Inotropes in goal-directed therapy: Do we need 'goals'?

There is substantial evidence to demonstrate the benefits of goal-directed hemodynamic optimization using fluid loading or inotropic support or both to improve outcome during major surgery. However, until now, only limited pathophysiological data have been available to explain this benefit. The maintenance of adequate tissue perfusion and global oxygen delivery is an essential goal for therapy. In an interesting study, Jhanji and colleagues provided additional data that emphasize the roles of optimization of intravascular fluid status and low doses of inotropes to improve microvascular blood flow and tissue oxygenation. This commentary aims to highlight some issues raised by this important study and provides additional elements to further position these results.     

Do we need new guidelines?

Early on in our medical training, we were told that experience is more important than knowledge in the medical field and that medicine is therefore not an exact science but an art. We were encouraged to become medical artists. Although this statement has proven to be largely correct, we perceived it as a provocation. The scientific nature of our profession of choice was being called into question. We had spent day and night cramming our heads full of knowledge and even after more than 30 years in the field were still trying to increase our knowledge on a daily basis, but this was apparently not highly valued. Based on the demands, the statement was justified and we are in fact shaped by medicine and the daily routine. In many critical situations intuition and experience, not learned data, determine what is right for a patient. It's not surprising that the terms "guidelines" and "quality control" set off mental warning bells in many colleagues who view medicine as an art. The reactions to new guidelines can be expected to range from an inexpressible feeling of discomfort to clear verbal rejection. The tem "total quality management" as specially developed and practiced in the Japanese auto industry will unavoidably be met with simple refusal. It is important for us to occasionally address quality assurance issues, and we must not avoid the necessary socio-economic discussion by hiding behind humanitarian and ethical arguments. One of the goals of the European Federation for Ultrasound in Medicine and Biology (EFSUMB) is quality assurance for ultrasound diagnostics [1]. As a result, the first guidelines for using ultrasound contrast agents were published in 2004 in Ultraschall in der Medizin/European Journal of Ultrasound, the official publication of EFSUMB [2]. An updated and enhanced version of these guidelines will be published in this issue [3]. These two publications are compatible with earlier publications regarding standardization [4-10], training [11-22]and continuing education [23-28].     

Do we need to innovate in critical care practice?

Fever is prevalent in the majority of patients after aneurysmal subarachnoid hemorrhage and is associated with worse outcome. Treatment of fever is highly recommended, but with low-grade evidence in current guidelines. The analysis by Schiefecker and colleagues reveals that the situation may be more complicated than at first glance and careless treatment may introduce further harm. The importance of this study lies in analyzing real-world multimodal neuromonitoring data, showing a pitfall in incautiously applied treatment paradigms.