Three decades of critical care trials: the lasting gains came from doing less harm

Design

Interpretive historical review of landmark randomised trials

Population

Multicentre adult intensive care trials from the early 1990s onwards

Primary outcome

Lessons on what practice was changed, corrected or remains uncertain

Effect

Rigid targets and intensive strategies often added little over good usual care

A historical review in Intensive Care Medicine, published on 13 August 2026, looked back over landmark multicentre randomised trials in adult intensive care since the early 1990s, across haemodynamics, ventilation, kidney replacement, antimicrobials, nutrition, glucose, transfusion and sedation.

The authors argue that many interventions with a strong physiological rationale failed to improve patient-centred outcomes. Protocols improved timeliness, but later pragmatic trials found that rigid targets and invasive algorithms often added little once usual care was good. Recent trials have repeatedly questioned whether more intensive intervention helps, pointing instead to timing, patient selection and treatment-related harm.

This is an interpretive review rather than a pooled analysis, so it offers a frame, not effect sizes. But the frame is useful at the bedside: when a target or intervention is escalated, ask whether trials actually showed benefit from going further.

• Before escalating a target or intervention, ask whether trials showed benefit from doing more
• Reassess established practices periodically; several have been reversed by later trials
• Weigh treatment-related harm, such as over-sedation or over-transfusion, as carefully as benefit
• Expect future trials to focus on subgroups, timing and long-term recovery

Why it matters

It challenges the instinct that a sicker patient always needs more intervention.

Don't overread it

This is an interpretive narrative review, not a systematic analysis with pooled effects.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.