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At the 1993 World Congress of the Federation in Madrid I was elected President of the World Federation. The Secretary General was Christopher Bryan Brown of the United States and the Treasurer was Dr David Ryan of the United Kingdom. It immediately became apparent that we had no Executive Member from the new elected delegates, which would cause a problem when the Executive changed 4 years later.

The intensive care environment is complex and sometimes confusing to both patients and their relatives. Decisions concerning diagnosis, treatment, and prognosis are often made in emergency situations with insufficient underlying information. Also, the clinical situation sometimes imposes great strain upon the intensive care physician and the assisting team. The discussion of different potential treatment options with relatives or patients might thus be both difficult and stressful and not the main priority. Furthermore, most patients admitted to the intensive care unit (ICU) are not competent and a priori excluded from any possibility of autonomous decision making. Today, in medical practice in general, there is a shift from paternalism towards shared decision making. Also, legislation in many countries mandates informed consent. The problems in the ICU setting are obvious. When and what to tell patients and relatives can be contentious issues and are influenced by the physician’s beliefs, knowledge, and attitudes just as much as more objective patient factors, making the situation even harder in clinical ICU practice.

Initial reports by Frerichs (1861) and Flint (1863) [], who had noted an association between advanced liver disease with ascites and acute oliguric renal failure in the absence of significant histological changes in the kidneys, led Heyd [], and later Helwig and Schutz [], to introduce the concept of the hepatorenal syndrome (HRS) to explain the increased frequency of acute renal failure after biliary surgery. However, because HRS could not be reproduced in animal models, pathophysiological concepts remained speculative and its clinical entity was not generally accepted. During the 1950s, HRS was more specifically characterised as a functional renal failure in patients with advanced liver disease, electrolyte disturbances and low urinary sodium concentrations []. Hecker and Sherlock [] showed its temporal reversibility by norepinephrine administration. Over the next few decades, haemodynamic and perfusion studies by Epstein and other investigators [] identified splanchnic and systemic vasodilatation and active renal vasoconstriction as the pathophysiological hallmarks of HRS. Improved models of ascites and circulatory dysfunction contributed to therapeutic advances, including the introduction of large-volume paracentesis, vasopressin analogues, and transjugular intrahepatic stent-shunt (TIPS), which in turn have led to an improved pathophysiological understanding of HRS [].

The HIV/AIDS epidemic in developing countries has raised unique challenges. Total health care expenditure is low in comparison to developed countries. The overwhelming effect of infectious diseases, malnutrition, and inadequate education, singularly and in combination seriously limit the capacity of such countries to deal with HIV/AIDS with effective long-term strategies. This review will focus on three aspects of the epidemic with emphasis on their impact on critically ill patients in developing countries.

Since 1974, when the first policies about ‘do not attempt resuscitation’ orders were published [], the decision not to resuscitate patients in cardiac arrest has been a controversial issue in medical practice. For this reason, the ‘do not attempt resuscitation’ order is, perhaps, the directive and the decision to withhold medical treatment with the widest bibliography. In this review, in accordance with the 2000 Guidelines for Cardiopulmonary Resuscitation [], I will use the term ‘do not attempt resuscitation (DNAR)’ instead of the more popular ‘do not resuscitate (DNR)’. The first sentence indicates more clearly the decision to take, because the success of a resuscitation is not always guaranteed.

During recent years, molecular genetics have become integrated with all aspects of medicine, and advances in this area may modify clinical daily practice deeply as the basic biological mechanisms of illness are understood. The new concepts have been emerging from the knowledge obtained from the study of the human genome, and thanks to advances in computer technology and molecular engineering and new kind of probes developed.

The concept of management is often reduced to accountable administrative processes. This misconception leads to considering that the main goal of an intensive care unit director is to control the magnitude and the final results of intensive care unit (ICU) costs. This is a serious error because it leaves aside the fact that all the steps in the administrative process — purchasing supplies, payments of wages, financial programme, accounting entries, charging of delivered service, costs and balance — are a mirror in terms of monetary units of the resource-consuming process that is necessary for the life support and care of the critically ill patient; the whole administrative process will always be subordinated to medical and nursing interventions.

Sepsis is one of the main problems in medicine due to its complexity from pathophysiology, clinical, and therapeutic standpoints. Although several definitions have been proposed for this syndrome, it can in general be assumed that it represents the clinical manifestation of a system response of the body to infection or to an inflammatory-associated acute disease [,]. Despite advances in medical practice, sepsis, severe sepsis, and septic shock, associated with different grading of organ(s) dysfunction/failure, are conditions that significantly limit quality of life and the ultimate survival of intensive care unit (ICU)patients. In any case, the health cost implications remain exorbitant []. Mortality rates as a result of sepsis are associated with a pattern characterized by progressive dysfunction/failure of non-pulmonary organ systems and, in particular, worsening neurologic, coagulation, and renal dysfunction over the first three days. Although initial pulmonary dysfunction is common in patients with sepsis syndrome, it is not associated with an increased mortality rate []. In five recent clinical trials that enrolled a total of 5661 patients with severe sepsis — the criteria being evidence of infection, systemic inflammatory response syndrome (SIRS), and at least one organ dysfunction/hypoperfusion — the incidences of septic shock ranged from 52 to 71% in the group of patients with severe sepsis. The mean was 58% [–]. A recent study used the International Classification of Diseases (ICD) nine hospital diagnostic codes for infection and acute organ dysfunction — to estimate 751 000 cases of severe sepsis per annum in the United States []. According to this data, septic shock would, therefore, be predicted to occur annually in 435 580 patients in the US. Mortality rate is a consequence of one or more factors such as:age, immunodepression, presence of diseases and/or chronic failure of one or multiple organ system dysfunctions and/or failure [, ]. Pathophysiologic mechanisms are basically related to Gram-negative bacteria endotoxin [], but also Gram-positive micro-organisms, viruses, and mycetes, which are supposedly responsible for the local and systemic release of several mediators that, in turn, might be responsible for the organic response to infection, characterised by cardiovascular instability, hyperthermia, hypothermia, leukocytes, and coagulation alterations as well as by involvement of one or multiple organs []. The term sepsis is related to the concept of multiple organ dysfunction syndrome (MODS), which is frequently identified with the end result of infection, although it has been shown that septic syndrome is not specific to infection and can also originate as a result of a variety of non-infectious stimuli such as pancreatitis, burns, and trauma []. The American College of Chest Physicians proposed new definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis []. Indeed, although remarkable progress has been achieved in defining the pathophysiology of sepsis, the terminology associated with research in this field has remained confusing.

The performance of an Intensive Care unit (ICU) has different aspects. For many years, the performance was synonymous with the standard mortality ratio (SMR). But nowadays, other aspects of performance are considered: from the patients, families, nurses, doctors and provider’s points of view. Several studies, on the other hand, have demonstrated the relationship between organisation and performance.

Research in critical care medicine is founded on the trust of our patients and their families. In order to understand the integrity of this mutually responsible relationship, it is important to review the foundations upon which it is built. Two core questions define our understanding of the importance between the patient’s expectations and our inherent clinical responsibilities. It is equally important to recognise that much of what has become today’s accepted critical care practice derives from uncontrolled clinical experimentation that each of us perform in the context of providing optimal patient care. Therefore it is important to understand the founding principles of the ethical considerations of patient care and research in the intensive care unit (ICU): Where do the principles come from and what do we learn from their application?