Critical care medicine
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Critical care medicine · Dec 2008
ReviewPropagation prevention: a complementary mechanism for "lung protective" ventilation in acute respiratory distress syndrome.
To describe the clinical implications of an often neglected mechanism through which localized acute lung injury may be propagated and intensified. ⋯ The diffuse injury that characterizes acute respiratory distress syndrome is often considered a process that begins synchronously throughout the lung, mediated by inhaled or blood-borne noxious agents. Relatively little attention has been paid to possibility that inflammatory lung injury may also begin focally and propagate sequentially via the airway network, proceeding mouth-ward from distal to proximal. Were this true, modifications of ventilatory pattern and position aimed at geographic containment of the injury process could help prevent its generalization and limit disease severity. The purposes of this communication are to call attention to this seldom considered mechanism for extending lung injury that might further justify implementation of low tidal volume/high positive end-expiratory pressure ventilatory strategies for lung protection and to suggest additional therapeutic measures implied by this broadened conceptual paradigm.
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Hyperkalemia is one of the few potentially lethal electrolyte disturbances. Prompt recognition and expeditious treatment of severe hyperkalemia are expected to save lives. This review is intended to provide intensivists and other interested clinicians with an understanding of the pathophysiology that underlies hyperkalemia, and a rational approach to its management. ⋯ A more complete understanding of potassium homeostasis in recent years has led to new approaches to the management of severe hyperkalemia. The physiologically based sequential approach still applies. The efficacy, pitfalls, and risks of the agents available for use at each step in the sequence are critically reviewed. Rational use of the available tools will allow clinicians to successfully treat severe hyperkalemia.