Zentralblatt für Chirurgie
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Comparative Study
[A totally implantable venous access device. Implantation in general or local anaesthesia? A retrospective cost analysis].
Implantation of venous access port systems can be performed in local or general anesthesia. In spite of the increasing rate of interventionally implanted systems, the surgical cut-down represents a safe alternative. Thus, the question arises whether--in context to the increasing health-economic pressure--open implantation in general anesthesia is still a feasible alternative to implantation in local anesthesia regarding OR efficiency and costs. ⋯ Our study shows that implantation of totally implantable venous access port systems in local anesthesia is superior in comparison to the implantation under general anesthesia regarding procedural times in the OR unit and costs. With the same operation duration, but less personnel and material expenditure, implantation in local anesthesia offers a potential economic advantage by permitting faster changing times. Implantation in GA only should be performed at a special request by the patient or in difficult venous conditions.
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In 2001 Leschi et al. published a new method to improve perfusion of the superior mesenteric artery (SMA) in operative therapy of acute and chronic visceral ischemia. They presented a retrograde aorto-mesenteric bypass following an arcuate course behind the left renal pedicle. Due to the intricate correct anatomic description of this vascular reconstruction this loop bypass was named the "French bypass". ⋯ The implantation of a "French bypass" represents a good option to reconstruct the SMA, combining the advantages of ante- and retrograde visceral bypasses. Furthermore this -bypass procedure allows to reconstruct distal segments of the -superior mesenteric artery in cases when long distance and peripheral stenosis impeded local thromendarterectomy. Perioperative morbidity and mortality are acceptable when the acute clinical situation is taken into account. The long-term benefit for the patients with regard to the prevention of intestinal ischemia and also the freedom from complaints is high.
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An adequate approach to surgically induced sepsis needs an early and targeted antibiotic therapy in addition to focus sanitation. The PCR-based LightCycler Septifast test can detect 90 % of the sepsis-associated microoganisms (e. g., Gram-positive, Gram-negative bacteria, fungi) within only a few hours. ⋯ This first systematic use of the time-saving LightCycler Septifast test shows that it can detect bacteremia in surgical patients at the ICU, with, in part, negative blood cultures. Positive Septifast test results which cannot be explained by clinical symptoms, occur rarely. The detection of pathological microbes with the Septifast test provides additional findings (72.2 %) for therapeutic decision-making, which can be obtained considerably more rapidly in comparison with conventional microbiological cultures (a few hours versus 2 days). For surgical patients with SIRS and subsequent need of intensive care, a Septifast test should be considered. In conclusion, it is recommended that the test should be further and systematically investigated.
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Comparative Study
[Microcirculatory failure of sublingual perfusion in septic-shock patients. Examination by OPS imaging and PiCCO monitoring].
Haemodynamic monitoring of septic patients is impeded by the discrepancy between the macrohaemodynamics and the microcirculation of internal organs. Pulse contour analysis (PiCCO) provides new parameters for an improved assessment of the volume status of critically ill patients. However, changes in regional circulation, in particular those affecting the splanchnic perfusion, have proven to be especially important. The aim of our study was to compare macrohaemodynamic parameters (PiCCO) with microcirculation (OPS imaging) in severely septic patients with multiple organ failure. ⋯ According to our findings, data acquired through PiCCO monitoring may be used for a rough estimation of the microcirculation during severe sepsis and multiple organ failure. For an assessment of the local conditions of perfusion, however, there are limits in the use of the parameters that were the object of our research. For the measurement at localisations which are accessible non-invasively and representative of the splanchnic perfusion, OPS is the more accurate method for characterisation of the microcirculation, although a more extensive and time-consuming analysis is needed.