus of treatment from attempting to cure to providing palliative care. Compassionate care of dying patients requires that critical care practitioners add yet another essential skill set to their more obvious background knowledge and procedural skills designed to sustain life. In 2013, critical care practitioners may recognize many of the problems faced by Ibsen in 1952. Although we have much more highly developed technology available, our patients are often much older, and many have multiple coexisting diseases. Determining how best to use the available technology for our patients’ benefit can be determined only through high-quality research. To the credit of our specialty, large national and international clinical-trial networks are systematically evaluating both established and new treatments in high-quality large-scale trials.5 Most of these trials are funded by competitive, peer-reviewed grants, and many of the trial reports have been published in the Journal.6-11 Although we cannot cover anywhere near the full range of critical care practice in our series, we have invited our authors to address many of