History of Critical Care

During the Crimean War, in the 1850s, nurses created a separate area near the nursing station for critically injured British soldiers; some identify this as the beginning of intensive care. In 1927, Dr. Walter Dandy of Johns Hopkins Hospital arranged for a special area for increased monitoring of his postoperative neurosurgical patients. And during World War II, shock units were created to care for the severely wounded and postoperative patients. All marked the implementation of particular attention given to critically ill patients.

Modern critical care began with the development of new technology, specifically the iron lung and negative pressure ventilation used during the 1952 polio epidemic. Dr. Bjørn Ibsen described the provision of this respiratory care in the Proceedings of the Royal Society of Medicine. Mechanical ventilators first became commercially available in the 1960s, followed by increasing use of automated monitoring of vital signs with alarms. Among the first modern critical care units opened in 1959 were those at the University of Southern California and the University of Pittsburgh, both staffed by specially trained critical care physicians.

Critical care is not an organ-based specialty but one that relies on the treatment provided in a specific area of the hospital: the intensive care unit. From its inception, critical care has relied on nurses who closely monitor vital signs for the sickest patients and provide continuous bedside interventions.

As the result of increasing pathophysiological and clinical research in the field, critical care has evolved significantly since Dr. Ibsen’s report, leading to the publication of several landmark trials that have changed the way we care for critically ill patients. For example, in 2001, the Early Goal-Directed Therapy trial by Dr. Emanuel Rivers and colleagues introduced a treatment protocol that became the mainstay of sepsis treatment for almost 15 years. Although this approach has since been challenged by several other studies (e.g., PROCESS, ARISE, and ProMISe), the Rivers trial remains part of any discussion about the history of sepsis management.

Advances have also occurred in management of respiratory failure and mechanical ventilation; the ARDSNet trial, published in 2000, concluded that lower tidal volumes lead to improved outcomes, and the results significantly changed the way we manage acute lung injury and acute respiratory distress syndrome (ARDS). Likewise, the ABC study on spontaneous awakening and breathing changed the practice of ventilator weaning. These studies continue to shape critical care practice today.