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Bruegger D, Abegg M. Prediction of cortical theta oscillations in humans for phase-locked visual stimulation. J Neurosci Methods 2021; 361:109288. [PMID: 34274403 DOI: 10.1016/j.jneumeth.2021.109288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The timing of an event within an oscillatory phase is considered to be one of the key strategies used by the brain to code and process neural information. Whereas existing methods of studying this phenomenon are chiefly based on retrospective analysis of electroencephalography (EEG) data, we now present a method to study it prospectively. New method: We present a system that allows for the delivery of visual stimuli at a specific phase of the cortical theta oscillation by fitting a sine to raw surface EEG data to estimate and predict the phase. One noteworthy feature of the method is that it can minimize potentially confounding effects of previous trials by using only a short sequence of past data. RESULTS In a trial with 10 human participants we achieved a significant phase locking with an inter-trial phase coherence of 0.39. We demonstrated successful phase locking on synthetic signals with a signal-to-noise ratio of less than - 20 dB. Comparison with existing method(s): We compared the new method to an autoregressive method published in the literature and found the new method was superior in mean phase offset, circular standard deviation, and prediction latency. CONCLUSIONS By fitting sine waves to raw EEG traces, we locked visual stimuli to arbitrary phases within the theta oscillatory cycle of healthy humans.
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Affiliation(s)
- D Bruegger
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Switzerland; Graduate School for Cellular and Biomedical Sciences (GCB), University of Bern, Switzerland.
| | - M Abegg
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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Saller T, Peterss S, Scheiermann P, Eser-Valeri D, Ehler J, Bruegger D, Chappell D, Kofler O, Hagl C, Hofmann-Kiefer K. Natriuretic Peptides as a Prognostic Marker for Delirium in Cardiac Surgery-A Pilot Study. ACTA ACUST UNITED AC 2020; 56:medicina56060258. [PMID: 32471143 PMCID: PMC7353880 DOI: 10.3390/medicina56060258] [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] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Delirium is a common and major complication subsequent to cardiac surgery. Despite scientific efforts, there are no parameters which reliably predict postoperative delirium. In delirium pathology, natriuretic peptides (NPs) interfere with the blood–brain barrier and thus promote delirium. Therefore, we aimed to assess whether NPs may predict postoperative delirium and long-term outcomes. Materials and Methods: To evaluate the predictive value of NPs for delirium we retrospectively analyzed data from a prospective, randomized study for serum levels of atrial natriuretic peptide (ANP) and the precursor of C-type natriuretic peptide (NT-proCNP) in patients undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (off-pump coronary bypass grafting; OPCAB). Delirium was assessed by a validated chart-based method. Long-term outcomes were assessed 10 years after surgery by a telephone interview. Results: The overall incidence of delirium in the total cohort was 48% regardless of the surgical approach (CABG vs. OPCAB). Serum ANP levels > 64.6 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 100% (75.3–100) and specificity of 42.9% (17.7–71.1). Serum NT-proCNP levels >1.7 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 92.3% (64.0–99.8) and specificity of 42.9% (17.7–71.1). Both NPs could not predict postoperative survival or long-term cognitive decline. Conclusions: We found a positive correlation between delirium and preoperative plasma levels of ANP and NT-proCNP. A well-powered and prospective study might identify NPs as biomarkers indicating the risk of delirium and postoperative cognitive decline in patients at risk for postoperative delirium.
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Affiliation(s)
- Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
- Correspondence: ; Tel.: +49-89-4400-73410
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (S.P.); (C.H.)
| | - Patrick Scheiermann
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
| | - Daniela Eser-Valeri
- Department of Psychiatry, University Hospital, LMU Munich, 80336 Munich, Germany;
| | - Johannes Ehler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center, 18057 Rostock, Germany;
| | - Dirk Bruegger
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
| | - Daniel Chappell
- Clinic for Anaesthesia, Surgical Intensive Care, Emergency Medicine and Pain Therapy, Klinikum Frankfurt Hoechst, 65929 Frankfurt/Main, Germany;
| | - Othmar Kofler
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (S.P.); (C.H.)
| | - Klaus Hofmann-Kiefer
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (P.S.); (D.B.); (O.K.); (K.H.-K.)
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Brettner F, Chappell D, Schwartz L, Lukasz A, Kümpers P, Becker BF, Reichart B, Rehm M, Bruegger D. Vascular Endothelial Dysfunction during Cardiac Surgery: On-Pump versus Off-Pump Coronary Surgery. Eur Surg Res 2017; 58:354-368. [PMID: 29073603 DOI: 10.1159/000480431] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 05/08/2017] [Accepted: 08/16/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Cardiac surgery often causes ischemia and development of a systemic inflammatory response syndrome, which impairs vascular barrier function, normally maintained by the endothelial cell line and the endothelial glycocalyx (EG). The EG normally covers and protects healthy endothelial cells throughout the vasculature. The aim of the present study was to assess the disruption of the cellular part of the microvascular barrier by determining parameters of endothelial cell activation known to influence and reflect cell-cell junctional integrity. Particular attention was placed on angiopoietins and their important effects on endothelial gap junctions. Furthermore, comparative measurements were undertaken in patients undergoing on- and off-pump cardiac surgery, the latter group presumably experiencing less ischemic stress. METHODS 30 patients undergoing elective coronary artery bypass surgery were assigned to the conventional coronary artery bypass (CCAB) group (n = 15) or the off-pump coronary artery bypass grafting (OPCAB) group (n = 15). Blood samples were obtained for measuring angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), vascular endothelial (VE)-cadherin, and endocan at various time points. RESULTS There were significant increases in all measured parameters in both study groups versus the respective basal values. Maximal increases were as follows: Ang-1: CCAB +220%, OPCAB +166%, p < 0.05 each; Ang-2: CCAB +150%, OPCAB +20%, p < 0.05 each; VE-cadherin: CCAB +87%, OPCAB +66%, p < 0.05 each; endocan: CCAB +323%, OPCAB +72%, p < 0.05 each. CONCLUSION The present study demonstrates the activation of endothelial cells, shedding of cell-cell contacts and a potential intrinsic counterregulation by Ang-1 and endocan in patients undergoing major cardiac surgery. Quantitatively greater deviations of parameters in the CCAB than in the OPCAB group suggest a relation between the occurrence of ischemia/reperfusion and the extent of endothelial activation.
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Affiliation(s)
- Florian Brettner
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany.,Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Daniel Chappell
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany
| | - Lisa Schwartz
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany
| | - Alexander Lukasz
- Department of Medicine, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Münster, Germany
| | - Philipp Kümpers
- Department of Medicine, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Münster, Germany
| | - Bernhard F Becker
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Bruno Reichart
- Department of Cardiac Surgery, University Hospital of Munich (LMU), Munich, Germany
| | - Markus Rehm
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany
| | - Dirk Bruegger
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany
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Wildhaber R, Mortier S, Haeberlin A, Sweda R, Bruegger D, Niederhauser T, Jacomet M, Goette J, Tanner H. 073_16840-D1 A Novel 2-D Spatial-Temporal ECG Representation Using Multipolar Esophageal Catheters: A Pilot Study. JACC Clin Electrophysiol 2017. [DOI: 10.1016/j.jacep.2017.09.013] [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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Bruegger D, Brettner F, Rossberg I, Nussbaum C, Kowalski C, Januszewska K, Becker BF, Chappell D. Acute Degradation of the Endothelial Glycocalyx in Infants Undergoing Cardiac Surgical Procedures. Ann Thorac Surg 2015; 99:926-31. [DOI: 10.1016/j.athoracsur.2014.10.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/25/2014] [Accepted: 10/03/2014] [Indexed: 01/22/2023]
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Deubelbeiss A, Zahno ML, Zanoni M, Bruegger D, Zanoni R. Real-Time RT-PCR for the Detection of Lyssavirus Species. J Vet Med 2014; 2014:476091. [PMID: 26464934 PMCID: PMC4590848 DOI: 10.1155/2014/476091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 09/19/2014] [Accepted: 09/24/2014] [Indexed: 11/17/2022] Open
Abstract
The causative agents of rabies are single-stranded, negative-sense RNA viruses in the genus Lyssavirus of Rhabdoviridae, consisting of twelve classified and three as yet unclassified species including classical rabies virus (RABV). Highly neurotropic RABV causes rapidly progressive encephalomyelitis with nearly invariable fatal outcome. Rapid and reliable diagnosis of rabies is highly relevant for public and veterinary health. Due to growing variety of the genus Lyssavirus observed, the development of suitable molecular assays for diagnosis and differentiation is challenging. This work focused on the establishment of a suitable real-time RT-PCR technique for rabies diagnosis as a complement to fluorescent antibody test and rabies tissue culture infection test as gold standard for diagnosis and confirmation. The real-time RT-PCR was adapted with the goal to detect the whole spectrum of lyssavirus species, for nine of which synthesized DNA fragments were used. For the detection of species, seven probes were developed. Serial dilutions of the rabies virus strain CVS-11 showed a 100-fold higher sensitivity of real-time PCR compared to heminested RT-PCR. Using a panel of thirty-one lyssaviruses representing four species, the suitability of the protocol could be shown. Phylogenetic analysis of the sequences obtained by heminested PCR allowed correct classification of all viruses used.
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Affiliation(s)
- A. Deubelbeiss
- Institute of Virology and Immunology, 3012 Berne, Switzerland
| | - M.-L. Zahno
- Institute of Virology and Immunology, 3012 Berne, Switzerland
| | - M. Zanoni
- Institute of Virology and Immunology, 3012 Berne, Switzerland
| | - D. Bruegger
- Institute of Virology and Immunology, 3012 Berne, Switzerland
| | - R. Zanoni
- Institute of Virology and Immunology, 3012 Berne, Switzerland
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Chappell D, Bruegger D, Potzel J, Jacob M, Brettner F, Vogeser M, Conzen P, Becker BF, Rehm M. Hypervolemia increases release of atrial natriuretic peptide and shedding of the endothelial glycocalyx. Crit Care 2014; 18:538. [PMID: 25497357 PMCID: PMC4201669 DOI: 10.1186/s13054-014-0538-5] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/08/2014] [Indexed: 12/17/2022]
Abstract
Introduction Acute normovolemic hemodilution (ANH) and volume loading (VL) are standard blood-sparing procedures. However, VL is associated with hypervolemia, which may cause tissue edema, cardiopulmonary complications and a prolonged hospital stay. The body reacts to hypervolemia with release of atrial natriuretic peptide (ANP) from the heart. ANP has been shown to deteriorate the endothelial glycocalyx, a vital part of the vascular permeability barrier. The aim of the present study was to evaluate and compare ANP release and damage to the glycocalyx during ANH and VL. Methods ANH or VL with 6% hydroxyethyl starch 130/0.4 was administered prior to elective surgery in patients of good cardiopulmonary health (n =9 in each group). We measured concentrations of ANP in plasma and of three main constituent parts of the glycocalyx (hyaluronan, heparan sulfate and syndecan 1) in serum before and after ANH or VL. Heparan sulfate and syndecan 1 levels in urine were also determined. Results In contrast to ANH, VL (20 ml/kg) induced a significant release of ANP (approximately +100%, P <0.05) and increased the serum concentration of two glycocalyx constituents, hyaluronan and syndecan 1 (both by about 80%, P <0.05). Elevation of syndecan 1 was also detected in the urine of patients undergoing VL, but no increase was found in patients undergoing ANH. Heparan sulfate levels were not influenced by either procedure. Conclusion These data suggest that hypervolemia increases the release of ANP and causes enhanced shedding of the endothelial glycocalyx. This perturbation must be expected to impair the vascular barrier, implying that VL may not be as safe as generally assumed and that it should be critically evaluated.
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Affiliation(s)
- Daniel Chappell
- Department of Anesthesiology, University Hospital of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Dirk Bruegger
- Department of Anesthesiology, University Hospital of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Julia Potzel
- Department of Anesthesiology, University Hospital of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Matthias Jacob
- Department of Anesthesiology, University Hospital of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Florian Brettner
- Department of Anesthesiology, University Hospital of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Michael Vogeser
- Department of Clinical Chemistry, University Hospital of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Peter Conzen
- Department of Anesthesiology, University Hospital of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Bernhard F Becker
- Walter-Brendel Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, Schillerstrasse 44, 80336, Munich, Germany.
| | - Markus Rehm
- Department of Anesthesiology, University Hospital of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Hoechter D, Hanfstingl VVD, Czerner S, Bruegger D, Winter H, Preissler G, Zwissler B, Schramm R. 247 * THE MUNICH LUNG TRANSPLANT GROUP: USE OF INTRAOPERATIVE EXTRACORPOREAL DEVICE WITH LOW VERSUS HIGH HEPARINISATION IN LUNG TRANSPLANTATION. Interact Cardiovasc Thorac Surg 2014. [DOI: 10.1093/icvts/ivu276.247] [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: 11/13/2022] Open
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Bruegger D, Schwarz F, Reichart B, Chappell D. Facial emphysema after insertion of gastric tube. Ann Thorac Surg 2013; 95:1805. [PMID: 23608271 DOI: 10.1016/j.athoracsur.2012.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 08/28/2012] [Accepted: 09/13/2012] [Indexed: 10/26/2022]
Affiliation(s)
- Dirk Bruegger
- Department of Anesthesiology, University Hospital Munich, Munich, Germany.
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Annecke T, Rehm M, Bruegger D, Kubitz JC, Kemming GI, Stoeckelhuber M, Stoekelhuber M, Becker BF, Conzen PF. Ischemia-reperfusion-induced unmeasured anion generation and glycocalyx shedding: sevoflurane versus propofol anesthesia. J INVEST SURG 2012; 25:162-8. [PMID: 22583012 DOI: 10.3109/08941939.2011.618524] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Vascular leakage after ischemia-reperfusion (IR) is largely attributed to the destruction of the endothelial barrier and its associated negatively charged glycocalyx. In vitro, sevoflurane attenuates these changes. Therefore, we compared sevoflurane with propofol with regard to the protection of the glycocalyx and the release of negatively charged substances in vivo. METHODS After surgical preparation under midazolam-fentanyl, nine pigs each received either propofol or sevoflurane. Ischemia of 90 min was induced by a balloon catheter in the thoracic aorta. After 120 min of reperfusion, the anesthetics were changed back to midazolam-fentanyl. Five animals, each without aortic occlusion, served as time controls. Blood electrolyte parameters were measured, from which the strong ion gap (SIG) was calculated. Serum heparan sulfate concentrations and immunohistology served as a marker of glycocalyx destruction. RESULTS Immediately after reperfusion, SIG increased significantly only in the propofol group (+6.7 mEq/l versus baseline; p < .05), remaining stable in sevoflurane and both time-controlled groups. Initially, heparan sulfate concentration increased comparably in both experimental groups, but after 120 min, it became stable in sevoflurane-anesthetized animals, while increasing further in the propofol group (p < .05). CONCLUSIONS Unmeasured anions, predictive of negative outcome in previous studies, did not increase significantly in sevoflurane-anesthetized animals. Additionally, there was less heparan sulfate shedding over time, signaling less destruction of the glycocalyx. Therefore, in this in-vivo situation, sevoflurane proves to be superior to propofol in protecting the endothelium from IR injury.
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Affiliation(s)
- Thorsten Annecke
- Department of Anesthesiology, University Hospital, Ludwig-Maximilians University Munich, Munich, Germany.
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Michel S, Weis F, Sodian R, Beiras-Fernandez A, Bigdeli AK, Kaczmarek I, Bruegger D. Use of methylene blue in the treatment of refractory vasodilatory shock after cardiac assist device implantation: report of four consecutive cases. J Clin Med Res 2012; 4:212-5. [PMID: 22719809 PMCID: PMC3376881 DOI: 10.4021/jocmr804w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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] [Accepted: 12/29/2011] [Indexed: 11/15/2022] Open
Abstract
Vasodilatory shock frequently occurs after cardiac surgery, particularly after cardiac assist device implantation. This complication is often associated with high mortality, especially if refractory to conventional vasoconstrictor treatment. Methylene blue, a guanylate cyclase inhibitor, has been successfully used in the management of vasodilatory shock associated with cardiopulmonary bypass. We present four successive cases after implantation of cardiac assist devices suffering from norepinephrine and vasopressin refractory severe vasodilatory shock. In all patients, administration of a single dose of methylene blue (2 mg/kg body weight) resulted in an immediate and persistent decrease in vasoconstrictor dosages and serum lactate concentrations. Despite of this benefit, all patients deceased during hospital stay, however, this was not related to the methylene blue treatment. Methylene blue seems to be a promising therapeutical option in patients with otherwise resistant vasodilatory shock after cardiac assist device implantation. However, controlled clinical trials are necessary to substantiate safety and efficacy.
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Affiliation(s)
- Sebastian Michel
- Department of Cardiac Surgery, Ludwig-Maximilians-University, Munich, Germany
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Weig T, Dolch ME, Frey L, Bruegger D, Boekstegers P, Sodian R, Irlbeck M. Delayed intracardial shunting and hypoxemia after massive pulmonary embolism in a patient with a biventricular assist device. J Cardiothorac Surg 2011; 6:133. [PMID: 21989045 PMCID: PMC3199243 DOI: 10.1186/1749-8090-6-133] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 10/11/2011] [Indexed: 11/25/2022] Open
Abstract
We describe the interdisciplinary management of a 34-year-old woman with dilated cardiomyopathy three months postpartum on a cardiac biventricular assist device (BVAD) as bridge to heart transplantation with delayed onset of intracardial shunting and subsequent hypoxemia due to massive pulmonary embolism. After emergency surgical embolectomy pulmonary function was highly compromised (PaO2/FiO2 54) requiring bifemoral veno-venous extracorporeal membrane oxygenation. Transesophageal echocardiography detected atrial level hypoxemic right-to-left shunting through a patent foramen ovale (PFO). Percutaneous closure of the PFO was achieved with a PFO occluder device. After placing the PFO occluder device oxygenation increased significantly (Δ paO2 119 Torr). The patient received heart transplantation 20 weeks after BVAD implantation and was discharged from ICU 3 weeks after transplantation. An increase in pulmonary vascular resistance in patients on BVAD can reopen a PFO resulting in atrial right-to-left shunting and subsequent hypoxemia. The case demonstrates the usefulness of transesophageal echocardiography examinations in the detection of this unexpected event. Percutaneous placement of a PFO occluder device is an appropriate strategy to stop intracardiac shunting through PFO in fixed elevation of pulmonary vascular resistance.
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Affiliation(s)
- Thomas Weig
- Department of Anaesthesiology, Ludwig-Maximilians-University, Munich, Germany.
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Bruegger D, Schwartz L, Chappell D, Jacob M, Rehm M, Vogeser M, Christ F, Reichart B, Becker BF. Release of atrial natriuretic peptide precedes shedding of the endothelial glycocalyx equally in patients undergoing on- and off-pump coronary artery bypass surgery. Basic Res Cardiol 2011; 106:1111-21. [DOI: 10.1007/s00395-011-0203-y] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 07/01/2011] [Accepted: 07/06/2011] [Indexed: 10/18/2022]
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Bruegger D, Sadoni S, Primaychenko M, Sodian R, Schmitz C, Reichart B, Chappell D. Conservative treatment of a left atrial intramural hematoma after left atrial thrombus resection and concomitant mitral valve replacement--case report. J Cardiothorac Surg 2011; 6:50. [PMID: 21489267 PMCID: PMC3082235 DOI: 10.1186/1749-8090-6-50] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 04/13/2011] [Indexed: 11/24/2022] Open
Abstract
Left atrial intramural hematoma is a seldom cause of left atrial mass. It has been described to occur spontaneously, after interventional procedures, after blunt chest trauma, or after aortocoronary bypass surgery. We present a case of mitral valve replacement together with the removal of a large intraatrial space-occupying lesion. Intraoperative transesophageal echocardiography confirmed a successful resection of this mass. Surprisingly, upon admission to ICU, transesophageal and transthoracic echocardiography revealed a recurrence of an intramural lesion, closest matching a hematoma, which was confirmed by contrast-enhanced computed tomography. Surgical intervention was thoroughly discussed but a conservative management was favoured. 3 months after surgery, a reassessed transthoracic echocardiography and computed tomography demonstrated an almost complete resolution of the pre-existing hematoma.
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Affiliation(s)
- Dirk Bruegger
- Department of Anesthesiology, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377 Munich, Germany.
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Michel S, Bruegger D, Sodian R, Beiras-Fernandez A, Kur F, Bigdeli A, Weis M, Überfuhr P, Weis F, Reichart B. Use of methylene blue in the treatment of refractory hypotension after assist device implantation: report of five consecutive cases. Thorac Cardiovasc Surg 2011. [DOI: 10.1055/s-0030-1269285] [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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Jacob M, Chappell D, Stoeckelhuber M, Welsch U, Rehm M, Bruegger D, Kaczmarek I, Conzen P, Becker BF. Perspectives in microvascular fluid handling: does the distribution of coagulation factors in human myocardium comply with plasma extravasation in venular coronary segments? J Vasc Res 2010; 48:219-26. [PMID: 21088428 DOI: 10.1159/000318795] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 05/28/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Heterogeneity of vascular permeability has been suggested for the coronary system. Whereas arteriolar and capillary segments are tight, plasma proteins pass readily into the interstitial space at venular sites. Fittingly, lymphatic fluid is able to coagulate. However, heart tissue contains high concentrations of tissue factor, presumably enabling bleeding to be stopped immediately in this vital organ. The distribution of pro- and anti-coagulatively active factors in human heart tissue has now been determined in relation to the types of microvessels. METHODS AND RESULTS Samples of healthy explanted hearts and dilated cardiomyopathic hearts were immunohistochemically stained. Albumin was found throughout the interstitial space. Tissue factor was packed tightly around arterioles and capillaries, whereas the tissue surrounding venules and small veins was practically free of this starter of coagulation. Thrombomodulin was present at the luminal surface of all vessel segments and especially at venular endothelial cell junctions. Its product, the anticoagulant protein C, appeared only at discrete extravascular sites, mainly next to capillaries. These distribution patterns were basically identical in the healthy and diseased hearts, suggesting a general principle. CONCLUSIONS Venular extravasation of plasma proteins probably would not bring prothrombin into intimate contact with tissue factor, avoiding interstitial coagulation in the absence of injury. Generation of activated protein C via thrombomodulin is favored in the vicinity of venular gaps, should thrombin occur inside coronary vessels. This regionalization of distribution supports the proposed physiological heterogeneity of the vascular barrier and complies with the passage of plasma proteins into the lymphatic system of the heart.
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Affiliation(s)
- Matthias Jacob
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany.
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Becker BF, Chappell D, Bruegger D, Annecke T, Jacob M. Therapeutic strategies targeting the endothelial glycocalyx: acute deficits, but great potential. Cardiovasc Res 2010; 87:300-10. [PMID: 20462866 DOI: 10.1093/cvr/cvq137] [Citation(s) in RCA: 279] [Impact Index Per Article: 19.9] [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] [Indexed: 01/17/2023] Open
Abstract
Damage of the endothelial glycocalyx, which ranges from 200 to 2000 nm in thickness, decreases vascular barrier function and leads to protein extravasation and tissue oedema, loss of nutritional blood flow, and an increase in platelet and leucocyte adhesion. Thus, its protection or the restoration of an already damaged glycocalyx seems to be a promising therapeutic target both in an acute critical care setting and in the treatment of chronic vascular disease. Drugs that can specifically increase the synthesis of glycocalyx components, refurbish it, or selectively prevent its enzymatic degradation do not seem to be available. Pharmacological blockers of radical production may be useful to diminish the oxygen radical stress on the glycocalyx. Tenable options are the application of hydrocortisone (inhibiting mast-cell degranulation), use of antithrombin III (lowering susceptibility to enzymatic attack), direct inhibition of the cytokine tumour necrosis factor-alpha, and avoidance of the liberation of natriuretic peptides (as in volume loading and heart surgery). Infusion of human plasma albumin (to maintain mechanical and chemical stability of the endothelial surface layer) seems the easiest treatment to implement.
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Affiliation(s)
- Bernhard F Becker
- Department of Physiology, Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University, Schillerstrasse 44, Munich, Germany.
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Bigdeli AK, Schmitz C, Bruegger D, Weis F, Weis M, Michel S, Schmauss D, Reichart D, Reichart B, Sodian R. Heparin-Induced Thrombosis without Thrombocytopenia Causing Fulminant Pulmonary Embolism after Off-pump Coronary Artery Bypass Grafting. Heart Surg Forum 2009; 12:E368-70. [DOI: 10.1532/hsf98.20091057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Bruegger D, Rehm M, Abicht J, Paul JO, Stoeckelhuber M, Pfirrmann M, Reichart B, Becker BF, Christ F. Shedding of the endothelial glycocalyx during cardiac surgery: On-pump versus off-pump coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2009; 138:1445-7. [DOI: 10.1016/j.jtcvs.2008.07.063] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 07/22/2008] [Accepted: 07/22/2008] [Indexed: 11/26/2022]
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Bruegger D, Beiras-Fernandez A, Weis F, Weis M, Kur F. Extracorporeal support in a patient with cardiogenic shock due to Aerococcus urinae endocarditis. J Heart Valve Dis 2009; 18:418-420. [PMID: 19852146] [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: 05/28/2023]
Abstract
Aerococcus urinae is a newly identified Gram-positive coccus that causes serious infections. To date, only 15 cases of A. urinae infective endocarditis have been reported, but with a very high mortality. The case is reported of a patient with A. urinae double valve endocarditis. Following aortic and mitral valve replacement, the patient suffered from refractory cardiogenic shock; extracorporeal membrane oxygenation was used successfully as a rescue mechanical support.
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Affiliation(s)
- Dirk Bruegger
- Department of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany
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Weis F, Beiras-Fernandez A, Bruegger D, Kreth S, Sodian R, Kur F, Weis M, Nikolaou K. Huge intracardiac thrombosis in a patient on veno-arterial extracorporeal membrane oxygenation support. Interact Cardiovasc Thorac Surg 2008; 8:247-9. [DOI: 10.1510/icvts.2008.193391] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Bruegger D, Rehm M, Jacob M, Chappell D, Stoeckelhuber M, Welsch U, Conzen P, Becker BF. Exogenous nitric oxide requires an endothelial glycocalyx to prevent postischemic coronary vascular leak in guinea pig hearts. Crit Care 2008; 12:R73. [PMID: 18518977 PMCID: PMC2481466 DOI: 10.1186/cc6913] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 03/19/2008] [Accepted: 06/02/2008] [Indexed: 01/28/2023]
Abstract
Introduction Postischemic injury to the coronary vascular endothelium, in particular to the endothelial glycocalyx, may provoke fluid extravasation. Shedding of the glycocalyx is triggered by redox stress encountered during reperfusion and should be alleviated by the radical scavenger nitric oxide (NO). The objective of this study was to investigate the effect of exogenous administration of NO during reperfusion on both coronary endothelial glycocalyx and vascular integrity. Methods Isolated guinea pig hearts were subjected to 15 minutes of warm global ischemia followed by 20 minutes of reperfusion in the absence (Control group) and presence (NO group) of 4 μM NO. In further experiments, the endothelial glycocalyx was enzymatically degraded by means of heparinase followed by reperfusion without (HEP group) and with NO (HEP+NO group). Results Ischemia and reperfusion severely damaged the endothelial glycocalyx. Shedding of heparan sulfate and damage assessed by electron microscopy were less in the presence of NO. Compared with baseline, coronary fluid extravasation increased after ischemia in the Control, HEP, and HEP+NO groups but remained almost unchanged in the NO group. Tissue edema was significantly attenuated in this group. Coronary vascular resistance rose by 25% to 30% during reperfusion, but not when NO was applied, irrespective of the state of the glycocalyx. Acute postischemic myocardial release of lactate was comparable in the four groups, whereas release of adenine nucleotide catabolites was reduced 42% by NO. The coronary venous level of uric acid, a potent antioxidant and scavenger of peroxynitrite, paradoxically decreased during postischemic infusion of NO. Conclusion The cardioprotective effect of NO in postischemic reperfusion includes prevention of coronary vascular leak and interstitial edema and a tendency to forestall both no-reflow and degradation of the endothelial glycocalyx.
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Affiliation(s)
- Dirk Bruegger
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377 Munich, Germany.
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Bruegger D, Kemming GI, Jacob M, Meisner FG, Wojtczyk CJ, Packert KB, Keipert PE, Faithfull NS, Habler OP, Becker BF, Rehm M. Causes of metabolic acidosis in canine hemorrhagic shock: role of unmeasured ions. Crit Care 2008; 11:R130. [PMID: 18081930 PMCID: PMC2246228 DOI: 10.1186/cc6200] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 11/26/2007] [Accepted: 12/14/2007] [Indexed: 02/07/2023]
Abstract
Introduction Metabolic acidosis during hemorrhagic shock is common and conventionally considered to be due to hyperlactatemia. There is increasing awareness, however, that other nonlactate, unmeasured anions contribute to this type of acidosis. Methods Eleven anesthetized dogs were hemorrhaged to a mean arterial pressure of 45 mm Hg and were kept at this level until a metabolic oxygen debt of 120 mLO2/kg body weight had evolved. Blood pH, partial pressure of carbon dioxide, and concentrations of sodium, potassium, magnesium, calcium, chloride, lactate, albumin, and phosphate were measured at baseline, in shock, and during 3 hours post-therapy. Strong ion difference and the amount of weak plasma acid were calculated. To detect the presence of unmeasured anions, anion gap and strong ion gap were determined. Capillary electrophoresis was used to identify potential contributors to unmeasured anions. Results During induction of shock, pH decreased significantly from 7.41 to 7.19. The transient increase in lactate concentration from 1.5 to 5.5 mEq/L during shock was not sufficient to explain the transient increases in anion gap (+11.0 mEq/L) and strong ion gap (+7.1 mEq/L), suggesting that substantial amounts of unmeasured anions must have been generated. Capillary electrophoresis revealed increases in serum concentration of acetate (2.2 mEq/L), citrate (2.2 mEq/L), α-ketoglutarate (35.3 μEq/L), fumarate (6.2 μEq/L), sulfate (0.1 mEq/L), and urate (55.9 μEq/L) after shock induction. Conclusion Large amounts of unmeasured anions were generated after hemorrhage in this highly standardized model of hemorrhagic shock. Capillary electrophoresis suggested that the hitherto unmeasured anions citrate and acetate, but not sulfate, contributed significantly to the changes in strong ion gap associated with induction of shock.
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Affiliation(s)
- Dirk Bruegger
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377 Munich, Germany.
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Rehm M, Bruegger D, Christ F, Conzen P, Thiel M, Jacob M, Chappell D, Stoeckelhuber M, Welsch U, Reichart B, Peter K, Becker BF. Shedding of the Endothelial Glycocalyx in Patients Undergoing Major Vascular Surgery With Global and Regional Ischemia. Circulation 2007; 116:1896-906. [DOI: 10.1161/circulationaha.106.684852] [Citation(s) in RCA: 467] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Markus Rehm
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Dirk Bruegger
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Frank Christ
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Peter Conzen
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Manfred Thiel
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Matthias Jacob
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Daniel Chappell
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Mechthild Stoeckelhuber
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Ulrich Welsch
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Bruno Reichart
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Klaus Peter
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
| | - Bernhard F. Becker
- From the Clinic of Anesthesiology (M.R., D.B., F.C., P.C., M.T., M.J., D.C., K.P.), Department of Anatomy (M.S., U.W.), Clinic of Cardiac Surgery (B.R.), and Department of Physiology (B.F.B.), Ludwig-Maximilians-University, Munich, Germany
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Jacob M, Rehm M, Loetsch M, Paul JO, Bruegger D, Welsch U, Conzen P, Becker BF. The Endothelial Glycocalyx Prefers Albumin for Evoking Shear Stress-Induced, Nitric Oxide-Mediated Coronary Dilatation. J Vasc Res 2007; 44:435-43. [PMID: 17622736 DOI: 10.1159/000104871] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [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: 12/06/2006] [Accepted: 04/04/2007] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Shear stress induces coronary dilatation via production of nitric oxide (NO). This should involve the endothelial glycocalyx (EG). A greater effect was expected of albumin versus hydroxyethyl starch (HES) perfusion, because albumin seals coronary leaks more effectively than HES in an EG-dependent way. METHODS Isolated hearts (guinea pigs) were perfused at constant pressure with Krebs-Henseleit buffer augmented with 1/3 volume 5% human albumin or 6% HES (200/0.5 or 450/0.7). Coronary flow was also determined after EG digestion (heparinase) and with nitro-L-arginine (NO-L-Ag). RESULTS Coronary flow (9.50 +/- 1.09, 5.10 +/- 0.49, 4.87 +/- 1.19 and 4.15 +/- 0.09 ml/min/g for 'albumin', 'HES 200', 'HES 450' and 'control', respectively, n = 5-6) did not correlate with perfusate viscosity (0.83, 1.02, 1.24 and 0.77 cP, respectively). NO-L-Ag and heparinase diminished dilatation by albumin, but not additively. Alone NO-L-Ag suppressed coronary flow during infusion of HES 450. Electron microscopy revealed a coronary EG of 300 nm, reduced to 20 nm after heparinase. Cultured endothelial cells possessed an EG of 20 nm to begin with. CONCLUSIONS Albumin induces greater endothelial shear stress than HES, despite lower viscosity, provided the EG contains negative groups. HES 450 causes some NO-mediated dilatation via even a rudimentary EG. Cultured endothelial cells express only a rudimentary glycocalyx, limiting their usefulness as a model system.
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Affiliation(s)
- Matthias Jacob
- Clinic of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany.
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Jacob M, Bruegger D, Rehm M, Stoeckelhuber M, Welsch U, Conzen P, Becker BF. The endothelial glycocalyx affords compatibility of Starling's principle and high cardiac interstitial albumin levels. Cardiovasc Res 2007; 73:575-86. [PMID: 17196565 DOI: 10.1016/j.cardiores.2006.11.021] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [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] [Received: 01/24/2006] [Revised: 11/08/2006] [Accepted: 11/16/2006] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To test the role of an oncotic pressure gradient across the endothelial glycocalyx with respect to extravasation of fluid and colloids and development of tissue edema in a whole organ setting. METHODS We measured filtration in the intact coronary system of isolated guinea pig hearts, comparing colloid-free perfusion and perfusion with 1.67% albumin or 2% hydroxyethylstarch (oncotic pressures 5.30 vs. 11.10 mm Hg, respectively). Heparinase was used to alter the endothelial glycocalyx. RESULTS Extremely high net organ hydraulic conductivity was obtained with colloid-free perfusion (9.14 microl/min/g tissue). Supplementing perfusate with albumin caused a significant decrease, also vs. hydroxyethylstarch (1.04 vs. 2.67 microl/min/g, p < 0.05). Albumin also lowered edema formation vs. the other perfusion modes (p < 0.05). Stripping the glycocalyx of heparan sulfate reduced the effect of colloids, especially that of albumin. The steady-state concentrations of hydroxyethylstarch and albumin in the mixed interstitial fluid leaving the intact coronary bed averaged about 95% of the intravascular level. Electron and light microscopy indicated that colloid extravasated mainly in the venular sections. CONCLUSION We propose a low-filtration model for the coronary system with different barrier properties in arteriolar/capillary and venular sections. Arteriolar/capillary: very little fluid and colloid extravasation due to the endothelial surface layer formed by the glycocalyx and albumin plus the endothelial strand barrier; venular: little net extravsation of fluid and colloids despite large pores, because of low hydrostatic and oncotic pressure differences between intra- and extravascular spaces. The latter sites provide physiological access of large solutes (colloids) to the tissue.
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Affiliation(s)
- Matthias Jacob
- Clinic of Anesthesiology, Ludwig-Maximilians University Munich, Nussbaumstr. 20, D-80336 Munich, Germany.
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Jacob M, Bruegger D, Rehm M, Welsch U, Conzen P, Becker BF. Contrasting effects of colloid and crystalloid resuscitation fluids on cardiac vascular permeability. Anesthesiology 2006; 104:1223-31. [PMID: 16732094 DOI: 10.1097/00000542-200606000-00018] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.2] [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: 11/26/2022]
Abstract
BACKGROUND Fluid extravasation may lead to myocardial edema and consequent reduction in ventricular function. Albumin is presumed to interact with the endothelial glycocalyx. The authors' objective was to compare the impact of different resuscitation fluids (human albumin, hydroxyethyl starch, saline) on vascular integrity. METHODS In an isolated perfused heart model (guinea pig), Krebs-Henseleit buffer was augmented with colloids (one third volume 5% albumin or 6% hydroxyethyl starch 130/0.4) or crystalloid (0.9% saline). Perfusion pressure and vascular fluid filtration (epicardial transudate formation) were assessed at different flow rates. After global, stopped-flow ischemia (37 degrees C, 20 min), hearts were reperfused with the same resuscitation fluid additives. In a second series, the authors applied the respective perfusates after enzymatic digestion of the endothelial glycocalyx (heparinase, 10 U over 15 min). RESULTS Both 5% albumin and 6% hydroxyethyl starch decreased fluid extravasation versus saline (68.4 +/- 5.9, 134.8 +/- 20.5, and 436.8 +/- 14.7 microl/min, respectively, at 60 cm H(2)O perfusion pressure; P < 0.05), the corresponding colloid osmotic pressures being 2.95, 5.45, and 0.00 mmHg. Digestion of the endothelial glycocalyx decreased coronary integrity in both colloid groups. After ischemia, a transient increase in vascular leak occurred with Krebs-Henseleit buffer containing hydroxyethyl starch and saline, but not with albumin. The authors observed no difference between intravascular and bulk interstitial colloid concentration in the steady state. Notwithstanding, electron microscopy revealed an intact endothelial glycocalyx and no interstitial edema in the albumin group. CONCLUSION Ex vivo, albumin more effectively prevented fluid extravasation in the heart than crystalloid or artificial colloid. This effect was partly independent of colloid osmotic pressure and may be attributable to an interaction of albumin with the endothelial glycocalyx.
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Affiliation(s)
- Matthias Jacob
- Clinic of Anesthesiology, Ludwig-Maximilians University Munich, Germany
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Abstract
Microcirculatory dysfunctions play a central role in the pathophysiology of sepsis and shock. Modern methods enable microvascular monitoring in man and offer the possibility to test the effect of novel therapeutical strategies for sepsis. Furthermore, these techniques may be future tools for the monitoring of critically ill patients. In this review, we will describe four microvascular monitoring devices and give an overview of the microcirculatory changes observed during the course of sepsis. Laser Doppler fluxmetry is an easy to use noninvasive technique to measure tissue perfusion enabling monitoring of the effect of different catecholamines on the gastric perfusion during sepsis. Increased microvascular permeability and altered blood flow in septic patients can be quantified by venous congestion plethysmography. Alterations in sublingual microvascular blood flow are detected by intravital microscopy in septic patients and were identified as an outcome predictor. Furthermore, the role of gastrointestinal pCO2-tonometry for microcirculatory monitoring of the perfusion of splanchnic organs during sepsis is discussed. The true clinical value of these techniques has yet to be established and will depend on larger clinical trials showing an impact on diagnostics and patient management.
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Affiliation(s)
- A Bauer
- Klinik für Anaesthesiologie, Klinikum der Universität München-Grosshadern, Marchioninistrasse 15, 81377 München-Grosshadern
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Bruegger D, Jacob M, Becker BF, Rehm M. Authors' reply to the commentsby Drs. Ring and Kellum. Intensive Care Med 2006. [DOI: 10.1007/s00134-005-0037-x] [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: 11/29/2022]
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Bruegger D, Jacob M, Scheingraber S, Conzen P, Becker BF, Finsterer U, Rehm M. Changes in acid-base balance following bolus infusion of 20% albumin solution in humans. Intensive Care Med 2006. [DOI: 10.1007/s00134-005-0053-x] [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: 10/25/2022]
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Bauer A, Demetz F, Bruegger D, Schmoelz M, Schroepfer S, Martignoni A, Baschnegger H, Hoelzl J, Thiel M, Choukér A, Peter K, Gamble J, Christ F. Effect of high altitude and exercise on microvascular parameters in acclimatized subjects. Clin Sci (Lond) 2006; 110:207-15. [PMID: 16194151 DOI: 10.1042/cs20050217] [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: 11/17/2022]
Abstract
The role of microvascular fluid shifts in the adaptation to hypobaric hypoxia and its contribution to the pathophysiology of AMS (acute mountain sickness) is unresolved. In a systematic prospective study, we investigated the effects of hypobaric hypoxia and physical exercise alone, and in combination, on microvascular fluid exchange and related factors. We used computer-assisted VCP (venous congestion plethysmography) on the calves of ten altitude-acclimatized volunteers. We investigated the effects of: (i) actively climbing to an altitude of 3196 m, (ii) airlifting these subjects to the same altitude, and (iii) exercise at low altitude. CFC (capillary filtration capacity), Pvi (isovolumetric venous pressure) and Qa (calf blood flow) were assessed before and after each procedure and then repeated after an overnight rest. Measurements of CFC showed no evidence of increased microvascular permeability after any of the procedures. Pvi was significantly decreased (P<0.001) from 20.3±4.4 to 8.9±4.3 mmHg after active ascent, and was still significantly lower (P=0.009) after overnight rest at high altitude (13.6±5.9 mmHg). No such changes were observed after the passive ascent (16.7±4.0 mmHg at baseline; 17.3±4.5 mmHg after passive ascent; and 19.9±5.3 mmHg after overnight rest) or after exercise at low altitude. After the active ascent, Qa was significantly increased. We also found a significant correlation between Qa, Pvi and the number of circulating white blood cells. In conclusion, we found evidence to support the hypothesis that increased microvascular permeability associated with AMS does not occur in acclimatized subjects. We also observed that the microvascular equilibrium pressure (Pvi) fell in inverse relation to the increase in Qa, especially in hypoxic exercise. We hypothesize that this inverse relationship reflects the haemodynamic changes at the microvascular interface, possibly attributable to the flow-induced increases in endothelial surface shear forces.
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Affiliation(s)
- Andreas Bauer
- Clinic for Anaesthesiology, Ludwig-Maximilians University Munich, Marchioninistr. 15, 81377 Munich, Germany.
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Bruegger D, Jacob M, Rehm M, Loetsch M, Welsch U, Conzen P, Becker BF. Atrial natriuretic peptide induces shedding of endothelial glycocalyx in coronary vascular bed of guinea pig hearts. Am J Physiol Heart Circ Physiol 2005; 289:H1993-9. [PMID: 15964925 DOI: 10.1152/ajpheart.00218.2005] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.3] [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: 11/22/2022]
Abstract
Atrial natriuretic peptide (ANP) is reported to enhance vascular permeability in vivo. Our aim was to evaluate the impact of ANP on coronary extravasation of fluids and macromolecules and on the integrity of the endothelial glycocalyx. Isolated guinea pig hearts ( n = 6/group) were perfused with Krebs-Henseleit buffer in a Langendorff mode. A 6% hydroxyethyl starch (HES) solution was infused into the coronary system for 20 min without (Control group) and simultaneously with (ANP group) ANP at 10−9 M. In two further series, the glycocalyx was enzymatically degraded by means of heparinase (Hep) application (10 IU over 15 min), followed again by the infusion of HES in the absence (Hep group) and presence (ANP+Hep group) of ANP. Net fluid filtration, extravasation of HES, electron microscopic visualization of the glycocalyx, and quantification of shedding of syndecan-1, a component of the glycocalyx, were determined. An increase in fluid leak was observed in ANP, ANP+Hep, and Hep hearts [+29%, +31%, +14%, respectively; a decrease was observed in Control hearts (−13%)]. Similarly, an accelerated extravasation of colloid was observed in these three groups. Coronary release of syndecan-1 increased 9- to 18-fold during infusion of ANP. Electron microscopy revealed a dramatic degradation of the glycocalyx after ANP. These results indicate that the endothelial glycocalyx serves as a barrier to transmural exchange of fluid and colloid in the coronary vascular system. ANP causes rapid shedding of individual components of the glycocalyx and histologically detectable degradation. Thus the permeability-increasing effect of ANP may be at least partially related to changes in the integrity of the endothelial glycocalyx.
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Affiliation(s)
- Dirk Bruegger
- Clinic for Anesthesiology, Ludwig-Maximilians-Univ., Marchioninistr. 15, D-81377 Munich, Germany
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Bruegger D, Jacob M, Scheingraber S, Conzen P, Becker BF, Finsterer U, Rehm M. Changes in acid-base balance following bolus infusion of 20% albumin solution in humans. Intensive Care Med 2005; 31:1123-7. [PMID: 15999255 DOI: 10.1007/s00134-005-2683-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [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: 01/28/2005] [Accepted: 05/26/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate changes in acid-base balance following bolus infusions of a 20% albumin solution. DESIGN AND SETTING Randomized prospective study in a university hospital. PATIENTS AND PARTICIPANTS Two groups of eight patients each undergoing gynecological surgery. INTERVENTIONS Patients were randomly assigned to receive either 0.9% saline or lactated Ringer's solution. At the end of surgery two boluses of 0.5 g/kg body weight of a 20% albumin solution were administered. Arterial blood gases, electrolytes, and total protein were measured. The strong ion difference and the amount of weak plasma acid were calculated. pH and titratable acidity of the 20% albumin solution were determined. MEASUREMENTS AND RESULTS The infusion of a 20% albumin solution resulted in a significant decrease in pH from 7.284 to 7.262 in the saline group and from 7.422 to 7.394 in the Ringer's group. In both groups the 20% albumin solution caused an increase in strong ion difference and an increase in the amount of weak plasma acid. The observed changes in serum bicarbonate concentration were in good agreement with the changes in strong ion difference and the amount of weak plasma acid. The 20% albumin solution possessed a pH of 6.95 and a titratable acidity of 8.5 [corrected] mEq/l. CONCLUSIONS According to the Stewart approach, the observed changes in acid-base balance are the net result of the two opposing effects of the strong ion difference and the amount of weak plasma acid. Alternatively, the acidifying effect of the 20% albumin solution may stem from the titratable acid content of the solution.
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Affiliation(s)
- Dirk Bruegger
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377 Munich, Germany
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Jacob M, Bruegger D, Conzen P, Becker BF, Finsterer U, Rehm M. Development and validation of a mathematical algorithm for quantifying preoperative blood volume by means of the decrease in hematocrit resulting from acute normovolemic hemodilution. Transfusion 2005; 45:562-71. [PMID: 15819678 DOI: 10.1111/j.0041-1132.2005.04292.x] [Citation(s) in RCA: 13] [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] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The interindividual variability of blood volume (BV) is high. The aim of this work was to use the decrease in large-vessel hematocrit (HK(LV)) during acute normovolemic hemodilution (ANH) as an instrument for estimating preoperative BV. STUDY DESIGN AND METHODS In 39 patients, (Group 1) preoperative ANH was performed. Plasma volume, red cell volume, and HK(LV) were measured before and 30 minutes after ANH, respectively. In a retrospective analysis, a mathematical algorithm was developed for estimating BV before ANH by means of the measured changes in HK(LV) and the amount of blood removed during ANH. To validate the method prospectively, ANH was performed in an additional 10 patients (Group 2). Preoperative BV was estimated and measured in the same way as in Group 1. RESULTS In Group 1, the mean difference between estimated and measured BV before ANH was 200 +/- 403 mL (5.14 +/- 10.12%; p > 0.05; r = 0.8). In Group 2, the estimated BV before ANH was 41 +/- 348 mL (-0.53 +/- 7.84%) lower than the measured BV (p > 0.05; r = 0.94). In this group, however, two patients with an extraordinarily small (2691 mL) and large (6172 mL) preoperative BV, respectively, were identified correctly by means of the algorithm. CONCLUSIONS The changes in HK(LV) determined during ANH provide a good "bedside" estimation of preoperative BV.
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Affiliation(s)
- Matthias Jacob
- Anesthesiology Clinic, Ludwig-Maximilians University, Munich, Germany.
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Bruegger D, Bauer A, Rehm M, Niklas M, Jacob M, Irlbeck M, Becker BF, Christ F. Effect of hypertonic saline dextran on acid-base balance in patients undergoing surgery of abdominal aortic aneurysm*. Crit Care Med 2005; 33:556-63. [PMID: 15753747 DOI: 10.1097/01.ccm.0000155986.01926.95] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [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: 11/25/2022]
Abstract
OBJECTIVE To evaluate the magnitude and cause of metabolic acidosis after infusion of 7.5% sodium chloride 6% dextran 70. DESIGN Randomized, prospective clinical study. SETTING University hospital. PATIENTS Two groups of 14 patients each, undergoing repair of abdominal aortic aneurysm. INTERVENTIONS Patients were randomly assigned to receive either 250 mL of hypertonic saline dextran (HSD) or a conventional fluid regimen with 250 mL of hydroxyethyl starch in normal saline solution (H-NS) during the period of aortic clamping. Additionally, normal saline was used in both groups to reach a target pulmonary artery occlusion pressure of 15-18 mmHg. pH, Paco2, and serum concentrations of sodium, potassium, magnesium, calcium, chloride, lactate, albumin, and phosphate were measured. Strong ion difference was calculated as (sodium + potassium + magnesium + calcium) - (chloride + lactate). The amount of weak plasma acid was calculated. MEASUREMENTS AND MAIN RESULTS The infusion of HSD resulted in an immediate large increase in serum sodium (19 mmol/L) and chloride (22 mmol/L), whereas the infusion of H-NS led only to mild increases in serum sodium (3 mmol/L) and chloride (6 mmol/L). Both HSD and H-NS caused concomitant and equal decreases in the amount of weak plasma acid, strong ion difference, and pH (7.28-7.30). The reduction of bicarbonate was also identical and proportional to the extent of dilution due to infusion of HSD and H-NS. This induced metabolic acidosis was corrected spontaneously in both groups 24 hrs after surgery. CONCLUSION Both the intravenous administration of 7.5% sodium chloride and the conventional fluid regimen with saline-based 6% hydroxyethyl starch solution resulted in a metabolic acidosis of equal extent. This suggests dilution of plasma buffers or a decrease in strong ion difference to be the primary cause of metabolic acidosis.
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Affiliation(s)
- Dirk Bruegger
- Clinic of Anesthesiology, Ludwig-Maximilians-University Munich, Germany
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Abstract
A 32-year-old morbidly obese woman with an obstructing dislocated gastric band is presented. Because of prolonged vomiting, a metabolic alkalosis would be expected, but instead an impressive high anion gap acidosis was observed. Because of a highly positive urine ketone test and a high serum concentration of beta-hydroxybutyrate, a ketoacidosis caused by starvation appears to be the primary cause of this metabolic acidosis. This type of acidosis was treated successfully with intravenous administration of glucose and insulin as well as sodium bicarbonate, with urgent removal of the band.
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Affiliation(s)
- Dirk Bruegger
- Clinic for Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
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Bruegger D, Christ F. [Internet--a practical guide for anaesthetists. Part 1: Emergency medicine]. Anaesthesist 2003; 52:246-52. [PMID: 12666007 DOI: 10.1007/s00101-003-0466-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- D Bruegger
- Klinik für Anästhesiologie, Klinikum Grosshadern, Ludwig Maximilians Universität München, Munich
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Bauer A, Bruegger D, Gamble J, Christ F. Influence of different cuff inflation protocols on capillary filtration capacity in human calves -- a congestion plethysmography study. J Physiol 2002; 543:1025-31. [PMID: 12231656 PMCID: PMC2290538 DOI: 10.1113/jphysiol.2002.018291] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [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: 11/08/2022] Open
Abstract
It has been suggested that venous congestion plethysmography (VCP) substantially underestimates microvascular permeability by activation of a veni-arteriolar constrictor mechanism, even when using small (< 25 mmHg) congestion pressure steps. We studied human lower limbs of 18 young healthy volunteers to test whether the congestion pressure step size of the VCP protocol has an influence on the values of the capillary filtration capacity (CFC) and isovolumetric venous pressure (P(vi)). Two different dual stage VCP pressure step protocols, with 3 and 10 mmHg steps, were used in randomised order and separated by a transient reduction in congestion pressure. Since lymph flow is known to increase after venous congestion, we also looked to see if changes in the estimated lymph flow (J(v)L) occur as a result of these VCP protocols. The measured CFC (median [25th; 75th percentile]) was 2.6 [2.5; 3.2] x 10(-3) ml (100 ml)(-1) min(-1) mmHg(-1) with the 3 mmHg pressure step protocol, which was not different from the value of 2.9 [2.7; 3.4] x 10(-3) ml (100 ml)(-1) min(-1) mmHg(-1) obtained with 10 mmHg pressure steps. However, when either of these step sizes was applied after a transient venous decongestion, significantly higher values of CFC, 4.0 [3.4; 4.1] x 10(-3) and 3.5 [3.1; 4.5] x 10(-3) ml (100 ml)(-1) min(-1) mmHg(-1), respectively, were obtained (P < 0.05). The assessment of P(vi) was also independent of the pressure protocol (10 mmHg: 8.0 [5.7; 13.2] mmHg and 3 mmHg: 15.7 [12.5; 18.5] mmHg), but when P(vi) was measured after the transient deflation, significantly higher values were found with both 10 and 3 mmHg steps (24.1 [20.9; 27.3] and 30.4 [28.9; 30.9] mmHg, respectively; P < 0.01). The transient pressure reduction was associated with a rise in estimated J(v)L from 0.04 [0.03; 0.05] to 0.12 [0.08; 0.18] and 0.04 [0.04; 0.05] to 0.09 [0.07; 0.10] ml (100 ml)(-1) min(-1), respectively (P < 0.01). The first stage data from these protocols shows that the value of CFC is not influenced by the size of the cumulative venous pressure steps, providing they are of 10 mmHg or less. The data also show that J(v)L can be estimated with small step VCP protocols. We hypothesise that the sudden reduction in cuff pressure after venous congestion is associated with a temporary upregulation of lymph flow. As the congestion pressure is raised again, there is a modulation of the enhanced lymph flow, such that the resulting CFC slope appears greater than that obtained in the first stage of the protocol.
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Affiliation(s)
- A Bauer
- Clinic for Anaesthesiology, Ludwig-Maximilians University Munich, 81377 Munich, Germany
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Bruegger D, Bauer A, Finsterer U, Bernasconi P, Kreimeier U, Christ F. Microvascular changes during anesthesia: sevoflurane compared with propofol. Acta Anaesthesiol Scand 2002; 46:481-7. [PMID: 12027839 DOI: 10.1034/j.1399-6576.2002.460502.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [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: 11/23/2022]
Abstract
BACKGROUND We have developed a non-invasive computer-assisted venous congestion plethysmograph to measure the microvascular parameters in the lower limbs. This enables the assessment of microvascular changes following the induction of standardized anesthesia with either sevoflurane or propofol. METHODS In a prospective randomized trial we measured the capillary filtration coefficient (CFC), isovolumetric venous pressure (Pvi), an index of the balance of Starling forces, and limb blood flow 24 h preoperatively, immediately after induction of anesthesia and on the 1st and 2nd postoperative day. Anesthesia was maintained with either 1.0% sevoflurane and 5 microg/kg/h remifentanil or propofol (3 mg/kg/h), and 5 microg/kg/h remifentanil in 20 female patients undergoing breast surgery. RESULTS Preoperatively we found no significant differences between the mean CFC values of the sevoflurane group (3.7+/-0.3 ml/min 100 ml tissue/mmHg x 10-3=CFCU) and the propofol group (3.5+/-0.3 CFCU). In the sevoflurane group CFC decreased significantly to 2.9+/-0.2 CFCU, whereas it was unchanged in the propofol group. Both groups revealed a significant reduction in Pvi during steady-state anesthesia. Limb blood flow remained unchanged. There was an overall significant positive correlation between the perioperative fluid substitution and the difference between the preoperative and intraoperative CFC values (r = 0.64, P<0.01). CONCLUSION The decreased CFC in response to sevoflurane may result in less extravasation of fluids into the interstitial space, thereby reducing intraoperative fluid requirements. These data suggest that sevoflurane may be the preferred anesthetic agent in subjects susceptible to large intraoperative fluid shifts.
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Affiliation(s)
- D Bruegger
- Clinic for Anesthesiology, Ludwig Maximilians University Munich, Germany
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Glynn M, Sanford T, Hoover L, Kinsey W, Dobbs L, Bruegger D. Characterization of human papillomavirus in airway papillomas by histologic and biochemical analysis. Ann Otol Rhinol Laryngol 1999; 108:1073-7. [PMID: 10579235 DOI: 10.1177/000348949910801109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [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: 11/17/2022]
Abstract
The role of human papillomavirus (HPV) in airway papillomas has been well defined in recent literature. The chronicity and recurrence of papillomas has been postulated to be a result of residual viral genome in tissue treated with standard laser techniques. Thirteen patients with airway papillomas were selected for study with polymerase chain reaction (PCR) methods to detect viral DNA. Specimens taken prior to laser therapy and specimens taken at laser margins were consistently positive for HPV DNA by PCR. The HPV DNA is apparently present in tissues after macroscopic disease has been ablated by laser techniques. Histologic analysis of laser biopsies demonstrated fragments of squamous epithelium with cytologic features of HPV infection. Laser treatment is ineffective in eradicating HPV-infected tissues from airway papillomas, and this finding supports the notion that recurrence is a product of HPV incorporated into tissue not ablated by laser irradiation. Specific methods, results, and clinical correlation will be discussed.
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Affiliation(s)
- M Glynn
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City 66160-7380, USA
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