Journal of the Royal College of Surgeons of Edinburgh
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J R Coll Surg Edinb · Aug 2001
Case ReportsNear total transection of the trachea following percutaneous dilatational tracheostomy.
The bedside procedure of percutaneous dilatational tracheostomy (PDT) in the intensive care unit continues to gain popularity. Percutaneous dilatational tracheostomy is recommended as simple, safe and cost-effective. The procedure can be associated with serious life-threatening complications. We report a case of near total transection of the trachea following PDT.
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An understanding of the normal functioning of the heart and how it fails is important since it allows rational treatment. Pre-existing cardiac disease and myocardial dysfunction is common in the surgical patient. Moreover, the stress response of surgery and the alterations in body physiology seen in the post-operative period may further aggrivate any cardiac compromise. ⋯ The postoperative patient is at risk of these changes because of the stress response, analgesic therapy, inappropriate fluid management, hypoxia and previous cardiac compromise. The patient with sepsis is at further risk because of alterations in both systolic and diastolic function, which may be the result of inadequate fluid resuscitation and also release of a variety of inflammatory mediators. Until treatments, which are aimed at correcting the effects of these mediators, are proven to be beneficial then the septic patient will continue to be managed according to the physiological principles as outlined by Starling.
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Critically ill patients are hypermetabolic and have increased nutrient requirements. Although it is assumed that nutritional support is beneficial in this group of patients there are no well designed clinical trials to test this hypothesis. The rationale for nutritional support, therefore, is based upon clinical judgement. ⋯ Calorie intake was shown to be often considerably in excess of metabolic requirements alone, and variable study design has made comparisons impossible. Despite the lack of knowledge regarding even the most simple of nutritional requirements in these patients, the administration of specific micronutrients and specialised supplements has attracted attention. Again, many of these more recent studies are limited because of poor study design.