Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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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.
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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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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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Following reperfusion of preserved organ grafts, various pathomechanisms are activated that may impair graft function and viability beyond ischemic damage. This so-called reperfusion injury includes generation of oxygen radicals, recruitment and activation of circulating inflammatory cells, and liberation of numerous mediators acting both locally and systemically. Alterations in microvascular perfusion are of central importance where further graft damage is concerned. The present review covers the current knowledge about the underlying mechanisms, the organ-specific application in the clinical setting, and the possible immunological consequences of reperfusion injury.
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Understanding of peptic ulcer disease has dramatically changed within the last years. Today ulcer disease can be considered as a chronic infection. Based on this new pathophysiological concept treatment policies for ulcer bleeding and perforation have to be revised. ⋯ Because of an effective medical treatment of the ulcer disease with eradication, the operation should be restricted to ulcer excision and ulcer oversewing in bleeding or perforated gastric ulcer and duodenotomy, ulcer ligation and extraluminal ligature in bleeding duodenum ulcer and excision and oversewing with pyloroplasty in perforated duodenal ulcer. More definite surgery is not reasonable and should be avoided. With treatment policies based on early elective operation in high risk groups and medical treatment in the other patients a mortality of 5% or less can be achieved.