Voltaire, French writer and historian (1694-1778).
The introduction of the pulmonary artery catheter (PAC) in the early 70’s by Swan and colleagues became the monitoring tool that defined critical care medicine for the next 4 decades. [1,2] The PAC became synonymous with critical care medicine. The era of the PAC resulted in a style of medicine that can best be characterized as aggressive. If some care is good, more care is even better. However almost all medical interventions be they invasive procedures, diagnostic tests, imaging studies, mechanical ventilation, surgery or drugs have some risk of adverse effects.[3] In some cases, these harms outweigh the benefits. This may be particularly so in ICU patients who are highly vulnerable and at an increased risk of iatrogenic complications.[4] Beginning in 1996 the safety and effectiveness of the PAC came into question.[5] Subsequent studies demonstrated that the PAC provided misleading “physiologic variables” that could lead to inappropriate therapeutic interventions and that the use of the PAC did not improve patient outcome.[6-8] The PAC has now all but been abandoned[9]. In 2000 the ARDSnet group published their now landmark study which demonstrated that mechanical ventilation with low tidal volume of 6mls/kg/IBW improved patient outcome as compared to the standard approach (12ml/kg/IBW).[10] The last decade has witnessed a slew of studies that have challenged conventional wisdom and which have led to a gentler, less invasive approach to the critically ill patient… this has led to the paradigm that “Less may be More” (see list below).[3,4] We now realize that our goal as intensivists is too be supportive and allow the body to heal itself while at the same time limiting the harm we cause with the arsenal of therapeutic and diagnostic weapons that we have at our disposal.
Interventions for which less has been shown to be associated with better outcomes:（已经被证明措施愈少预后越佳的方案）
Lower tidal volume and lower plateau pressures [10] 低潮气量与低平台压
Less blood [11,12]少输血
Less invasive hemodynamic monitoring [9,13]减少有创血流动力学监测
Less fluids [14-16]少补液
Less insulin and less intensive glycemic control [17,18]减少胰岛素与强化血糖监测
Less antibiotics; de-escalation of empiric therapy and shorter course [19-21]减少抗菌药物，经验性降阶梯治疗及短疗程
Less sedation and less benzodiazepines [22-24] 减少镇静及苯二氮唑类
Less corticosteroids; 200mg hydrocortisone (equ) daily for sepsis and COPD [25-28] 减少皮质激素。脓毒症与COPD每日200mg
Less CXR; no daily CXR [29,30]减少胸片，不需要每日查胸片
Less oxygen; hyperoxia kills (COPD) and damages the brain and lungs [31-40]减少吸氧，高氧血症增加COPD病死率，并伤及脑/肺
Less calories and protein; trophic feeds/underfeeding may be safe [41-43]低热低蛋白，低喂养
Less early feeding (delayed feeding) [44]延迟喂养
Less antiarrhythmics; no prophylactic lidocaine in AMI [45]延迟干预心律不齐
Less intense renal replacement therapy [46-49]减少强化肾脏替代治疗
Less blood pressure control (in ischemic stroke) and hemorrhagic stroke [50-52]减少缺血性/出血性卒中的血压控制
Less/ NO TPN [53,54]不用或少用全肠外营养
NO stress ulcer prophylaxis (= less C.diff. and less pneumonia) [55-57]不需应激性溃疡预防=减少难辨梭菌与肺炎发生
NO dopamine [58-60]不用多巴胺！
NO CVP monitoring [61]不用CVP监测
NO PAC monitoring [9]不用PAC监测
NO EDGT for sepsis [62]sepsis不用EGDT
NO “supranormal” hemodynamic targets.[63,64]超生理指标不需要
NO diuretics for acute renal failure [65]急性肾衰不用利尿剂
NO hetastarch [66,67]不用羟乙基淀粉
NO central line for norepinephrine [68]去甲肾不需经中心静脉输注
NO extended post-operative antibiotic prophylaxis术后不必长期预防应用性抗菌药物
NO inhaled NO (nitric oxide) for ARDS [69]ARDS不需NO吸入
NO routine central line changes or infusion set changes不必定期更换中心静脉导管或输液装置
NO early tracheostomy for ventilated patients [70]机械通气不需要早期气切
NO high frequency oscillating ventilation (HFOV)[71,72]不适用高频震荡通气
NO chlorhexidine mouthwash or body bathing [73,74]不需要氯已定擦浴或漱口
NO supplemental growth hormone or thyroid hormone for acute critical illness [75,76]重病无需生长激素或甲状腺补充
NO Activated Protein C [77] 不需要APC（活性蛋白C）
NO MRSA/MDRO screening and protective isolation [78-80]无需MRSA/MDRO筛查或保护性隔离
NO therapeutic hypothermia [81,82]不需要治疗性低温
Ganz W, Donosco R, Marcus HS et al. A new technique for measurment of cardiac output by thermodilution in man. Am J Cardiol 1971; 27:392-96.
Swan HJ, Ganz W, Forrester J et al. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med 1970; 283:447-51.
Grady D, Redberg RF. Less is more: how less health care can result in better health. Arch Intern Med 2010; 170:749-50.
Knox M, Pickkers P. “Less is More” in Critically ill patients. Not too intensive. JAMA Intern Med 2013; 173:1369-72.
Connors AF, Speroff T, Dawson NV et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 1996; 276:889-97.
Marik PE, Baram M, Vahid B. Does the central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134:172-78.
Harvey S, Harrison DA, Singer M et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet 2005; 366:472-77.
Sandham JD, Hull RD, Brant RF et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348:5-14.
Marik PE. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive Care 2013; 3:38.
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342:1301-8.
Salpeter SR, Buckley JS, Chatterjee S. Impact of More Restrictive Blood Transfusion Strategies on Clinical Outcomes: A Meta-analysis and Systematic Review. Am J Med 2014; 127:124-31.
Marik PE, Corwin HL. Efficacy of RBC transfusion in the critically ill: A systematic review of the literature. Crit Care Med 2008; 36:2667-74.
Marik PE. Non-invasive cardiac output monitors. A state-of-the-art review. J Cardiothorac Vasc Anesth 2013; 27:121-34.
Maitland K, Kiguli S, Opoka RO et al. Mortality after fluid bolus in african children with severe infection. N Engl J Med 2011; 364:2483-95.
Hilton AK, Bellomo R. A critique of fluid bolus resuscitation in severe sepsis. Crit Care 2012; 16:302.
Marik PE. Early management of severe sepsis: Concepts and controversies. Chest 2104.
Intensive versus conventional glucose control in critically ill patients: The NICE-Sugar Study Investigators. N Engl J Med 2009; 360:1283-97.
Marik PE. Tight glycemic control in acutely ill patients: low evidence of benefit, high evidence of harm! Intensive Care Med 2016; 42:1475-77.
Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A et al. De-escalation of emperical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive Care Med 2014; 40:32-40.
Bouadma L, Luyt CE, Tubach F et al. Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trila): a multicentre randomised controlled trial. Lancet 2010; 375:463-74.
Chastre J, Wolff M, Fagon JY et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA 2003; 290:2588-98.
Barr J, Fraser GL, Puntillo K et al. Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium in Adult Patients in the Intensive Care Unit. Crit Care Med 2013; 41:263-306.
Girard TD, Kress JP, Fuchs BD et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371:126-34.
Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechancial ventilation: a randomised trial. Lancet 2010; 375:475-80.
Marik PE. Glucocorticoids in sepsis: disectiong facts from fiction. Crit Care 2011; 15:158.
Moran JL, Graham PL, Rockliff S et al. Updating the evidence for the role of corticosteroids in severe sepsis and shock: A Bayesian meta-analytic perspective. Crit Care 2010; 14:R134.
Leuppi JD, Schuetz P, Bingisser R et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease. The REDUCE randomized clinical trial. JAMA 2013; 309:2223-31.
Annane D, Bellisant E, Bollaert PE et al. Corticosteroids in the treatment of severe sepsis and septic shock in adults: A systematic review. JAMA 2009; 301:2349-61.
Hejblum G, Chalumeau-Lemoine L, Ioos V et al. Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study. Lancet 2009; 374:1687-93.
Kroner A, Binnekade JM, Graat ME et al. On-demand rather than daily-routine chest radiography prescription may change neither the number nor the impact of chest computed tomography and ultrasound studies in a multidisciplinary intensive care unit. Anesthesiol 2008; 108:40-45.
de los Santos R, Seidenfeld JJ, Anzueto A et al. One hundred percent oxygen lung injury in adult baboons. Am Rev Respir Dis 1987; 136:657-61.
New A. Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient. Emerg Med J 2006; 23:144-46.
Austin MA, Wills KE, Blizzard L et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ 2010; 341:c5462.
de Jonge E, Peelen L, Keijzers PJ et al. Association between administered oxygen, arterial partial oxygen pressure and mortality in mechanically ventilated intensive care unit patients. Crit Care 2008; 12:R156.
Cameron L, Pilcher J, Weatherall M et al. The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD. Postgrad Med J 2012; 88:684-89.
Rincon F, Kang J, Maltenfort M et al. Association between hyperoxia and mortality after stroke: A multicenter cohort study. Crit Care Med 2013; 42.
Janz DR, Hollenbeck RD, Pollock JS et al. Hyperoxia is associated with increased mortality in patients treated with mild therapeutic hypothermia after sudden cardiac arrest. Crit Care Med 2012; 40:3135-39.
Bellomo R, Bailey M, Eastwood GM et al. Arterial hyperoxia and in-hospital mortality after resuscitation from cardiac arrest. Crit Care 2011; 15:R90.
Kilgannon JH, Jones AE, Parrillo JE et al. Relationship between supranormal oxygen tension and outcome after resuscitation from cardiac arrest. Circulation 2011; 123:2717-22.
Davis DP, Meade W, Sise MJ et al. Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury. Journal of Neurotrauma 2009; 26:2217-23.
Initial trophic vs full enteral feeding in patients with acute lung injury. The EDEN randomized trial. JAMA 2012; 307:795-803.
Marik PE, Hooper MH. Normocaloric versus hypocaloric feeding on the outcomes of ICU patients: A systematic review and meta-analysis. Intensive Care Med 2016; 42:316-23.
Puthucheary ZA, Rawal J, McPhail M et al. Acute skeletal muscle wasting in critical illness. JAMA 2013; 310:1591-600.
Bakker OJ, van Goor H, Bosscha K et al. Early versus On-Demand Nasoenteric Tube Feeding in Acute Pancreatitis. N Engl J Med 2014; 371:1983-93.
Sadowski ZP, Alexander JH, Skrabucha B et al. Multicenter randomized trial and a systematic overview of lidocaine in acute myocardial infarction. Am Heart J 1999; 137:792-98.
Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008; 359:7-20.
Bouman CS, Oudemans-van Straaten HM, Tijssen JG et al. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial. Crit Care Med 2002; 30:2205-11.
Augustine JJ, Sandy D, Seifert TH et al. A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis 2004; 44:1000-1007.
Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 2009; 361:1627-38.
He J, Zhang Y, Xu T et al. Effect of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke. The CATIS Randomzed Clinical Trial. JAMA 2014; 311:479-89.
Sandset EC, Bath PM, Boysen G et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet 2011; 377:741-50.
Qureshi AI, Palesch YY, Barsan WG et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med 2016; 375:1033-43.
Casaer MP, Mesotten D, Hermans G et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365:506-17.
Marik PE, Pinsky MR. Death by total parenteral nutrition. Intensive Care Med 2003; 29:867-69.
Marik PE, Vasu T, Hirani A et al. Stress ulcer prophylaxis in the new millennium: A systematic review and meta-analysis. Crit Care Med 2010; 38:2222-28.
Krag M, Perner A, Wetterslev J et al. Stress ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients. A systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Intensive Care Med 2014; 40:11-22.
Marik PE. Stress ulcer prophylaxis de-adoption: What the barrier? Crit Care Med 2016; 44:1939-41.
Chen HH, Anstrom KJ, Givertz MM et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction. The ROSE Acute Heart Failure Randomized Trial. JAMA 2013; 310:2533-43.
De Backer D, Biston P, Devriendt J et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 2010; 362:779-89.
Low dose dopamine in patients with early renal dysfunction: a placebo-controlled trial. Lancet 2000; 356:2139-43.
Marik PE, Cavallazzi R. Does the Central Venous Pressure (CVP) predict fluid responsiveness: An update meta-analysis and a plea for some common sense. Crit Care Med 2013; 41:1774-81.
Angus DC, Barnato AE, Bell D et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe investigators. Intensive Care Med 2015; 41:1549-60.
Hayes MA, Timmins AC, Yau E et al. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med 1994; 330:1717-22.
Gattinoni L, Brazzi L, Pelosi P et al. A trial of goal-oriented hemodynamic therapy in critically ill patients. N Engl J Med 1995; 333:1025-32.
Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ 2006; 333:420.
Perner A, Haase N, Guttormsen AB et al. Hydroxyethyl starch 130/0.4 versus Ringers Acetate in severe sepsis. N Engl J Med 2012; 367:124-34.
Gattas DJ, Dan A, Myburgh J et al. Fluid resuscitation with 6% hydroxyethyl starch (130/0.4) in acutely ill patients: an updated systematic review and meta-analysis. Anesth Analg 2012; 114:159-69.
Cardenas-Garcia J, Schaub KF, Belchikov YG et al. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med 2015; 10:581-85.
Adhikari NK, Dellinger RP, Lundin S et al. Inhaled nitric oxide does not reduce mortality in patients with acute respiratory distress syndrome regardless of severity: systematic review and meta-analysis. Crit Care Med 2014; 42:404-12.
Young D, Harrison DA, Cuthbertson BH et al. Effect of early vs. late tracheostomy placement on survival in patients receiving mechanical ventilation. The TracMan randomized trial. JAMA 2013; 309:2121-29.
Ferguson ND, Cook DJ, Guyatt GH et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med 2013; 368:795-805.
Young D, Lamb S, Shah S et al. High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med 2013; 368:806-13.
Noto MJ, Domenico HJ, Byrne DW et al. Chlorhexidine bathing and health care-assocaited infections. A randomized clinical trial. JAMA 2015; 313:369-78.
Klompas M, Speck K, Howell MD et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation. systematic review and meta-analysis. JAMA Intern Med 2014; 174:751-61.
Takala J, Ruokonen E, Webster NR et al. Increased mortality associated with growth hormone treatment in critically ill adults. N Engl J Med 1999; 341:785-92.
Farwell AP. Thyroid hormone therapy is not indicated in the majority of patients with the sick euthyroid syndrome. Endocrine Practice 2008; 14:1180-1187.
Ranieri VM, Thompson BT, Barie PS et al. Drotrecogin Alfa (activated) in adults with septic shcok. N Engl J Med 2012; 366:2055-64.
Derde LP, Cooper BS, Goossens H et al. Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial. Lancet Infect Dis 2013.
Harris AD, Pineles L, Belton B et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU. A randomized trial. JAMA 2013.
Huang SS, Septimus E, Kleinman K et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 2013;2255-65.
Nielsen N, Wetterslev J, Cronberg T et al. Targeted temperature management at 33C versus 36C after cardiac arrest. N Engl J Med 2013; 369:2197-206.
Alderson P, Gadkary C, Signorini DF. Therapeutic hypothermia for head injury. Cochrane Database of Systematic Reviews 2004;CD001048.
Paul Marik真的是一个“less is more”的激进的倡导者，我甚至怀疑这些意见中有没有夹杂了“私货”，甚至出于“为了不用而不用”的目的而强行推行某些概念，例如肺动脉导管，实际上随着超声等血流动力学开展，PAC的价值也在逐渐显现—— 之前很多用上了的患者是不需要的，而现在发现是不少该用的没用上！
