Zentralblatt für Chirurgie
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Legal consent to medical treatment requires comprehensive clarification and the patient's capability to consent. Minors under 14 years are usually not capable of consent -- the right to decide rests with the parents. With persons over 14 years the doctor must test for capability to consent. ⋯ Since minors under 18 years are only limitedly contractually capable, the approval of the statutory guardian suffices. With contractually incapable adults the court-appointed guardian or in serious cases the Guardianship Court decides. The legal position is explained, using three sample cases.
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Skin and soft tissue infections are common diseases. The spectrum ranges from slight furuncles to severe necrotizing soft tissue infections. Grampositive bacteria account for 70-80 % of cases as causative organisms. ⋯ Necrotizing skin and soft tissue infections call for programmed redebridement. If systemic signs of inflammation are present (fever > 38 degrees C, leukocytosis, CRP elevation) or significant comorbidity exists, application of antibiotics is indicated. The prognosis in operatively treated patients is dependent on the time of surgical intervention.
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The treatment of severe diffuse peritonitis is still associated with a mortality of up to 50 %. Particularly the postoperative peritonitis shows high mortality rates due to septic organ failures. ⋯ Dependent on the severity of the peritoneal reaction, further treatment consists of primary abdominal closure and relaparotomy on demand, programmed lavage or laparostomy respectively. Septic complications have to be treated by intensive care medicine.
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Regardless of improved diagnostics and therapeutic options, complicated intraabdominal infections remain a challenge in medicine. The prognosis of secondary peritonitis depends upon diagnosis and therapy in time. ⋯ Antimicrobial and supportive therapy is initiated before surgery and should be continued throughout and after the operation. Surgery aims on clearing the focus with a one-step-procedure in order to reduce perioperative morbidity and mortality.
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Nosocomial infections are the major cause for morbidity and mortality in hospital. In Germany 3.5 % of patients developed nosocomial infections, 15 % of these are wound infections post surgery. ⋯ Risk factors others than the suspected contamination rate at the end of the operation have to be detected. Indication, choice of the antibiotic agent and timing of antibiotic prophylaxis will be discussed.