The Surgical clinics of North America
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Surg. Clin. North Am. · Aug 1985
ReviewSpecial problems in the diagnosis and treatment of surgical sepsis.
Since sepsis is the most frequent single cause of death after surgery and trauma, its development should be anticipated in elderly patients or those with disease or trauma causing intestinal leaks, particularly if the patient had massive transfusions or was in shock. Diagnosis may be extremely difficult, particularly if the infection is intraperitoneal. Furthermore, patients with impaired host defenses may show only a failure to thrive and then a progressive MOF. ⋯ If the infection persists for more than 2 to 3 weeks, infection by enterococci and fungi must be considered. If shock develops, maintaining an O2 consumption of at least 130 to 160 ml per minute per m2 is a particularly important part of the resuscitation. Although controversial, raising the hematocrit to 40 to 45 per cent or higher is often of value.
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From the foregoing accounts of preoperative assessment of myocardial performance, as well as preload and afterload status it is clear that the proper anesthesia techniques and agents can be selected. Physiologically optimal adjustments of preload, afterload, and myocardial function can be attained by the appropriate, harmonious selection of anesthesia technique and vasoactive drugs made on the basis of close hemodynamic monitoring preoperatively, intraoperatively, and in the immediate postoperative period.
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Surg. Clin. North Am. · Aug 1985
Review Clinical TrialTherapy of critically ill postoperative patients based on outcome prediction and prospective clinical trials.
An objective physiologic approach to therapy of high-risk postoperative patients was developed using survival as the criterion to determine the relative importance of variables and optimal goals for these variables. A protocol, based on a branch chain decision tree, also was developed from outcome data. When tested prospectively against the standard of care, this protocol markedly reduced mortality and morbidity.
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Surg. Clin. North Am. · Aug 1985
ReviewMyocardial function in the critically ill: factors influencing left and right ventricular performance in patients with sepsis and trauma.
Myocardial performance in critically ill patients is primarily responsive to the need to supply O2 to the periphery. An increase in CO is the common finding in an acute illness characterized by an increase in systemic VO2 (for example, sepsis and trauma), since acute variations in flow are the most efficacious mode of augmenting systemic O2t to match the VO2. The lower systemic VO2 of a patient with an acute cardiac illness explains why the CO in this disease is not as elevated as that found in the acutely ill patient with sepsis or trauma. ⋯ Vasodilators may be used to increase CO by reducing impedance to ventricular ejection; they may also improve LV compliance, thereby allowing the administration of more fluid (that is, increasing preload) without an untoward rise in the PCWP. If vasodilators are without effect or are potentially dangerous because of concomitant hypotension, inotropic support to increase O2t is required. A brief summary of interventional pharmacologic support in acute illness is depicted in Figure 8.
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The cardiac surgeon is faced with RV failure in two main situations: in isolation or in patients with left-sided cardiac assist. Adequate volume loading, correction of acidosis and oxygenation, cardiac pacing, pharmacologic agents, and systemic intra-aortic balloon pumping allow stabilization in most of these patients. ⋯ When the right ventricle is profoundly depressed, a mechanical assist pump is the only device capable of restoring systemic perfusion. Like the left ventricle, the right ventricle, given time and support, can recover enough function to allow weaning from the assist device and survival.