While more than half of the ICU patients have either sepsis/infection or are on antimicrobial - How we practice infectious diseases differ significantly between an ICU and other even in the same country (sometimes even different ICUs in the same hospital).
Understanding such practice is fundamental to improve patients' outcome, antibiotic resistance, length of stay, morbidity as well as antimicrobial resistance.
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I have observed in recent years that critically ill patients in the ICU are sometimes maintained on mechanical hyperventilation with propofol sedation. ln my opinion, this is harmful and counterproductive. All hypnotics are inherently toxic, including anesthetic inhalation agents. The toxicity of propofol is notorious. George Washington Crile described how he cured sepsis and peritonitis 100 years ago when primitive needle technology made intravenous access impractical. He used massive doses of intramuscular morphine that caused his patients to become essentially comatose for up to a week, without the help of intravenous fluids or even antibiotics. This cured cases of sepsis and peritonitis. Crile had discovered the nervous component of what was then called "shock". He describes his discoveries and treatment strategies in his famous book called "Anoci-association" that can be accessed free of charge via the Internet. With our modern machines, medications and monitors we can do better. We can safely maintain deliberate high levels of "permissive hypercarbia" that offsets the respiratory depression caused by modern synthetic opioids; the combination works like love and marriage. Hypercarbia optimizes cardiopulmonary performance and enhances the release of oxygen from the hemoglobin molecule, and therefore optimizes tissue oxygenation. This is helpful in all forms of sepsis and especially helpful in stubborn cases of infestation with "facultative anaerobes" that proliferate in poorly perfused and oxygenated tissues where antibiotic "penetration" is limited, such as Lyme Disease, MRSA and so forth. Last, but not least, non-toxic opioid supplementation reduces reliance on toxic hypnotic agents. The best choice for a hypnotic agent is anesthetic inhalation agents, which can be maintained at precise levels, adjusted quickly, and rapidly rid from the body. These principles could revolutionize the care of critically ill patients if they were fully utilized.
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