Zentralblatt für Chirurgie
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Multiple trauma often leads to systemic inflammatory reaction and multiple organ dysfunction. Modulation of this response may be promising. ⋯ Hence, supportive care of failing organs, treatment of hypoxemia and maintenance of an appropriate systemic blood pressure remain the mainstay of critical care therapy. Widely accepted therapeutic measures are (i) immediate treatment of hypoxia by administration of oxygen and ventilatory support, if needed, to maintain an oxygen tension of 60 mmHg or higher (ii) maintenance of adequate oxygen content by transfusion of red packed cells in order to restore a hematocrit of 23-30% (iii) treatment of hypovolemia by infusion of crystalloids, colloids and blood products (iv) normoventilation and restoration of a normal or elevated blood pressure in patients with severe head injury (v) immobilisation and early administration of methylprednisolone in patients with spinal cord injury (vi) analgesia by administration of opioids, non-steroidal antiinflammatory drugs, or ketamine (vii) sedation with benzodiazepines, gamma-hydroxbutyrate or propofol (viii) early enteral nutrition (ix); antibiotic therapy of infections (x) pressure controlled ventilation in patients with acute lung injury (xi) continuous veno-venous hemofiltration in patients developing acute renal failure and (xii) early surgical interventions to control bleeding and/or to evacuate intracerebral hematomas.
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Adequate prehospital care of the severely traumatised patient is important to prevent or attenuate early as well as late life threatening complications, such as tissue hypoxia, ischemia/reperfusion injury and finally multiple organ failure. A mismatch of oxygen supply and oxygen demand is a hallmark in the pathophysiology of multiple trauma. Oxygen supply may be diminished by the following factors: shock-related decrease of cardiac output, anemia and hypoxia. ⋯ Furthermore, ventilatory support is indicated when respiratory failure, loss of consciousness, or severe shock are present. Additional oxygen should be given whenever possible, even in the absence of an overt hypoxic state. Important additional measures are cervical spine immobilisation and reposition as well as splinting of long bone fractures or luxations, in order to avoid secondary injury of the spinal cord or ongoing tissue and vascular damage.
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Review
[Does multi-vessel disease of brain supplying arteries modify the procedure in carotid operations?].
In a prospective evaluation 159 patients with carotid artery stenosis showed a multiple artery disease in 78 to 99% depending on the grade of cerebral artery insufficiency. Contralateral occlusion process could be detected in 15.7%, internal and common carotid artery occlusion in 16 patients (10%). 1595 patients picked out of the literature have been analyzed in respect of the natural history which showed a risk to develop a stroke in 4.5%/year. In further 1286 operated patients of other reports the morbidity and mortality rate ranged 4.5% and the risk of further neurologic events after operation was 2.4%/year. The use of an intraluminal shunt after thrombendarterectomy proved to be a good procedure to lower the morbidity and mortality rate without any intraoperative monitoring.
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Operative procedures in multiple injured patients consist in the first stage in life-saving operations such as control of bleeding and cerebral decompression. Operative measures during the urgent second operative phase have to be undertaken under consideration of the development of a multiple organ failure syndrome. ⋯ Delayed operative procedures should only be performed after stabilization of the overall patient situation to prevent enhancement of the systemic inflammatory response. The required operative procedures of the multiple injuries have to be attributed to the respective operative phases.
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The percentage of elderly people among surgical patients has been continuously rising. The purpose of this study was to show the course of operation and hospitalization of seniors in a department for general surgery. 191 patients aged 75 or older underwent surgery during the six months of observation. Information about preoperative social and environmental conditions, operative and postoperative treatments, complications, secondary symptoms and rehabilitation and homecare after discharge was retrospectively compiled. ⋯ Discharge into the accustomed environment was possible for 74.7% (118) of the successful cases. Old patients show a good physical and psychological acceptance of surgery and hospitalization, if they are well prepared and secondary symptoms are appropriately therapied. The decision for routine operation in sufficient time can help avoid an emergency operation with poor prognosis.