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Appel D, Böger R, Windolph J, Heinze G, Goetz AE, Hannemann J. Asymmetric dimethylarginine predicts perioperative cardiovascular complications in patients undergoing medium-to-high risk non-cardiac surgery. J Int Med Res 2021; 48:300060520940450. [PMID: 32842812 PMCID: PMC7453459 DOI: 10.1177/0300060520940450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objectives Perioperative cardiovascular events remain an important factor that affects surgery outcome. We assessed if asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthesis, predicts perioperative risk, and if pre-operative supplementation with L-arginine/L-citrulline improves the plasma L-arginine/ADMA ratio. Methods In this prospective study, planned thoracic and/or abdominal surgery patients were randomized to receive L-arginine/L-citrulline (5 g/day) or placebo 1 to 5 days before surgery. We measured perioperative plasma ADMA and L-arginine levels. The primary outcome was a 30-day combined cardiovascular endpoint. Results Among 269 patients, 23 (8.6%) experienced a major adverse cardiovascular event. ADMA and C-reactive protein were significantly associated with the incidence of cardiovascular complications in the multivariable-adjusted analysis. The L-arginine plasma concentration was significantly higher on the day of surgery with L-arginine/L-citrulline supplementation compared with placebo. In patients with high pre-operative ADMA, there was a non-significant trend towards reduced incidence of the primary endpoint with L-arginine/L-citrulline supplementation (six vs. nine events). Conclusions ADMA is a predictor of major adverse cardiovascular complications in the perioperative period for patients who are undergoing major abdominal and/or thoracic surgery. Supplementation with L-arginine/L-citrulline increased the L-arginine plasma concentration, enhanced the L-arginine/ADMA ratio, and induced a trend towards fewer perioperative events.
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Affiliation(s)
- Daniel Appel
- University Medical Center Hamburg-Eppendorf, Department of Anesthesiology, Hamburg, DE, Germany
| | - Rainer Böger
- University Medical Center Hamburg-Eppendorf, Institute of Clinical Pharmacology and Toxicology, Hamburg, DE, Germany
| | - Julia Windolph
- University Medical Center Hamburg-Eppendorf, Institute of Clinical Pharmacology and Toxicology, Hamburg, DE, Germany
| | - Gina Heinze
- University Medical Center Hamburg-Eppendorf, Department of Anesthesiology, Hamburg, DE, Germany
| | - Alwin E Goetz
- University Medical Center Hamburg-Eppendorf, Department of Anesthesiology, Hamburg, DE, Germany
| | - Juliane Hannemann
- University Medical Center Hamburg-Eppendorf, Institute of Clinical Pharmacology and Toxicology, Hamburg, DE, Germany
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2
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Olotu C, Lebherz L, Härter M, Mende A, Plümer L, Goetz AE, Zöllner C, Kriston L, Kiefmann R. Improvement of perioperative care of the elderly patient (PeriAge): protocol of a controlled interventional feasibility study. BMJ Open 2019; 9:e031837. [PMID: 31767591 PMCID: PMC6886921 DOI: 10.1136/bmjopen-2019-031837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Geriatric patients have a pronounced risk to suffer from postoperative complications. While effective risk-specific perioperative measures have been studied in controlled experimental settings, they are rarely found in routine healthcare. This study aims (1) to implement a multicomponent preoperative and intraoperative intervention, and investigate its feasibility, and (2) exploratorily assess the effectiveness of the intervention in routine healthcare. METHODS AND ANALYSIS Feasibility and exploratory effectiveness of the intervention will be investigated in a monocentric, prospective, non-randomised, controlled trial. The intervention includes systematic information for patients and family about measures to prevent postoperative complications; preoperative screening for frailty, malnutrition, strength and mobility with nutrient supplementation and physical exercise (prehabilitation) as needed. Further components focus on potentially inadequate medication, patient blood-management and carbohydrate loading prior to surgery, retainment of orientation aids in the operating room and a geriatric anaesthesia concept. Data will successively be collected from control, implementation and intervention groups. Patients aged 65+ with impending surgery will be included. A sample size of 240, n=80 per group, is planned. Assessments will take place at inclusion and 2, 30 and 180 days after surgery. Mixed-methods analyses will be performed. Exploratory effectiveness will be assessed using mixed segmented regressions. The primary endpoint is functional status. Secondary endpoints include cognitive performance, health-related quality of life, length of inpatient stay and occurrence of postoperative complications. Feasibility will be assessed through semi-structured interviews with staff and patients and quantitative analyses of the data quality, focussing on practicability, acceptance, adoption and fidelity to protocol. ETHICS AND DISSEMINATION The study will be carried out in accordance with the Helsinki Declaration and to principles of good scientific practice. The Ethics Committee of the Medical Association Hamburg, Germany, approved the protocol (study ID: PV5596). Results will be disseminated in scientific journals and healthcare conferences. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT03325413.
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Affiliation(s)
- Cynthia Olotu
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lisa Lebherz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Mende
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lili Plümer
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alwin E Goetz
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Levente Kriston
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Kiefmann
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Mende A, Riegel AK, Plümer L, Olotu C, Goetz AE, Kiefmann R. Determinants of Perioperative Outcome in Frail Older Patients. Dtsch Arztebl Int 2019; 116:73-82. [PMID: 30950393 DOI: 10.3238/arztebl.2019.0073] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 07/17/2018] [Accepted: 10/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Older patients are undergoing surgery in increasing numbers. Frailty is a key risk factor associated with higher rates of complications and mortality, longer hospital stays, and functional impairment. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed, including guidelines from Germany and abroad. RESULTS Many studies have been published on the assessment of frailty and its consequences, but the scientific investigation of this topic and the clinical utility of the findings are made more difficult by the lack of a uniform definition and of uniform instruments for assessment. Some definitions of frailty include only physical aspects, while others encompass cognitive, emotional, and social factors as well. Despite this variability, the assessment of frailty enables better estimation of the perioperative risk so that the patient can be optimally prepared for the operation. Especially for frail elderly patients, an interdisciplinary approach is called for over the entire perioperative treatment period. CONCLUSION In the future, the definition of frailty will need to be standardized so that this parameter can be properly assessed and investigated in comparative studies.
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Affiliation(s)
- Anna Mende
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf (UKE); Rotkreuzklinikum München
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Kiefmann M, Tank S, Tritt MO, Keller P, Heckel K, Schulte-Uentrop L, Olotu C, Schrepfer S, Goetz AE, Kiefmann R. Dead space ventilation promotes alveolar hypocapnia reducing surfactant secretion by altering mitochondrial function. Thorax 2019; 74:219-228. [PMID: 30636196 DOI: 10.1136/thoraxjnl-2018-211864] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/29/2018] [Accepted: 09/10/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND In acute respiratory distress syndrome (ARDS), pulmonary perfusion failure increases physiologic dead space ventilation (VD/VT), leading to a decline of the alveolar CO2 concentration [CO2]iA. Although it has been shown that alveolar hypocapnia contributes to formation of atelectasis and surfactant depletion, a typical complication in ARDS, the underlying mechanism has not been elucidated so far. METHODS In isolated perfused rat lungs, cytosolic or mitochondrial Ca2+ concentrations ([Ca2+]cyt or [Ca2+]mito, respectively) of alveolar epithelial cells (AECs), surfactant secretion and the projected area of alveoli were quantified by real-time fluorescence or bright-field imaging (n=3-7 per group). In ventilated White New Zealand rabbits, the left pulmonary artery was ligated and the size of subpleural alveoli was measured by intravital microscopy (n=4 per group). Surfactant secretion was determined in the bronchoalveolar lavage (BAL) by western blot. RESULTS Low [CO2]iA decreased [Ca2+]cyt and increased [Ca2+]mito in AECs, leading to reduction of Ca2+-dependent surfactant secretion, and alveolar ventilation in situ. Mitochondrial inhibition by ruthenium red or rotenone blocked these responses indicating that mitochondria are key players in CO2 sensing. Furthermore, ligature of the pulmonary artery of rabbits decreased alveolar ventilation, surfactant secretion and lung compliance in vivo. Addition of 5% CO2 to the inspiratory gas inhibited these responses. CONCLUSIONS Accordingly, we provide evidence that alveolar hypocapnia leads to a Ca2+ shift from the cytosol into mitochondria. The subsequent decline of [Ca2+]cyt reduces surfactant secretion and thus regional ventilation in lung regions with high VD/VT. Additionally, the regional hypoventilation provoked by perfusion failure can be inhibited by inspiratory CO2 application.
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Affiliation(s)
- Martina Kiefmann
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Sascha Tank
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc-Oliver Tritt
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Paula Keller
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Kai Heckel
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Cynthia Olotu
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Sonja Schrepfer
- Division of Adult Cardiothoracic Surgery, University of California San Francisco, San Francisco, California, USA.,Department of Cardiac Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Alwin E Goetz
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Kiefmann
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Hoffmann N, Kubitz JC, Goetz AE, Beckers SK. Patient safety in undergraduate medical education: Implementation of the topic in the anaesthesiology core curriculum at the University Medical Center Hamburg-Eppendorf. GMS J Med Educ 2019; 36:Doc12. [PMID: 30993170 PMCID: PMC6446467 DOI: 10.3205/zma001220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 01/07/2019] [Accepted: 01/22/2019] [Indexed: 05/07/2023]
Abstract
Introduction: The focus of public attention and health policy is increasingly being drawn to patient safety. According to studies, more than 30,000 patients die each year as a result of medical errors. To date, learning objectives such as patient safety have not played a role in the core curriculum for medical education in Germany. The National Competence-Based Catalogue of Learning Objectives for Undergraduate Medical Education contains a total of 13 learning objectives relating to this subject. Methods: In a descriptive study, learning content was implemented within the "Operative Medicine" study block offered by the Faculty of Medicine at Universität Hamburg. The definition and occurrence of errors as well as strategies for dealing with and avoiding errors were set as the learning objectives for an interactive lecture, problem-based learning (PBL) case as well as the bedside teaching on anaesthesiology. Students were able to evaluate the lecture directly. During the simulator session on anaesthesia, the safety-relevant information that students requested from patients was compared with the questions asked by a control group in the previous trimester. Results: The topic of patient safety could be integrated into the "Operative Medicine" curriculum through a number of minor changes to classes. The accounts of personal experiences and importance assigned to the subject were considered positive, while content perceived as redundant was criticised. In the simulator, the students appeared to request more comprehensive preoperative safety-relevant information than the control group. Conclusion: The subject's relevance, positive feedback and trend towards a change in behaviour in the simulator lead the authors to deem introduction of the topic of patient safety a success.
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Affiliation(s)
- Nicolas Hoffmann
- University Medical Center Hamburg-Eppendorf, Center for Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Hamburg, Germany
- *To whom correspondence should be addressed: Nicolas Hoffmann, University Medical Center Hamburg-Eppendorf, Center for Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Martinistr. 52, D-20246 Hamburg, Germany, Phone: +49 (0)40/7410-0, Fax: +49 (0)40/7410-54963, E-mail:
| | - Jens C. Kubitz
- University Medical Center Hamburg-Eppendorf, Center for Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Hamburg, Germany
| | - Alwin E. Goetz
- University Medical Center Hamburg-Eppendorf, Center for Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Hamburg, Germany
| | - Stefan K. Beckers
- RWTH Aachen, Faculty of Medicine, University Hospital RWTH Aachen, Anaesthesiology Clinic, Aachen, Germany
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Appel D, Seeberger M, Schwedhelm E, Czorlich P, Goetz AE, Böger RH, Hannemann J. Asymmetric and Symmetric Dimethylarginines are Markers of Delayed Cerebral Ischemia and Neurological Outcome in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2018; 29:84-93. [DOI: 10.1007/s12028-018-0520-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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7
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Holzmann MS, Winkler MS, Strunden MS, Izbicki JR, Schoen G, Greiwe G, Pinnschmidt HO, Poppe A, Saugel B, Daum G, Goetz AE, Heckel K. Syndecan-1 as a biomarker for sepsis survival after major abdominal surgery. Biomark Med 2018; 12:119-127. [DOI: 10.2217/bmm-2017-0231] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Maximilian S Holzmann
- Department of Anesthesiology, Center of Anesthesiology & Intensive Care, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Martin S Winkler
- Department of Anesthesiology, Center of Anesthesiology & Intensive Care, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Mike S Strunden
- Department of Anesthesiology & Intensive Care Asklepios Clinic Harburg, Eißendorfer Pferdeweg 52, 21052 Hamburg, Germany
| | - Jakob R Izbicki
- Department for General, Visceral & Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Gerhard Schoen
- Institute for Medical Biometry & Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Gillis Greiwe
- Department of Anesthesiology, Center of Anesthesiology & Intensive Care, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Hans O Pinnschmidt
- Institute for Medical Biometry & Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Annika Poppe
- Department of Anesthesiology, Center of Anesthesiology & Intensive Care, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology & Intensive Care, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Guenter Daum
- Clinic & Polyclinic for Vascular Medicine, University Heart Center, Martinistr 52, 20246, Hamburg, Germany
| | - Alwin E Goetz
- Department of Anesthesiology, Center of Anesthesiology & Intensive Care, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - Kai Heckel
- Department of Anesthesiology, Center of Anesthesiology & Intensive Care, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
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8
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Winkler MS, Kluge S, Holzmann M, Moritz E, Robbe L, Bauer A, Zahrte C, Priefler M, Schwedhelm E, Böger RH, Goetz AE, Nierhaus A, Zoellner C. Markers of nitric oxide are associated with sepsis severity: an observational study. Crit Care 2017; 21:189. [PMID: 28709458 PMCID: PMC5513203 DOI: 10.1186/s13054-017-1782-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/29/2017] [Indexed: 02/23/2023] Open
Abstract
Background Nitric oxide (NO) regulates processes involved in sepsis progression, including vascular function and pathogen defense. Direct NO measurement in patients is unfeasible because of its short half-life. Surrogate markers for NO bioavailability are substrates of NO generating synthase (NOS): L-arginine (lArg) and homoarginine (hArg) together with the inhibitory competitive substrate asymmetric dimethylarginine (ADMA). In immune cells ADMA is cleaved by dimethylarginine-dimethylaminohydrolase-2 (DDAH2). The aim of this study was to investigate whether concentrations of surrogate markers for NO bioavailability are associated with sepsis severity. Method This single-center, prospective study involved 25 controls and 100 patients with surgical trauma (n = 20), sepsis (n = 63), or septic shock (n = 17) according to the Sepsis-3 definition. Plasma lArg, hArg, and ADMA concentrations were measured by mass spectrometry and peripheral blood mononuclear cells (PBMCs) were analyzed for DDAH2 expression. Results lArg concentrations did not differ between groups. Median (IQR) hArg concentrations were significantly lower in patient groups than controls, being 1.89 (1.30–2.29) μmol/L (P < 0.01), with the greatest difference in the septic shock group, being 0.74 (0.36–1.44) μmol/L. In contrast median ADMA concentrations were significantly higher in patient groups compared to controls, being 0.57 (0.46–0.65) μmol/L (P < 0.01), with the highest levels in the septic shock group, being 0.89 (0.56–1.39) μmol/L. The ratio of hArg:ADMA was inversely correlated with disease severity as determined by the Sequential Organ Failure Assessment (SOFA) score. Receiver-operating characteristic analysis for the presence or absence of septic shock revealed equally high sensitivity and specificity for the hArg:ADMA ratio compared to the SOFA score. DDAH2 expression was lower in patients than controls and lowest in the subgroup of patients with increasing SOFA. Conclusions In patients with sepsis, plasma hArg concentrations are decreased and ADMA concentrations are increased. Both metabolites affect NO metabolism and our findings suggest reduced NO bioavailability in sepsis. In addition, reduced expression of DDAH2 in immune cells was observed and may not only contribute to blunted NO signaling but also to subsequent impaired pathogen defense.
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Affiliation(s)
- Martin Sebastian Winkler
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. .,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Maximilian Holzmann
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Eileen Moritz
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Linda Robbe
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Antonia Bauer
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Corinne Zahrte
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marion Priefler
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Edzard Schwedhelm
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Rainer H Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Alwin E Goetz
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian Zoellner
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Punke MA, Goepfert MS, Kluge S, Reichenspurner H, Goetz AE, Reuter DA. Perioperative glycemic control with a computerized algorithm versus conventional glycemic control in cardiac surgical patients undergoing cardiopulmonary bypass with blood cardioplegia. J Cardiothorac Vasc Anesth 2015; 28:1273-7. [PMID: 25281044 DOI: 10.1053/j.jvca.2014.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In critical illness, hypoglycemia and hyperglycemia seem to influence outcome. While hypoglycemia can lead to organ dysfunction, hyperglycemia can lead to surgical site infections (SSI). In cardiac surgery, the use of blood cardioplegia is associated with high blood glucose levels. A computer-based algorithm (CBA) for guiding insulin towards normoglycemia might be beneficial. The authors' primary study end-point was the duration in a predefined blood glucose target range of 80 mg/dL to 150 mg/dL. Patients with conventional therapy served as controls. DESIGN Prospective, randomized trial. SETTING University hospital. PARTICIPANTS Seventy-five patients. INTERVENTIONS The start of therapy was the beginning of cardiopulmonary bypass. Group A: Therapy with CBA and measurement of blood glucose every 30 minutes. Group B: Measurement of blood glucose every 15 minutes using the identical CBA. Group C: Conventional therapy using a fixed insulin dosing scheme. End of therapy was defined as discharge from ICU. MEASUREMENT AND MAIN RESULTS Glucose administration during cardioplegia did not differ between groups (A: 33 ± 12 g; B: 32 ± 12 g; C: 38 ± 20 g). Glucose levels in groups A and B stayed significantly longer in the target interval compared with group C (A: 75 ± 20%; B: 72 ± 19%; C: 50 ± 34%, p < 0.01 n = 25, respectively). There were no significant differences regarding ICU stay and SSI rates. CONCLUSIONS Early computer-based insulin therapy allows practitioners to better achieve normoglycemia in patients undergoing major cardiac surgery with the use of blood cardioplegia.
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Affiliation(s)
- Mark Andree Punke
- Department of Anesthesiologyy, University Medical Center Hamburg-Eppendorf, Martinistrasse, Hamburg, Germany.
| | - Matthias S Goepfert
- Department of Anesthesiologyy, University Medical Center Hamburg-Eppendorf, Martinistrasse, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse, Hamburg, Germany
| | - Alwin E Goetz
- Department of Anesthesiologyy, University Medical Center Hamburg-Eppendorf, Martinistrasse, Hamburg, Germany
| | - Daniel A Reuter
- Department of Anesthesiologyy, University Medical Center Hamburg-Eppendorf, Martinistrasse, Hamburg, Germany
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Kubitz JC, Richter HP, Petersen C, Goetz AE, Reuter DA. Right ventricular stroke volume variation: a tool to assess right ventricular volume responsiveness. Minerva Anestesiol 2014; 80:992-995. [PMID: 24351934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND So far, only left ventricular functional preload indices are used as a routine to assess volume responsiveness. Right ventricular (RV) functional preload indices have been described, but offer no continuous monitoring. METHODS Following ethical approval, a pressure-induced right ventricular failure (RVF) was induced with continuous infusion of a thromboxane-A2-analogue (U46619) in 15 anesthetized and ventilated pigs. Before and after increasing mean pulmonary artery pressure (MPAP) by 50%, right ventricular stroke volume variation (RVSVV) was assessed with an ultrasonic pulmonary artery flow probe. Measurements were repeated following volume depletion (- 300 mL) and stepwise retransfusion (200 mL of whole blood and 200 mL of a colloid solution). RESULTS A significant and systematic increase in RVSVV during induction of RVF was observed. Volume depletion led to an increase in RVSVV and re-transfusion led to a decrease in RVSVV. RVSVV was higher and a significant decrease in RVSVV was present in all animals experiencing an increase in CO by more than 5% during retransfusion. CONCLUSION RVSVV seems to reflect volume requirement of the right ventricle and it might prove a reliable parameter to assess volume responsiveness in RVF.
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Affiliation(s)
- J C Kubitz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, Hamburg-Eppendorf University Hospital, University of Hamburg, Hamburg, Germany -
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Spieth PM, Bluth T, Gama De Abreu M, Bacelis A, Goetz AE, Kiefmann R. Mechanotransduction in the lungs. Minerva Anestesiol 2014; 80:933-941. [PMID: 24299920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Mechanical ventilation may induce or aggravate lung injury, a phenomenon known as ventilator induced lung injury (VILI). On a macroscopic level, the effects of mechanical stress and strain on lung tissue are well described. Increased tidal volumes may lead to volutrauma, raised airway pressures may cause barotrauma and cyclic collapse and reopening of alveolar units contributes to atelectrauma. These three harmful mechanisms may lead to local and systemic pulmonary inflammatory response known as biotrauma. The purpose of this review was to elucidate fundamental mechanisms involved in the mechanotransduction of mechanical stimuli on a cellular level. Bronchial epithelial cells in the distal airways as well as alveolar epithelial cells are exposed to a variety of mechanical forces. These cells are involved in sensing and translation of mechanical stimuli into an inflammatory response. This review provides insight into current knowledge of cellular and molecular pathways during the process of pulmonary epithelial mechanosensation and mechanotransduction under different mechanical conditions. Since evidence for specific pathways is generally lacking in some fields of alveolar epithelial mechanotransduction, this article aims at providing reasonable hypothesis for further investigation.
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Affiliation(s)
- P M Spieth
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Therapy, University Hospital Carl Gustav Carus, Dresden, Germany -
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Sattinger E, Diedrichs S, Brickwedel J, Detter C, Reichenspurner H, Goetz AE, Kubitz J. Arterial blood gases from central venous lines: a sign for malformation. Br J Anaesth 2014; 113:301-3. [PMID: 25038166 DOI: 10.1093/bja/aeu249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bachmann KA, Trepte CJC, Tomkötter L, Hinsch A, Stork J, Bergmann W, Heidelmann L, Strate T, Goetz AE, Reuter DA, Izbicki JR, Mann O. Effects of thoracic epidural anesthesia on survival and microcirculation in severe acute pancreatitis: a randomized experimental trial. Crit Care 2013; 17:R281. [PMID: 24314012 PMCID: PMC4056310 DOI: 10.1186/cc13142] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 11/18/2013] [Indexed: 02/06/2023]
Abstract
Introduction Severe acute pancreatitis is still a potentially life threatening disease with high mortality. The aim of this study was to evaluate the therapeutic effect of thoracic epidural anaesthesia (TEA) on survival, microcirculation, tissue oxygenation and histopathologic damage in an experimental animal model of severe acute pancreatitis in a prospective animal study. Methods In this study, 34 pigs were randomly assigned into 2 treatment groups. After severe acute pancreatitis was induced by intraductal injection of glycodesoxycholic acid in Group 1 (n = 17) bupivacaine (0.5%; bolus injection 2 ml, continuous infusion 4 ml/h) was applied via TEA. In Group 2 (n = 17) no TEA was applied. During a period of 6 hours after induction, tissue oxygen tension (tpO2) in the pancreas and pancreatic microcirculation was assessed. Thereafter animals were observed for 7 days followed by sacrification and histopathologic examination. Results Survival rate after 7 days was 82% in Group 1 (TEA) versus 29% in Group 2: (Control) (P <0.05). Group 1 (TEA) also showed a significantly superior microcirculation (1,608 ± 374 AU versus 1,121 ± 510 AU; P <0.05) and tissue oxygenation (215 ± 64 mmHg versus 138 ± 90 mmHG; P <0.05) as compared to Group 2 (Control). Consecutively, tissue damage in Group 1 was reduced in the histopathologic scoring (5.5 (3 to 8) versus 8 (5.5 to 10); P <0.05). Conclusions TEA led to improved survival, enhanced microcirculatory perfusion and tissue oxygenation and resulted in less histopathologic tissue-damage in an experimental animal model of severe acute pancreatitis.
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Trepte CJ, Haas SA, Nitzschke R, Salzwedel C, Goetz AE, Reuter DA. Prediction of Volume-Responsiveness During One-Lung Ventilation: A Comparison of Static, Volumetric, and Dynamic Parameters of Cardiac Preload. J Cardiothorac Vasc Anesth 2013; 27:1094-100. [DOI: 10.1053/j.jvca.2013.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Indexed: 11/11/2022]
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Eichler L, Truskowska K, Goetz AE, Zöllner C. Brief report: leaking esophageal probe may lead to false ventilator settings when guiding positive end-expiratory pressure by transpulmonary pressure. Anesth Analg 2013; 117:649-651. [PMID: 23868893 DOI: 10.1213/ane.0b013e31829ec090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Esophageal pressure (Pes) is a surrogate for intrapleural pressure. Measuring Pes during mechanical ventilation allows for positive end-expiratory pressure adjustments by transpulmonary pressure (PL), which has been shown to improve oxygenation and outcome in acute respiratory distress syndrome patients. In morbidly obese patients, we saw progressively increasing PL measurements, although airway pressure (Paw), intra-abdominal pressure, and patient position did not change. On further examination, we determined that the gradual increases of PL were artifacts caused by a leak in the pressure probes, which resulted in underestimation of Pes and overestimation of PL as derived from the equation Paw - Pes = PL.
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Affiliation(s)
- Lars Eichler
- From the Department of Anesthesiology, University Hospital Eppendorf, Hamburg, Germany
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Trepte CJC, Eichhorn V, Haas SA, Stahl K, Schmid F, Nitzschke R, Goetz AE, Reuter DA. Comparison of an automated respiratory systolic variation test with dynamic preload indicators to predict fluid responsiveness after major surgery. Br J Anaesth 2013; 111:736-42. [PMID: 23811425 DOI: 10.1093/bja/aet204] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Predicting the response of cardiac output to volume administration remains an ongoing clinical challenge. The objective of our study was to compare the ability to predict volume responsiveness of various functional measures of cardiac preload. These included pulse pressure variation (PPV), stroke volume variation (SVV), and the recently launched automated respiratory systolic variation test (RSVT) in patients after major surgery. METHODS In this prospective study, 24 mechanically ventilated patients after major surgery were enrolled. Three consecutive volume loading steps consisting of 300 ml 6% hydroxyethylstarch 130/0.4 were performed and cardiac index (CI) was assessed by transpulmonary thermodilution. Volume responsiveness was considered as positive if CI increased by >10%. RESULTS In total 72 volume loading steps were analysed, of which 41 showed a positive volume response. Receiver operating characteristic (ROC) curve analysis revealed an area under the curve (AUC) of 0.70 for PPV, 0.72 for SVV and 0.77 for RSVT. Areas under the curves of all variables did not differ significantly from each other (P>0.05). Suggested cut-off values were 9.9% for SVV, 10.1% for PPV, and 19.7° for RSVT as calculated by the Youden Index. CONCLUSION In predicting fluid responsiveness the new automated RSVT appears to be as accurate as established dynamic indicators of preload PPV and SVV in patients after major surgery. The automated RSVT is clinically easy to use and may be useful in guiding fluid therapy in ventilated patients.
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Affiliation(s)
- C J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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Haas SA, Trepte CJC, Nitzschke R, Jürgens TP, Goepfert MS, Goetz AE, Reuter DA. An assessment of global end-diastolic volume and extravascular lung water index during one-lung ventilation: is transpulmonary thermodilution usable? Anesth Analg 2013; 117:83-90. [PMID: 23592603 DOI: 10.1213/ane.0b013e31828f2c39] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The thermodilution curve assessed by transpulmonary thermodilution is the basis for calculation of global end-diastolic volume index (GEDI) and extravascular lung water index (EVLWI). Until now, it was unclear whether the method is affected by 1-lung ventilation. Therefore, aim of our study was to evaluate the impact of 1-lung ventilation on the thermodilution curve and assessment of GEDI and EVLWI. METHODS In 23 pigs, mean transit time, down slope time, and difference in blood temperature (ΔTb) were assessed by transpulmonary thermodilution. "Gold standard" cardiac output was measured by pulmonary artery flowprobe (PAFP) and used for GEDIPAFP and EVLWIPAFP calculations. Measurements were performed during normovolemia during double-lung ventilation (M1), 15 minutes after 1-lung ventilation (M2) and during hypovolemia (blood withdrawal 20 mL/kg) during double-lung ventilation (M3) and again 15 minutes after 1-lung ventilation (M4). RESULTS Configuration of the thermodilution curve was significantly affected by 1-lung ventilation demonstrated by an increase in ΔTb and a decrease in mean transit time and down slope time (all P < 0.04) during normovolemia and hypovolemia. GEDIPAFP was lower after 1-lung ventilation during normovolemia (M1: 459.9 ± 67.5 mL/m(2); M2: 397.0 ± 54.8 mL/m(2); P = 0.001) and hypovolemia (M3: 300.6 ± 40.9 mL/m(2); M4: 275.2 ± 37.6 mL/m(2); P = 0.03). EVLWIPAFP also decreased after 1-lung ventilation in normovolemia (M1: 9.0 [7.3, 10.1] mL/kg; M2: 7.4 [5.8, 8.3] mL/kg; P = 0.01) and hypovolemia (M3: 7.4 [6.3, 9.7] mL/kg; M4: 5.8 [5.2, 7.4]) mL/kg; P = 0.0009). CONCLUSION Configuration of the thermodilution curve and therefore assessment of GEDI and EVLWI are significantly affected by 1-lung ventilation.
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Affiliation(s)
- Sebastian A Haas
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.
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Petzoldt M, Riedel C, Braeunig J, Haas S, Goepfert MS, Treede H, Baldus S, Goetz AE, Reuter DA. Stroke volume determination using transcardiopulmonary thermodilution and arterial pulse contour analysis in severe aortic valve disease. Intensive Care Med 2013; 39:601-11. [DOI: 10.1007/s00134-012-2786-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 10/24/2012] [Indexed: 01/29/2023]
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Trepte CJC, Bachmann KA, Stork JH, Friedheim TJ, Hinsch A, Goepfert MS, Mann O, Izbicki JR, Goetz AE, Reuter DA. The impact of early goal-directed fluid management on survival in an experimental model of severe acute pancreatitis. Intensive Care Med 2013; 39:717-26. [PMID: 23287870 DOI: 10.1007/s00134-012-2775-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 10/01/2012] [Indexed: 12/16/2022]
Abstract
PURPOSE Severe acute pancreatitis (SAP) remains a life-threatening disease with classic etiology of systemic inflammatory response and mortality between 30 and 50 %. The aim of the present study is to compare two different treatment strategies of goal-directed hemodynamic management and evaluate their impact on survival, microcirculation, tissue oxygenation, and histopathologic damage in acute pancreatitis in a prospective animal study. METHODS Thirty-four domestic pigs were randomly assigned to two different treatment groups. After induction of acute pancreatitis, in group 1 volume administration was guided by central venous pressure (CVP >12 mmHg) and mean arterial pressure (MAP). In group 2, hemodynamic management was guided primarily by left-ventricular stroke volume variation (SVV <10 %), MAP, and cardiac output (CO). Treatment according to randomization was performed for 6 h, and tissue oxygen tension in the pancreas and pancreatic microcirculation were evaluated. Thereafter, animals were observed for 7 days and then sacrificed. Standardized tissue specimens were taken post mortem, and histopathologic scoring was performed. RESULTS Survival after 7 days was 29.4 % in group 2 versus 11.8 % in group 1 (p < 0.05). Pancreatic oxygen tension (138.0 ± 89.5 mmHg versus 71.1 ± 35.3 mmHg; p < 0.05) and pancreatic microcirculation (1,209.9 ± 630 AU versus 732 ± 315 AU; p < 0.05) were significantly higher in group 2. Significantly less histopathologic damage within the pancreas could be analyzed post mortem in group 2. CONCLUSIONS Goal-directed hemodynamic management guided by stroke volume variation led to improved survival, tissue oxygenation, and microcirculatory perfusion, as well as less histopathologic damage in an animal model of severe acute pancreatitis.
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Affiliation(s)
- Constantin J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Olotu C, Nitzschke R, Kiefmann R, Goetz AE. [When the resting membrane potential becomes restless. Acute hyperkalemia in the perioperative phase]. Anaesthesist 2012; 61:821-31; quiz 832-3. [PMID: 22968394 DOI: 10.1007/s00101-012-2078-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Acute hyperkalemia is a life-threatening event and often occurs abruptly and without warning in the perioperative field. Risk factors are found on multiple levels as they can derive from a patients pre-existing condition or result from the surgical intervention or management of anesthesia. The therapy of hyperkalemia depends on the dimensions of electrolyte disturbance and a distinction can be made between therapeutic measures with a rapid and those with a long-term effect.
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Affiliation(s)
- C Olotu
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20247 Hamburg, Deutschland.
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Kronas N, Kubitz JC, Forkl S, Kemming GI, Goetz AE, Reuter DA. Functional Hemodynamic Parameters Do Not Reflect Volume Responsiveness in the Immediate Phase After Acute Myocardial Ischemia and Reperfusion. J Cardiothorac Vasc Anesth 2011; 25:780-3. [DOI: 10.1053/j.jvca.2010.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Indexed: 11/11/2022]
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Richter HP, Petersen C, Goetz AE, Reuter DA, Kubitz JC. Detection of right ventricular insufficiency and guidance of volume therapy are facilitated by simultaneous monitoring of static and functional preload parameters. J Cardiothorac Vasc Anesth 2011; 25:1051-5. [PMID: 21924635 DOI: 10.1053/j.jvca.2011.07.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Acute right ventricular failure (RVF) is a life-threatening condition. This study investigated whether the combination of central venous pressure (CVP) and left ventricular functional preload parameters, such as stroke volume variation (SVV) and pulse pressure variation (PPV), can be used for the detection of acute RVF and for guidance of volume therapy. DESIGN AND SETTING Experimental study in a university laboratory. PARTICIPANTS Fifteen anesthetized and ventilated pigs. MEASUREMENTS AND MAIN RESULTS For the induction of RVF, mean pulmonary artery pressure (MPAP) was increased by 50% with a continuous infusion of a thromboxane-A(2) analog (U46619). Then, blood removal (300 mL) and retransfusion (blood 200 mL + colloid solution 200 mL) were performed. An analysis of volume responders and nonresponders was implemented. Increasing MPAP (25.1 to 37.4 mmHg) led to decreases in mean arterial pressure (72.2 to 60.1 mmHg) and cardiac output (2.8 to 2.3 L/min, p < 0.05). CVP (11.3 to 12.6 mmHg), PPV (13% to 17%), and SVV (11 to 14%) increased significantly (p < 0.05). During volume removal, MPAP (37.4 to 34.1 mmHg), mean arterial pressure (60.1 to 53.2 mmHg), and cardiac output (2.3 to 2.1 L/min) decreased (p < 0.05), whereas PPV and SVV remained unchanged. During volume loading, CVP increased in volume responders and nonresponders; however, PPV decreased in responders only. CONCLUSIONS Increases of CVP and SVV or PPV are suspicious for RVF. However, SVV and PPV fail to predict volume responsiveness in RVF. Changes in SVV and PPV during a volume-loading maneuver can be used to assess volume responsiveness.
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Affiliation(s)
- Hans Peter Richter
- Department of Anaesthesiology, Center of Anaesthesiology and Intensive Care Medicine, University of Hamburg, Hamburg, Germany.
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Haas S, Haese A, Goetz AE, Kubitz JC. Haemodynamics and cardiac function during robotic-assisted laparoscopic prostatectomy in steep Trendelenburg position. Int J Med Robot 2011; 7:408-13. [DOI: 10.1002/rcs.410] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2011] [Indexed: 11/07/2022]
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Affiliation(s)
- G N Schmidt
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesie und Intensivmedizin, Martinistrasse 52, Hamburg, Germany.
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Wilbring M, Petzoldt M, Gulbins H, Goetz AE, Reichenspurner H. Successful weaning from extracorporal circulation using a pumpless extracorporal lung assist device in a patient with intraoperative hypercapnic lung failure during aortic valve replacement. Thorac Cardiovasc Surg 2011; 60:299-301. [PMID: 21442582 DOI: 10.1055/s-0030-1270945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We present a case of a 59-year-old female suffering from massive pulmonary edema with consecutive hypercapnic lung failure immediately following elective aortic valve replacement. Due to severe restrictive ventilation disorder, mechanical ventilation was inadequate. A pumpless lung assist (PECLA, iLA, Novalung®, Talheim, Germany)--a device for extracorporeal carbon dioxide elimination--was used for successful weaning from extracorporeal circulation (ECC). Within 24 hours respiratory function had normalized and the patient could be extubated. The further clinical course and follow-up at 3 months remained uneventful. This report describes the first intraoperative use of the PECLA device in a cardiac surgery patient to promote weaning from ECC.
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Affiliation(s)
- M Wilbring
- Department for Cardiac Surgery, Center for Cardiology and Cardiovascular Surgery, Martinistrasse 51, Hamburg, Germany.
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Strunden MS, Heckel K, Goetz AE, Reuter DA. Perioperative fluid and volume management: physiological basis, tools and strategies. Ann Intensive Care 2011; 1:2. [PMID: 21906324 PMCID: PMC3159903 DOI: 10.1186/2110-5820-1-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 03/21/2011] [Indexed: 12/21/2022] Open
Abstract
Fluid and volume therapy is an important cornerstone of treating critically ill patients in the intensive care unit and in the operating room. New findings concerning the vascular barrier, its physiological functions, and its role regarding vascular leakage have lead to a new view of fluid and volume administration. Avoiding hypervolemia, as well as hypovolemia, plays a pivotal role when treating patients both perioperatively and in the intensive care unit. The various studies comparing restrictive vs. liberal fluid and volume management are not directly comparable, do not differ (in most instances) between colloid and crystalloid administration, and mostly do not refer to the vascular barrier's physiologic basis. In addition, very few studies have analyzed the use of advanced hemodynamic monitoring for volume management. This article summarizes the current literature on the relevant physiology of the endothelial surface layer, discusses fluid shifting, reviews available research on fluid management strategies and the commonly used fluids, and identifies suitable variables for hemodynamic monitoring and their goal-directed use.
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Affiliation(s)
- Mike S Strunden
- Center of Anesthesiology and Intensive Care Medicine, Department of Anesthesiology, Hamburg-Eppendorf University Medical Center Martinistraße 52, 20246 Hamburg, Germany.
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Wilbring M, Petzold M, Gulbins H, Goetz AE, Reichenspurner H. Successful weaning from extracorporal circulation using a pumpless extracorporal lung assist device in a patient with intraoperative hypercapnic lung failure during aortic valve replacement. Thorac Cardiovasc Surg 2011. [DOI: 10.1055/s-0030-1269283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Schmid F, Goepfert MS, Kuhnt D, Eichhorn V, Diedrichs S, Reichenspurner H, Goetz AE, Reuter DA. The Wolf Is Crying in the Operating Room. Anesth Analg 2011; 112:78-83. [DOI: 10.1213/ane.0b013e3181fcc504] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Maisch S, Gamon E, Ilisch A, Goetz AE, Schmidt GN. Comparison of the over-the-head, lateral and alternating positions during cardiopulmonary resuscitation performed by a single rescuer with a bag--valve--mask device. Emerg Med J 2010; 28:974-8. [PMID: 20947917 DOI: 10.1136/emj.2010.098251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The 2005 guidelines for cardiopulmonary resuscitation (CPR) do not include a statement on performance of basic life support by a single healthcare professional using a bag-valve-mask device. Three positions are possible: chest compressions and ventilations from over the head of the casualty (over-the-head CPR), from the side of the casualty (lateral CPR), and chest compressions from the side and ventilations from over the head of the casualty (alternating CPR). The aim of this study was to compare CPR quality of these three positions. METHODS 102 healthcare professionals were randomised to a crossover design and performed a 2-min CPR test on a manikin for each position. RESULTS The hands-off time over a 2-min interval was not significantly different between over-the-head (median 31 s) and lateral (31 s) CPR, but these compared favourably with alternating CPR (36 s). Over-the-head CPR resulted in significantly more chest compressions (155) compared with lateral (152) and alternating CPR (149); the number of correct chest compressions did not differ significantly (119 vs 122 vs 109). Alternating CPR resulted in significantly less inflations (eight) compared with over-the-head (ten) and lateral CPR (ten). Lateral CPR led to significantly less correct inflations (three) compared with over-the-head (five) and alternating CPR (four). CONCLUSIONS In the case of a single healthcare professional using a bag-valve-mask device, the quality of over-the-head CPR is at least equivalent to lateral, and superior to alternating CPR. Because of the potential difficulties in bag-valve-mask ventilation in the lateral position, the authors recommend over-the-head CPR.
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Affiliation(s)
- Stefan Maisch
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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Goerig M, Goetz AE. [Co-editors and editors with Jewish origins of the first German journals for anaesthesia. Their fate under National Socialism and an attempt at a biographical appreciation]. Anaesthesist 2010; 59:818-41. [PMID: 20842476 DOI: 10.1007/s00101-010-1748-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The decision to publish the journals Der Schmerz and Narkose und Anaesthesie in 1928 was an important step towards the professionalization of anaesthesiology in Germany. The appearance of both journals, which for economic reasons merged into Schmerz - Narkose - Anaesthesie 1 year later, was initiated and vehemently supported by Jewish physicians. As editors and co-editors they were deeply involved with the editorial tasks of the journals for years from the early beginnings. When the National Socialistic Party took over the government in Germany many of the Jewish colleagues were forced to quit their editorial tasks, were eliminated and replaced by "Arians", they were persecuted and often arrested, forced to emigrate or decided to commit suicide due to inhumane personal circumstances. It is our intention to recall the biography and the terrible fate of the nearly unknown Jewish members of the editorial board of the first German anaesthesia journals. Moreover the biographic sketches promote a continuous discussion about the victims of an inhumane and barbarous ideology.
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Affiliation(s)
- M Goerig
- Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20240 Hamburg.
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Maisch S, Issleib M, Kuhls B, Mueller J, Horlacher T, Goetz AE, Schmidt GN. A Comparison Between Over-The-Head and Standard Cardiopulmonary Resuscitation Performed by Two Rescuers: A Simulation Study. J Emerg Med 2010; 39:369-76. [DOI: 10.1016/j.jemermed.2009.04.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Revised: 02/26/2009] [Accepted: 04/10/2009] [Indexed: 10/20/2022]
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Abstract
One-lung ventilation causes adverse effects in pulmonary gas exchange and cardiocirculatory function. These adverse effects become particularly important for patients with underlying cardiopulmonary comorbidities. Alterations in pulmonary gas exchange have been investigated in several experimental and clinical trials. However, the hemodynamic consequences of one-lung ventilation are to a great extent unknown. Furthermore, no conclusive recommendations exist as to which kind of hemodynamic monitoring should be preferred in the situation of one-lung ventilation. Many issues regarding hemodynamic monitoring in one-lung ventilation remain unacknowledged. This article will review the current literature on hemodynamic monitoring in one-lung ventilation in order to derive recommendations for the application of hemodynamic monitoring in this specific peri-operative situation.
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Affiliation(s)
- S Haas
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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33
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Abstract
Idiopathic orthostatic hypotension (formerly known as Shy-Drager syndrome) is a multiple system atrophy, which is characterized by autonomic dysregulation. Providing perioperative hemodynamic stability during narcosis is therefore a particular challenge. The effects of general anesthesia on systemic vascular resistance and cardiac output in a patient with idiopathic orthostatic hypotension undergoing retropubic prostatectomy will be reported. In the case presented perioperative hemodynamic stability was achieved by aggressive volume therapy guided by global end-diastolic volume measurement and low-dose catecholamine therapy.
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Affiliation(s)
- I Ionescu
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Deutschland
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Schmid F, Goepfert MS, Diedrichs S, Goetz AE, Reuter DA. Patient monitor and ventilation workstation alarming patterns during cardiac surgery. Crit Care 2009. [PMCID: PMC4084354 DOI: 10.1186/cc7632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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35
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Abstract
BACKGROUND The effect of resident training in anaesthesiology on operating room (OR) economics is an issue of debate. Comparisons of anaesthesia process times between residents and consultants might be systematically skewed by interactions of anaesthesia technique and patient factors. METHODS In this prospective, observational study, we analysed anaesthesia process times in 599 cases performed for four different surgical services in a University hospital. The following factors were recorded for each case and used in multivariate analyses of process times: age, American Society of Anesthesiologist (ASA) status, BMI, emergency status, the educational level of the anaesthetist, and the anaesthesia technique. RESULTS In the non-adjusted comparison, only for two of seven anaesthetic techniques did resident cases have statistically significant longer induction times than consultant cases: general anaesthesia with placement of a central venous catheter [mean (sd) anaesthesia time for resident cases 38.2 (17.0) vs 22.3 (10.0) min for consultant cases, P=0.001] and general anaesthesia with a laryngeal mask airway [resident cases 11.3 (5.5) vs consultant cases 7.3 (5.0) min, P=0.003]. Anaesthetic technique had the greatest effect on anaesthesia induction time. Educational level of the anaesthetist and age of the patients had small, but significant effects. CONCLUSIONS Anaesthesia cases performed by residents have in some, but not in all, anaesthesia techniques increased process times compared with cases performed by consultants. This limits a possible negative impact on OR economics by resident education. Patient-based factors including ASA status, BMI, and emergency status have minimal or no effect on anaesthesia process times.
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Affiliation(s)
- M Schuster
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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36
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Kubitz JC, Forkl S, Annecke T, Kronas N, Goetz AE, Reuter DA. Systolic pressure variation and pulse pressure variation during modifications of arterial pressure. Intensive Care Med 2008; 34:1520-4. [PMID: 18427779 DOI: 10.1007/s00134-008-1114-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Accepted: 03/24/2008] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study was performed to investigate the effect of vasopressor therapy on systolic pressure variation (SPV) and pulse pressure variation (PPV) compared to experimentally measured left ventricular stroke volume variation (SVV). DESIGN AND SETTING Prospective study in a university laboratory. SUBJECTS Twelve anesthetized and mechanically ventilated pigs. INTERVENTIONS Increase in mean arterial pressure (by 100%) using phenylephrine and decrease (by 38%) using adenosine. MEASUREMENTS AND RESULTS SPV and PPV were calculated and compared to SVV derived from aortic blood flow measurements. SPV was significantly affected by changes in arterial pressure [4.6% (1.5) vs. 6.3% (2.1), p < 0.05, increased vs. decreased arterial pressure], whereas PPV did not change during modifications of arterial pressure. During baseline conditions and decreased afterload, correlation with SVV was good both for SPV (r =0.892 and r = 0.859, respectively) and for PPV (r = 0.870 and r = 0.871, respectively) (all p < 0.001). Correlation with SVV was only moderate during increased arterial pressure (r = 0.683 for SPV and r = 0.732 for PPV, p < 0.05). CONCLUSION For guiding fluid therapy in patients under vasopressor support, PPV seems superior to SPV.
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Affiliation(s)
- Jens C Kubitz
- Department of Anesthesiology, University of Hamburg, Hamburg-Eppendorf University Hospital, Hamburg, Germany.
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37
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Abstract
BACKGROUND In many hospitals operating room (OR) utilization rates and turnover times (the time from the end of the previous surgical procedure to the beginning of the next) are used as indicators of OR workflow inefficiency. However, there have been no detailed studies to determine whether these indicators really provide an adequate picture of avoidable wasting of time in the OR. METHODS All relevant OR processes in a busy surgical suite with nine ORs were studied in detail over an 8-week period. Productive OR processes, and also reasons for unused times, were recorded by independent observers at 5-minute intervals; they were able to code for 10 different productive activities and 20 different reasons for unused time. Unused time in the OR, the OR utilization rate and the average perioperative turnover times were calculated for each day and a correlation analysis was performed. RESULTS In all, 3,501 OR hours and 790 surgical cases were studied. Productive processes accounted for 85.7% of the total OR time; the unused times were times with no scheduled cases (7.7%) and waiting times that arose for many different reasons (6.6%). Correlation analysis showed that there was no close correlation between waiting time and OR utilization (Spearman's r(s) 0.104 and r(s) 0.233). The correlations between total unused time (r(s) 0.718 and r(s) 0.745) and time with no scheduled cases (r(s) 0.706 and r(s) 0.620) and utilization were more robust, but for any given OR utilization rate the range of corresponding unused time or time without scheduled cases per day was considerable. The correlation between waiting time and perioperative turnover times was negligible (r(s) 0.185 and r(s) 0.175). When different definitions of utilization rate or perioperative turnover were used the results obtained were virtually identical. CONCLUSIONS Utilization rate and perioperative turnover time cannot be used as indicators of OR workflow efficiency, since they cannot identify the days during which avoidable waiting times occur. If the aim is to identify underused OR time and factors that hamper workflow efficiency, waiting times and times without scheduled cases need to be recorded directly and separately.
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Affiliation(s)
- M Schuster
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité-Universitätsmedizin Berlin, Charité Campus Mitte/Campus Virchow-Klinikum, Berlin.
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38
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Affiliation(s)
- A E Goetz
- Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg.
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Salzwedel C, Petersen C, Blanc I, Koch U, Goetz AE, Schuster M. The Effect of Detailed, Video-Assisted Anesthesia Risk Education on Patient Anxiety and the Duration of the Preanesthetic Interview: A Randomized Controlled Trial. Anesth Analg 2008; 106:202-9, table of contents. [DOI: 10.1213/01.ane.0000287665.96156.72] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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40
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Maisch S, Ntalakoura K, Boettcher H, Helmke K, Friederich P, Goetz AE. [Severe accidental hypothermia with cardiac arrest and extracorporeal rewarming. A case report of a 2-year-old child]. Anaesthesist 2007; 56:25-9. [PMID: 17096105 DOI: 10.1007/s00101-006-1110-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In patients with severe hypothermia and cardiac arrest, active rewarming is recommended by extracorporeal circulation with cardiopulmonary bypass. The current guidelines for resuscitation of the European Resuscitation Council now include the recommendation regarding patients with hypothermia remaining comatose after initial resuscitation to accomplish an active rewarming only up to a temperature of 32-34 degrees C and to maintain a mild hypothermia for 12-24 h. We report the case of a 2-year-old boy who suffered from severe hypothermia after falling into ice-cold water. On discovery cardiac arrest with asystole was present and the first measured temperature was 23.8 degrees C. Resuscitation led to restoration of spontaneous circulation. The patient was rewarmed by extracorporeal circulation with cardiopulmonary bypass to 33 degrees C then mild hypothermia was maintained for a further 12 h. On the third day after the accident the patient was extubated and after a further 9 days was discharged without any sequelae.
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Affiliation(s)
- S Maisch
- Klinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg.
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41
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Wichmann MW, Eben R, Angele MK, Brandenburg F, Goetz AE, Jauch KW. Fast-track rehabilitation in elective colorectal surgery patients: a prospective clinical and immunological single-centre study. ANZ J Surg 2007; 77:502-7. [PMID: 17610680 DOI: 10.1111/j.1445-2197.2007.04138.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent clinical data indicate that fast-track surgery (multimodal rehabilitation) leads to shorter postoperative length of hospital stay, faster recovery of gastrointestinal function as well as reduced morbidity and mortality rates. To date, no study has focused on the effects of fast-track surgery on postoperative immune function. This study was initiated to determine whether fast-track rehabilitation results in improved clinical and immunological outcome of patients undergoing colorectal surgery. METHODS Forty patients underwent either conventional or fast-track rehabilitation after colorectal surgery. In addition to clinical parameters (return of gastrointestinal function, food intake, pain score, complication rates and postoperative length of stay), we determined parameters of perioperative immunity by flow cytometry (lymphocyte subgroups) and enzyme-linked immunosorbent assay (interleukin-6). RESULTS Our findings indicate a better-preserved cell-mediated immune function (T cells, T-helper cells, natural killer cells) after fast-track rehabilitation, whereas the pro-inflammatory response (C-reactive protein, interleukin-6) was unchanged in both study groups. Furthermore, we detected a significantly faster return of gastrointestinal function (first bowel movement P<0.001, food intake P<0.05), significantly reduced pain scores in the postoperative course (P < 0.05) and a significantly shorter length of postoperative stay (P<0.001) in patients undergoing fast-track rehabilitation. CONCLUSION Fast-track rehabilitation after colorectal surgery results in better-preserved cell-mediated immunity when compared with conventional postoperative care. Furthermore, patients undergoing fast-track rehabilitation suffer from less pain and have a faster return of gastrointestinal function in the postoperative course. In addition, postoperative length of hospital stay was significantly shorter in fast-track patients.
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Affiliation(s)
- Matthias W Wichmann
- Department of Surgery, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany.
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42
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Tank S, Stork K, Skibba W, Zittel S, Andresen H, Goetz AE, Beck H. Akzidentelle Intoxikation durch unbeschriftete, generische transdermale Fentanylpflaster nach unzureichender Aufklärung. Anaesthesist 2007; 56:1137-41. [PMID: 17846727 DOI: 10.1007/s00101-007-1240-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A somnolent 78-year-old male patient was brought to our emergency room by an ambulance with the presumptive diagnosis of stroke. Cranial computed tomography provided no evidence. On the intensive care unit of the neurosurgical department the patient was completely undressed. Covered by a sock and underwear the ICU staff found five unlabeled, transparent patches. Under the presumptive diagnosis of an opioid intoxication by a transdermal therapeutic system naloxone was infused over 3 days. The patient reported after rapidly awaking that fentanyl patches had been prescribed by his family practitioner the day before. The patient recovered without any sequelae.
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Affiliation(s)
- S Tank
- Klinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg.
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43
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Abstract
As ventricular fibrillation is the most frequent initial heart rhythm causing out-of-hospital sudden cardiac arrest, defibrillation is of essential significance. Automated external defibrillators (AEDs) have been available for some years and as a result defibrillation can be carried out by individuals other than physicians and healthcare providers such as trained first responders and untrained lay rescuers. This so-called public access defibrillation nourished hope of progress in the treatment of sudden cardiac arrest. However, several limitations exist, such as low frequency of sudden cardiac arrest in public, rare use of publicly placed AEDs, low cost effectiveness, legal requirements and insufficient public willingness to help. Due to these restrictions of public access defibrillation other measures are more promising than the attempt at general distribution of AEDs. These measures are primary or secondary prophylaxis of sudden cardiac arrest, general knowledge of adequate activation of emergency medical services, implementation of first responder teams equipped with AEDs and particularly a better education in and application of the well-established principles of cardiopulmonary resuscitation.
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Affiliation(s)
- S Maisch
- Klinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg.
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44
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Abstract
After the amendments to the regulations for the licence to practice medicine, the rating of the faculty of anesthesiology has clearly increased. In the following article a concept will be described whereby these standards were implemented at the University of Hamburg. The basic principle, especially the training in the practical proficiencies, is to achieve a continuous learning process from students through to specialists for anesthesiology.
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Affiliation(s)
- G N Schmidt
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg.
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45
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Kubitz JC, Annecke T, Forkl S, Kemming GI, Kronas N, Goetz AE, Reuter DA. Validation of pulse contour derived stroke volume variation during modifications of cardiac afterload. Br J Anaesth 2007; 98:591-7. [PMID: 17456489 DOI: 10.1093/bja/aem062] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Left ventricular stroke volume variation (SVV) or its surrogates are useful tools to assess fluid responsiveness in mechanically ventilated patients. So far it is unknown, how changes in cardiac afterload affect SVV. Therefore, this study compared left ventricular SVV derived by pulse contour analysis with SVV measured using an ultrasonic flow probe and investigated the influence of cardiac afterload on left ventricular SVV. METHODS In 13 anaesthetized, mechanically ventilated pigs [31(SD 6) kg], we compared cardiac output (CO), stroke volume (SV), and SVV determined by pulse contour analysis and by an ultrasonic aortic flow signal (Bland-Altman analysis). After obtaining baseline measurements, cardiac afterload was increased using phenylephrine and decreased using adenosine (both continuously administered). Measurements were performed with a constant tidal volume (12 ml kg-1) without PEEP. RESULTS Neither increasing mean arterial pressure (MAP) [from 59 (7) to 116 (19)] nor decreasing MAP [from 63 (7) to 39 (4)] affected CO, SV, and SVV (both methods). Method comparison revealed a bias for SVV of 0.1% [standard error of the mean (SE) 0.8] at baseline, -1.2% (SE 0.8) during decreased and 4.0% (SE 0.7) during increased afterload, the latter being significantly different from the others (P<0.05). Thereby, pulse contour analysis tended to underestimate SVV during decreased afterload and to overestimate SVV during increased afterload. Limits of agreement were approximately 6% for all points of measurement. CONCLUSIONS Left ventricular SVV is not affected by changes in cardiac afterload. There is a good agreement of pulse contour with flow derived SVV. The agreement decreases, if afterload is extensively augmented.
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Affiliation(s)
- J C Kubitz
- Department of Anesthesiology, Insitute for Surgical Research, Ludwig Maximillians University Munich, and Hamburg-Eppendorf University Hospital, Hamburg, Germany
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46
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Lankenau G, Fiege M, Goetz AE, Krause T. Möglichkeiten und Grenzen der interventionellen Schmerztherapie bei Tumorpatienten. Visc Med 2007. [DOI: 10.1159/000097472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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47
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Goepfert MS, Schwedhelm E, Felbinger TW, Reuter D, Lamm P, Kilger E, Goetz AE. Influence of a perioperative ω-3 fatty acid infusion on prostanoid metabolism during CPB cardiac surgery. Thorac Cardiovasc Surg 2007. [DOI: 10.1055/s-2007-967417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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48
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Goepfert MS, Reuter D, Akyol D, Lamm P, Kilger E, Goetz AE. Goal directed fluid management reduces the use of vasoactive drugs and shortens need of postoperative ICU-therapy in cardiac surgery patients. Thorac Cardiovasc Surg 2007. [DOI: 10.1055/s-2007-967341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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49
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Affiliation(s)
- A E Goetz
- Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum, Martinistrasse 52, 20246 Hamburg-Eppendorf.
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50
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Goepfert MSG, Reuter DA, Akyol D, Lamm P, Kilger E, Goetz AE. Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients. Intensive Care Med 2006; 33:96-103. [PMID: 17119923 DOI: 10.1007/s00134-006-0404-2] [Citation(s) in RCA: 213] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2005] [Accepted: 09/18/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We examined whether guiding therapy by an algorithm based on optimizing the global end-diastolic volume index (GEDVI) reduces the need for vasopressor and inotropic support and helps to shorten ICU stay in cardiac surgery patients. DESIGN AND SETTING Single-center clinical study with a historical control group at an university hospital. PATIENTS Forty cardiac bypass surgery patients were included prospectively and compared with a control group. INTERVENTIONS In the goal-directed therapy (GDT) group hemodynamic management was guided by an algorithm based on GEDVI. Hemodynamic goals were: GEDVI above 640 ml/m2, cardiac index above 2.5 l/min/m2, and mean arterial pressure above 70 mmHg. The control group was treated at the discretion of the attending physician based on central venous pressure, mean arterial pressure, and clinical evaluation. RESULTS In the GDT group duration of catecholamine and vasopressor dependence was shorter (187+/-70 vs. 1458+/-197 min), and fewer vasopressors (0.73+/-0.32 vs. 6.67+/-1.21 mg) and catecholamines (0.01+/-0.01 vs. 0.83+/-0.27mg) were administered. They received more colloids (6918+/-242 vs. 5514+/-171ml). Duration of mechanical ventilation (12.6+/-3.6 vs. 15.4+/4.3 h) and time until achieving status of fit for ICU discharge (25+/-13 vs. 33+/-17h) was shorter in the GDT group. CONCLUSIONS Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vasopressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery.
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Affiliation(s)
- Matthias S G Goepfert
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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