Canadian journal of surgery. Journal canadien de chirurgie
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This review examines the principles and practice of antibiotic prophylaxis in surgery. Such prophylaxis is required to decrease the frequency of postoperative infection in most patients with clean-contaminated and contaminated wounds, to prevent infrequent but devastating infection of prostheses in cardiovascular and orthopedic surgery and to prevent endocarditis in noncardiac surgery in patients who have valvular heart disease. Prophylaxis should begin before operation; it is usually unnecessary afterwards. ⋯ The latter is more certain, but oral prophylaxis in bowel surgery may offer additional protection by reducing colonic flora, and topical wound and peritoneal antibiotics may be augment protective antibiotic levels at those sites. Antibiotics, such as the cephalosporin cefazolin (but not cephalothin), which penetrate blood and tissues rapidly and for prolonged periods, afford excellent prophylaxis at most sites. But for prophylaxis in colonic surgery, antibiotics directed against Bacteroides fragilis may be superior, and to prevent endocarditis in noncardiac surgery, vancomycin or a combination of penicillin and an aminoglycoside is best.
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Mortality in patients in septic shock remains high (50% to 80%) despite available treatment. In a 76-year-old women with hypodynamic septic shock intra-aortic balloon counterpulsation (IABC) successfully improved the hemodynamic status to the point at which the patient could maintain adequate cardiac output without assistance. ⋯ Its value in hyperdynamic shock remains doubtful. Since the mortality associated with septic shock has not decreased despite modern management, there is justification in searching for new modalities of treatment, and the use of IABC seems most appropriate and promising.