Der Anaesthesist
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Selective digestive tract decontamination (SDD) is a method where topical non-absorbable antibiotics are applied to the oropharynx and stomach which primarily is aimed at the prevention of ventilator-associated pneumonia. The rationale for SDD is that ventilator associated pneumonia usually originates from the patients'own oropharyngeal microflora. SDD is also used for the prevention of gut-derived infections in acute necrotizing pancreatitis and in liver transplantation. ⋯ However, the most important drawback of SDD is the development of resistance and an increased selection pressure towards Gram-positive pathogens, especially in institutions with endemic multi-resistant microorganisms. Thus, it appears that "selective" must not only be interpreted as selective suppression of pathogenic bacteria but rather as selection of appropriate groups of patients with respect to underlying diseases and severity of illness. Furthermore, it means selection of ICUs where the endemic resistance patterns might allow the use of SDD at a relatively low risk for selection of resistant microorganisms, which is still the major concern associated with SDD.
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In long-term treatment opioids seem to have only minimal side-effects compared with other analgesics and co-analgesics. Nevertheless, some risks have to be considered. While immunosuppression, neurotoxicity, teratogenity, tolerance and addiction are clinically not relevant or very rare, cognitive impairment, sedation and obstipation may have a clinical impact. ⋯ For clinical practice of long-term opioid therapy in non-malignant pain a specialized knowledge in pain management is a prerequisite. Future studies with more sophisticated methodology will be necessary to advocate more precise guidelines. However, the therapeutic recommendations from the DGSS consensus conference allow a safer,well structured and validated use of opioids for chronic non-malignant pain.