Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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Despite significant progress the therapy of peritonitis remains challenging. With a mortality of up to 20% peritonitis is a predominant cause of death due to surgical infections. An early and efficient source control combined with effective antibiotic therapy and modern intensive care and sepsis therapy are definitive for the outcome and prognosis of secondary peritonitis. ⋯ An operative revision should be performed only on demand. The antibiotic therapy should begin with a broadly calculated empirical therapy and should later be adapted to microbiological findings. The therapy of sepsis requires standardized and state of the art intensive care.
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Infection or injury, including surgical procedures, induces an inflammatory response of the host organism. This immune response must be finely tuned and precisely regulated, because deficiencies or excesses of the inflammatory response cause morbidity and shorten the lifespan. Activated receptors of the innate immune system (pattern recognition receptors, PRRs), which recognize pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs) including injured tissue-associated intracellular proteins (alarmins), lead to an exaggerated immune response. ⋯ Besides increased numbers of regulatory T cells there is a shift from a phenotype of inflammatory Th1 cells to an antiinflammatory phenotype of Th2 cells characterized by the production of interleukin-10. Key mediators of sepsis are HMGB1, MIF and complement factor C5a. With the identification of central pathomechanistic events, e.g. amplification of the coagulation, complement and inflammation cascades, immune dysbalance and neuroimmunomodulation via the cholinergic anti-inflammatory reflex, the opportunity now exists to apply these insights to the development of new and novel therapeutics aimed at modulating rather than inhibiting the systemic host response to infection.
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Review Comparative Study
[Tracheostomy in intensive care long-term ventilation : indications, techniques and complications].
Percutaneous tracheostomy has become an established procedure in airway management of critically ill patients. It offers advantages over prolonged tracheal intubation and conventional tracheotomy. Nowadays six different techniques are available in Germany, all of which are based on Seldinger's technique. ⋯ It must be noted further that despite its minimally invasive nature percutaneous tracheostomy is still a surgical manipulation on the airway of a critically ill patient. Immediate recognition and adequate treatment of any complications are of primary importance. To reduce airway complications bronchoscopic surveillance is absolutely necessary.
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Tracheal injuries are altogether rare events and can be divided into three broad categories: tracheobronchial injuries caused by external violence, iatrogenic ruptures of the trachea and inhalation trauma. Successful management of tracheobronchial injuries requires a fast and straightforward diagnostic evaluation. In all severely injured patients with cervicothoracic involvement an injury of the tracheobronchial system should be actively excluded. Although it is commonly agreed that posttraumatic injuries require surgical intervention the management of iatrogenic injuries is presently shifting towards a more conservative treatment.
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Injuries of the midfoot comprise fractures, dislocations and/or fracture dislocations of the Chopart and Lisfranc joint lines. Fracture dislocations, in particular, represent prognostically severe lesions which may compromise foot function to a substantial degree. A number of injuries of the midfoot (up to one quarter) are still primarily overlooked. ⋯ Latent instability may be revealed by dynamic assessment employing stress fluoroscopy. Chronic instability may be detected by weight-bearing radiographs displaying manifest displacement and malalignment under load. The principal strategy of treatment includes anatomical reconstruction of the joint structures, the geometric proportions of the medial, central and lateral foot columns and the diagnostics and treatment of ligamentous instabilities.