A total of 4,956 medical professionals from 84 countries attended the 26th International
Symposium on Intensive Care and Emergency Medicine (ISICEM) in Brussels, Belgium.
The 4-day conference, which took place from 21 to 24 March 2006, featured 769 presentations
in 124 sessions, and covered a vast range of general, clinical, and experimental medicine
topics in a variety of formats, from lectures to tutorials to pro-con debates.
Although the majority of attendees traveled to Brussels to learn about advances in
their disciplines, the meeting also provided an opportunity to view intensive care
from a broader perspective. What needs to be done to improve the quality of care?
How can people in different fields, or in different countries, work together? How
can we profit from the experiences – and experience – of others? What can we do better?
And where is there a need for research?
The international experts who spoke at the 26th ISICEM provided a wealth of information
from a variety of perspectives. Some themes and insights from the conference are identified
in the following.
We don't know
One striking trend in the presentations was the frequent use of some variation of
the phrase 'We don't know' (see Table 1). From the very first morning, in the opening
session, conference organizer Jean-Louis Vincent (Brussels, Belgium) set the stage
by asking why, over many years, so many studies have shown no impact on outcomes.
'Are we experts in negative studies?', he asked. After naming a variety of commonly
used interventions that research has shown should not be used, he asked in mock despair
'Can we sometimes add something to our list?'
There are obviously multitudes of things that physicians do know about treating patients.
But the fact remains that much of what intensivists do is based on intuition rather
than on evidence. 'Most recommendations are actually expert opinions ... We think
that this is reasonable', said Vincent. In fact, many current practices and treatments
may be harmful, suggested Mervyn Singer (London, UK). 'We assume we're doing the right
thing, but are we?', he asked in a talk entitled 'Primum non Nocere' ('First do no
Consensus versus controversy
Intensivists disagree about the value of many approaches to patient care. Several
of these were the focus of pro-con debates at the conference (see Table 2). The meeting
demonstrated that reaching consensus on the recommendation of treatments and approaches
can also be a difficult task.
In his presentation on the new guidelines of the Surviving Sepsis Campaign to be
published in late 2006, Phillip Dellinger (Camden, NJ, USA) stated that recommendations
on three topics – glycemic control, recombinant activated protein C, and steroids
– had to undergo multiple attempts at consensus, culminating in obtaining 80% or greater
consensus through a secret ballot of 52 voting committee members. Furthermore, there
was 'a lot of debate' prior to approval of continuing to recommend beginning antibiotics
within the first hour of recognition of severe sepsis, a recommendation felt to be
very important but sometimes very difficult to achieve.
Evidence in favor of tight glucose control in surgical patients was presented by Greet
van den Berghe (Leuven, Belgium). She also presented research published recently by
her group (see Additional file 1) showing that intensive insulin therapy in the medical
intensive care unit (ICU) significantly reduced morbidity among all patients, and
also lowered mortality when the patients were treated for at least 3 days.
Although intensivists disagree over whether glucose levels need to be maintained between
80 and 110 mg/dl in intensive care patients, Dellinger said that the Surviving Sepsis
Committee felt that the evidence supports tight glucose control.
The group from Leuven also received one of five Poster Awards for work on the effect
of blood glucose control on mitochondria (see Table 3).
The session on the new American and European guidelines for cardiopulmonary resuscitation
highlighted yet another topic of controversy. There are two major changes to the guidelines.
First, they recommend a single shock instead of three stacked shocks for ventricular
fibrillation, followed by immediate resumption of cardiopulmonary resuscitation. The
second change is an emphasis on thoracic compressions rather than ventilation, with
30 compressions now being recommended instead of 15, along with two breaths.
The speakers agreed on the importance of compressions, on the fact that ventilation
interrupts perfusion, and on the 'abysmal' survival rates (somewhere between 2% and
12%) that still follow out-of-hospital cardiopulmonary resuscitation. With the previous
guidelines, said Bernd Böttiger (Heidelberg, Germany), Chairman-Elect of the European
Resuscitation Council, less than 50% of the time spent performing cardiopulmonary
resuscitation was devoted to compressions, which are necessary to maintain coronary
and cerebral perfusion pressure.
The issue that proved controversial at the session was whether ventilation should
be provided at all, with speaker Gordon Ewy (Tucson, AZ, USA) proposing a compression-only
algorithm to address what he saw as two main problems: rescuer hesitance to perform
mouth-to-mouth resuscitation, and the fact that 'two quick breaths is an oxymoron
– it can't be done'.
Of course, the fact that there is initial disagreement over a treatment does not mean
that it will never be adopted. In a talk entitled 'Diffusion of Innovations', Roy
Brower (Baltimore, MD, USA) shared a colleague's insight that 'In order to improve
care, you first have to get your team to agree on what you want to do, and how you're
going to do it, and that's consensus building'. Developing consensus in the ICU environment
is invaluable, Brower said. He pointed out that some good ideas take a while to catch
on. For example, as early as 1601 there was evidence that lemon juice could prevent
scurvy, but the British Navy did not begin ordering citrus fruits for sailors until
Today, few doctors in North America and Europe would recognize scurvy if they saw
it. Thirty years ago, a US Surgeon General boldly (and mistakenly) claimed that infectious
disease was a thing of the past. Yet in 2006 serious health threats – including epidemics,
terrorism, and natural disasters – are increasingly affecting mankind on a global
According to Dennis Maki (Madison, WI, USA), on an average day almost twice as many
people die from infectious diseases as from cancer and heart disease combined, and
the list of emerging infectious diseases is growing month by month. Outbreaks of West
Nile virus, influenza, and severe acute respiratory syndrome have demonstrated how
quickly diseases can spread, as well as the existence of related problems – such as
threats to the blood supply – and the importance of infection control measures.
Current concern over the spread of avian influenza (H5N1) has highlighted the importance
of preparation. Even so, Jan Bakker (Rotterdam, The Netherlands) emphasized that 'the
problem that's coming to us is numbers'. Using the computer modeling program Flusurge
developed by the US Centers for Disease Control and Prevention, Bakker estimated that
15,000 patients would be admitted to the hospitals in The Netherlands (population
16 million) in the fifth week of an 8-week influenza pandemic, with 3,400 of those
needing ICU admission and 1,500 requiring mechanical ventilation. The current capacity
in The Netherlands, however, is 820 beds with mechanical ventilation, and a total
of 1,200 ICU/high dependency unit beds.
Tragically, while intensivists struggle to find ways to treat illnesses and injuries,
other equally devoted groups are working to cause them. In a talk on 'Biological Weapons',
Dennis Maki pointed out that Soviet research into using smallpox as a biological weapon
accelerated with worldwide eradication of the disease. The saran gas attack in Tokyo
showed that biological weapons are being used. The New York World Trade Center attacks
and the London and Madrid bombings demonstrate that, in the words of Yoram Kluger
(Tel Aviv, Israel), explosions and bombs will remain main weapons of terrorists. Kluger
presented graphic photographs of injuries sustained by victims of bomb attacks.
Charles Sprung (Jerusalem, Israel) provided advice for preparing a hospital to receive
multiple casualties. 'Unfortunately', said Sprung, 'we at Hadassah have become experts
in terrorist response'.
Paul Pepe (Dallas, TX, USA) highlighted the many challenges of dealing with a natural
disaster such as Hurricane Katrina, which devastated New Orleans, Louisiana, in August
2005. Medical personnel were overwhelmed by the scale of the problem. How do you rescue
– let alone reach – 200,000 people? What rules of triage do you follow? How do you
provide medical attention for chronic problems without access to medical records?
'The rules were completely changed', Pepe said.
What can intensivists do? 'If you haven't preplanned then you should expect chaos
after a disaster occurs', said Christopher Farmer (Rochester, MN, USA). 'During a
large-scale disaster, the hospital essentially becomes a critical care unit. Who's
in charge and who's directing all of these things? What role do you and I have in
this process, and where are our responsibilities?' Farmer cited two new publications
offering recommendations for the delivery of critical care services in connection
with an epidemic or bioterrorist attack (see Additional file 1). In addition, the
Society of Critical Care Medicine has completed a pilot for a new Hospital Mass Casualty
Disaster Management Program designed to train noncritical care people to provide basic
skills in the event of a disaster, and a textbook is in development.
The importance of disaster medical response is widely acknowledged, said Farmer, but
'basically and functionally we ignore this as critical care professionals ... Almost
every aspect of a workable and sustainable model for a disaster critical care response
remains undeveloped at this time'.
Most intensivists are busy enough handling noncrisis situations. In their search for
ways to streamline the care of their patients, intensivists are increasingly turning
Speaking in a session on 'Good Care', Gordon Rubenfeld (Seattle, WA, USA) stated:
'There is considerable evidence throughout all of medicine that protocol-based care
[can improve outcomes]'. 'Sometimes it doesn't even matter what the protocol is',
he said, 'Just making people stratify their care and organize their care can improve
outcomes on its own'.
Protocols are evidence based, and represent what the literature would have us believe
is best practice, said Stanley Nasraway (Boston, MA, USA). One advantage of protocols
is that they standardize care, and standardizing care reduces variability, he said.
'If you reduce variability, you can reduce error and complications. ... If you reduce
error and complications you improve outcomes, and sure enough, frequently you also
A presentation by Stephan Jakob (Bern, Switzerland) highlighted how one hospital was
able to reduce costs and the median length of ICU stay by such measures as restructuring
daily routines, changing from an open to a closed ICU model, performing joint rounds
with specialists, and instituting protocols.
Not everyone is in favor of protocols, however (Fig. 1). Protocols require significant
time and personnel, and adherence tends to dwindle the longer they are in place. 'I
like guidelines, but I'm a little concerned when we try to implement them too widely',
said Jean-Louis Vincent. 'We should not simplify too much the complexity of our world'.
Treating critically ill patients is indeed a complex task. Many of the speakers at
the meeting acknowledged the importance of working together, with an emphasis on communication
and multidisciplinary care.
Communication is paramount for preventing conflict in the ICU, said Elie Azoulay (Paris,
France). Conflicts can occur within the care team, between members of the care team
and families, and within families – and often these conflicts result from contradictory
or insufficient information. Azoulay highly recommended using family conferences to
involve families in decisions about patient care.
Kenneth Hillman (Liverpool, Australia) shared his personal approach to communicating
with the families of ICU patients. He suggested explaining to them that sometimes
different healthcare workers say things in different ways; that often it will be necessary
to try various approaches and treatments ('It may look like uncertainty, but this
is the way we practice'); that the situation can change by the hour or by the minute;
that families should look at the patient rather than at the monitors; and that families
should take care of themselves, because they may be in for a marathon.
Improving communication is not the only way to improve care in the ICU. Many speakers
stressed the importance of a multidisciplinary approach to intensive care. 'We need
to work together as a team during rounds to exchange visions about patient management',
said Jean-Louis Vincent. 'And when I say "we" it's not just doctors, it's our team'.
The involvement of nursing staff in the implementation of protocols is 'paramount',
said Bernard De Jonghe (Poissy, France). In a crisis, said Charles Sprung, 'You've
got to work as a team, from the emergency department through the ICU to CT and the
operating rooms. The surgeons, anesthesio-logists, nurses, and administrators have
to work together'. Intensive care societies need to collaborate to provide guidance
in combating epidemics, said Jan Bakker. And according to Paul Pepe there is a need
for multinational cooperation in dealing with global challenges.
Intensive care is a comparatively new discipline, born in response to the polio epidemic
of the 1950s. In the intervening years, said Derek Angus (Pittsburgh, PA, USA), intensive
care in the United States has become 'massive, variable, and less than ideal'. Angus
predicted that the future will be characterized by 'more patients, sicker patients,
at a higher cost, with relatively speaking less money, less resources, and fewer people'.
Changes will have to be fairly large scale to make a difference, he said, and they
will have to involve people outside of the profession. 'The profession has a responsibility
to get out there and talk with the public, with politicians, with our colleagues outside
of intensive care'.
Will technology become more important than clinical acumen in the future? It was certainly
plentiful at the meeting, with 71 exhibitors demonstrating equipment designed to help
the intensivist. Jean-Paul Mira (Paris, France), speaking on 'Biology of the Future',
identified new tools that may be of use in intensive care, including genomics, proteomics,
gene chips, ImmunoPCR (for looking at tiny levels of proteins), and software that
allows researchers to analyze how a gene can modify another one. In one of the final
presentations of the meeting, held at 5 p.m. on Friday, the audience traveled via
the Internet to the neurosurgical ICU of the University of California at Los Angeles,
where, through a robot located on the ward, the presenter spoke with staff members
on duty and visited a comatose patient in her bed.
Technology alone cannot heal patients, however. (In fact, the robot presentation was
delayed by 30 min due to a power failure.) 'You still have to be a good doctor', Mira
Will good doctors of the future be able to resolve the issues of uncertainty presented
in Table 1? Will they be able to improve the lives of intensive care patients more
quickly and at lower cost? Will they be able to reach consensus, find solutions to
global challenges, improve care, and work together?
We hope so. But in truth, we don't know.
ICU = intensive care unit.
The authors declare that they have no competing interests.
Additional File 1
A PDF file containing a reading list of a selection of articles referred to at the
Click here for file