Zentralblatt für Chirurgie
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Minimal invasive, or more specifically laparoscopic surgery is now the standard procedure in an increasing number of surgical specialties. Inflating the abdomen with CO2 for long periods confronts the anesthesiologist with a number of problems that influence the choice of anesthetic and the monitoring deemed necessary. The increased intraabdominal pressure (IAP) and for some operations the extreme Trendelenburg position can disturb alveolar ventilation and compromise oxygenation. ⋯ Balanced anesthesia or total intravenous anesthesia is to be preferred, and the drugs employed should have rapid elimination kinetics with a short recovery time, since wound closure time is drastically reduced. Inhalational anesthesia alone may inhibit hypoxic pulmonary vasoconstriction thereby unduly increasing oxygen desaturation. The necessary degree of muscle relaxation still remains to be defined.
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The clinical syndrome sepsis has been redefined recently, and the SIRS (systemic inflammatory response syndrome) concept has been developed. In the initial phase of sepsis, different mediator systems are activated finally resulting in a generalized endothelial inflammatory reaction. This reaction may lead to a vicious circle with subsequent multiple organ failure. ⋯ Replacement of antithrombin III, continuous venovenous hemofiltration, application of high doses of immunoglobulins and of low doses of hydrocortisone have been used. A monoclonal antibody against endotoxin (Centoxin) was taken from the German market in January 1993. Experimental aspects of treatment include the administration of C1 esterase inhibitor, pharmacological inhibition of nitric oxide (NO), plasmapheresis, the application of non-steroidal anti-inflammatory agents and of high-dose naloxone as well as manipulation of cytokines.
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Airway disruptions after blunt chest trauma are rather infrequent with an incidence of about 1%. Even in large centers with many such casualties they are episodical. The clinical picture is not an uniform one, and typical clinical signs occur often without an airway lesion. ⋯ Both patients experienced a smooth recovery with good longterm results. In blunt chest trauma presenting with subcutaneous emphysema, pneumomediastinum, pneumothorax, hemoptysis and respiratory distress, tracheobronchial disruption should be considered. In this case, expert bronchoscopy, preferably by a surgeon with large thoracic experience, is mandatory.
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The so-called percutaneous dilatational tracheostomy-essentially a minimally invasive puncture method-inserting the tracheal cannula by a modified Seldinger-technique is an alternative method to the conventional operative tracheostomy. The percutaneous dilatational tracheostomy was evaluated in a prospective trial (June 92-January 93) on 50 consecutive surgical (n = 36), medical (n = 10), and neurological-neurosurgical (n = 4) critically ill patients (29 m, 21 f; age 14-87 years) with need for prolonged mechanical ventilation. After an average duration of endotracheal intubation of 6 (0-22) days, the procedure was endoscopically guided and controlled via the endotracheal tube. ⋯ Infection of stoma site, misplacement of cannula, rupture of the tube cuff, and pneumothorax were not noticed. On 13 decannulated patients stenosis of the trachea was not found in a period of 6-8 weeks following the tracheostomy. As a bedside procedure the percutaneous dilatational tracheostomy is safe and quick and should therefore be the method of choice for critically ill patients who require a tracheostomy.