Presse Med
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Review
[Postoperative management. Critical care in intra-abdominal infection after surgical intervention].
UNDERESTIMATED FREQUENCY: Post-operative intraabdominal infections usually appear as abscesses or injury of the bowel, either alone or in combination. These complications of frequently underestimated frequency are characterized by high mortality. ⋯ ALARM SIGNS: In a patient who recently underwent abdominal surgery, the onset of abnormal signs must be considered as an alarm which imposes ruling out intraabdominal complications. Unexplained multiple organ failure or septic shock in the post-operative period of intraabdominal surgery must lead to considering explorative laparotomy.
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A MAJOR CHALLENGE: Management of post-operative pain is insufficient. One out of 2 patients suffers intense or very intense pain during the first days after surgery. The inefficacy of analgesic therapy is related to lack of a sufficiently organized pain-relief protocol. ⋯ LOW COST: Optimally, the entire procedure, integrated into an overall quality assurance program, is directed by one reference physician assisted by a nurse specially qualified in pain relief. The overall financial burden, including drug costs, material and health care personnel is minimal. In French units, it has been estimated at around 10 to 20 F per patient per day.
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A FREQUENT AND SEVERE EVENT: The incidence and the pathogenic mechanisms of cardiac complications in general surgery patients are now well described. Acute myocardial necrosis, the most frequent complication, is observed in 3 to 5% of patients at risk. Most are silent subendocardial lesions, but may have a short-term or mid-term life-threatening effect in these surgery patients. ⋯ The immediate postoperative period is characterized by increased left ventricular load and metabolic disturbances, increased release of catecholinergic mediators and hypercoagulability, factors related to the effect of anesthesia on circulation and surgical stimuli. These modifications compromise the energy balance in the myocardium and favor the development of left ventricular failure. ECG RECORDINGS: Continuous recordings in the postoperative period have shown that although the number of episodes of myocardial ischemia is not affected during surgery, their number doubles during the postoperative period, a factor predicting postoperative infarction.
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A PUBLIC HEALTH CHALLENGE: Cerebral vascular events are the third most frequent cause of death in the adult population and the number one cause of disabilities, a public health challenge both in terms of health care service and health care expenditures.
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Review Comparative Study
[General or locoregional anesthesia: which to choose for a patient at risk?].
HIGH RISK SITUATIONS: The risk of surgery is higher in certain situations (subjects over 70 years of age, underlying disease states). Procedures lasting more than 3 hours or performed in emergency situations also increase the risk. The question is often raised as to which type of anesthesia, general or locoregional, is the most appropriate to lower the risk of complications in such situations. ⋯ It also eliminates the neuroendocrine response to surgical stress. MODEST EFFECT: Only a few precise parameters can differentiate risk between general and locoregional anesthesia. However, the type of anesthesia has little effect on overall morbidity or mortality, which depend more on the general status of the patient and the surgical procedure performed.