Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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A high-risk patient is a challenge to the anaesthesiologist. If surgical intervention is indicated the perioperative anaesthesiological management has to be carefully adapted to the requirements of the patient. If the patient is classified a high-risk at the preoperative anaesthesiological assessment, the therapeutic management has to aim at optimizing the patient's preoperative physical status. ⋯ During the postoperative period each high-risk patient has to be observed in the intensive care unit to continue intraoperative monitoring and therapy. Patients at risk of postoperative myocardial ischaemia or infarction should be closely monitored for 3-5 days postoperatively. The perioperative risk of morbidity and mortality associated with elective surgical procedures has to be evaluated for each patient and the risk-benefit analysis discussed in a interdisciplinary dialogue involving the surgeon, the patient and the patient's family.
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Lung volume reduction (LVR) is a new surgical approach designed to relieve shortness of breath and to improve exercise tolerance in patients with severe lung emphysema. Selection of patients for LVR is based on history, clinical investigation, chest X-ray studies, CT scan, lung perfusion scan, lung function testing, and blood gas analysis. Selection criteria are severe emphysema (FEV1 20-35% pred., TLC > 120% pred., RV > 250% pred.), dyspnea despite optimized medical therapy, abstinence from smoking, acceptable nutritional status and rehabilitation potential. ⋯ Three cases of a delayed pneumothorax were observed. Early hospital mortality (< 30 days) was 1.7% and 90 days mortality 3.4%. Few follow-up data are available beyond 1 year, and the long-term benefit of LVR surgery therefore remains to be defined.
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In the last two decades our understanding of the pathophysiology of severe head injury has significantly increased. It has become evident that secondary neuronal damage may occur and should be prevented. It is ischemia, similar to that seen with stroke and aneurysmal subarachnoid hemorrhage, that causes secondary brain damage. ⋯ Moreover, there are some new pharmacological concepts for changing the threshold for ischemia in brain tissue. At the present time, however, valid data concerning clinical use are still not available. Therefore, mild hyperventilation and sedation during the initial post-traumatic phase and lowering of intracranial pressure by osmotherapeutics remain the most important treatment modalities, as they were 20 years ago.