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Critically ill patients depend on artificial nutrition for the maintenance of their metabolic functions and lean body mass, as well as for limiting underfeeding-related complications. Current guidelines recommend enteral nutrition (EN), possibly within the first 48 hours, as the best way to provide the nutrients and prevent infections. EN may be difficult to realize or may be contraindicated in some patients, such as those presenting anatomic intestinal continuity problems or splanchnic ischemia. A series of contradictory trials regarding the best route and timing for feeding have left the medical community with great uncertainty regarding the place of parenteral nutrition (PN) in critically ill patients. Many of the deleterious effects attributed to PN result from inadequate indications, or from overfeeding. The latter is due firstly to the easier delivery of nutrients by PN compared with EN increasing the risk of overfeeding, and secondly to the use of approximate energy targets, generally based on predictive equations: these equations are static and inaccurate in about 70% of patients. Such high uncertainty about requirements compromises attempts at conducting nutrition trials without indirect calorimetry support because the results cannot be trusted; indeed, both underfeeding and overfeeding are equally deleterious. An individualized therapy is required. A pragmatic approach to feeding is proposed: at first to attempt EN whenever and as early as possible, then to use indirect calorimetry if available, and to monitor delivery and response to feeding, and finally to consider the option of combining EN with PN in case of insufficient EN from day 4 onwards.

Recent papers discussed include a positive trial of early tracheostomy, two negative studies of targeted noninvasive ventilation, the long awaited results of the high versus low positive end-expiratory pressure Acute Respiratory Distress Syndrome Clinical Trial Network trial and a simple but illuminating study into prognostic markers and end-points of resucitation.

Early recognition of sick patients with a poor prognosis, and the rapid institution of appropriate therapy are tenets of good medical management across all specialties. Here we highlight five recent papers that aid us in achieving such goals in and around the intensive care unit (ICU). Both score-generating clinical tools and clinical acumen are championed for identifying the sick, while appropriate, early intervention in acute deterioration is shown to be beneficial, before and after ICU admission. Saline or albumen for resuscitation? The answer became clearer in May, as did what to do about all those mobile phones...

In the present commentary I review some current therapeutic debates. Is noninvasive ventilation going to become the gold standard for acute hypercapnic respiratory failure, and if we have to intubate and ventilate then what is the gold standard for sedation? Old therapies are challenged (e.g. diuretics may worsen outcome) and new ones suggested (e.g. some critically ill patients may benefit from regular erythropoietin). In addition, we must of course mention steroids and sepsis.

We were surprised to read the letter "Tight glycaemic control: intelligent technology or a nurse-wise strategy?" by de Graaff and colleagues [1]. In this letter, the use of complex protocols for tight glucose control is questioned, and a strategy as used in Leuven is proposed: based on nurses' experience, guided with only a few very simple guidelines. Glucose control is not simple but complex. This complexity is underscored by major problems that have been encountered with respect to safety and efficiency. Many factors are known to influence glucose control. Standardizing glucose control has been found to improve both safety and the efficiency of glucose control [2]. Moreover, results obtained with unstandardized treatment protocols as proposed by de Graaff et al. should be interpreted with great caution, as the exact characteristics of the therapy are unknown. We agree with de Graaff et al. that paper protocols can become too complex and may result in bad compliance, efficiency and safety. Computer protocols are generally easy to follow and require fewer glucose measurements than paper-based protocols [3-5]. In our own three-year experience, nurses – both novice and experienced – are very pleased with the efficient process a computer provides. Still, we also value wise nurses and allow our computer protocol to be overridden when needed. Abandoning advanced standardized therapy in favor of relying on human decision-making would clearly be a step backward in our view. The current "5 million lives campaign" by the Institute for Healthcare Improvement calls for a 50% reduction of harm related to high-alert medications (including insulin) focusing on standardization strategies to reduce the chance of human error [6]. In our opinion, a computer program recommending an insulin level, and seeing to it that glucose gets checked in time is the most standardized, effortless, safe and efficient form of glucose control currently available.

This issue's Recently published papers commentary considers the popular and muddy waters of glycaemic control, stops briefly to ponder the incidence of pulmonary embolus in acute exacerbations of chronic obstructive pulmonary disease, promotes novel studies in the areas of traumatic brain injury and extracorporeal circuits, and rounds off with a potentially dogma-challenging study in cardiac arrest.

We compared a computer-driven weaning protocol (SmartCare on Evita XL; Drager, Lubeck, Germany) with our paper-based nurse-driven weaning protocol.

This issue's recently published papers concentrates on early goal directed therapy, starting with new data from the original study through to new studies that may have a major bearing on the treatment of septic shock in years to come. A timely reminder about talking, walking and teaching clinical medicine completes the roundup.

This issue's recently published papers commentary takes a long hard look at the surprisingly topically issue of oxygen. To give a balanced perspective, topical ventilatory studies are also discussed.