Crit Care Resusc
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Case Reports
Suxamethonium-induced hyperkalaemia in a patient with a normal potassium level before rapid-sequence intubation.
The use of suxamethonium (succinylcholine) for rapid-sequence intubation may be limited by hyperkalaemia. Modest pre-induction hyperkalaemia is usually disregarded. We present a patient who underwent emergency surgery for a perforated peptic ulcer after being bedbound for 26 days because of a head injury. ⋯ Blood tests during resuscitation showed a serum potassium level of 8.8 mmol/L. Immobilisation, denervation and intra-abdominal infection were risk factors for hyperkalaemia in this patient. This report reinforces the need to identify risk factors for hyperkalaemia before administration of suxamethonium, even when serum potassium levels are normal.
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Case Reports
Severe pneumonia with pneumatoceles and patent foramen ovale in an infant: optimal ventilation strategy?
We discuss a case of severe pneumonia with pneumatoceles in a 2-month old infant. Despite peak and plateau airway pressures kept below 30 and 25 cmH(2)O, respectively, the infant developed bilateral pneumothorax and pneumomediastinum caused by pneumatocele rupture, necessitating bilateral intercostal drainage. Application of positive end-expiratory pressure (PEEP) of 10 cmH(2)O at FIO(2) of 0.7 worsened oxygenation, and transthoracic echocardiography showed right-to-left shunting of blood through the patent foramen ovale. ⋯ The open lung strategy of higher increments of PEEP and lower FIO(2) for lung protective ventilation actually proved deleterious to our patient. We conclude that a subset of patients with acute respiratory distress syndrome with refractory hypoxaemia may have right-to-left shunting of blood through a patent foramen ovale. This can be detected by echocardiography, and these patients may benefit from a ventilation strategy aimed at lowering pulmonary vascular resistance.
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Haemodynamic instability and respiratory failure are common in critically ill patients, with sepsis being a frequent cause. Echocardiography is a useful, practical and safe bedside tool for diagnosis and management of these problems. ⋯ Its use can help determine whether, and when, continuous haemodynamic monitoring should be instituted. It is the best monitor for the management of sepsis because of its broad clinical utility and as a reference for the judicious use of invasive monitoring.
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Comment Letter Biography Historical Article
History of mouth-to-mouth rescue breathing: some matters concerning John and Anthony Fothergill.