Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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The advantages and disadvantages associated with epidural opioids require careful selection of the opioid and its dosage. There is presently no ideal opioid available for epidural use. Comparative pharmacokinetic data help to select the appropriate epidural opioid. ⋯ Epidural morphine treatment is an alternative to step 4 of the WHO treatment regimen for patients with intractable pain or those suffering from systemic opioid side effects. Careful selection of patients helps to increase successful treatment. If implantable devices (ports or pumps, according to the life expectancy) are employed, the intrathecal route of administration is preferable to the epidural route, as the latter has a 10 times higher morphine dose requirement.
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Pain therapy is a central medical task and a legal duty. Not the anaesthetist but the pain-causing surgeon is responsible for therapy of pain. Pain as a negative sensation is subjective and individual. ⋯ Opioids are used with caution in abdominal surgery because of their negative effects (obstipation), the same is the case with Novalgin in trauma patients because of its effect on temperature and leukopenia. Patient-controlled analgesia with appropriate devices means further progress for suitable patients. Effective pain therapy within the framework of successful surgery is feasible and influences patients' comfort and possibly even their morbidity and mortality.
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Within a period of 6 years we operated on 109 patients with De Quervain's disease. Of the patients 82% recovered completely, 18% had slight residual complaints, e.g. stress-dependent discomfort and irritations of the superficial radial nerve. The operative technique is presented in detail and the frequency of anatomical variations of the first extensor tendon compartment is emphasized.
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At the intensive care unit of the Clinic for General and Abdominal Surgery and the Clinic for Emergency Medicine in Mainz, various scores (APACHE II score, HIS, TISS, ASA score), laboratory parameters (serum creatinine, white blood count, platelet count, serum lactate, serum elastase, Quick), body temperature, age as well as presence of a malignant underlying or associated disease, were analyzed with regard to their prognostic significance in 169 postoperative admissions. Apart from univariate analysis (Wilcoxon test) and a multivariate analysis (stepwise logistic regression), the value of the scores is demonstrated on the basis of sensitivity, specificity and correctness, as well as the behaviour of the scores at certain decisive points (cut-off point). Of the parameters studied, the APACHE II score, the HISS, the TISS and serum lactate had a significant influence on the outcome of intensive care. ⋯ However, insufficient discrimination between patients who die and patients who survive means that these parameters cannot be used for individual therapeutic decisions in severely ill patients. The decision between the institution or cessation of intensive care is made by the physician or the medical team. Due to the use of prognostic factors, such as scores, decision-making can be objectified and therefore made easier.
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Spilled gallstones abandoned intraperitoneally may cause serious complications. The following case history describes a patient who had undergone a laparoscopic cholecystectomy elsewhere 2 years previously, and who had to have a laparotomy because of a pararenal abscess caused by spilled gallstones. fatal sepsis ensued and the patient died on the 6th postoperative day.