Zentralblatt für Chirurgie
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The clinical syndrome sepsis has been redefined recently, and the SIRS (systemic inflammatory response syndrome) concept has been developed. In the initial phase of sepsis, different mediator systems are activated finally resulting in a generalized endothelial inflammatory reaction. This reaction may lead to a vicious circle with subsequent multiple organ failure. ⋯ Replacement of antithrombin III, continuous venovenous hemofiltration, application of high doses of immunoglobulins and of low doses of hydrocortisone have been used. A monoclonal antibody against endotoxin (Centoxin) was taken from the German market in January 1993. Experimental aspects of treatment include the administration of C1 esterase inhibitor, pharmacological inhibition of nitric oxide (NO), plasmapheresis, the application of non-steroidal anti-inflammatory agents and of high-dose naloxone as well as manipulation of cytokines.
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No data exist in the literature pertaining to the problems of laparoscopic surgery in infants and children. However it is reasonable to assume that minimal invasive surgery will find increasing application in these patients in the future. The anesthesiological problems met during surgery are representatively demonstrated and discussed in the context of a case report. ⋯ This can be prevented by ventilating with a sufficient level of PEEP. On the other hand, the reduction of venous return caused by increased IAP and aggravated by the necessarily high PEEP can compromise circulation. Adequate volume substitution is essential.
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The present investigation was initiated to quantify the effect of a CO2-peritoneum on CO2-absorption (VCO2res) and other respiratory variables during laparoscopic surgical procedures. ⋯ This increase in ventilation can easily be established in pulmonary uncompromised patients. Problems in adequately increasing minute volume are expected in chronic obstructive lung disease and with maximal VCO2res. Monitoring of at least petCO2 is strongly recommended since the individual course of VCO2res cannot be predicted.
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The so-called percutaneous dilatational tracheostomy-essentially a minimally invasive puncture method-inserting the tracheal cannula by a modified Seldinger-technique is an alternative method to the conventional operative tracheostomy. The percutaneous dilatational tracheostomy was evaluated in a prospective trial (June 92-January 93) on 50 consecutive surgical (n = 36), medical (n = 10), and neurological-neurosurgical (n = 4) critically ill patients (29 m, 21 f; age 14-87 years) with need for prolonged mechanical ventilation. After an average duration of endotracheal intubation of 6 (0-22) days, the procedure was endoscopically guided and controlled via the endotracheal tube. ⋯ Infection of stoma site, misplacement of cannula, rupture of the tube cuff, and pneumothorax were not noticed. On 13 decannulated patients stenosis of the trachea was not found in a period of 6-8 weeks following the tracheostomy. As a bedside procedure the percutaneous dilatational tracheostomy is safe and quick and should therefore be the method of choice for critically ill patients who require a tracheostomy.
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94 patients have been operated upon for haemorrhagic gastroduodenal ulcer disease in the Wenckebach-Krankenhaus during the years 1986-1990. In all but 6 patients the ulcer has been controlled by an emergency gastroscopy. 25 of these patients had to undergo emergency operation at once for persistent bleeding after gastroscopy. From the other patients, another 31 suffered rebleeding and had to be laparotomised in an emergency procedure, too. ⋯ There was no difference in mortality-rates between resective and non resective procedures. Our aim to operate upon the patients in an elective way could be achieved in about one third only. Many patients refused an operation after primary control of bleeding.