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Mueller-Graf F, Frenkel P, Merz J, Reuter S, Vollmar B, Tusman G, Pulletz S, Böhm SH, Zitzmann A, Reuter DA, Adler A. Respiratory gating improves correlation between pulse wave transit time and pulmonary artery pressure in experimental pulmonary hypertension. Physiol Meas 2024; 45:03NT02. [PMID: 38422512 DOI: 10.1088/1361-6579/ad2eb5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 02/29/2024] [Indexed: 03/02/2024]
Abstract
Objective. Since pulse wave transit time (PWTT) shortens as pulmonary artery pressure (PAP) increases it was suggested as a potential non-invasive surrogate for PAP. The state of tidal lung filling is also known to affect PWTT independently of PAP. The aim of this retrospective analysis was to test whether respiratory gating improved the correlation coefficient between PWTT and PAP.Approach. In each one of five anesthetized and mechanically ventilated pigs two high-fidelity pressure catheters were placed, one directly behind the pulmonary valve, and the second one in a distal branch of the pulmonary artery. PAP was raised using the thromboxane A2 analogue U46619 and animals were ventilated in a pressure controlled mode (I:E ratio 1:2, respiratory rate 12/min, tidal volume of 6 ml kg-1). All signals were recorded using the multi-channel platform PowerLab®. The arrival of the pulse wave at each catheter tip was determined using a MATLAB-based modified hyperbolic tangent algorithm and PWTT calculated as the time interval between these arrivals.Main results. Correlation coefficient for PWTT and mean PAP wasr= 0.932 for thromboxane. This correlation coefficient increased considerably when heart beats either at end-inspiration (r= 0.978) or at end-expiration (r= 0.985) were selected (=respiratory gating).Significance. The estimation of mean PAP from PWTT improved significantly when taking the respiratory cycle into account. Respiratory gating is suggested to improve for the estimation of PAP by PWTT.
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Affiliation(s)
- Fabian Mueller-Graf
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, D-18057 Rostock, Germany
- Rudolf-Zenker-Institute for Experimental Surgery, University Medical Center Rostock, D-18057 Rostock, Germany
| | - Paul Frenkel
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, D-18057 Rostock, Germany
| | - Jonas Merz
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, D-18057 Rostock, Germany
| | - Susanne Reuter
- Rudolf-Zenker-Institute for Experimental Surgery, University Medical Center Rostock, D-18057 Rostock, Germany
| | - Brigitte Vollmar
- Rudolf-Zenker-Institute for Experimental Surgery, University Medical Center Rostock, D-18057 Rostock, Germany
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Buenos Aires, Argentina
| | - Sven Pulletz
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, D-18057 Rostock, Germany
| | - Stephan H Böhm
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, D-18057 Rostock, Germany
| | - Amelie Zitzmann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, D-18057 Rostock, Germany
| | - Daniel A Reuter
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, D-18057 Rostock, Germany
| | - Andy Adler
- Systems and Computer Engineering, Carleton University, Ottawa, Canada
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Saugel B, Annecke T, Bein B, Flick M, Goepfert M, Gruenewald M, Habicher M, Jungwirth B, Koch T, Kouz K, Meidert AS, Pestel G, Renner J, Sakka SG, Sander M, Treskatsch S, Zitzmann A, Reuter DA. Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies. J Clin Monit Comput 2024:10.1007/s10877-024-01132-7. [PMID: 38381359 DOI: 10.1007/s10877-024-01132-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 01/18/2024] [Accepted: 01/25/2024] [Indexed: 02/22/2024]
Abstract
Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Thorsten Annecke
- Department of Anesthesiology and Intensive Care Medicine, Cologne Merheim Medical Center, Hospital of the University of Witten/Herdecke, Cologne, Germany
| | - Berthold Bein
- Department for Anaesthesiology, Asklepios Hospital Hamburg St. Georg, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Goepfert
- Department of Anaesthesiology and Intensive Care Medicine, Alexianer St. Hedwigkliniken Berlin, Berlin, Germany
| | - Matthias Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, Evangelisches Amalie Sieveking Krankenhaus, Hamburg, Germany
| | - Marit Habicher
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Bettina Jungwirth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Tilo Koch
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Agnes S Meidert
- Department of Anaesthesiology, University Hospital LMU Munich, Munich, Germany
| | - Gunther Pestel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jochen Renner
- Department of Anesthesiology and Intensive Care Medicine, Municipal Hospital Kiel, Kiel, Germany
| | - Samir G Sakka
- Department of Intensive Care Medicine, Gemeinschaftsklinikum Mittelrhein gGmbH, Academic Teaching Hospital of the Johannes Gutenberg University Mainz, Koblenz, Germany
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Amelie Zitzmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| | - Daniel A Reuter
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
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Zitzmann A, Bandorf T, Merz J, Müller-Graf F, Prütz M, Frenkel P, Reuter S, Vollmar B, Fuentes NA, Böhm SH, Reuter DA. Pressure- vs. volume-controlled ventilation and their respective impact on dynamic parameters of fluid responsiveness: a cross-over animal study. BMC Anesthesiol 2023; 23:320. [PMID: 37726649 PMCID: PMC10507836 DOI: 10.1186/s12871-023-02273-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/08/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND AND GOAL OF STUDY Pulse pressure variation (PPV) and stroke volume variation (SVV), which are based on the forces caused by controlled mechanical ventilation, are commonly used to predict fluid responsiveness. When PPV and SVV were introduced into clinical practice, volume-controlled ventilation (VCV) with tidal volumes (VT) ≥ 10 ml kg- 1 was most commonly used. Nowadays, lower VT and the use of pressure-controlled ventilation (PCV) has widely become the preferred type of ventilation. Due to their specific flow characteristics, VCV and PCV result in different airway pressures at comparable tidal volumes. We hypothesised that higher inspiratory pressures would result in higher PPVs and aimed to determine the impact of VCV and PCV on PPV and SVV. METHODS In this self-controlled animal study, sixteen anaesthetised, paralysed, and mechanically ventilated (goal: VT 8 ml kg- 1) pigs were instrumented with catheters for continuous arterial blood pressure measurement and transpulmonary thermodilution. At four different intravascular fluid states (IVFS; baseline, hypovolaemia, resuscitation I and II), ventilatory and hemodynamic data including PPV and SVV were assessed during VCV and PCV. Statistical analysis was performed using U-test and RM ANOVA on ranks as well as descriptive LDA and GEE analysis. RESULTS Complete data sets were available of eight pigs. VT and respiratory rates were similar in both forms. Heart rate, central venous, systolic, diastolic, and mean arterial pressures were not different between VCV and PCV at any IVFS. Peak inspiratory pressure was significantly higher in VCV, while plateau, airway and transpulmonary driving pressures were significantly higher in PCV. However, these higher pressures did not result in different PPVs nor SVVs at any IVFS. CONCLUSION VCV and PCV at similar tidal volumes and respiratory rates produced PPVs and SVVs without clinically meaningful differences in this experimental setting. Further research is needed to transfer these results to humans.
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Affiliation(s)
- Amelie Zitzmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Schillingallee 35, 18057, Rostock, Germany.
| | - Tim Bandorf
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Jonas Merz
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Fabian Müller-Graf
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Maria Prütz
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Paul Frenkel
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Susanne Reuter
- Rudolf-Zenker Institute for Experimental Surgery, University Medical Centre of Rostock, Rostock, Germany
| | - Brigitte Vollmar
- Rudolf-Zenker Institute for Experimental Surgery, University Medical Centre of Rostock, Rostock, Germany
| | - Nora A Fuentes
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Schillingallee 35, 18057, Rostock, Germany
- Department of Research, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Stephan H Böhm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Daniel A Reuter
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Schillingallee 35, 18057, Rostock, Germany
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Zitzmann A, Pulletz S, Gonzales‐Rios P, Frenkel P, Teschendorf P, Kremeier P, Löser B, Krukewitt L, Reuter DA, Böhm SH, Müller‐Graf F. Regional ventilation in spontaneously breathing COVID-19 patients during postural maneuvers assessed by electrical impedance tomography. Acta Anaesthesiol Scand 2023; 67:185-194. [PMID: 36268561 PMCID: PMC9874544 DOI: 10.1111/aas.14161] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Received: 05/11/2022] [Revised: 08/26/2022] [Accepted: 10/13/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Gravity-dependent positioning therapy is an established concept in the treatment of severe acute respiratory distress syndrome and improves oxygenation in spontaneously breathing patients with hypoxemic acute respiratory failure. In patients with coronavirus disease 2019, this therapy seems to be less effective. Electrical impedance tomography as a point-of-care functional imaging modality for visualizing regional ventilation can possibly help identify patients who might benefit from positioning therapy and guide those maneuvers in real-time. Therefore, in this prospective observational study, we aimed to discover typical patterns in response to positioning maneuvers. METHODS Distribution of ventilation in 10 healthy volunteers and in 12 patients with hypoxemic respiratory failure due to coronavirus disease 2019 was measured in supine, left, and right lateral positions using electrical impedance tomography. RESULTS In this study, patients with coronavirus disease 2019 showed a variety of ventilation patterns, which were not predictable, whereas all but one healthy volunteer showed a typical and expected gravity-dependent distribution of ventilation with the body positions. CONCLUSION Distribution of ventilation and response to lateral positioning is variable and thus unpredictable in spontaneously breathing patients with coronavirus disease 2019. Electrical impedance tomography might add useful information on the immediate reaction to postural maneuvers and should be elucidated further in clinical studies. Therefore, we suggest a customized individualized positioning therapy guided by electrical impedance tomography.
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Affiliation(s)
- Amelie Zitzmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyUniversity Medical Centre RostockRostockGermany
| | - Sven Pulletz
- Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyUniversity Medical Centre RostockRostockGermany
| | - Pablo Gonzales‐Rios
- Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyUniversity Medical Centre RostockRostockGermany,Department of Anaesthesiology and Intensive Care MedicineKlinikum OsnabrückOsnabrückGermany
| | - Paul Frenkel
- Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyUniversity Medical Centre RostockRostockGermany
| | - Peter Teschendorf
- Department of Anaesthesiology and Intensive Care MedicineKlinikum OsnabrückOsnabrückGermany
| | - Peter Kremeier
- Simulation Center for Clinical VentilationWaldbronnGermany
| | - Benjamin Löser
- Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyUniversity Medical Centre RostockRostockGermany
| | - Lisa Krukewitt
- Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyUniversity Medical Centre RostockRostockGermany
| | - Daniel A. Reuter
- Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyUniversity Medical Centre RostockRostockGermany
| | - Stephan H. Böhm
- Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyUniversity Medical Centre RostockRostockGermany
| | - Fabian Müller‐Graf
- Department of Anaesthesiology, Intensive Care Medicine and Pain TherapyUniversity Medical Centre RostockRostockGermany
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Mueller-Graf F, Frenkel P, Albus CF, Henkel M, Reuter S, Vollmar B, Tusman G, Adler A, Pulletz S, Böhm SH, Zitzmann A, Reuter DA. Ventilation Induces Changes in Pulse Wave Transit Time in the Pulmonary Artery. Biomedicines 2023; 11:biomedicines11010182. [PMID: 36672690 PMCID: PMC9855784 DOI: 10.3390/biomedicines11010182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/06/2023] [Accepted: 01/08/2023] [Indexed: 01/13/2023] Open
Abstract
Pulse wave transit time (PWTT) shortens as pulmonary artery pressure (PAP) increases and was therefore suggested as a surrogate parameter for PAP. The aim of this analysis was to reveal patterns and potential mechanisms of ventilation-induced periodic changes in PWTT under resting conditions. To measure both PWTT and PAP in five healthy pigs, two pulmonary artery Mikro-Tip™ catheters were inserted into the pulmonary vasculature: one with the tip placed in the pulmonary artery trunk, and a second one placed in a distal segment of the pulmonary artery. Animals received pressure-controlled mechanical ventilation. Ventilation-dependent changes were seen in both variables, PWTT and mean PAP; however, changes in PWTT were not synchronous with changes in PAP. Thus, plotting the value of PWTT for each heartbeat over the respective PAP revealed a characteristic hysteresis. At the beginning of inspiration, PAP rose while PWTT remained constant. During further inspiration, PWTT started to decrease rapidly as mPAP was about to reach its plateau. The same time course was observed during expiration: while mPAP approached its minimum, PWTT increased rapidly. During apnea this hysteresis disappeared. Thus, non-synchronous ventilation-induced changes in PWTT and PAP were found with inspiration causing a significant shortening of PWTT. Therefore, it is suggested that the respiratory cycle should be considered when using PWTT as a surrogate for PAP.
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Affiliation(s)
- Fabian Mueller-Graf
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, 18057 Rostock, Germany
- Rudolf-Zenker-Institute for Experimental Surgery, University Medical Center Rostock, 18057 Rostock, Germany
- Correspondence: ; Tel.: +49-381-494-146232
| | - Paul Frenkel
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Chiara Felicitas Albus
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Maike Henkel
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Susanne Reuter
- Rudolf-Zenker-Institute for Experimental Surgery, University Medical Center Rostock, 18057 Rostock, Germany
| | - Brigitte Vollmar
- Rudolf-Zenker-Institute for Experimental Surgery, University Medical Center Rostock, 18057 Rostock, Germany
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar de Plata 7600, Argentina
| | - Andy Adler
- Systems and Computer Engineering, Carleton University, Ottawa, ON K1S5B6, Canada
| | - Sven Pulletz
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Stephan H. Böhm
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Amelie Zitzmann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Daniel A. Reuter
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Schillingallee 35, 18057 Rostock, Germany
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Walter U, Cantré D, Zitzmann A. In reply: Withholding therapeutic interventions in brain(stem) death: is it a self-fulfilling prophecy? Can J Anaesth 2022; 69:1437-1438. [PMID: 36097132 PMCID: PMC9587097 DOI: 10.1007/s12630-022-02325-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Uwe Walter
- Department of Neurology, Rostock University Medical Center, Rostock, Germany.
- Center for Transdisciplinary Neurosciences Rostock (CTNR), Rostock University Medical Center, Rostock, Germany.
| | - Daniel Cantré
- Institute of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Amelie Zitzmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
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Walter U, Eggert M, Walther U, Kreienmeyer J, Henker C, Arndt H, Cantré D, Zitzmann A. A red flag for diagnosing brain death: decompressive craniectomy of the posterior fossa. Can J Anaesth 2022; 69:900-906. [PMID: 35585474 PMCID: PMC9279213 DOI: 10.1007/s12630-022-02265-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 12/04/2022] Open
Abstract
PURPOSE Brain death/death by neurologic criteria (BD/DNC) may be determined in many countries by a clinical examination that shows coma, brainstem areflexia, and apnea, provided the conditions causing reversible loss of brain function are excluded a priori. To date, accounts of recovery from BD/DNC in adults have been limited to noncompliance with guidelines. CLINICAL FEATURES We report the case of a 72-yr-old man with a combined primary infratentorial (hemorrhagic) and secondary global (anoxic) brain lesion in whom decompressive craniectomy of the posterior fossa and six-hour therapeutic hypothermia (33-34°C) followed by 8-hour rewarming to ≥ 36°C were conducted. Thirteen hours later, clinical findings of brain function loss were documented in addition to guideline-compliant exclusion of reversible causes (arterial hypotension, intoxication, depressant drug effects, relevant metabolic or endocrine disequilibrium, chronic hypercapnia, neuromuscular disorders, and administration of a muscle relaxant). Since a primary infratentorial brain lesion was present, German guidelines required further ancillary testing. Doppler ultrasonography revealed some preserved cerebral circulation, and BD/DNC was not diagnosed. Approximately 24 hr after rewarming to ≥ 36°C, the patient exhibited respiratory efforts. He continued with assisted respiration until final asystole/apnea, without regaining additional brain function other than mild signs of hemispasticity. Follow-up computed tomography showed partial herniation of the cerebellum through the craniectomy gap of the posterior fossa, alleviating caudal brain stem compression. CONCLUSIONS Therapeutic decompressive craniectomy of the posterior fossa may allow for delayed reversal of apnea. In these patients, proof of cerebral circulatory arrest should be mandatory for diagnosing BD/DNC.
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Affiliation(s)
- Uwe Walter
- Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany.
- Center for Transdisciplinary Neurosciences Rostock (CTNR), Rostock University Medical Center, Rostock, Germany.
| | - Maximilian Eggert
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
- Department of Anesthesiology and Perioperative Intensive Care Medicine, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Udo Walther
- Institute of Toxicology and Pharmacology, Rostock University Medical Center, Rostock, Germany
| | - Jürgen Kreienmeyer
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Christian Henker
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
- Department of Orthopedics, Trauma and Spine Surgery, KMG Hospital Güstrow, Güstrow, Germany
| | - Hanka Arndt
- Institute of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Daniel Cantré
- Institute of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Amelie Zitzmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
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Löser B, Haas A, Zitzmann A, Dankert A, Treskatsch S, Reuter DA, Haas S, Glass Ä, Petzoldt M. Institutional infrastructural preconditions and current perioperative anaesthesia practice in patients undergoing transfemoral transcatheter aortic valve implantation: a cross-sectional study in German heart centres. BMJ Open 2021; 11:e045330. [PMID: 34348946 PMCID: PMC8340292 DOI: 10.1136/bmjopen-2020-045330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Transfemoral transcatheter aortic valve implantation (TF-TAVI) is an established therapy for patients with symptomatic aortic stenosis, which requires periprocedural anaesthesia care. In 2015, the German Federal Joint Committee released a directive on minimally invasive heart valve interventions which defines institutional infrastructural requirements in German heart centres. But still generally accepted expert consensus recommendations or national or international guidelines regarding periprocedural anaesthesia management for TF-TAVI are lacking. This nationwide cross-sectional study had two major objectives: first to assess the concordance with existing national regulations regarding infrastructural requirements and second to evaluate the status quo of periprocedural anaesthesia management for patients undergoing TF-TAVI in German heart centres. DESIGN Multicentre cross-sectional online study to evaluate the periprocedural anaesthesia management. SETTING In this nationwide cross-sectional study, electronic questionnaires were sent out to anaesthesia departments at TF-TAVI-performing centres in Germany in March 2019. PARTICIPANTS 78 anaesthesia departments of German heart centres. RESULTS 54 (69.2%) centres returned the questionnaire of which 94.4% stated to hold regular Heart Team meetings, 75.9% to have ready-to-use heart-lung machines available on-site, 77.8% to have cardiac surgeons and 66.7% to have perfusionists routinely attending throughout TF-TAVI procedures. Regarding periprocedural anaesthesia management, 41 (75.9%) of the participating centres reported to predominantly use 'monitored anaesthesia care' and 13 (24.1%) to favour general anaesthesia. 49 (90.7%) centres stated to use institutional standard operating procedures for anaesthesia. Five-lead ECG, central venous lines, capnometry and intraprocedural echocardiography were reported to be routine measures in 85.2%, 83.3%, 77.8% and 51.9% of the surveyed heart centres. CONCLUSIONS The concordance with national regulations, anaesthesia management and in-house standards for TF-TAVI vary broadly among German heart centres. According to the opinion of the authors, international expert consensus recommendations and/or guidelines would be helpful to standardise peri interventional anaesthesia care.
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Affiliation(s)
- Benjamin Löser
- Department of Anaesthesiology, Center of Anaesthesiology and Intensive Care Medicine, University Medicine Rostock, Rostock, Germany
| | - Annika Haas
- Department of Anaesthesiology, Center of Anaesthesiology and Intensive Care Medicine, University Medicine Rostock, Rostock, Germany
| | - Amelie Zitzmann
- Department of Anaesthesiology, Center of Anaesthesiology and Intensive Care Medicine, University Medicine Rostock, Rostock, Germany
| | - Andre Dankert
- Department of Anaesthesiology, Center of Anaesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sascha Treskatsch
- Department of Anaesthesiology and Operative Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Daniel A Reuter
- Department of Anaesthesiology, Center of Anaesthesiology and Intensive Care Medicine, University Medicine Rostock, Rostock, Germany
| | - Sebastian Haas
- Department of Anaesthesiology, Center of Anaesthesiology and Intensive Care Medicine, University Medicine Rostock, Rostock, Germany
| | - Änne Glass
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, University Medicine Rostock, Rostock, Germany
| | - Martin Petzoldt
- Department of Anaesthesiology, Center of Anaesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Mencke T, Zitzmann A, Reuter DA. [New aspects of rapid sequence induction including treatment of pulmonary aspiration]. Anaesthesist 2021; 70:171-184. [PMID: 33410921 DOI: 10.1007/s00101-020-00901-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pulmonary aspiration of solid components leads to displacement of the tracheobronchial tree, the aspiration of acidic gastric juices to chemical pneumonitis (Mendelson's syndrome) and the aspiration of oropharyngeal secretions or gastrointestinal pathogens to aspiration pneumonia. Principally, pulmonary aspiration can occur at any stage of anesthesia. In the clinical routine the aim must therefore be to identify those patients who have an increased risk of aspiration. When this is successful, measures can be taken to reduce the risk; these can be regional anaesthesia or the performance of general anaesthesia as rapid sequence induction (RSI). If severe pulmonary aspiration occurs despite all preventive measures, mostly during induction of anaesthesia, extensive experience and rapid action are necessary. This can only be achieved if the induction to RSI is performed by three persons with supervision of the trainee anaesthetist by a consultant anaesthetist.
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Affiliation(s)
- T Mencke
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
| | - A Zitzmann
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - D A Reuter
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
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Mencke T, Zitzmann A, Reuter DA. [56-year-old male with mechanical ileus after cystectomy : Preparation for the medical specialist examination: Part 15]. Anaesthesist 2019; 68:146-149. [PMID: 30989304 DOI: 10.1007/s00101-019-0548-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- T Mencke
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
| | - A Zitzmann
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - D A Reuter
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
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Funcke S, Saugel B, Koch C, Schulte D, Zajonz T, Sander M, Gratarola A, Ball L, Pelosi P, Spadaro S, Ragazzi R, Volta CA, Mencke T, Zitzmann A, Neukirch B, Azparren G, Giné M, Moral V, Pinnschmidt HO, Díaz-Cambronero O, Estelles MJA, Velez ME, Montañes MV, Belda J, Soro M, Puig J, Reuter DA, Haas SA. Individualized, perioperative, hemodynamic goal-directed therapy in major abdominal surgery (iPEGASUS trial): study protocol for a randomized controlled trial. Trials 2018; 19:273. [PMID: 29743101 PMCID: PMC5944092 DOI: 10.1186/s13063-018-2620-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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] [Received: 10/26/2017] [Accepted: 03/28/2018] [Indexed: 01/04/2023] Open
Abstract
Background Postoperative morbidity and mortality in patients undergoing surgery is high, especially in patients who are at risk of complications and undergoing major surgery. We hypothesize that perioperative, algorithm-driven, hemodynamic therapy based on individualized fluid status and cardiac output optimization is able to reduce mortality and postoperative moderate and severe complications as a major determinant of the patients’ postoperative quality of life, as well as health care costs. Methods/design This is a multi-center, international, prospective, randomized trial in 380 patients undergoing major abdominal surgery including visceral, urological, and gynecological operations. Eligible patients will be randomly allocated to two treatment arms within the participating centers. Patients of the intervention group will be treated perioperatively following a specific hemodynamic therapy algorithm based on pulse-pressure variation (PPV) and individualized optimization of cardiac output assessed by pulse-contour analysis (ProAQT© device; Pulsion Medical Systems, Feldkirchen, Germany). Patients in the control group will be treated according to standard local care based on established basic hemodynamic treatment. The primary endpoint is a composite comprising the occurrence of moderate or severe postoperative complications or death within 28 days post surgery. Secondary endpoints are: (1) the number of moderate and severe postoperative complications in total, per patient and for each individual complication; (2) the occurrence of at least one of these complications on days 1, 3, 5, 7, and 28 in total and for every complication; (3) the days alive and free of mechanical ventilation, vasopressor therapy and renal replacement therapy, length of intensive care unit, and hospital stay at day 7 and day 28; and (4) mortality and quality of life, assessed by the EQ-5D-5L™ questionnaire, after 6 months. Discussion This is a large, international randomized controlled study evaluating the effect of perioperative, individualized, algorithm-driven ,hemodynamic optimization on postoperative morbidity and mortality. Trial registration Trial registration: NCT03021525. Registered on 12 January 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2620-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sandra Funcke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Universitätsklinikum Giessen und Marburg GmbH, 35392, Giessen, Germany
| | - Dagmar Schulte
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Universitätsklinikum Giessen und Marburg GmbH, 35392, Giessen, Germany
| | - Thomas Zajonz
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Universitätsklinikum Giessen und Marburg GmbH, 35392, Giessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Universitätsklinikum Giessen und Marburg GmbH, 35392, Giessen, Germany
| | - Angelo Gratarola
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Savino Spadaro
- Department of Anesthesia and Intensive Care, University of Ferrara, Sant Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
| | - Riccardo Ragazzi
- Department of Anesthesia and Intensive Care, University of Ferrara, Sant Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
| | - Carlo Alberto Volta
- Department of Anesthesia and Intensive Care, University of Ferrara, Sant Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
| | - Thomas Mencke
- Department of Anesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Amelie Zitzmann
- Department of Anesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Benedikt Neukirch
- Department of Anesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Gonzalo Azparren
- Department of Anesthesiology, Hospital Santa Creu i Sant Pau, C/ Mas Casanovas 90, 08041, Barcelona, Spain
| | - Marta Giné
- Department of Anesthesiology, Hospital Santa Creu i Sant Pau, C/ Mas Casanovas 90, 08041, Barcelona, Spain
| | - Vicky Moral
- Department of Anesthesiology, Hospital Santa Creu i Sant Pau, C/ Mas Casanovas 90, 08041, Barcelona, Spain
| | - Hans Otto Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Oscar Díaz-Cambronero
- Department of Anaesthesiology, Perioperative Medicine Research Group, Hospital Universitari i Politecnic La Fe, Instituto de Investigación Sanitaria La Fe (IIS laFe), Valencia, Spain
| | - Maria Jose Alberola Estelles
- Department of Anaesthesiology, Perioperative Medicine Research Group, Hospital Universitari i Politecnic La Fe, Instituto de Investigación Sanitaria La Fe (IIS laFe), Valencia, Spain
| | - Marisol Echeverri Velez
- Department of Anaesthesiology, Perioperative Medicine Research Group, Hospital Universitari i Politecnic La Fe, Instituto de Investigación Sanitaria La Fe (IIS laFe), Valencia, Spain
| | - Maria Vila Montañes
- Department of Anaesthesiology, Perioperative Medicine Research Group, Hospital Universitari i Politecnic La Fe, Instituto de Investigación Sanitaria La Fe (IIS laFe), Valencia, Spain
| | - Javier Belda
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Marina Soro
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Jaume Puig
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Daniel Arnulf Reuter
- Department of Anesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Sebastian Alois Haas
- Department of Anesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
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13
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Affiliation(s)
- F Wiens
- Funktionelle Morphologie, Institut für Anatomie, Ruhr-Universität Bochum, Deutschland.
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Weber MA, Hasford J, Taillens C, Zitzmann A, Hahalis G, Seggewiss H, Langbehn AF, Fassbender D, Buchwalsky R, Theisen K. Low-dose aspirin versus anticoagulants for prevention of coronary graft occlusion. Am J Cardiol 1990; 66:1464-8. [PMID: 2251993 DOI: 10.1016/0002-9149(90)90535-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The prevention of graft occlusion by aspirin (100 mg/day) or heparin followed by phenprocoumon was investigated in a randomized trial in 235 patients after aortocoronary bypass operation. Aspirin treatment started 24 hours before, and heparin 6 hours and phenprocoumon 2 days after surgery. The results of the vein graft angiography and the clinical outcome 3 months postoperatively did not differ: 22% of 218 vein graft distal anastomoses in the aspirin group and 20% of 272 in the anticoagulant group were occluded. At least 1 occluded distal anastomosis was present in 38% of 74 patients in the aspirin-treated group and in 39% of 86 in the anticoagulant group. Worst-case analysis of all randomized patients showed graft occlusions, cardiovascular complications or lost to follow-up in 42% of 122 aspirin-treated patients compared with 41% of 113 patients treated with anticoagulants. For grafts with endarterectomy the occlusion rate was lower in the aspirin (12% of 49) than in the anticoagulant (22% of 41) group (p less than or equal to 0.05). Increased perioperative blood loss in the aspirin group (1,211 +/- 814 ml in the first 48 hours vs 874 +/- 818 ml in the anticoagulant group [p less than or equal to 0.001]) without a higher reoperation rate indicates effective platelet inhibition with low-dose aspirin. Because occlusion rates were equal but high in these patients with advanced stage of coronary artery disease, a combination of low-dose aspirin and anticoagulation should be investigated to reduce graft occlusion rates further.
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Affiliation(s)
- M A Weber
- Medizinische Klinik Innenstadt, Universität, München, Federal Republic of Germany
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Zitzmann A, Kreuzer E, Huber RM, Kenn RW, Pfeifer KJ. [Diagnosis of a perforating aortic aneurysm as a late complication following enlarging aortoplasty using central venous digital subtraction angiography]. Digitale Bilddiagn 1988; 8:87-9. [PMID: 3042258] [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] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
11 years after patch aortoplasty due to coarctation of the aorta a 33 year-old patient experienced two spontaneous haemoptyses. A centralvenous digital subtraction angiography demonstrated a large aneurysm of the proximal descending aorta penetrating the left upper lobe of the lung. The successful emergency surgical treatment consisted of implantation of a dacron-prosthesis.
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Affiliation(s)
- A Zitzmann
- Radiologische Abteilung, Chirurgischen Klinik Innenstadt, Ludwig Maximilians Universität München
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