Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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Over the last twenty years, the most dramatic change in American surgical care has been the shift from inpatient to outpatient surgical care. Ambulatory surgery in the 1990s, with its demonstrated ability to lower individual patient and overall societal surgical care costs, while maintaining quality equal to inpatient services, has been embraced by all segments of the American health care delivery system. ⋯ It also appears likely that ever increasing numbers of surgical operations will be completed on an outpatient basis. Ambulatory surgery is one of those rare socioeconomic-political movements in which all participants have benefitted as demonstrated by public interest and demand, surgeon satisfaction, patient participation, and, most importantly, payer encouragement and mandate.
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Existing scoring systems have failed to reflect the pathophysiological changes during ICU therapy, and do not provide reliable criteria for the prediction of outcome in surgical patients. The aim of the present project was to establish a comprehensive scoring system for daily evaluation of physiological parameters and therapeutic interventions in a surgical intensive care unit, and to identify score patterns in the course of ICU treatment to be used for prospective clinical decisions. In a prospective study of 123 consecutive patients who required intensive care for more than two consecutive days we documented 10 physiological parameters and a set of 14 therapeutic interventions on a daily basis over a total of 1274 days. ⋯ At that point, HDWS was superior to APACHE II with respect to the predictive power as assessed by receiver operator characteristic curves. No patient who fulfilled all four unfavorable HDWS-patterns during the first week of ICU treatment survived (but these were only two patients). We conclude that the limited power of scores obtained on admission to predict outcome in surgical patients may be improved by trend analysis of scores over time which also take into account the patients' response to therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
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Visceral outpatient operations are well established in Dresden. Since 1978, 13,948 cases have been operated on in general surgery. Most patients (57.8%) had local anesthesia; only 9.2% needed general anesthesia. ⋯ With careful selection of patients and the right indication, complications are rare in outpatient surgery. In only 0.7% of all cases did wound infections occur postoperatively. None of the patients died.
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The culture and transplantation of keratinocytes are considered an important progress in the treatment of severe burns. The keratinocyte grafts take best (50 to 90%) on remaining dermal structures after deep dermal (II b) burns. ⋯ As vital wound cover they allow for a rapid and near scarless reepithelialization. For deep (III) burns we use composite grafts of cultured auto-keratinocytes on allo-dermis with increasing success (up to 75% take rate) without rejection.
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Establishing day care and short stay surgery in trauma departments requires a careful estimation of the perioperative risks. Having the therapy be successful for each patient admitted to day care surgery should have precedence over any economic limitations. In day care surgery a trauma surgeon has to make sure that appropriate postoperative supervision is available for each patient discharged from the hospital. The surgeon is responsible for qualified care on an outpatient basis.