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The recognition of categories of ‘more is less’ in the ICU has improved patient outcomes and resulted in more rational, comfortable, and less expensive care. 

ICU management is accompanied and typified by complex and aggressive interventions, encompassing all facets of patients with critical illness care. These interventions, however, are associated with greater patient discomfort, costs, and resource utilization, and are only desirable if the attendant benefits justify these adverse consequences. Since there are very few ICU interventions proven effective in improving outcomes, and much less mortality (and most of those dealing with ventilatory strategies), it may be difficult to assess the value of many routine treatments, protocols, and device usage.

Since the turn of the last century, studies of aggressive ICU interventions previously thought appropriate have indicated a lack of evidence base with, often, a tendency toward harm, which may be summarized as ‘more is less’. For instance:

Although rapid, early fluid administration in septic shock is considered appropriate and recommended in guidelines, the very large volume administration (Early Goal-Directed Therapy) popular a few years ago is now associated with complications of fluid overload and greater length of mechanical ventilation and not generally recommended.

Intensive comfort measures among mechanically ventilated patients with high-dose continuous sedatives and analgesics are associated with longer ventilator dependence, increased likelihood of delirium, and longer ICU stays. Lighter sedation and more common sedative vacations are likely better strategies and are not associated with greater patient discomfort.

Pulse-dose corticosteroids, which had previously been popular in the treatment of diverse conditions such as post-cardiac arrest states, sepsis, and ARDS, have now been shown deleterious and are currently ordered in much lower doses or not at all.

Intensive blood sugar control in the ICU, popular in the early 2000s for both medical and surgical patients is now associated with worse outcomes. It is specifically cautioned against in most guidelines.

High-caloric and high-protein nutrition for patients with critical illness have worse outcomes in certain patients and early total parenteral nutrition (TPN) is particularly associated with sepsis and hyperglycemia. These forms of nutritional supplementations are usually not recommended and the optimal nutritional support for patients with critical illness continues to be debated.

Blood transfusions, which were once recommended to achieve a goal greater than 10.0g/L were found to be costly and associated with some worse outcomes and now are usually triggered at 7.0g/L among most ICU patients (though I feel that the lower target is too restrictive for many patients).

Renal replacement therapy, a common intervention for ICU patients with acute kidney injury (AKI), has been found to not improve ultimate outcomes among many patients, specifically when started relatively early (ie. less than three days after the establishment of AKI).

Pulmonary artery catheters, which I placed nearly daily in the past, have been associated with increased complications and worse outcomes and are no longer generally recommended among ICU patients with respiratory failure or sepsis, among other indications.

Aggressive targeted temperature management with core body cooling after cardiac arrest, almost universally prescribed in past years, is now generally not recommended with organizations such as the American Heart Association and the International Liaison Committee on Resuscitation now recommending a strategy of simple fever avoidance.

Intensive antibiotic use has been associated with increased bacterial resistance, costs, c. difficile infection and other complications and the modern paradigm has emphasized narrow anti-bacterial spectrums, briefer courses of therapy and rapid de-escalation when culture reports are available and the patient otherwise improving.

Among mechanically ventilated patients, higher airway pressures and tidal volumes, traditional in past decades, particularly in post-operative patients, are now injurious and associated with greater mortality in some patients, so Lung-protective Ventilation with low-tidal volume, higher-PEEP, and lower airway and driving pressures are now more often recommended for ARDS and many other patients with respiratory failure of diverse causes.

The recognition of categories of ‘more is less’ in the ICU has resulted in more rational, comfortable, and less expensive care and better outcomes for our vulnerable patients. As our profession’s motto is ‘primum non nocere’, many aggressive interventions, popular in the last century, ought to be discarded unless clinical experience suggests significantly improved outcomes. Finally, although we all respect the physiologic plausibility of our interventions, it should be remembered that we are treating patients and not sterile organ systems, and that over-treatment may be as dangerous as under-treatment.