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In Reply: We appreciate the high esteem in which Dr Zijlstra and colleagues place RCTs and join them in wishing that more trials would be undisputedly positive. They suggest changing, and possibly lowering, the standards of evidence on which intensivists should base care because the interventions tested in RCTs generally target only 1 of many problems; thus, outcomes such as mortality are hard to modify and, by extension, the trials will always have a high likelihood of failure.

Although we do not believe that RCTs should be abandoned, we do agree that RCTs should continue to test interventions better designed to influence important clinical outcomes. The 2 particular trials we discussed,^1-2 although attempting to manipulate a rather narrow spectrum of the wide set of physiologic derangements seen in critically ill patients, were both notable in that they demonstrated the feasibility of disseminating and testing quite complex interventions. Thus, these trials . . . [Full Text of this Article]

Jean-Daniel Chiche, MD
jean-daniel.chiche@cch.aphp.fr
Department of Critical Care Medicine
AP-HP, Hopital Cochin
University René Descartes
Paris, France

Derek C. Angus, MD, MPH
CRISMA Laboratory
Department of Critical Care Medicine
School of Medicine
University of Pittsburgh
Pittsburgh, Pennsylvania

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