脓毒症病人液体治疗推荐方案

脓毒症、重症脓毒症及脓毒症休克是外科感染的不同阶段。脓毒症是指合并全身炎性反应综合征(SIRS)的严重感染。多种因素如创伤、感染等均可引起脓毒症的发生,当脓毒症病情进展发生脏器功能损害后则为重症脓毒症,而脓毒性休克则指尽管进行了积极、合理的液体复苏仍伴有休克和组织低灌注的重症脓毒症[1]。     

创伤脓毒症新认识

严重烧、创伤及外科大手术应激打击极易诱发脓毒症等感染并发症,进一步发展可导致脓毒性休克、多器官功能障碍综合征（Multiple organ dysfunction syndrome,MODS）,是临床烧、创伤和危重患者最主要死亡原因之一。创伤脓毒症发病机制非常复杂、临床救治十分困难,内容涉及感染、炎症、免疫、凝血及组织损害等一系列基本问题,并与机体多系统、多器官病理生理改变密切相关。因此,深入探讨创伤脓毒症的发生规律与病理生理机制,寻求新的有效防治途径,对于创伤脓毒症的早期识别、诊断和干预,降低患者的病死率及提高生活质量具有重要意义。     

从循证医学的角度探讨液体复苏在外科严重脓毒症患者治疗中如何趋利避害

外科脓毒症（sepsis）常继发于严重创伤后的感染和各种化脓性感染．如大面积烧伤创面感染、开放性骨折合并感染、急性弥漫性腹膜炎、急性梗阻性化脓性胆管炎、静脉导管感染、肠源性感染和原有免疫功能下降的患者如糖尿病、尿毒症等。脓毒症感染的入侵部位主要有呼吸道、胃肠道、泌尿道、创伤创面等。脓毒症如得不到控制,可因炎性介质失控．发生级联或网络反应．导致因感染所致的全身性炎性反应综合征（SIRS）、脏器受损和功能障碍,严重者可致严重脓毒症（severe sepsis）和多器官功能不全综合征（MODS）。     

网状内皮的防御:与脓毒性外科创伤及烧伤病人心肺功能的关系

导言严重多发性全身创伤和大手术病人发生脓毒症具有极大的临床重要性。无数研究证明,损伤后的脓毒症是创伤死亡率高的原因。诚然,即使应用现代的外科技术、抗菌疗法的进步和有经验的病人监护,严重损伤病人的死亡率并未如预期那样改进,原因在于与严重脓毒症有关的多器官衰竭的发生率虽晚     

细菌移位与外科疾病

脓毒症是严重创伤后病人常见的并发症和死亡原因,在部分病例中却找不到原发感染灶。目前认为肠道细菌移位可能是一个原因。本文阐述了细菌移位的概念、机理以及细菌移位与失血性休克、烧伤、肠梗阻、梗阻性黄疸等常见外科疾病的关系。     

外科脓毒症免疫功能障碍的监测与调理策略

脓毒症是一种严重的感染并发症,通常是由微生物感染、严重烧（创）伤及外科大手术对机体应激打击等引发,并伴有全身炎症反应综合征和MODS,从而导致在ICU中的高发病率及病死率.长期以来,由于临床医师对于外科打击后机体免疫功能障碍的确切机制及其在脓毒症中的作用认识不足,临床上缺乏切实有效的免疫功能监测手段和调理措施.近年来随着对脓毒症发病本质的逐步了解,临床医师已认识到脓毒症发病机制非常复杂,除感染与炎症过程外,机体免疫功能障碍参与了脓毒症的病理生理过程,且发挥关键作用.因此,对烧（创）伤、外科大手术后脓毒症机体免疫状况的合理监测,寻求新的有效防治途径,对于严重脓毒症的早期识别、诊断和干预,降低重症患者病死率及提高患者生命质量具有重大意义.     

血必净注射液在严重创伤患者全身炎症反应中的临床研究

严重创伤患者并发严重脓毒症及随之发生的多器官功能不全综合征（MODS）是导致严重创伤患者高死亡率的一个重要因素。目前认为,脓毒症的发生和发展并不一定依赖于细菌和细菌毒素,真正启动脓毒症的是大量参与炎症反应的炎症介质。因此。如何有效控制全身炎症反应就显得至关重要,     

结肠穿孔急诊术后伤口感染的防治

术后切口感染是常见的结肠手术后并发症之一,最常见于结肠穿孔急诊术后。结肠穿孔急诊术后伤口感染并发症包括系列病理过程,涵盖浅表组织感染、深部组织坏死感染甚至器官周围间隙感染,常引发严重感染导致腹膜炎、脓毒症甚至感染性休克,需要及时手术处理。对其合理防治的策略应该将术前良好评估、有效控制合并症、术后良好伤口护理、识别术后伤口感染、合理使用抗菌药物、及时外科清创以及引流一系列措施整合为一体。     

外科脓毒症病人的液体治疗

<正>液体治疗是外科脓毒症病人的重要组成部分,及时有效合理的液体治疗是脓毒症和脓毒症休克复苏最重要的初始环节。液体治疗的种类十分丰富,据脓毒症发展的不同阶段与程度,合理选择、搭配各种液体是脓毒症抢救成功的重要前提[1]。     

外科手术对人体免疫系统成分的影响

手术或创伤后的普遍免疫抑制状态可促使肿瘤转移和术后脓毒症的发生。虽然已有许多体内和体外研究证实这种手术后免疫抑制状态的存在,但对其具体的动态变化尚知之不详。本研究旨在检测外科创伤对人体循环淋巴细胞亚群的影响,及其与血浆免疫抑制蛋白变化的关系。     

Prognosis of outcome of radical surgery in patients with lung cancer associated with severe complications and concurrent diseases

From 1981 to 2001 (20 years) 1307 patients with lung cancer underwent surgery. Postoperative lethality was 1.7% (after 635 pneumonectomies it was 2.4%, after 672 lob- and bilobectomies--1.2%). Medical histories of 171 operated patients with severe concomitant diseases was studied to analyze surgical outcomes depending on such important factors as age, concomitant diseases, surgical trauma. It is demonstrated that age of patients is not a factor of postoperative prognosis, but concomitant diseases and surgical trauma (i.e. pneumonectomy) are important factors of it. Results of surgery in the group of patients with four and more concomitant diseases after pneumonectomy were most unfavorable (lethality was 22.9%). In less severe surgical trauma (lobectomy) results of surgery were more favorable. It is concluded that surgery in patients with a lot of concomitant diseases must be less radical to obtain lower lethality. Radicality of treatment in these patients is ensured due to complex chemo- and radiation therapy after surgery.     

Factors affecting length of stay after isolated femoral shaft fractures

BACKGROUND: Controlling escalating health care costs is important for hospitals and has far reaching implications for society. Hospital length of stay (LOS) is one of the most reliable predictors of cost after trauma. Our purpose was to establish LOS after isolated femur fractures treated by intramedullary (IM) nail. METHODS: The trauma registry was queried to identify patients. Patients were excluded if they required assistive ambulatory devices before injury, had chronic/terminal illness or compromised brain function. There were 102 patients with an average age of 27 years. Statistical analysis was completed. RESULTS: The average LOS was 3.9 days. In all, 27 patients stayed longer than 4 days. Reasons included social (7), medical (10), and hospital delays (10). The average time from arrival to surgery was 17 hours. The average time from surgery to physical therapy was 1.3 days. Patients who had surgery more than 24 hours after arrival stayed longer. Patients requiring placement stayed 2.4 days longer until placement was found. CONCLUSIONS: Factors the hospital can control to reduce LOS include time to surgery, time for physical therapy evaluation, and radiology delays (for spine clearance radiographs). Physical therapy availability within 24 hours of surgery is important and should include weekends and holidays. Early evaluation of social factors including homelessness or obstacles to independent living may reduce time to find placement. LOS reduction after femur fractures will decrease the cost of trauma to the hospital. In addition, LOS reduction will possibly increase bed availability and minimize the time spent on diversion yielding greater revenues and increasing patient satisfaction.     

Arthrofibrosis

Arthrofibrosis represents a severe complication in joints after trauma and surgery, with loss of motion due to an excessive fibrotic response in the repair process. Patients with primary arthrofibrosis suffer from a general fibrotic healing response after injury or surgery, while patients with secondary arthrofibrosis exhibit loss of motion due to a local fibrotic healing response. Nonisometric positioning of cruciate ligament grafts, notch impingement, or hardware problems may lead to secondary arthrofibrosis. In contrast, the etiology of primary arthrofibrosis is still unknown. There are alterations of the extracellular matrix with an increase of collagen type VI expression similar to other local or systemic fibrotic disorders. A chronic inflammatory process may play a crucial role in the mechanism of primary arthrofibrosis and may indicate an immune response. It may be reasonable to assume that primary arthrofibrosis is an independent disease while secondary arthrofibrosis represents a true complication in joints resulting from trauma and surgery. Secondary arthrofibrosis can commonly be managed by arthroscopic procedures. Treatment of primary arthrofibrosis should usually include resection of dense fibrotic tissue in the anterior compartment of the knee and open posterior capsulotomy to allow full extension of the knee joint.     

Anaesthesia for maxillofacial surgery

Airway management is central to anaesthesia for maxillofacial surgery. Not only is there a shared airway to contend with, difficult airways are frequently encountered. The main pathologies that present for surgery include trauma, infection, cancer and craniofacial deformities. All of these may present an airway challenge in either elective or emergency settings but a similar approach to the airway can be used in all these scenarios. Other surgical procedures include dental extractions, temporomandibular joint (TMJ) arthrocentesis, salivary gland surgery and facial aesthetic surgery.It is vital that clear airway management plans including rescue plans are made at the outset. These must be communicated to the surgical and anaesthetic team in advance. Trauma is excluded as it will be covered in a separate review article.     

面部外伤的早期美容修复

目的:分析总结面部外伤的早期修复经验,指导临床相关工作。方法:对1993年1月至2004年12月间急诊处理并行早期修复的727例面部外伤患者进行回顾性分析总结。结果:727例患者中,经随诊发现:2例感染,2例创缘有血运障碍,3例拆线时伤口有部分裂开,4例伤愈后欠平整,11例在近期(1～4个月)内有瘢痕增生、局部潮红、切口线痕高出皮面且较硬。97%患者(705例)取得了满意的效果。结论:为减少后续治疗,对面部外伤急诊处理中的早期修复应予以高度重视并要考虑美学要求。主要经验是:早期细致清创至关重要;掌握手术技巧分层对位缝合;选择精细的缝合器械与材料;做好术后各项预防瘢痕增生的措施等。     

Spontaneous otogenic pneumocephalus

Otogenic pneumocephalus is uncommon. Typical causes include trauma, tumor, infection, and nasosinusal or mastoid surgery but spontaneous otogenic pneumocephalus is very exceptional. We report a case of spontaneous otogenic pneumocephalus located in the left temporal lobe revealed by sudden onset aphasia. The temporal pneumatocele was cured through an epidural subtemporal approach with needle puncture of the aeroma and duroplasty. Two years after surgery, no recurrence was observed and the patient remained symptom free.     

Injuries of pancreatoduodenal organs

Ten-year experience of treatment of 213 patients with trauma of the pancreas and 56 patients with trauma of the duodenum is analyzed. Combined injury of other organs was seen in 80% patients. Diagnostic policy included intraoperative revision in open abdominal trauma and dynamic observation with US, roentgenography, CT and laboratory tests in closed trauma wich doesn't require urgent surgery. The diagnosis was verified during laparoscopy and contrast duodenography. Surgical treatment results in patients with trauma of the pancreas depending on the variant of surgery are analyzed. The role of drug treatment of traumatic pancreatitis with 5-ftoruracil and octreotid is stressed. It is demonstrated that these principles allowed us to reduce complications rate to 11.7% and lethality to 6.7% from 71.7% and 37.0% respectively. It is established that suturing of duodenal wall on the decompressive nasoduodenal tube is effective within 6 hours after trauma. Later, for prophylaxis of suture insufficiency the duodenum must be switched off. Adequate drainage and depression of secretion with octreotid are very important for success of surgery. In this approach there were no cases of sutures insufficiency among 16 patients in the last 3 years.     

Definition of complex trauma and general management principles

Summary Complex joint trauma is a term reserved for specific and severe injuries that include two or more structural elements of the joint. These structural elements are the articulating bones, the major ligaments of the joint, the local soft tissue envelope and the neurovascular structures. Complex joint trauma has a high risk for complications and requires a special treatment algorhythm. A staged surgical protocol with initial soft tissue debridement, closed joint reduction and external fixation of the extremity followed by secondary recontructive surgery after soft tissue recovery is suggested.      

Has anything changed in the quality of continuing education in orthopaedic/trauma surgery? Evaluation 1 year after implementation of a new code of practice for resident training in orthopaedic/trauma surgery in Bavaria

OBJECTIVE: It was the aim of this study to evaluate any changes in the quality of orthopaedic/trauma training 1 year after implementation of the new code of practice for resident training in Bavarian clinics. METHODS: A questionnaire was prepared by the Educational Committee and the Junges Forum of the German Trauma Society and sent to all 120 instructors (and their medical staff) for resident training in Bavaria for general surgery, trauma surgery as well as orthopaedic/trauma surgery on July 26 2005. RESULTS: While 56% of the chairmen claimed to perform a structured, curricular training, only 18% of the residents could verify this. In a similar manner, the majority of chairmen were satisfied with the new code of practice for resident training, while the majority of residents and attendings were not. CONCLUSION: One year after implementation of a new code of practice for resident training in Bavaria, surgical training structures are not well established. There is a large discrepancy in the evaluation of training quality between chairmen and residents. It is therefore imperative to develop recommendations for structuring orthopaedic/trauma training.     

Perioperative Management of von Willebrand Disease in Dermatologic Surgery

BACKGROUND: Von Willebrand disease (VWD) is the most common inherited bleeding disorder, affecting an estimated 0.1% to 1% of the population. It is caused by a qualitative or quantitative defect of von Willebrand factor. Primary manifestations include intractable mucocutaneous bleeding after surgery or trauma. OBJECTIVE: The objective was to review the pathophysiology and clinical features of VWD and to propose a perioperative management strategy for patients with this condition undergoing dermatologic surgery. METHODS AND MATERIALS: Literature is reviewed. RESULTS: The various types and clinical manifestations of this condition are reviewed, and a perioperative strategy is presented for managing patients with VWD who undergo cutaneous oncologic or cosmetic surgical procedures. CONCLUSIONS: In most cases, dermatologic surgery can be safely performed in patients with VWD. The use of appropriate therapeutic prophylaxis in conjunction with a hematologist is indicated in high-risk, nonelective procedures.