Abstract
Critical care medicine has matured greatly as a field in the past decade. Much has been learned concerning the institution of life support therapies to sustain patients with diverse and multiple organ failures, thus providing patients with a window of opportunity to recover from potentially life-ending insults. The management of critically ill patients has increasingly involved creation of a highly controlled environment by care providers, with patients immobilized, tethered to devices, and receiving multiple drugs to facilitate the entire process. Although it has been assumed that such control of the patient has been necessary to implement essential therapies and to tailor life support systems such as mechanical ventilation, this assumption may be unfounded or at least overplayed, as knowledge of the adverse effects of this approach have been identified and quantified. Extant information, based on observational studies and a few interventional trials, would suggest a radically different approach to care is warranted, even given the difficulties in reversing the current culture of critical care management. Specifically, methods to avoid entirely, or minimize, neuromuscular blockade and sedation are supported by recent literature. These methods include the use of noninvasive ventilation in appropriately selected patients, the development of mechanical ventilators more synchronous with patient efforts and needs, and the use of sedation strategies to avoid drug accumulations with protracted effects. These methods, in turn, afford opportunities to avoid extreme immobilization and institute physiotherapy earlier than previously had been thought possible. In addition to the neuropsychiatric and neuromuscular benefits that could derive from minimizing opiate administration in critically ill patients, gut hypomotility could be avoided. This, in turn, could facilitate earlier and more complete enteral nutrition. Even when opioids have to be administered in generous amounts for control of pain that may accompany critical illness, it is now possible to block the peripheral actions of these medications with the μ-receptor antagonist methylnaltrexone. Other new drugs being introduced into the critical care unit such as dexmedetomidine may also provide a greater ability to achieve analgesia and anxiolysis without some of the adverse concomitant effects seen with more traditional drug regimens. The ultimate goal of this multipronged program to facilitate the maintenance of patients who are more interactive with their care providers, and the life support provided in the intensive care unit would be to speed the pace of recovery and to diminish the need for the protracted rehabilitation that often follows survival from critical illness.
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