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AbstractThe practice of medicine is often represented as a dualism: is medicine a 'science' or an 'art'? This dualism has been long‐lasting, with evident appeal for the medical profession. It also appears to have been rhetorically powerful, for example in enabling clinicians to resist the encroachment of 'scientific' evidence‐based medicine into core areas of medical work such as individual clinical judgement. In this article I want to make the case for a more valid conceptualisation of medical practice: that it is a 'craft' activity. The case I make is founded on a theoretical synthesis of the concept of craft, combined with an analysis of ethnographic observations of routine medical practice in intensive care. For this context the craft aspects of medical work can be seen in how biomedical and other types of knowledge are used in practice, the embodied skills and practical judgement of practitioners and the technological and material environment. These aspects are brought together in two conceptual dimensions for 'craft': first, the application of knowledge; second, interaction with the material world. Some practical and political implications of a 'craft' metaphor for medical practice are noted.

Decision-making by intensivists around accepting patients to intensive care units is a complex area, with often high-stakes, difficult, emotive decisions being made with limited patient information, high uncertainty about outcomes and extreme pressure to make these decisions quickly. This is exacerbated by a lack of clear guidelines to help guide this difficult decision-making process, with the onus largely relying on clinical experience and judgement. In addition to uncertainty compounding decision-making at the individual clinical level, it is further complicated at the multi-speciality level for the senior doctors and surgeons referring to intensive care units. This is a systematic review of the existing literature about this decision-making process and the factors that help guide these decisions on both sides of the intensive care unit admission dilemma. We found many studies exist assessing the patient factors correlated with intensive care unit admission decisions. Analysing these together suggests that factors consistently found to be correlated with a decision to admit or refuse a patient from intensive care unit are bed availability, severity of illness, initial ward or team referred from, patient choice, do not resuscitate status, age and functional baseline. Less research has been done on the decision-making process itself and the factors that are important to the accepting intensivists; however, similar themes are seen. Even less research exists on referral decision and demonstrates that in addition to the factors correlated with intensive care unit admission decisions, other wider variables are considered by the referring non-intensivists. No studies are available that investigate the decision-making process in referring non-intensivists or the mismatch of processes and pressure between the two sides of the intensive care unit referral dilemma.

Decision-making by intensivists around accepting patients to intensive care units is a complex area, with often high-stakes, difficult, emotive decisions being made with limited patient information, high uncertainty about outcomes and extreme pressure to make these decisions quickly. This is exacerbated by a lack of clear guidelines to help guide this difficult decision-making process, with the onus largely relying on clinical experience and judgement. In addition to uncertainty compounding decision-making at the individual clinical level, it is further complicated at the multi-speciality level for the senior doctors and surgeons referring to intensive care units. This is a systematic review of the existing literature about this decision-making process and the factors that help guide these decisions on both sides of the intensive care unit admission dilemma. We found many studies exist assessing the patient factors correlated with intensive care unit admission decisions. Analysing these together suggests that factors consistently found to be correlated with a decision to admit or refuse a patient from intensive care unit are bed availability, severity of illness, initial ward or team referred from, patient choice, do not resuscitate status, age and functional baseline. Less research has been done on the decision-making process itself and the factors that are important to the accepting intensivists; however, similar themes are seen. Even less research exists on referral decision and demonstrates that in addition to the factors correlated with intensive care unit admission decisions, other wider variables are considered by the referring non-intensivists. No studies are available that investigate the decision-making process in referring non-intensivists or the mismatch of processes and pressure between the two sides of the intensive care unit referral dilemma.

The maxim 'Primum non nocere' is almost as old as the practice of medicine. In combination with the principles of beneficence, autonomy and justice, and whilst keeping in mind the confidence and dignity of the patient, it should constitute the basis of our behaviours as physicians and nurses. Since diagnostic and therapeutic interventions have become more complex and their risk/benefit ratios more difficult to assess, the importance of safety and quality of care rises. Avoiding the infliction of harm on our patients has moved into the focus of clinical medicine. Patient safety is now viewed as a priority even by the Presidency of the European Union. Physicians in intensive care medicine deal with the most fragile and dependent human beings, often struggling with multiple co-morbid diseases and physiological derangements at the limits of survival. These patients are often reliant on numerous invasive technologies for their survival. Moreover, the almost universal need for multiple pharmacological interventions - combinations of which have often never been rigorously tested before - places the critically ill patients at a very high risk of being harmed by the physician's interventions. More than 120 internationally known experts introduce their current knowledge of patient safety and quality of care in intensive care medicine in over 50 chapters covering the following fields: - Safety in intensive care medicine - Decision making - Culture and behaviour - Structure and processes - Protocolised medicine - First, do no harm - Safety during technical support - Training, teaching and education - Risk management - Ethical issues - Future approaches This book should be read by every manager who has responsibility for the acutely ill. It is an invaluable educational and reference tool for physicians and nurses in intensive care medicine and will help to improve the safety and overall care for critically ill patients. with contributions from: LM Aitken, R Alvisi, R Amerling, PJD Andrews, A Artigas, D De Backer, N Badjatia, M Bauer, G Bertolini, A Biasi Cavalcanti, JF Bion, BW Böttiger, CSC Bouman, A Boumendil, FA Bozza, J Braithwaite, G Brattebø, FM Brunkhorst, DDG Bugano, M Capuzzo, M Cecconi, W Chaboyer, J Chen, E Coiera, K Colpaert, CR Cooke, JR Curtis, BH Cuthbertson, AL Cuvello Neto, KJ Deans, J Decruyenaere, J-M Dominguez-Roldan, Y Donchin, C Druml, G Dubreuil, R Endacott, A Esteban, R Ferrer, H Flaatten, J Fragata, F Frutos-Vivar, C Garcia-Alfaro, M Garrouste-Orgeas, TD Girard, ARJ Girbes, J Graf, D Grimaldi, ABJ Groeneveld, B Guidet, U Günther, N Harbord, DA Harrison, C Hartog, N Heming, F Hernandez-Hazañas, K Hillman, P Holder, MH Hooper, M Imhoff, U Janssens, JM Kahn, E Knobel, M Knobel, J Lipman, T Lisboa, Y Livne, S Lorent, M Makdisse, A Marques, GD Martich, ML Martinez, SA Mayer, DK Menon, PC Minneci, J-P Mira, X Monnet, RP Moreno, T Muders, C Natanson, A Navas, G Ntoumenopoulos, SA Nurmohamed, HM Oudemans-van Straaten, R Paterson, O Peñuelas, JG Pereira, C Pierrakos, LF Poli-de-Figueiredo, CE Pompilio, D Poole, A Pronovost, C Putensen, K Reinhart, J Rello, A Rhodes, Z Ricci, C Richard, F Rincon, JA Roberts, E Roeb, C Ronco, GD Rubenfeld, D Salgado, JIF Salluh, G Satkurunath, A Schneider, C Schwebel, E Silva, M Singer, EGM Smit, M Soares, L Soufir, A Tabah, J-L Teboul, P Teschendorf, N Theuerkauf, J-F Timsit, M Ulldemolins, A Valentin, JM Varghese, J-L Vincent, B Volpe, CS Waldmann, RR West, S West, JF Winchester, H Wrigge

Introduction: Diversity has become a key-strategic element of success in various political and economic fields. The European Society of Intensive Care Medicine (ESICM) decided to make diversity a key strategic priority for the future and appointed a Task-Force on this topic. Methods: In a consensus process, three Working-Groups, nominated by Task-Force members, developed statements on strategic future topics. In addition, diversity-related data available from the membership database have been analyzed and reported in aggregated form. Results: The Task-Force decided to nominate working groups on (1) "sex, gender identity and sexual orientation", (2) "ethnicity, culture and socio-economic status", and (3) "multiprofessionalism". These are the first prioritized topics for the near future. The first diversity-report shows targetable items in all three domains. Conclusion: The diversity Task-Force defined actionable items for a one- and three-year plan that are especially aiming at the identification of potential gaps and an implementation of concrete projects for members of the ESICM.

Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock. The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575-590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock? Four types of statements were used: definition, recommendation, best practice and statement of fact. Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring. This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock.

"Surgical site infections (SSI) greatly concern clinicians, as they are associated with significant morbidity and mortality, prolonged hospitalization, and costs. Antibiotic prophylaxis plays a pivotal role among the procedures that are usually employed for the prevention of surgical-related infections. This narrative review aims to cover some of the particular situations when the clinician might consider individualizing antibiotic prophylaxis for a patient. With the rising incidence of multi-drug resistant bacteria carriage among not only hospitalized or institutionalized patients but also patients from the community, there might be a tendency to use extended-spectrum antibiotics for longer periods for surgical infection prevention. However, the inappropriate use of antibiotics increases the selection pressure, thus favoring the spreading of resistant bacteria. Moreover, specific patient characteristics or pathologies might need to be considered to customize the type, dose, or length of administration of an antibiotic as surgical prophylaxis. Using prosthetic material or prolonged surgeries with large fluid shifts are other situations when individualized antibiotic prophylaxis might be thought of. Keeping in mind that it is of utmost importance that everyone adheres to the current guidelines for surgical antibiotic prophylaxis, customization of local protocols according to well-thought-out strategies might prove beneficial in SSI prevention."

Purpose To provide consensus, and a list of experts recommendations regarding the basic skills for head-to-toe ultrasonography in the intensive care setting. Methods The Executive Committee of the European Society of Intensive Care (ESICM) commissioned the project and supervised the methodology and structure of the consensus. We selected an international panel of 19 expert clinicians-researchers in intensive care unit (ICU) with expertise in critical care ultrasonography (US), plus a non-voting methodologist. The panel was divided into five subgroups (brain, lung, heart, abdomen and vascular ultrasound) which identified the domains and generated a list of questions to be addressed by the panel. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Statements were classified as a strong recommendation (84% of agreement), weak recommendation (74% of agreement), and no recommendation (less than 74%), in favor or against. Results This consensus produced a total of 74 statements (7 for brain, 20 for lung, 20 for heart, 20 for abdomen, 7 for vascular Ultrasound). We obtained strong agreement in favor for 49 statements (66.2%), 8 weak in favor (10.8%), 3 weak against (4.1%), and no consensus in 14 cases (19.9%). In most cases when consensus was not obtained, it was felt that the skills were considered as too advanced. A research agenda and discussion on training programs were implemented from the results of the consensus. Conclusions This consensus provides guidance for the basic use of critical care US and paves the way for the development of training and research projects. ; Funding Agencies|ESICM