The process above described in detail was the same with small difference among all the four consensus conferences [6–8, 33]. The first three consensus conferences focused on cardiac anesthesia and intensive care (6), on the perioperative period of any surgery (7), and on patients with or at risk for acute kidney injury (8). The perioperative consensus process and results have already been described in details on a Springer book [34].

The four consensus conferences included between 340 and 1,090 participants from 61 to 77 countries. All were based on a systematic review of literature, on two web-based surveys that preceded and followed, respectively, an international meeting. Each time we published a manuscript on the consensus results on an international journal. There were only a small difference related to the systematic review (according to the broadness and complexity of the subject) and some variance in the question posed by the web survey [5]. However, the five-step process for democratic consensus building is now well tested and to our knowledge is the only method employed to democratically share the decision process with a global audience and to allow to reach an agreement among a population of colleagues in a worldwide horizon.

This consensus conference identified the 15 interventions with the strongest evidence of a positive or negative effect on mortality in the critical care setting. This summary of evidence may serve as a fundamental guide for clinicians worldwide to orientate their clinical practice, as this is the largest and global survey of intensivists’ opinion on ICU treatment reported so far.

This conference is the fourth to be based on the new concept of democracy-based medicine. This process enhances the possibilities of communication and consensus building between pairs, allowing for a global debate of colleagues on the published evidence. The more and more frequent updates in evidence-based medicine will probably benefit from the diffusion of new information technologies and from the methods made available by the new democracy-based medicine. A dedicated web site has recently been created to perform updates of these consensus conferences and create new ones, www.​democracybasedme​dicine.​org.