Critical care "normality": individualized versus protocolized care.

Area of Science:

• Critical care medicine
• Physiology
• Pathology

Background:

• Critically ill patients exhibit diverse physiological needs that change over time.
• Protocolized, goal-directed therapies (GDT) show benefits in acute settings (ER, perioperative).
• Extrapolation of acute GDT benefits to medium- and long-term critical care is questionable.

Purpose of the Study:

• To explore the limitations of standardized GDT in evolving critical illness.
• To identify factors necessitating adaptive treatment strategies beyond acute care.
• To discuss the impact of mitochondrial dysfunction, altered hemodynamics, and organ-specific failures on long-term critical care.

Main Methods:

• Literature review and synthesis of current evidence on critical care pathways.
• Analysis of physiological changes in prolonged critical illness.
• Discussion of specific organ failures (mitochondrial, gut, liver) and their management implications.

Main Results:

• Mitochondrial dysfunction may render GDT detrimental in later stages.
• Arterial pressure targets likely need adjustment as patients approach a 'hibernative' state.
• Sedatives, pressors, gut failure, and liver dysfunction significantly impact inflammatory and immune profiles.

Conclusions:

• Adaptive, individualized care is crucial for critically ill patients beyond the acute phase.
• Understanding evolving pathophysiology, including venous engorgement and gut edema, is key to optimizing outcomes.
• Novel therapeutic approaches may be needed for chronic stages of critical illness, such as septic vascular failure.