The Surgical clinics of North America
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Surg. Clin. North Am. · Apr 2012
ReviewPrevention of chronic pain after surgical nerve injury: amputation and thoracotomy.
Although techniques for acute pain management have improved in recent years, a dramatic reduction in the incidence and severity of chronic pain following surgery has not occurred. Amputation and thoracotomy, although technically different, share the commonalities of unavoidable nerve injury and the frequent presence of persistent postsurgical neuropathic pain. The authors review the risk factors for the development of chronic pain following these surgeries and the current evidence that supports analgesic interventions. The inconclusive results from many preemptive analgesic studies may require us to reconceptualize the perioperative treatment period as a time of gradual neurologic remodeling.
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Hemorrhage remains a leading cause of morbidity and death in both civilian and military trauma. Restoration of effective end-organ perfusion by stopping hemorrhage and restoring intravascular volume in such a way as to minimize acidosis, hypothermia, and coagulopathy, almost always requires the use of blood and/or blood-component therapy. The best method to manage life-threatening hemorrhage is to avoid the circumstance that prompted it or to mitigate blood loss early in the injury cycle; otherwise, blood replacement must suffice. This article reviews current understanding of massive transfusion, along with its attendant unintended consequences, in the management of patients with profound hemorrhage.
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Surg. Clin. North Am. · Apr 2012
ReviewHypoperfusion, shock states, and abdominal compartment syndrome (ACS).
Cardiovascular dysfunction and failure are commonly encountered in patients with intra-abdominal hypertension or abdominal compartment syndrome. Accurate assessment and optimization of preload, afterload, and contractility are essential to restoring end-organ perfusion and maximizing patient survival. Application of a goal-directed resuscitation strategy, including abdominal decompression, when indicated, improves cardiac function, reverses end-organ failure, and minimizes intra-abdominal hypertension-related patient morbidity and mortality.
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Surg. Clin. North Am. · Apr 2012
ReviewPostoperative pulmonary complications: pneumonia and acute respiratory failure.
Postoperative pulmonary complications (atelectasis, pneumonia, pulmonary edema, acute respiratory failure) are common, particularly after abdominal and thoracic surgery, pneumonia and atelectasis being the most common. Postoperative pneumonia is associated with increased morbidity, length of hospital stay, and costs. ⋯ Acute respiratory failure is a life-threatening pulmonary complication that requires institution of mechanical ventilation and admission to the intensive care unit, and is associated with increased risk for ventilator-associated pneumonia. This article discusses epidemiology, risk factors, diagnosis, treatment, and prevention of these pulmonary complications in surgical patients.
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For surgical patients, appropriate selection and administration of fluids can mitigate against organ failure, whereas improper dosing can exacerbate already injured systems. Fluid and electrolyte goals and deficiencies must be defined for individual patients to provide the appropriate combination of resuscitation and maintenance fluids. Specific electrolyte abnormalities should be anticipated, identified, and corrected to optimize organ functions. Using the strong-ion approach to acid-base assessment, delivered fluids that contain calculated amounts of electrolytes will interact with the patient's plasma charge and influence the patient's pH, allowing the clinician to achieve a more precise end point.