The Surgical clinics of North America
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Local and regional block provides an effective means for the control of postoperative pain. In surgery involving the trunk, it serves as a useful alternative to epidural analgesia. With the increasing use of low molecular weight heparin, the use of peripheral nerve block is increasingly popular for patients undergoing lower limb surgery.
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For many reasons, nonopioid analgesics have proven to be of immense benefit in postoperative pain relief. Consideration of the limitations and side effects of opioids confirms the need for alternative, complementary analgesics. The current understanding of pain pathophysiology recognizes that many tissue and neuronal factors and changes are invoked by tissue damage, producing peripheral and central sensitization, and some of these may be modulated by the use of NSAIDs, NMDA antagonists, and local anesthetic agents. ⋯ Tramadol is interesting because it has nonopioid and opioid actions that can be attributed to the two isomers found in the racemic mixture. Spinal neostigmine and the use of adenosine represent completely different mechanisms of nonopioid analgesia being investigated. Nonopioids, including lidocaine, ketamine, the anticonvulsants, and the antidepressants, are necessary for the treatment of patients with the difficult clinical problem of neuropathic pain that can present in the postoperative period.
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The cost and impact of early post-transplant complications continue to be high. Diagnosis and management involves a high index of suspicion, rapid diagnostic and therapeutic interventions, and elimination of technical problems. Preoperative assessment of the donor and recipient medical condition and meticulous attention to detail during the technical performance of OLTx are the mainstays in achieving a good outcome.
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The hepatopulmonary syndrome is a disease entity seen in association with liver failure and other disease entities. It is a devastating consequence of liver failure that results in a significant morbidity for affected patients. ⋯ Recent research, however, has begun to unravel the pathobiology of the vascular dilations that arise in the lungs of patients with liver failure. In this article, a compendium of current knowledge is presented, as well as the contemporary methods for identifying and treating patients.
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Because it is unique in being portable, rapid, and noninvasive, ultrasound is particularly suited to the trauma setting. When performed by the surgeon, it offers immediate feedback that can be incorporated into the management plan for the patient. ⋯ Enthusiasm for surgeons as ultrasonographers will likely increase now that the Advanced Trauma Life Support Subcommittee of the American College of Surgeons has published an algorithm that includes ultrasound for the assessment of patients with blunt truncal injuries. As a rapid, sensitive, and specific diagnostic test for the detection of pericardial tamponade, hemothorax, and hemoperitoneum, ultrasound is now an integral part of the practice at many Level I trauma centers.