New horizons (Baltimore, Md.)
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The diffuse lung injury process known as adult respiratory distress syndrome (ARDS) remains a major cause of mortality and morbidity. The time course of the clinical disease has changed dramatically as support systems have improved. ⋯ Multiple system organ failure is now the leading cause of death in the posttrauma patient in the ICU. ARDS from shock and trauma must now be studied not solely as a primary pulmonary process but as a critical component of a generalized inflammatory reaction to distant tissue trauma.
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Pulmonary edema is a common component of adult respiratory failure. The edema process is much more complex than simply excess water and/or protein crossing the microvascular membrane. The interstitial space itself is an active component of pulmonary edema, as are the alveolar type I and type II cells. ⋯ The role of edema itself in lung failure is variable. Depending on the disease, water content correlates well with impaired oxygenation in cardiogenic edema and relatively poorly in increased permeability edema, especially established adult respiratory distress syndrome. Recognition of the mechanisms, measurements, and relevance of lung edema is of considerable importance in the critical care setting.
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Smoke inhalation injury is a complex of disease processes best understood and treated when defined in terms of the time period after injury. The early phase (0 to 36 hrs) is characterized by diagnosis and treatment of carbon monoxide and cyanide toxicity and by management of early airways edema, bronchorrhea, and bronchoconstriction with aggressive pulmonary toilet. ⋯ With onset of the inflammation-infection phase, the risk of nosocomial pneumonia increases markedly, as does the impairment in lung function as a result of marked increase in oxygen consumption and CO2 production. Nutrition, stress modification, avoidance of muscle fatigue, and control of infection are the key treatment modalities.
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Considerable attention has been directed toward the study of oxygen transport principles in the adult respiratory distress syndrome (ARDS). In particular, concerns have been voiced regarding disturbed tissue oxygen extraction creating a pathologic dependency of oxygen consumption on oxygen delivery. This article discusses oxygen transport principles, data relevant to the oxygen extraction controversy, and implications regarding the pathogenesis and potential therapies for ARDS.
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Neuromuscular blocking agents are powerful drugs that are being used with increasing frequency in critical care medicine. The choice of a particular muscle relaxant is influenced by the patient's underlying condition and the side-effects of the drugs. ⋯ Prolonged paralysis for days to weeks after the discontinuation of neuromuscular blocking agents is an uncommon but devastating complication, the etiology of which is poorly understood. Physicians in critical care medicine should receive formal training in the use of neuromuscular blocking drugs.