OBJECTIVES: Democracy-based medicine is a combination of evidence-based medicine (systematic review), expert assessment, and worldwide voting by physicians to express their opinions and self-reported practice via the Internet. The authors applied democracy-based medicine to key trials in critical care medicine. DESIGN AND SETTING: A systematic review of literature followed by web-based voting on findings of a consensus conference. PARTICIPANTS: A total of 555 clinicians from 61 countries. INTERVENTIONS: The authors performed a systematic literature review (via searching MEDLINE/PubMed, Scopus, and Embase) and selected all multicenter randomized clinical trials in critical care that reported a significant effect on survival and were endorsed by expert clinicians. Then they solicited voting and self-reported practice on such evidence via an interactive Internet questionnaire. Relationships among trial sample size, design, and respondents' agreement were investigated. The gap between agreement and use/avoidance and the influence of country origin on physicians' approach to interventions also were investigated. MEASUREMENTS AND MAIN RESULTS: According to 24 multicenter randomized controlled trials, 15 interventions affecting mortality were identified. Wide variabilities in both the level of agreement and reported practice among different interventions and countries were found. Moreover, agreement and reported practice often did not coincide. Finally, a positive correlation among agreement, trial sample size, and number of included centers was found. On the contrary, trial design did not influence clinicians' agreement. CONCLUSIONS: Physicians' clinical practice and agreement with the literature vary among different interventions and countries. The role of these interventions in affecting survival should be further investigated to reduce both the gap between evidence and clinical practice and transnational differences.

• Klíčová slova
• anesthesia, consensus conference, critically ill, intensive care, mortality, survival,
• MeSH
• internacionalita * MeSH
• kritický stav MeSH
• lékaři MeSH
• lidé MeSH
• medicína založená na důkazech metody   MeSH
• mortalita v nemocnicích * MeSH
• multicentrické studie jako téma statistika a číselné údaje   MeSH
• péče o pacienty v kritickém stavu metody   MeSH
• randomizované kontrolované studie jako téma statistika a číselné údaje   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• konsensus - konference MeSH
• systematický přehled MeSH

OBJECTIVE: Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings. DESIGN: A systematic review of the literature followed by a consensus-based voting process. SETTING: A web-based international consensus conference. PARTICIPANTS: Two hundred fifty-one physicians from 46 countries. INTERVENTIONS: The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines. MEASUREMENTS AND MAIN RESULTS: The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed. CONCLUSION: The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale.

• Klíčová slova
• anesthesia, consensus conference, critically ill, democracy-based medicine, mortality, perioperative,
• MeSH
• internet MeSH
• kardiochirurgické výkony škodlivé účinky   mortalita   MeSH
• kritický stav mortalita   terapie   MeSH
• lékaři * MeSH
• lidé MeSH
• mortalita trendy   MeSH
• péče o pacienty v kritickém stavu metody   MeSH
• perioperační péče metody   MeSH
• průzkumy a dotazníky * MeSH
• randomizované kontrolované studie jako téma metody   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• systematický přehled MeSH

The authors aimed to identify interventions documented by randomized controlled trials (RCTs) that reduce mortality in adult critically ill and perioperative patients, followed by a survey of clinicians' opinions and routine practices to understand the clinicians' response to such evidence. The authors performed a comprehensive literature review to identify all topics reported to reduce mortality in perioperative and critical care settings according to at least 2 RCTs or to a multicenter RCT or to a single-center RCT plus guidelines. The authors generated position statements that were voted on online by physicians worldwide for agreement, use, and willingness to include in international guidelines. From 262 RCT manuscripts reporting mortality differences in the perioperative and critically ill settings, the authors selected 27 drugs, techniques, and strategies (66 RCTs, most frequently published by the New England Journal of Medicine [13 papers], Lancet [7], and Journal of the American Medical Association [5]) with an agreement ≥67% from over 250 physicians (46 countries). Noninvasive ventilation was the intervention supported by the largest number of RCTs (n = 13). The concordance between agreement and use (a positive answer both to "do you agree" and "do you use") showed differences between Western and other countries and between anesthesiologists and intensive care unit physicians. The authors identified 27 clinical interventions with randomized evidence of survival benefit and strong clinician support in support of their potential life-saving properties in perioperative and critically ill patients with noninvasive ventilation having the highest level of support. However, clinician views appear affected by specialty and geographical location.

• Klíčová slova
• anesthesia, consensus conference, critically ill, democracy-based medicine, intensive care, mortality, perioperative, survival,
• MeSH
• internet * trendy   MeSH
• jednotky intenzivní péče trendy   MeSH
• kritický stav mortalita   terapie   MeSH
• lékaři * trendy   MeSH
• lidé MeSH
• mortalita trendy   MeSH
• péče o pacienty v kritickém stavu metody   trendy   MeSH
• průzkumy a dotazníky * MeSH
• randomizované kontrolované studie jako téma metody   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• systematický přehled MeSH

There has been significant progress throughout 2013 in cardiothoracic and vascular anaesthesia and intensive care. There has been a revolution in the medical and interventional management of atrial fibrillation. The medical advances include robust clinical risk scoring systems, novel oral anticoagulants, and growing clinical experience with a new antiarrhythmic agent. The interventional advances include left atrial appendage occlusion for stroke reduction, generalization of ablation techniques in cardiac surgery, thoracoscopic ablation techniques, and the emergence of the hybrid ablation procedure. Recent European guidelines have defined the organization and practice of two subspecialties, namely general thoracic surgery and grown-up congenital heart disease. The pivotal role of an effective multidisciplinary milieu is a central theme in both these clinical arenas. The anaesthesia team features prominently in each of these recent guidelines aimed at harmonizing delivery of perioperative care for these patient cohorts across Europe. Web-Enabled Democracy-Based Consensus is a system that allows physicians worldwide to agree or disagree with statements and expert consensus meetings and has the potential to increase the understanding of global practice and to help clinicians better define research priorities. This "Democratic based medicine", firstly used to assess the interventions that might reduce perioperative mortality has been applied in 2013 to the setting of critically ill patient with acute kidney injury. These advances in 2013 will likely further improve perioperative outcomes for our patients.

• Klíčová slova
• European Society of Cardiology., ablation therapy, anaesthesia team, apixaban, atrial fibrillation, bleeding, clinical risk scoring system, dabigatran, general thoracic surgery, grown-up congenital heart disease, guidelines, hybrid procedure, left atrial appendage occlusion, minimally invasive surgery, multidisciplinary milieu, novel oral anticoagulants, rivaroxaban, stroke, vernakalant,
• Publikační typ
• časopisecké články MeSH