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Fechner J, El-Boghdadly K, Spahn DR, Motsch J, Struys MMRF, Duranteau O, Ganter MT, Richter T, Hollmann MW, Rossaint R, Bercker S, Rex S, Drexler B, Schippers F, Morley A, Ihmsen H, Kochs E. Anaesthetic efficacy and postinduction hypotension with remimazolam compared with propofol: a multicentre randomised controlled trial. Anaesthesia 2024; 79:410-422. [PMID: 38221513 DOI: 10.1111/anae.16205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/16/2024]
Abstract
Remimazolam, a short-acting benzodiazepine, may be used for induction and maintenance of total intravenous anaesthesia, but its role in the management of patients with multiple comorbidities remains unclear. In this phase 3 randomised controlled trial, we compared the anaesthetic efficacy and the incidence of postinduction hypotension during total intravenous anaesthesia with remimazolam vs. propofol. A total of 365 patients (ASA physical status 3 or 4) scheduled for elective surgery were assigned randomly to receive total intravenous anaesthesia with remimazolam (n = 270) or propofol (n = 95). Primary outcome was anaesthetic effect, quantified as the percentage of time with Narcotrend® Index values ≤ 60, during surgery (skin incision to last skin suture), with a non-inferiority margin of -10%. Secondary outcome was the incidence of postinduction hypotensive events. Mean (SD) percentage of time with Narcotrend Index values ≤ 60 during surgery across all patients receiving remimazolam (93% (20.7)) was non-inferior to propofol (99% (4.2)), mean difference (97.5%CI) -6.28% (-8.89-infinite); p = 0.003. Mean (SD) number of postinduction hypotension events was 62 (38.1) and 71 (41.1) for patients allocated to the remimazolam and propofol groups, respectively; p = 0.015. Noradrenaline administration events (requirement for a bolus and/or infusion) were also lower in patients allocated to remimazolam compared with propofol (14 (13.5) vs. 20 (14.6), respectively; p < 0.001). In conclusion, in patients who were ASA physical status 3 or 4, the anaesthetic effect of remimazolam was non-inferior to propofol.
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Stroda A, Mauermann E, Ionescu D, Szczeklik W, De Hert S, Filipovic M, Beck Schimmer B, Spadaro S, Matute P, Ganter MT, Ovezov A, Turhan SC, van Waes J, Lagarto F, Theodoraki K, Gupta A, Gillmann HJ, Guzzetti L, Kotfis K, Larmann J, Corneci D, Buggy DJ, Howell SJ, Lurati Buse G. Pathological findings associated with the updated European Society of Cardiology 2022 guidelines for preoperative cardiac testing: an observational cohort modelling study. Br J Anaesth 2024; 132:675-684. [PMID: 38336516 DOI: 10.1016/j.bja.2023.12.036] [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: 07/29/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes. METHODS This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression. RESULTS In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67-78] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE. CONCLUSIONS The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing.
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Affiliation(s)
- Alexandra Stroda
- Department of Anaesthesiology, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany.
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Daniela Ionescu
- Department of Anaesthesia and Intensive Care, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Stefan De Hert
- Department of Anaesthesiology and Peri-operative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Miodrag Filipovic
- Division of Anaesthesiology, Intensive Care, Rescue and Pain Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Beatrice Beck Schimmer
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Purificación Matute
- Department of Anaesthesia, Hospital Clinic of Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Michael T Ganter
- Department of Anaesthesiology and Intensive Care Medicine, Klinik Hirslanden, Zurich, Switzerland
| | - Alexey Ovezov
- Department of Anaesthesiology, Moscow Regional Research Clinical Institute, Moscow, Russia
| | - Sanem C Turhan
- Department of Anaesthesiology and ICU, Ankara University Medical School, Ankara, Turkey
| | - Judith van Waes
- Department of Anaesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Filipa Lagarto
- Department of Anaesthesiology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Kassiani Theodoraki
- Aretaieion University Hospital National and Kapodistrian University of Athens, Athens, Greece
| | - Anil Gupta
- Department of Perioperative Medicine and Intensive Care, Karolinska Hospital and Institution for Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Hans-Jörg Gillmann
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Luca Guzzetti
- Anesthesia and Intensive Care Department, University Hospital, Varese, Italy
| | - Katarzyna Kotfis
- Department of Anaesthesiology, Intensive Therapy and Pain Management, Pomeranian Medical University, Szczecin, Poland
| | - Jan Larmann
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dan Corneci
- Anesthesia and Intensive Care Department III, Carol Davila University of Medicine and Pharmacy Bucharest, Central Military Emergency University Hospital "Dr. Carol Davila Bucharest", Bucharest, Romania
| | - Donal J Buggy
- Department of Anaesthesiology, Mater University Hospital, Dublin, Ireland
| | - Simon J Howell
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Giovanna Lurati Buse
- Department of Anaesthesiology, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany; CARID, Cardiovascular Research Institute Düsseldorf, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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Filipovic MG, Baettig SJ, Ganter MT, Asai T, Luedi MM. Diabetes mellitus and the risk of aspiration - Safe and (ultra)sound? J Clin Anesth 2024:111396. [PMID: 38267325 DOI: 10.1016/j.jclinane.2024.111396] [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] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 01/13/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Mark G Filipovic
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Sascha J Baettig
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anaesthesiology and Critical Care Medicine, Medical Faculty, Klinik Hirslanden Zurich, University of Zurich, Zurich, Switzerland
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University, Koshigaya Hospital, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama 343-8555, Japan
| | - Markus M Luedi
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Anesthesiology, Rescue and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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Schläpfer M, Schadde E, Braun J, Soll C, Breitenstein S, Weber M, Gutknecht S, Ganter MT, Filipovic M, Beck-Schimmer B. Effect of volatile versus total intravenous anaesthesia on circulating tumour cells after pancreatic adenocarcinoma resection: multicentre randomized clinical trial. Br J Surg 2024; 111:znad357. [PMID: 37963143 PMCID: PMC10771133 DOI: 10.1093/bjs/znad357] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/08/2023] [Accepted: 06/13/2023] [Indexed: 11/16/2023]
Affiliation(s)
- Martin Schläpfer
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Erik Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of Surgery, Rush University Medical Centre, Chicago, Illinois, USA
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Julia Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Christopher Soll
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Stefan Breitenstein
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Markus Weber
- Department of Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - Stefan Gutknecht
- Department of Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anaesthesiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Miodrag Filipovic
- Department for Anaesthesiology, Intensive, Rescue and Pain Medicine, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Beatrice Beck-Schimmer
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute of Physiology, University of Zurich, Zurich, Switzerland
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Lunkiewicz J, Gasciauskaite G, Roche TR, Akbas S, Nöthiger CB, Ganter MT, Meybohm P, Hottenrott S, Zacharowski K, Raimann FJ, Rivas E, López-Baamonde M, Beller EA, Tscholl DW, Bergauer L. User Perceptions of Avatar-Based Patient Monitoring for Intensive Care Units: An International Exploratory Sequential Mixed-Methods Study. Diagnostics (Basel) 2023; 13:3391. [PMID: 37958287 PMCID: PMC10650006 DOI: 10.3390/diagnostics13213391] [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: 09/05/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Visual Patient Avatar ICU is an innovative approach to patient monitoring, enhancing the user's situation awareness in intensive care settings. It dynamically displays the patient's current vital signs using changes in color, shape, and animation. The technology can also indicate patient-inserted devices, such as arterial lines, central lines, and urinary catheters, along with their insertion locations. We conducted an international, multi-center study using a sequential qualitative-quantitative design to evaluate users' perception of Visual Patient Avatar ICU among physicians and nurses. Twenty-five nurses and twenty-five physicians from the ICU participated in the structured interviews. Forty of them completed the online survey. Overall, ICU professionals expressed a positive outlook on Visual Patient Avatar ICU. They described Visual Patient Avatar ICU as a simple and intuitive tool that improved information retention and facilitated problem identification. However, a subset of participants expressed concerns about potential information overload and a sense of incompleteness due to missing exact numerical values. These findings provide valuable insights into user perceptions of Visual Patient Avatar ICU and encourage further technology development before clinical implementation.
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Affiliation(s)
- Justyna Lunkiewicz
- Department of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (J.L.); (T.R.R.); (S.A.); (C.B.N.); (E.A.B.)
| | - Greta Gasciauskaite
- Department of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (J.L.); (T.R.R.); (S.A.); (C.B.N.); (E.A.B.)
| | - Tadzio Raoul Roche
- Department of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (J.L.); (T.R.R.); (S.A.); (C.B.N.); (E.A.B.)
| | - Samira Akbas
- Department of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (J.L.); (T.R.R.); (S.A.); (C.B.N.); (E.A.B.)
| | - Christoph B. Nöthiger
- Department of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (J.L.); (T.R.R.); (S.A.); (C.B.N.); (E.A.B.)
| | - Michael T. Ganter
- Institute of Anesthesiology and Critical Care Medicine, Clinic Hirslanden Zurich, 8032 Zurich, Switzerland;
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, University of Wuerzburg, 97070 Wuerzburg, Germany; (P.M.); (S.H.)
| | - Sebastian Hottenrott
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, University of Wuerzburg, 97070 Wuerzburg, Germany; (P.M.); (S.H.)
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, 60629 Frankfurt, Germany
| | - Florian Jürgen Raimann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, 60629 Frankfurt, Germany
| | - Eva Rivas
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Hospital Clinic of Barcelona, University of Barcelona, 08007 Barcelona, Spain; (E.R.); (M.L.-B.)
| | - Manuel López-Baamonde
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Hospital Clinic of Barcelona, University of Barcelona, 08007 Barcelona, Spain; (E.R.); (M.L.-B.)
| | - Elisabeth Anna Beller
- Department of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (J.L.); (T.R.R.); (S.A.); (C.B.N.); (E.A.B.)
| | - David Werner Tscholl
- Department of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (J.L.); (T.R.R.); (S.A.); (C.B.N.); (E.A.B.)
| | - Lisa Bergauer
- Department of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (J.L.); (T.R.R.); (S.A.); (C.B.N.); (E.A.B.)
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6
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Lurati Buse G, Larmann J, Gillmann HJ, Kotfis K, Ganter MT, Bolliger D, Filipovic M, Guzzetti L, Chammartin F, Mauermann E, Ionescu D, Szczeklik W, De Hert S, Beck-Schimmer B, Howell SJ. NT-proBNP or Self-Reported Functional Capacity in Estimating Risk of Cardiovascular Events After Noncardiac Surgery. JAMA Netw Open 2023; 6:e2342527. [PMID: 37938844 PMCID: PMC10632953 DOI: 10.1001/jamanetworkopen.2023.42527] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 09/13/2023] [Indexed: 11/10/2023] Open
Abstract
Importance Nearly 16 million surgical procedures are conducted in North America yearly, and postoperative cardiovascular events are frequent. Guidelines suggest functional capacity or B-type natriuretic peptides (BNP) to guide perioperative management. Data comparing the performance of these approaches are scarce. Objective To compare the addition of either N-terminal pro-BNP (NT-proBNP) or self-reported functional capacity to clinical scores to estimate the risk of major adverse cardiac events (MACE). Design, Setting, and Participants This cohort study included patients undergoing inpatient, elective, noncardiac surgery at 25 tertiary care hospitals in Europe between June 2017 and April 2020. Analysis was conducted in January 2023. Eligible patients were either aged 45 years or older with a Revised Cardiac Risk Index (RCRI) of 2 or higher or a National Surgical Quality Improvement Program, Risk Calculator for Myocardial Infarction and Cardiac (NSQIP MICA) above 1%, or they were aged 65 years or older and underwent intermediate or high-risk procedures. Exposures Preoperative NT-proBNP and the following self-reported measures of functional capacity were the exposures: (1) questionnaire-estimated metabolic equivalents (METs), (2) ability to climb 1 floor, and (3) level of regular physical activity. Main Outcome and Measures MACE was defined as a composite end point of in-hospital cardiovascular mortality, cardiac arrest, myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care. Results A total of 3731 eligible patients undergoing noncardiac surgery were analyzed; 3597 patients had complete data (1258 women [35.0%]; 1463 (40.7%) aged 75 years or older; 86 [2.4%] experienced a MACE). Discrimination of NT-proBNP or functional capacity measures added to clinical scores did not significantly differ (Area under the receiver operating curve: RCRI, age, and 4MET, 0.704; 95% CI, 0.646-0.763; RCRI, age, and 4MET plus floor climbing, 0.702; 95% CI, 0.645-0.760; RCRI, age, and 4MET plus physical activity, 0.724; 95% CI, 0.672-0.775; RCRI, age, and 4MET plus NT-proBNP, 0.736; 95% CI, 0.682-0.790). Benefit analysis favored NT-proBNP at a threshold of 5% or below, ie, if true positives were valued 20 times or more compared with false positives. The findings were similar for NSQIP MICA as baseline clinical scores. Conclusions and relevance In this cohort study of nearly 3600 patients with elevated cardiovascular risk undergoing noncardiac surgery, there was no conclusive evidence of a difference between a NT-proBNP-based and a self-reported functional capacity-based estimate of MACE risk. Trial Registration ClinicalTrials.gov Identifier: NCT03016936.
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Affiliation(s)
- Giovanna Lurati Buse
- Anesthesiology Department University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Jan Larmann
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hans-Jörg Gillmann
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Michael T. Ganter
- Department of Anesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Miodrag Filipovic
- Division of Anesthesiology, Intensive Care, Rescue and Pain Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Luca Guzzetti
- Anesthesia and Intensive Care Department, University Hospital, Varese, Italy
| | - Frédérique Chammartin
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Department of Anesthesiology, Zurich City Hospital, Zurich, Switzerland
| | - Daniela Ionescu
- Department of Anaesthesia and Intensive Care I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine Jagiellonian University Medical College, Kraków, Poland
| | - Stefan De Hert
- Department of Anaesthesiology and Peri-operative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Beatrice Beck-Schimmer
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon J. Howell
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, United Kingdom
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Baettig SJ, Filipovic MG, Hebeisen M, Meierhans R, Ganter MT. Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study. Anaesthesia 2023; 78:1327-1337. [PMID: 37587543 DOI: 10.1111/anae.16117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
Point-of-care gastric sonography offers an objective approach to assessing individual pulmonary aspiration risk before induction of general anaesthesia. We aimed to evaluate the potential impact of routine pre-operative gastric ultrasound on peri-operative management in a cohort of adult patients undergoing elective or emergency surgery at a single centre. According to pre-operative gastric ultrasound results, patients were classified as low risk (empty, gastric fluid volume ≤ 1.5 ml.kg-1 body weight) or high risk (solid, mixed or gastric fluid volume > 1.5 ml.kg-1 body weight) of aspiration. After sonography, examiners were asked to indicate changes in aspiration risk management (none; more conservative; more liberal) to their pre-defined anaesthetic plan and to adapt it if patient safety was at risk. We included 2003 patients, 1246 (62%) of which underwent elective and 757 (38%) emergency surgery. Among patients who underwent elective surgery, 1046/1246 (84%) had a low-risk and 178/1246 (14%) a high-risk stomach, with this being 587/757 (78%) vs. 158/757 (21%) among patients undergoing emergency surgery, respectively. Routine pre-operative gastric sonography enabled changes in anaesthetic management in 379/2003 (19%) of patients, with these being a more liberal approach in 303/2003 (15%). In patients undergoing elective surgery, pre-operative gastric sonography would have allowed a more liberal approach in 170/1246 (14%) and made a more conservative approach indicated in 52/1246 (4%), whereas in patients undergoing emergency surgery, 133/757 (18%) would have been managed more liberally and 24/757 (3%) more conservatively. We showed that pre-operative gastric ultrasound helps to identify high- and low-risk situations in patients at risk of aspiration and adds useful information to peri-operative management. Our data suggest that routine use of pre-operative gastric ultrasound may improve individualised care and potentially impact patient safety.
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Affiliation(s)
- S J Baettig
- Institute of Anaesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - M G Filipovic
- Department of Anaesthesiology and Pain Medicine, Inselspital Berne University Hospital, University of Berne, Berne, Switzerland
| | - M Hebeisen
- Department of Biostatistics, Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Zurich, Switzerland
| | - R Meierhans
- Department of Anaesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - M T Ganter
- Institute of Anaesthesiology and Critical Care Medicine, Medical Faculty, Klinik Hirslanden Zurich | University of Zurich, Zurich, Switzerland
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Bergauer L, Akbas S, Braun J, Ganter MT, Meybohm P, Hottenrott S, Zacharowski K, Raimann FJ, Rivas E, López-Baamonde M, Spahn DR, Noethiger CB, Tscholl DW, Roche TR. Visual Blood, Visualisation of Blood Gas Analysis in Virtual Reality, Leads to More Correct Diagnoses: A Computer-Based, Multicentre, Simulation Study. Bioengineering (Basel) 2023; 10:bioengineering10030340. [PMID: 36978731 PMCID: PMC10044755 DOI: 10.3390/bioengineering10030340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023] Open
Abstract
Interpreting blood gas analysis results can be challenging for the clinician, especially in stressful situations under time pressure. To foster fast and correct interpretation of blood gas results, we developed Visual Blood. This computer-based, multicentre, noninferiority study compared Visual Blood and conventional arterial blood gas (ABG) printouts. We presented six scenarios to anaesthesiologists, once with Visual Blood and once with the conventional ABG printout. The primary outcome was ABG parameter perception. The secondary outcomes included correct clinical diagnoses, perceived diagnostic confidence, and perceived workload. To analyse the results, we used mixed models and matched odds ratios. Analysing 300 within-subject cases, we showed noninferiority of Visual Blood compared to ABG printouts concerning the rate of correctly perceived ABG parameters (rate ratio, 0.96; 95% CI, 0.92–1.00; p = 0.06). Additionally, the study revealed two times higher odds of making the correct clinical diagnosis using Visual Blood (OR, 2.16; 95% CI, 1.42–3.29; p < 0.001) than using ABG printouts. There was no or, respectively, weak evidence for a difference in diagnostic confidence (OR, 0.84; 95% CI, 0.58–1.21; p = 0.34) and perceived workload (Coefficient, 2.44; 95% CI, −0.09–4.98; p = 0.06). This study showed that participants did not perceive the ABG parameters better, but using Visual Blood resulted in more correct clinical diagnoses than using conventional ABG printouts. This suggests that Visual Blood allows for a higher level of situation awareness beyond individual parameters’ perception. However, the study also highlighted the limitations of today’s virtual reality headsets and Visual Blood.
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Affiliation(s)
- Lisa Bergauer
- Institute of Anaesthesiology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Samira Akbas
- Institute of Anaesthesiology, University Hospital Zurich, 8091 Zurich, Switzerland
- Correspondence: ; Tel.: +41-43-253-2242
| | - Julia Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, 8001 Zurich, Switzerland
| | - Michael T. Ganter
- Institute of Anaesthesiology and Intensive Care Medicine, Clinic Hirslanden Zurich, 8032 Zurich, Switzerland
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Sebastian Hottenrott
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, University of Wuerzburg, 97080 Wuerzburg, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, 60323 Frankfurt, Germany
| | - Florian J. Raimann
- Department of Anaesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, 60323 Frankfurt, Germany
| | - Eva Rivas
- Department of Anaesthesiology, Intensive Care Medicine, and Pain Therapy, Hospital Clinic of Barcelona, University of Barcelona, 08036 Barcelona, Spain
| | - Manuel López-Baamonde
- Department of Anaesthesiology, Intensive Care Medicine, and Pain Therapy, Hospital Clinic of Barcelona, University of Barcelona, 08036 Barcelona, Spain
| | - Donat R. Spahn
- Institute of Anaesthesiology, University Hospital Zurich, 8091 Zurich, Switzerland
| | | | - David W. Tscholl
- Institute of Anaesthesiology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Tadzio R. Roche
- Institute of Anaesthesiology, University Hospital Zurich, 8091 Zurich, Switzerland
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Asmis LM, Serra A, Krafft A, Licht A, Leisinger E, Henschkowski-Serra J, Ganter MT, Hauptmann S, Tinguely M, Kremer Hovinga JA. Recombinant ADAMTS13 for Hereditary Thrombotic Thrombocytopenic Purpura. N Engl J Med 2022; 387:2356-2361. [PMID: 36546627 DOI: 10.1056/nejmoa2211113] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 12/24/2022]
Abstract
A 27-year-old patient with a history of severe obstetrical complications and arterial thrombosis received a diagnosis of hereditary thrombotic thrombocytopenic purpura (TTP) due to severe ADAMTS13 deficiency when she presented with an acute episode in the 30th week of her second pregnancy. When the acute episode of hereditary TTP became plasma-refractory and fetal death was imminent, weekly injections of recombinant ADAMTS13 at a dose of 40 U per kilogram of body weight were initiated. The patient's platelet count normalized, and the growth of the fetus stabilized. At 37 weeks 1 day of gestation, a small-for-gestational-age boy was delivered by cesarean section. At the time of this report, the patient and her son were well, and she continued to receive injections of recombinant ADAMTS13 every 2 weeks. (Funded by the Swiss National Science Foundation.).
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Affiliation(s)
- Lars M Asmis
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
| | - Andreas Serra
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
| | - Alexander Krafft
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
| | - Abraham Licht
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
| | - Elke Leisinger
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
| | - Jana Henschkowski-Serra
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
| | - Michael T Ganter
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
| | - Steffen Hauptmann
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
| | - Marianne Tinguely
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
| | - Johanna A Kremer Hovinga
- From Zentrum für Perioperative Thrombose und Hämostase (L.M.A.), Nephrology and Dialysis (A.S., J.H.-S.), Obstetrics and Gynecology (A.K.), Emergency Center (A.L.), and Institute for Anesthesiology and Intensive Care (E.L., M.T.G.), Hirslanden Clinic (L.M.A.), the Institute of Pathology Enge and Muensterlingen (S.H., M.T.), and the Medical Faculty, University of Zurich (L.M.A., A.S., A.K., A.L., M.T.G., M.T.), Zurich, and the Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern (J.A.K.H.) - all in Switzerland
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Roche TR, Braun J, Ganter MT, Meybohm P, Herrmann J, Zacharowski K, Raimann FJ, Piekarski F, Spahn DR, Nöthiger CB, Tscholl DW, Said S. Voice alerting as a medical alarm modality for next-generation patient monitoring: a randomised international multicentre trial. Br J Anaesth 2021; 127:769-777. [PMID: 34454710 DOI: 10.1016/j.bja.2021.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/10/2021] [Revised: 06/21/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Acoustic alarms in medical devices are vital for patient safety. State-of-the-art patient monitoring alarms are indistinguishable and contribute to alarm fatigue. There are two promising new sound modalities for vital sign alarms. Auditory icons convey alarms as brief metaphorical sounds, and voice alerts transmit information using a clear-spoken language. We compared how reliably healthcare professionals identified alarms using these two modalities. METHODS This investigator-initiated computer-based multicentre simulation study included 28 anaesthesia providers who were asked to identify vital sign alarms in randomised order, once with voice alerts and once with auditory icons. We further assessed time to decision, diagnostic confidence, and perceived helpfulness. We analysed the results using mixed models, adjusted for possible confounders. RESULTS We assessed 14 alarms for each modality, resulting in 392 comparisons across all participants. Compared with auditory icons, healthcare providers had 58 times higher odds of correctly identifying alarms using voice alerts (odds ratio 58.0; 95% confidence interval [CI]: 25.1-133.6; P<0.001), made their decisions about 14 s faster (coefficient -13.9; 95% CI: -15.8 to -12.1 s; P<0.001), perceived higher diagnostic confidence (100% [392 of 392] vs 43% [169 of 392; P<0.001]), and rated voice alerts as more helpful (odds ratio 138.2; 95% CI: 64.9-294.1; P<0.001). The participants were able to identify significantly higher proportions of alarms with voice alerts (98.5%; P<0.001) and auditory icons (54.1%; P<0.001) compared with state-of-the-art alarms (17.9%). CONCLUSIONS Voice alerts were superior to auditory icons, and both were superior to current state-of-the-art auditory alarms. These findings demonstrate the potential that voice alerts hold for patient monitoring.
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Affiliation(s)
- Tadzio R Roche
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Julia Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anaesthesiology and Pain Therapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Johannes Herrmann
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Florian J Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Christoph B Nöthiger
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - David W Tscholl
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.
| | - Sadiq Said
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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11
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Haller G, Heim C, Meier K, Clerici N, Combescure C, Ganter MT, Schliessbach J, Kindler C, Eichenberger U, Kern C. Physician anaesthesia providers in Switzerland today and tomorrow: results of the National Anaesthesia Workforce Study (NAWOS). Swiss Med Wkly 2021; 151. [PMID: 34448557 DOI: 10.4414/smw.2021.w30003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
AIMS OF THE STUDY The Swiss healthcare system is highly ranked, given its unrestricted access to specialised care and short waiting lists for surgery. However, the need for anaesthetic and surgical care is escalating owing to the increasing size and ageing of the Swiss population. In addition, to address the persistent and recurrent SARS-CoV-2 pandemic crisis, the speciality of anaesthesia is under tremendous pressure to maintain an effective workforce in order to address population needs. The current number, characteristics and future evolution of the physician anaesthesia workforce in Switzerland are currently unknown. The purpose of this study was to assess the size and professional and sociodemographic characteristics of the current anaesthesia workforce in Switzerland and to forecast its development up to 2034. METHODS We performed a cross-sectional study using a 150-item questionnaire prepared by the National Anaesthesia Workforce Study Group (NAWOS). We included all physicians (trainees and certified) practising anaesthesia in Switzerland. We collected demographic and professional information, such as the current position, hospital characteristics, workload, number of shifts and future life plans. We built a computer-based Markov model with Monte Carlo simulations to project both supply and demand for physician anaesthesia provider positions. RESULTS Of the 2661 distributed questionnaires, 1985 (74.2%) were completed and returned. We found that the average age of anaesthesiologists practising in Switzerland was 45.2 years, with 44.3% of them being women and 76.9% holding a Swiss specialist title. Only 59.6% of respondents worked full time. The forecasting model showed a steady increase in the number of anaesthesiologists retiring by 2034, with 27% of full-time equivalent jobs being lost in the next 8 years. Even if existing full-time equivalent training positions are all filled, a gradual deficit of anaesthesiologists is to be expected after 2022, and the deficit should culminate in 2034 with a deficit ratio of 0.87. CONCLUSIONS Due to the upcoming high retirement rate of anaesthesiologists, Switzerland is likely to face a shortage of anaesthesiologists in the near future. To compensate for the shortage, the country will likely increase its reliance on medical staff trained abroad. Southern and eastern cantons of Switzerland are particularly at risk, given that they already heavily rely on foreign anaesthesia workforce. This reliance should be considered a national priority because anaesthesiologists are heavily involved in both the treatment of patients with respiratory complications of SARS-CoV2 infection and the care of surgical patients, the number of which is expected to rise steadily in upcoming years.
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Affiliation(s)
- Guy Haller
- Department of Acute Care Medicine, Division of Anaesthesiology, Geneva University Hospitals, Switzerland.,Department of Epidemiology and Preventive Medicine, Health Services Management and Research Unit, Monash University, Melbourne Victoria, Australia
| | - Christoph Heim
- Division of Anaesthesiology, Kantonsspital Münsterlingen, Thurgau, Switzerland
| | - Kaspar Meier
- Division of Anaesthesiology, Regionalspital Surselva, Ilanz, Graubunden, Switzerland
| | - Nicola Clerici
- Servizio di anestesiologia, Ospedale Regionale di Locarno, Ticino, Switzerland
| | - Christophe Combescure
- Department of Health and Community Medicine, Division of Clinical Epidemiology, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Switzerland
| | - Michael T Ganter
- Institute of Anaesthesiology, Kantonsspital Winterthur, Switzerland
| | - Jürg Schliessbach
- Institute of Anaesthesiology, Zurich University Hospital, University of Zurich, Switzerland
| | | | - Urs Eichenberger
- Department of Anaesthesiology, Intensive Care and Pain Medicine Balgrist University Hospital, University of Zurich, Switzerland
| | - Christian Kern
- Division of Anaesthesiology-Centre Hospitalier Universitaire Vaudois-CHUV, Lausanne, Switzerland
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12
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Garot O, Rössler J, Pfarr J, Ganter MT, Spahn DR, Nöthiger CB, Tscholl DW. Avatar-based versus conventional vital sign display in a central monitor for monitoring multiple patients: a multicenter computer-based laboratory study. BMC Med Inform Decis Mak 2020; 20:26. [PMID: 32041584 PMCID: PMC7011453 DOI: 10.1186/s12911-020-1032-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 08/30/2019] [Accepted: 01/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maintaining adequate situation awareness is crucial for patient safety. Previous studies found that the use of avatar-based monitoring (Visual Patient Technology) improved the perception of vital signs compared to conventional monitoring showing numerical and waveform data; and was further associated with a reduction of perceived workload. In this study, we aimed to evaluate the effectiveness of Visual Patient Technology on perceptive performance and perceived workload when monitoring multiple patients at the same time, such as in central station monitors in intensive care units or operating rooms. METHODS A prospective, within-subject, computer-based laboratory study was performed in two tertiary care hospitals in Switzerland in 2018. Thirty-eight physician and nurse anesthetists volunteered for the study. The participants were shown four different central monitor scenarios in sequence, where each scenario displayed two critical and four healthy patients simultaneously for 10 or 30 s. After each scenario, participants had to recall the vital signs of the critical patients. Perceived workload was assessed with the National Aeronautics and Space Administration Task-Load-Index (NASA TLX) questionnaire. RESULTS In the 10-s scenarios, the median number of remembered vital signs significantly improved from 7 to 11 using avatar-based versus conventional monitoring with a mean of differences of 4 vital signs, 95% confidence interval (CI) 2 to 6, p < 0.001. At the same time, the median NASA TLX scores were significantly lower for avatar-based monitoring (67 vs. 77) with a mean of differences of 6 points, 95% CI 0.5 to 11, p = 0.034. In the 30-s scenarios, vital sign perception and workload did not differ significantly. CONCLUSIONS In central monitor multiple patient monitoring, we found a significant improvement of vital sign perception and reduction of perceived workload using Visual Patient Technology, compared to conventional monitoring. The technology enabled improved assessment of patient status and may, thereby, help to increase situation awareness and enhance patient safety.
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Affiliation(s)
- Olivier Garot
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Juliane Pfarr
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anesthesiology and Pain Therapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christoph B Nöthiger
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - David W Tscholl
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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Pfarr J, Ganter MT, Spahn DR, Noethiger CB, Tscholl DW. Effects of a standardized distraction on caregivers’ perceptive performance with avatar-based and conventional patient monitoring: a multicenter comparative study. J Clin Monit Comput 2019; 34:1369-1378. [DOI: 10.1007/s10877-019-00429-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
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14
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Gerber TJ, Friedrich M, Herren Gerber R, Sartoretti-Schefer S, Ganter MT. Subdural Displacement of an Epidural Catheter With Spinal Cord Compression in a Patient With Chronic Cancer Pain: A Case Report. A A Pract 2019; 13:468-472. [DOI: 10.1213/xaa.0000000000001124] [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: 11/05/2022]
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15
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Pfarr J, Ganter MT, Spahn DR, Noethiger CB, Tscholl DW. Avatar-Based Patient Monitoring With Peripheral Vision: A Multicenter Comparative Eye-Tracking Study. J Med Internet Res 2019; 21:e13041. [PMID: 31317870 PMCID: PMC6668297 DOI: 10.2196/13041] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 12/10/2018] [Revised: 06/03/2019] [Accepted: 06/12/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Continuous patient monitoring has been described by the World Health Organization as extremely important and is widely used in anesthesia, intensive care medicine, and emergency medicine. However, current state-of-the-art number- and waveform-based monitoring does not ideally support human users in acquiring quick, confident interpretations with low cognitive effort, and there are additional problematic aspects such as alarm fatigue. We developed a visualization technology (Visual Patient), specifically designed to help caregivers gain situation awareness quickly, which presents vital sign information in the form of an animated avatar of the monitored patient. We suspected that because of the way it displays the information as large, colorful, moving graphic objects, caregivers might be able to perform patient monitoring using their peripheral vision, which may facilitate quicker detection of anomalies, independently of acoustic alarms. OBJECTIVE In this study, we tested the hypothesis that avatar-based monitoring, when observed with peripheral vision only, increases the number of perceptible changes in patient status as well as caregivers' perceived diagnostic confidence compared with a high-fidelity simulation of conventional monitoring, when observed with peripheral vision only. METHODS We conducted a multicenter comparative study with a within-participant design in which anesthesiologists with their peripheral field of vision looked at 2 patient-monitoring scenarios and tried to identify changes in patient status. To ensure the best possible experimental conditions, we used an eye tracker, which recorded the eye movements of the participants and confirmed that they only looked at the monitoring scenarios with their peripheral vision. RESULTS Overall, 30 participants evaluated 18 different patient status changes with each technology (avatar and conventional patient monitoring). With conventional patient monitoring, participants could only detect those 3 changes in patient status that are associated with a change in the auditory pulse tone display, that is, tachycardia (faster beeping), bradycardia (slower beeping), and desaturation (lower pitch of beeping). With the avatar, the median number of detected vital sign changes quadrupled from 3 to 12 (P<.001) in scenario 1, and more than doubled from 3 to 8 (P<.001) in scenario 2. Median perceived diagnostic confidence was confident for both scenarios with the avatar and unconfident in scenario 1 (P<.001), and very unconfident in scenario 2 (P=.024) with conventional monitoring. CONCLUSIONS This study introduces the concept of peripheral vision monitoring. The test performed showed clearly that an avatar-based display is superior to a standard numeric display for peripheral vision. Avatar-based monitoring could potentially make much more of the patient monitoring information available to caregivers for longer time periods per case. Our results indicate that the optimal information transmission would consist of a combination of auditory and avatar-based monitoring.
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Affiliation(s)
- Juliane Pfarr
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anesthesiology Kantonsspital Winterthur, Winterthur, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Christoph B Noethiger
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - David W Tscholl
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
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16
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Affiliation(s)
- Bastian Grande
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.,Simulation Center, University Hospital Zurich, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland
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Ganter MT, Geisen M, Hartnack S, Dzemali O, Hofer CK. Prediction of fluid responsiveness in mechanically ventilated cardiac surgical patients: the performance of seven different functional hemodynamic parameters. BMC Anesthesiol 2018; 18:55. [PMID: 29788919 PMCID: PMC5964892 DOI: 10.1186/s12871-018-0520-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 12/13/2017] [Accepted: 05/10/2018] [Indexed: 02/06/2023] Open
Abstract
Background Functional hemodynamic parameters such as stroke volume and pulse pressure variation (SVV and PPV) have been shown to be reliable predictors of fluid responsiveness in mechanically ventilated patients. Today, different minimally- and non-invasive hemodynamic monitoring systems measure functional hemodynamic parameters. Although some of these parameters are described by the same name, they differ in their measurement technique and thus may provide different results. We aimed to test the performance of seven functional hemodynamic parameters simultaneously in the same clinical setting. Methods Hemodynamic measurements were done in 30 cardiac surgery patients that were mechanically ventilated. Before and after a standardized intravenous fluid bolus, hemodynamics were measured by the following monitoring systems: PiCCOplus (SVVPiCCO, PPVPiCCO), LiDCOrapid (SVVLiDCO, PPVLiDCO), FloTrac (SVVFloTrac), Philips Intellivue (PPVPhilips) and Masimo pulse oximeter (pleth variability index, PVI). Prediction of fluid responsiveness was tested by calculation of receiver operating characteristic (ROC) curves including a gray zone approach and compared using Fisher’s Z-Test. Results Fluid administration resulted in an increase in cardiac output, while all functional hemodynamic parameters decreased. A wide range of areas under the ROC-curve (AUC’s) was observed: AUC-SVVPiCCO = 0.91, AUC-PPVPiCCO = 0.88, AUC-SVVLiDCO = 0.78, AUC-PPVLiDCO = 0.89, AUC-SVVFloTrac = 0.87, AUC-PPVPhilips = 0.92 and AUC-PVI = 0.68. Optimal threshold values for prediction of fluid responsiveness ranged between 9.5 and 17.5%. Lowest threshold values were observed for SVVLiDCO, highest for PVI. Conclusion All functional hemodynamic parameters tested except for PVI showed that their use allows a reliable identification of potential fluid responders. PVI however, may not be suitable after cardiac surgery to predict fluid responsiveness. Trial registration NCT02571465, registered on October 7th, 2015 (retrospectively registered).
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Affiliation(s)
- Michael T Ganter
- Institute of Anesthesiology, Kantonsspital Winterthur, Brauerstr. 15, 8401, Winterthur, Switzerland
| | - Martin Geisen
- Institute of Anesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Birmensdorferstr. 497, 8063, Zurich, Switzerland
| | - Sonja Hartnack
- Section of Epidemiology, Vetsuisse Faculty, University of Zurich, Winterthurerstr. 270, 8057, Zurich, Switzerland
| | - Omer Dzemali
- Division of Cardiac Surgery, Triemli City Hospital Zurich, Birmensdorferstr. 497, 8063, Zurich, Switzerland
| | - Christoph K Hofer
- Institute of Anesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Birmensdorferstr. 497, 8063, Zurich, Switzerland.
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Geisen M, Ganter MT, Hartnack S, Dzemali O, Hofer CK, Zollinger A. Accuracy, Precision, and Trending of 4 Pulse Wave Analysis Techniques in the Postoperative Period. J Cardiothorac Vasc Anesth 2017; 32:715-722. [PMID: 29217236 DOI: 10.1053/j.jvca.2017.09.006] [Citation(s) in RCA: 14] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the accuracy, precision, and trending ability of the following 4 pulse wave analysis devices to measure continuous cardiac output: PiCCO2 ([PCCO]; Pulsion Medical System, Munich, Germany); LiDCORapid ([LCCO]; LiDCO Ltd, London, UK); FloTrac/Vigileo ([FCCO]; Edwards Lifesciences, Irvine, CA); and Nexfin ([NCCO]; BMEYE, Amsterdam, The Netherlands). DESIGN Prospective, observational clinical study. SETTING Intensive care unit of a single-center, teaching hospital. PARTICIPANTS The study comprised 22 adult patients after elective coronary artery bypass surgery. INTERVENTIONS Three measurement cycles were performed in all patient durings their immediate postoperative intensive care stay before and after fluid loading. Hemodynamic measurements were performed 5 minutes before and immediately after the administration of 500 mL colloidal fluid over 20 minutes. MEASUREMENTS AND MAIN RESULTS PCCO, LCCO, FCCO, and NCCO were assessed and compared with cardiac output derived from intermittent transpulmonary thermodilution (ICO). One hundred thirty-two matched sets of data were available for analysis. Bland-Altman analysis using linear mixed effects models with random effects for patient and trial revealed a mean bias ±2 standard deviation (%error) of -0.86 ± 1.41 L/min (34.9%) for PCCO-ICO, -0.26 ± 2.81 L/min (46.3%) for LCCO-ICO, -0.28 ± 2.39 L/min (43.7%) for FCCO-ICO, and -0.93 ± 2.25 L/min (34.6%) for NCCO-ICO. Bland-Altman plots without adjustment for repeated measurements and replicates yielded considerably larger limits of agreement. Trend analysis for all techniques did not meet criteria for acceptable performance. CONCLUSIONS All 4 tested devices using pulse wave analysis for measuring cardiac output failed to meet current criteria for meaningful and adequate accuracy, precision, and trending ability in cardiac output monitoring.
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Affiliation(s)
- Martin Geisen
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli Hospital Zurich, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anaesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Sonja Hartnack
- Section of Epidemiology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Omer Dzemali
- Division of Cardiac Surgery, Triemli City Hospital Zurich, Zurich, Switzerland
| | - Christoph K Hofer
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli Hospital Zurich, Zurich, Switzerland.
| | - Andreas Zollinger
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli Hospital Zurich, Zurich, Switzerland
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Dzemali O, Ganter MT, Zientara A, Graves K, Behr R, Genoni M, Hofer CK. Evaluation of a New Sonoclot Device for Heparin Management in Cardiac Surgery. Clin Appl Thromb Hemost 2016; 23:20-26. [DOI: 10.1177/1076029616651148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient’s coagulation status by glass bead–activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot. Methods: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation. Results: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = −14.7%). Comparing S2 and S1, the glass bead–activated tests showed mean percentage differences of −18.9% (gbACTs), +37.4% (CR), and −3.7% (PF). Conclusion: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2.
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Affiliation(s)
- Omer Dzemali
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Michael T. Ganter
- Institute of Anaesthesiology and Pain Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Alicja Zientara
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Kirk Graves
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Renate Behr
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Michele Genoni
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Christoph K. Hofer
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital, Zurich, Switzerland
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Bischof DB, Ganter MT, Shore-Lesserson L, Hartnack S, Klaghofer R, Graves K, Genoni M, Hofer CK. Viscoelastic Blood Coagulation Measurement With Sonoclot Predicts Postoperative Bleeding in Cardiac Surgery After Heparin Reversal. J Cardiothorac Vasc Anesth 2015; 29:715-22. [DOI: 10.1053/j.jvca.2015.01.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Indexed: 01/22/2023]
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Abstract
The coagulation system is a complex network of interacting proteins and cells with extensive sensitivity, amplification and control pathways. The system represents a delicate balance between procoagulant and anticoagulant as well as profibrinolytic and antifibrinolytic activities. Clinically relevant phenotypes, e.g. bleeding and thrombosis, occur immediately when this balance is no longer in equilibrium. A correct understanding of the complex coagulation pathophysiology in the perioperative setting is essential for an effective treatment. In a bleeding patient, patient's history, clinical findings, routine and advanced laboratory coagulation testing as well as point-of-care coagulation monitoring help to reliably and readily identify the underlying coagulation disorder. Modern coagulation management is proactive, individualized, balanced and follows clearly defined algorithms. Coagulopathic bleeding can be successfully controlled with specific interventions in the coagulation system.
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Affiliation(s)
- M T Ganter
- Institut für Anästhesiologie, Universitätsspital Zürich, Rämistraße 100, 8091, Zürich, Schweiz.
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Levi M, Fries D, Gombotz H, van der Linden P, Nascimento B, Callum JL, Bélisle S, Rizoli S, Hardy JF, Johansson PI, Samama CM, Grottke O, Rossaint R, Henny CP, Goslings JC, Theusinger OM, Spahn DR, Ganter MT, Hess JR, Dutton RP, Scalea TM, Levy JH, Spinella PC, Panzer S, Reesink HW. Prevention and treatment of coagulopathy in patients receiving massive transfusions. Vox Sang 2011; 101:154-74. [PMID: 21749403 DOI: 10.1111/j.1423-0410.2011.01472.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- M Levi
- Academic Medical Center, Department of Internal Medicine Amsterdam, the Netherlands.
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Abstract
Platelets play a central role in primary hemostasis. Analysis of platelet function is therefore a cornerstone in the global assessment of the coagulation status in the perioperative setting, primarily in patients receiving antiplatelet medication, such as cyclooxygenase-1 inhibitors, adenosine diphosphate antagonists and glycoprotein IIb/IIIa inhibitors. In these patients, knowledge of residual platelet function is highly warranted in order to maintain an optimal and individual balance perioperatively between platelet function and inhibition - that is, bleeding and thrombosis. Traditional laboratory-based assays, such as light-transmission aggregometry and flow cytometry, are the clinical standards of platelet function testing today. Light-transmission aggregometry is one of the most widely used tests to identify and diagnose defects in platelet function. The majority of the conventional laboratory-based techniques are labor intensive, costly and time consuming, and require a high degree of experience and expertise to perform and interpret. Therefore, new automated technologies have been developed to measure platelet function more rapidly and easily, and several techniques can be used at the bedside, including whole blood aggregometry, high shear-induced platelet function assessment or viscoelastic measurement techniques. All methods assessing platelet function are summarized and their limitations are discussed in this article, emphasizing their perioperative use.
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Affiliation(s)
- Christoph K Hofer
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital, Zurich, Switzerland.
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Abstract
Abnormal coagulation parameters can be found in 25% of trauma patients with major injuries. Furthermore, trauma patients presenting with coagulopathy on admission have worse clinical outcome. Tissue trauma and systemic hypoperfusion appear to be the primary factors responsible for the development of acute traumatic coagulopathy immediately after injury. As a result of overt activation of the protein C pathway, the acute traumatic coagulopathy is characterised by coagulopathy in conjunction with hyperfibrinolysis. This coagulopathy can then be exacerbated by subsequent physiologic and physical derangements such as consumption of coagulation factors, haemodilution, hypothermia, acidemia and inflammation, all factors being associated with ongoing haemorrhage and inadequate resuscitation or transfusion therapies. Knowledge of the different mechanisms involved in the pathogenesis of acute traumatic coagulopathy is essential for successful management of bleeding trauma patients. Therefore, early evidence suggests that treatment directed at aggressive and targeted haemostatic resuscitation can lead to reductions in mortality of severely injured patients.
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Affiliation(s)
- Michael T Ganter
- Privatdozent of Anesthesiology, Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
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Bischof D, Dalbert S, Zollinger A, Ganter MT, Hofer CK. Thrombelastography in the surgical patient. Minerva Anestesiol 2010; 76:131-137. [PMID: 20150854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Coagulopathy in surgical patients is an important factor in triggering major perioperative complications, i.e., intra- or postoperative bleeding and thrombo-embolic events associated with an increased mortality and morbidity. Different methods exist to assess the coagulation status of patients before, during and after surgery. Routine coagulation tests have long been considered to be the clinical standard. However, these tests have considerable limitations. Information regarding the kinetics of clot formation, clot strength, interaction of the coagulation components, platelet function and fibrinolysis is not available. Moreover, there is an important delay in obtaining test results. In contrast, thrombelastography and thrombelastometry, which both measure the visco-elastic properties of whole blood, allow the dynamic assessment of a developing clot, from fibrin formation to clot strengthening and clot lysis. Both techniques are increasingly being used in daily clinical practice in order to detect perioperative coagulopathy and to guide predominantly pro-coagulant therapy in different settings. This article provides an overview of both techniques, thrombelastography (TEG) and thrombelastometry (ROTEM), and their field of perioperative application considering of recently published data.
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Affiliation(s)
- D Bischof
- Institute of Anesthesiology, University Hospital Zurich, Switzerland
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Brenni M, Worn M, Brüesch M, Spahn DR, Ganter MT. Successful rotational thromboelastometry-guided treatment of traumatic haemorrhage, hyperfibrinolysis and coagulopathy. Acta Anaesthesiol Scand 2010; 54:111-7. [PMID: 19860752 DOI: 10.1111/j.1399-6576.2009.02132.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [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: 02/06/2023]
Abstract
Transfusion of allogeneic blood products is associated with increased morbidity and mortality. Therefore, strategies for reducing transfusion of these products during trauma management are valuable. We report a case of severe blunt abdominal trauma, successfully treated with antifibrinolytic medication and fibrinogen concentrate. Rotational thromboelastometry (ROTEM) was used to identify hyperfibrinolysis and afibrinogenaemia. In order to achieve haemostasis, over a 3-h period, the patient received a total of 1 g of tranexamic acid, 7 U of packed red blood cells, 16 g of fibrinogen concentrate (Haemocomplettan P), 3500 ml of colloids and 5500 ml of lactated Ringer's solution. Together with surgical measures, this treatment stopped the bleeding and stabilised the patient. There was no transfusion of either fresh-frozen plasma or platelets. The limited need for allogeneic blood products is of particular interest, and clinical studies of the approach used here appear to be warranted.
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Affiliation(s)
- M Brenni
- Institute of Anaesthesiology, University Hospital Zürich, Zürich, Switzerland.
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Roux J, Carles M, Koh H, Goolaerts A, Ganter MT, Chesebro BB, Howard M, Houseman BT, Finkbeiner W, Shokat KM, Paquet AC, Matthay MA, Pittet JF. Transforming growth factor beta1 inhibits cystic fibrosis transmembrane conductance regulator-dependent cAMP-stimulated alveolar epithelial fluid transport via a phosphatidylinositol 3-kinase-dependent mechanism. J Biol Chem 2009; 285:4278-90. [PMID: 19996317 DOI: 10.1074/jbc.m109.036731] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Exogenous or endogenous beta(2)-adrenergic receptor agonists enhance alveolar epithelial fluid transport via a cAMP-dependent mechanism that protects the lungs from alveolar flooding in acute lung injury. However, impaired alveolar fluid clearance is present in most of the patients with acute lung injury and is associated with increased mortality, although the mechanisms responsible for this inhibition of the alveolar epithelial fluid transport are not completely understood. Here, we found that transforming growth factor beta1 (TGF-beta1), a critical mediator of acute lung injury, inhibits beta(2)-adrenergic receptor agonist-stimulated vectorial fluid and Cl(-) transport across primary rat and human alveolar epithelial type II cell monolayers. This inhibition is due to a reduction in the cystic fibrosis transmembrane conductance regulator activity and biosynthesis mediated by a phosphatidylinositol 3-kinase (PI3K)-dependent heterologous desensitization and down-regulation of the beta(2)-adrenergic receptors. Consistent with these in vitro results, inhibition of the PI3K pathway or pretreatment with soluble chimeric TGF-beta type II receptor restored beta(2)-adrenergic receptor agonist-stimulated alveolar epithelial fluid transport in an in vivo model of acute lung injury induced by hemorrhagic shock in rats. The results demonstrate a novel role for TGF-beta1 in impairing the beta- adrenergic agonist-stimulated alveolar fluid clearance in acute lung injury, an effect that could be corrected by using PI3K inhibitors that are safe to use in humans.
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Affiliation(s)
- Jérémie Roux
- Laboratory of Surgical Research, Department of Anesthesia, University of California, San Francisco, California 94110, USA.
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Goolaerts A, Roux J, Ganter MT, Shlyonsky V, Chraibi A, Stéphane R, Mies F, Matthay MA, Naeije R, Sariban-Sohraby S, Howard M, Pittet JF. Serotonin decreases alveolar epithelial fluid transport via a direct inhibition of the epithelial sodium channel. Am J Respir Cell Mol Biol 2009; 43:99-108. [PMID: 19717814 DOI: 10.1165/rcmb.2008-0472oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Hypoxia and epithelial stretch that are commonly observed in patients with acute lung injury have been shown to promote the release of serotonin (5-hydroxytryptamine, 5-HT) in vitro. However, whether 5-HT contributes to the decrease of alveolar epithelial fluid transport, which is a hallmark of lung injury, is unknown. Thus, we investigated the effect of 5-HT on ion and fluid transport across the alveolar epithelium. 5-HT caused a dose-dependent inhibition of the amiloride-sensitive current across primary rat and human alveolar epithelial type II cell monolayers, but did not affect Na(+)/K(+) ATPase function. Furthermore, we found that the 5-HT induced inhibition of ion transport across the lung epithelium was receptor independent, as it was not prevented by the blockade of 5-HT2R (5-HT receptor 2), 5-HT3R (5-HT receptor 3), or by pretreatment with an intracellular calcium-chelating agent, BAPTA-AM (1,2-bis(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid tetra(acetoxymethyl) ester). In addition, the stimulation of 5-HT1R (5-HT receptor 1), 5-HT2R (5-HT receptor 2), 5-HT4R (5-HT receptor 4), and 5-HT7R (5-HT receptor 7) failed to reproduce the 5-HT effect on amiloride-sensitive sodium transport. We ascertained that 5-HT directly inhibited the function of rat alphabetagamma epithelial sodium channel (ENaC), as determined by heterologous expression of rat ENaC in Xenopus oocytes that do not express endogenous ENaC nor 5-HT receptors (5-HTR). Exposure of mice to hypoxia for 1 hour induced a 30% increase of 5-HT secretion into the distal airways of mice. Finally, the intratracheal instillation of 5-HT inhibited the amiloride-sensitive fraction of alveolar fluid clearance in mice. Together, these results indicate that 5-HT inhibits the amiloride-sensitive fraction of the alveolar epithelial fluid transport via a direct interaction with ENaC, and thus can be an endogenous inhibitor of this ion channel.
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Affiliation(s)
- Arnaud Goolaerts
- Department of Anesthesia, Room 3C-38, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA.
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Hofer CK, Ganter MT. Coagulation Monitoring. Anesth Analg 2008. [DOI: 10.1213/ane.0b013e31818a0e0a] [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: 11/05/2022]
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Ganter MT, Schmuck S, Hamiel CR, Wischmeyer PE, Heule D, Zollinger A, Hofer CK. Monitoring Recombinant Factor VIIa Treatment: Efficacy Depends on High Levels of Fibrinogen in a Model of Severe Dilutional Coagulopathy. J Cardiothorac Vasc Anesth 2008; 22:675-80. [DOI: 10.1053/j.jvca.2008.01.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Indexed: 11/11/2022]
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Ganter MT, Roux J, Su G, Lynch SV, Deutschman CS, Weiss YG, Christiaans SC, Myazawa B, Kipnis E, Wiener-Kronish JP, Howard M, Pittet JF. Role of small GTPases and alphavbeta5 integrin in Pseudomonas aeruginosa-induced increase in lung endothelial permeability. Am J Respir Cell Mol Biol 2008; 40:108-18. [PMID: 18703797 DOI: 10.1165/rcmb.2007-0454oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pseudomonas aeruginosa is an opportunistic pathogen that can cause severe pneumonia associated with airspace flooding with protein-rich edema in critically ill patients. The type III secretion system is a major virulence factor and contributes to dissemination of P. aeruginosa. However, it is still unknown which particular bacterial toxin and which cellular pathways are responsible for the increase in lung endothelial permeability induced by P. aeruginosa. Thus, the first objective of this study was to determine the mechanisms by which this species causes an increase in lung endothelial permeability. The results showed that ExoS and ExoT, two of the four known P. aeruginosa type III cytotoxins, were primarily responsible for bacterium-induced increases in protein permeability across the lung endothelium via an inhibition of Rac1 and an activation of the RhoA signaling pathway. In addition, inhibition of the alphavbeta5 integrin, a central regulator of lung vascular permeability, prevented these P. aeruginosa-mediated increases in albumin flux due to endothelial permeability. Finally, prior activation of the stress protein response or adenoviral gene transfer of the inducible heat shock protein Hsp72 also inhibited the damaging effects of P. aeruginosa on the barrier function of lung endothelium. Taken together, these results demonstrate the critical role of the RhoA/alphavbeta5 integrin pathway in mediating P. aeruginosa-induced lung vascular permeability. In addition, activation of the stress protein response with pharmacologic inhibitors of Hsp90 may protect lungs against P. aeruginosa-induced permeability changes.
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Affiliation(s)
- Michael T Ganter
- Department of Anesthesia and Surgery, University of California San Francisco, San Francisco, California 94110, USA
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Abstract
PURPOSE OF REVIEW Several less invasive cardiac output monitoring techniques are now commercially available and have the potential to replace the pulmonary artery catheter under certain clinical circumstances. The aim of this review is to give a synopsis of the currently available cardiac output measurement methods. This information should help in selecting the appropriate technique in a particular clinical setting. RECENT FINDINGS An overview is given of the currently available techniques for cardiac output monitoring. Recent validation studies demonstrate that pulse wave analysis may be used reliably as an alternative to the pulmonary artery catheter in different clinical settings. The use of transesophageal echocardiography and Doppler measurements is limited due to high operator dependency, the partial carbon dioxide rebreathing technique should be applied in a precisely defined clinical setting to mechanically ventilated patients only, and pulsed dye densitometry as well as the bioimpedance technique are currently primarily applied in an investigational setting. SUMMARY Less invasive cardiac output monitoring techniques may replace the pulmonary artery catheter in different clinical settings considering the specific properties of these techniques. The pulmonary artery catheter, however, may still be recommended for cardiac output measurement in specific clinical situations when monitoring of pulmonary artery pressures is desirable.
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Affiliation(s)
- Christoph K Hofer
- Institute of Anesthesiology and Intensive Care Medicine, Triemli City Hospital, Switzerland.
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Abstract
Perioperative monitoring of blood coagulation is critical to better understand causes of hemorrhage, to guide hemostatic therapies, and to predict the risk of bleeding during the consecutive anesthetic or surgical procedures. Point-of-care (POC) coagulation monitoring devices assessing the viscoelastic properties of whole blood, i.e., thrombelastography, rotation thrombelastometry, and Sonoclot analysis, may overcome several limitations of routine coagulation tests in the perioperative setting. The advantage of these techniques is that they have the potential to measure the clotting process, starting with fibrin formation and continue through to clot retraction and fibrinolysis at the bedside, with minimal delays. Furthermore, the coagulation status of patients is assessed in whole blood, allowing the plasmatic coagulation system to interact with platelets and red cells, and thereby providing useful additional information on platelet function. Viscoelastic POC coagulation devices are increasingly being used in clinical practice, especially in the management of patients undergoing cardiac and liver surgery. Furthermore, they provide useful information in a large variety of clinical scenarios, e.g., massive hemorrhage, assessment of hypo- and hypercoagulable states, guiding pro- and anticoagulant therapies, and in diagnosing of a surgical bleeding. A surgical etiology of bleeding has to be considered when viscoelastic test results are normal. In summary, viscoelastic POC coagulation devices may help identify the cause of bleeding and guide pro- and anticoagulant therapies. To ensure optimal accuracy and performance, standardized procedures for blood sampling and handling, strict quality controls and trained personnel are required.
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Affiliation(s)
- Michael T Ganter
- Department of Anesthesia and Perioperative Care, University of CA San Francisco, San Francisco, California, USA
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Hofer CK, Ganter MT, Rist A, Klaghofer R, Matter-Ensner S, Zollinger A. The Accuracy of Preload Assessment by Different Transesophageal Echocardiographic Techniques in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2008; 22:236-42. [DOI: 10.1053/j.jvca.2007.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Indexed: 11/11/2022]
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Ganter MT, Schneider U, Heinzelmann M, Zaugg M, Lucchinetti E, Zollinger A, Hofer CK. How often should we perform arterial blood gas analysis during thoracoscopic surgery? J Clin Anesth 2008; 19:569-75. [PMID: 18083468 DOI: 10.1016/j.jclinane.2007.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Revised: 05/30/2007] [Accepted: 06/02/2007] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVES To continuously measure arterial blood gases (ABGs), to calculate the percentage of anticipated changes over time, and to develop recommendations for sampling frequencies of arterial blood gases in patients undergoing thoracoscopic surgery. DESIGN Prospective, observational clinical trial. SETTING University hospital. PATIENTS 43 consecutive elective patients undergoing thoracoscopic surgery with one-lung ventilation. INTERVENTIONS AND MEASUREMENTS A Paratrend 7 probe for continuous arterial partial pressure of oxygen and arterial partial pressure of carbon dioxide measurement was introduced through a radial artery cannula in the awake patient before surgery. Data were collected throughout the procedure until patients left the operating room. Afterward, time courses of arterial blood gas values were transformed into frequency space by fast Fourier transform analysis, and the expected deviations in arterial blood gases were calculated over time. MAIN RESULTS Forty-three consecutive patients undergoing thoracoscopic surgery were included, and arterial blood gas values were measured during a total of 141.5 h. Critical arterial partial pressure of oxygen values <or=60 mmHg were recorded in 16 patients for a total of 4.5 hours. Fourier amplitude spectra showed comparable characteristics of arterial partial pressure of oxygen and arterial partial pressure of carbon dioxide time courses in all patients. It takes only 5, 10, or 20 minutes for the arterial partial pressure of oxygen to change 10%, 20%, or 40%, respectively (95% confidence). CONCLUSIONS Current standards to monitor arterial blood gases are not sufficient to detect and prevent hypoxemic events during thoracoscopic surgery with one-lung ventilation. Intermittent arterial blood gas analyses must be performed more frequently, up to every 10 minutes, to detect changes of 20% in arterial partial pressure of oxygen.
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Affiliation(s)
- Michael T Ganter
- Department of Anesthesia and Perioperative Care, University of California, San Francisco General Hospital, San Francisco, CA 94110, USA.
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Roux J, Ganter MT, Goolaerts A, Finkbeiner W, Matthay MA, Pittet J. Transforming Growth Factor‐β1 Inhibits CFTR‐dependent cAMP‐stimulated Alveolar Epithelial Fluid Transport: Critical Role of Interleukin‐8. FASEB J 2008. [DOI: 10.1096/fasebj.22.1_supplement.932.7] [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] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ganter MT, Roux J, Miyazawa B, Howard M, Frank JA, Su G, Sheppard D, Violette SM, Weinreb PH, Horan GS, Matthay MA, Pittet JF. Interleukin-1beta causes acute lung injury via alphavbeta5 and alphavbeta6 integrin-dependent mechanisms. Circ Res 2008; 102:804-12. [PMID: 18276918 DOI: 10.1161/circresaha.107.161067] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Interleukin (IL)-1beta has previously been shown to be among the most biologically active cytokines in the lungs of patients with acute lung injury (ALI). Furthermore, there is experimental evidence that lung vascular permeability increases after short-term exposure to IL-1 protein, although the exact mechanism is unknown. Therefore, the objective of this study was to determine the mechanisms of IL-1beta-mediated increase in lung vascular permeability and pulmonary edema following transient overexpression of this cytokine in the lungs by adenoviral gene transfer. Lung vascular permeability increased with intrapulmonary IL-1beta production with a maximal effect 7 days after instillation of the adenovirus. Furthermore, inhibition of the alphavbeta6 integrin and/or transforming growth factor-beta attenuated the IL-1beta-induced ALI. The results of in vitro studies indicated that IL-1beta caused the activation of transforming growth factor-beta via RhoA/alphavbeta6 integrin-dependent mechanisms and the inhibition of the alphavbeta6 integrin and/or transforming growth factor-beta signaling completely blocked the IL-1beta-mediated protein permeability across alveolar epithelial cell monolayers. In addition, IL-1beta increased protein permeability across lung endothelial cell monolayers via RhoA- and alphavbeta5 integrin-dependent mechanisms. The final series of in vivo experiments demonstrated that pretreatment with blocking antibodies to both the alphavbeta5 and alphavbeta6 integrins had an additive protective effect against IL-1beta-induced ALI. In summary, these results demonstrate a critical role for the alphavbeta5/beta6 integrins in mediating the IL-1beta-induced ALI and indicate that these integrins could be a potentially attractive therapeutic target in ALI.
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Affiliation(s)
- Michael T Ganter
- Laboratory of Surgical Research, Department of Anesthesia, University of California, San Francisco 94110, USA
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Meyer S, Z'graggen BR, Blumenthal S, Borgeat A, Ganter MT, Reyes L, Booy C, Neff TA, Spahn DR, Beck-Schimmer B. Hypoxia attenuates effector-target cell interaction in the airway and pulmonary vascular compartment. Clin Exp Immunol 2007; 150:358-67. [PMID: 17892511 PMCID: PMC2219348 DOI: 10.1111/j.1365-2249.2007.03495.x] [Citation(s) in RCA: 4] [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: 12/14/2022] Open
Abstract
Leucocyte infiltration is known to play an important role in hypoxia-induced tissue damage. However, little information is available about hypoxia and interaction of effector (neutrophils) with target cells (alveolar epithelial cells, AEC; rat pulmonary artery endothelial cells, RPAEC). The goal of this study was to elucidate hypoxia-induced changes of effector-target cell interaction. AEC and RPAEC were exposed to 5% oxygen for 2-6 h. Intercellular adhesion molecule-1 (ICAM-1) expression was determined and cell adherence as well as cytotoxicity assays were performed. Nitric oxide and heat shock protein 70 (HSP70) production was assessed in target cells. Under hypoxic conditions enhanced ICAM-1 production was found in both cell types. This resulted in an increase of adherent neutrophils to AEC and RPAEC. The death rate of hypoxia-exposed target cells decreased significantly in comparison to control cells. Nitric oxide (NO) concentration was enhanced, as was production of HSP70 in AEC. Blocking NO production in target cells resulted in increased cytotoxicity in AEC and RPAEC. This study shows for the first time that target cells are more resistant to effector cells under hypoxia, suggesting hypoxia-induced cell protection. An underlying mechanism for this phenomenon might be the protective effect of increased levels of NO in target cells.
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Affiliation(s)
- S Meyer
- Institute of Anaesthesiology, and Institute of Physiology and Center for Intergrative Human Physiology, University of Zurich, Zurich, Switzerland
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Ganter MT, Monn A, Tavakoli R, Klaghofer R, Zollinger A, Hofer CK. Kaolin-Based Activated Coagulation Time Measured by Sonoclot in Patients Undergoing Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2007; 21:524-8. [PMID: 17678778 DOI: 10.1053/j.jvca.2006.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [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: 05/23/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVES In vivo data for the kaolin-based ACT test from the Sonoclot Analyzer (SkACT, Sienco Inc, Arvada, CO) are lacking. The aim of this study was to compare SkACT with an established kaolin-based ACT from Hemochron (HkACT) and anti-Xa activity in patients undergoing cardiopulmonary bypass (CPB). DESIGN Prospective observational study. SETTING Community hospital. PARTICIPANTS Fifty patients scheduled for elective cardiac surgery. INTERVENTIONS Blood samples were taken before CPB at baseline (T0) and after heparinization (T1 and T2), on CPB after administration of aprotinin (5, 15, 30, 60 minutes; T3-T6), and at the end after protamine infusion (T7). MEASUREMENTS AND MAIN RESULTS A total of 375 blood samples were analyzed. ACT measurements were comparable for SkACT and HkACT at each measurement time point. Overall bias +/- standard deviation between SkACT and HkACT was -19 +/- 75 seconds (-2.4% +/- 11.7%). Mean bias between SkACT and HkACT at each time point ranged from -35 to 3 seconds (-4.5% to 2.6%) and showed no statistical significance over time. Heparin sensitivity of SkACT and HkACT, defined as (ACT(Tx)-ACT(T0))/(anti-Xa(Tx)-anti-Xa(T0)), significantly increased for measurements during CPB (p < 0.001) but without significant difference between the 2 methods. Test variability was comparable for both ACT measurement techniques. Overall test variability was 7.5% +/- 7.4% for SkACT and 7.8% +/- 11% for HkACT. CONCLUSIONS Accuracy and performance of SkACT and HkACT were comparable for heparin monitoring in patients undergoing CPB for elective cardiac surgery. However, both tests were affected significantly after initiating CPB and aprotinin infusion.
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Affiliation(s)
- Michael T Ganter
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94110, USA.
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Abstract
Complement activation has been reported after major trauma. However, little is known about the clinical relevance and the mechanisms of complement activation early after trauma. Therefore, the aim of this study was to measure complement activation, to identify the roles of injury severity and hypoperfusion, to determine the predominant activated pathway, and to identify the clinical significance of early complement activation in trauma patients. A total of 208 adult trauma patients were enrolled in this prospective single-center cohort study of major trauma patients. Blood samples were obtained within 30 min after injury before any significant fluid resuscitation. Complement (C5b-9) was activated early after trauma, correlated with injury severity and tissue hypoperfusion, and was associated with increased mortality rate and with the development of organ failure such as acute lung injury and acute renal failure. The alternative pathway seems to be the predominant activated complement pathway early after trauma. However, the classical and/or the lectin pathway initiated complement activation because of the correlation between plasma levels of C4d and C3a/C5b-9. Finally, in patients with low C3a levels, C5b-9 levels correlated with plasma levels of prothrombin fragments 1 + 2, a marker of thrombin generation, suggesting additional C3-independent complement activation by thrombin after severe trauma. In summary, complement activation via its amplification by the alternative pathway is observed early after trauma and correlates with injury severity, tissue hypoperfusion, and worse clinical outcomes. Besides complement activation by the classical and/or lectin pathways, there is an independent association between thrombin generation and complement activation.
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Affiliation(s)
- Michael T Ganter
- Departments of Anesthesia, San Francisco General Hospital, University of California San Francisco, California 94110, USA.
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Abstract
OBJECTIVES Coagulopathy following major trauma is conventionally attributed to activation and consumption of coagulation factors. Recent studies have identified an acute coagulopathy present on admission that is independent of injury severity. We hypothesized that early coagulopathy is due to tissue hypoperfusion, and investigated derangements in coagulation associated with this. METHODS This was a prospective cohort study of major trauma patients admitted to a single trauma center. Blood was drawn within 10 minutes of arrival for analysis of partial thromboplastin and prothrombin times, prothrombin fragments 1+2, fibrinogen, thrombomodulin, protein C, plasminogen activator inhibitor-1, and D-dimers. Base deficit (BD) was used as a measure of tissue hypoperfusion. RESULTS A total of 208 patients were enrolled. Patients without tissue hypoperfusion were not coagulopathic, irrespective of the amount of thrombin generated. Prolongation of the partial thromboplastin and prothrombin times was only observed with an increased BD. An increasing BD was associated with high soluble thrombomodulin and low protein C levels. Low protein C levels were associated with prolongation of the partial thromboplastin and prothrombin times and hyperfibrinolysis with low levels of plasminogen activator inhibitor-1 and high D-dimer levels. High thrombomodulin and low protein C levels were significantly associated with increased mortality, blood transfusion requirements, acute renal injury, and reduced ventilator-free days. CONCLUSIONS Early traumatic coagulopathy occurs only in the presence of tissue hypoperfusion and appears to occur without significant consumption of coagulation factors. Alterations in the thrombomodulin-protein C pathway are consistent with activated protein C activation and systemic anticoagulation. Admission plasma thrombomodulin and protein C levels are predictive of clinical outcomes following major trauma.
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Affiliation(s)
- Karim Brohi
- Department of Surgery, University of California at San Francisco, San Francisco, CA, USA.
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Ganter MT, Monn A, Tavakoli R, Genoni M, Klaghofer R, Furrer L, Honegger H, Hofer CK. Monitoring activated clotting time for combined heparin and aprotinin application: in vivo evaluation of a new aprotinin-insensitive test using Sonoclot☆. Eur J Cardiothorac Surg 2006; 30:278-84. [PMID: 16828293 DOI: 10.1016/j.ejcts.2006.05.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [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: 12/25/2005] [Revised: 04/11/2006] [Accepted: 05/08/2006] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Kaolin-based activated clotting time assessed by HEMOCHRON (HkACT) is a clinical standard for heparin monitoring alone and combined with aprotinin during cardiopulmonary bypass (CPB). However, aprotinin is known to prolong not only celite-based but also kaolin-based activated clotting time. Overestimation of activated clotting times implies a potential hazardous risk of subtherapeutic heparin anticoagulation. Recently, a novel 'aprotinin-insensitive' activated clotting time test has been developed for the SONOCLOT analyzer (SaiACT). The aim of our study was to evaluate SaiACT in patients undergoing CPB in presence of heparin and aprotinin. METHODS Blood samples were taken from 44 elective cardiac surgery patients at the following measurement time points: baseline (T0); before CPB after heparinization (T1 and T2); on CPB, before administration of aprotinin (T3); 15, 30, and 60 min on CPB after administration of aprotinin (T4, T5, and T6); after protamine infusion (T7). On each measurement time point, activated clotting time was assessed with HkACT and SaiACT, both in duplicate. Furthermore, the rate of factor Xa inhibition and antithrombin concentration were measured. Statistical analysis was done using Bland and Altman analysis, Pearson's correlation, and ANOVA with post hoc Bonferroni-Dunn correction. RESULTS Monitoring anticoagulation with SaiACT showed reliable readings. Compared to the established HkACT, SaiACT values were lower at all measurement time points. On CPB but before administration of aprotinin (T3), SaiACT values (mean+/-SD) were 44+/-118 s lower compared to HkACT. However, the difference between the two measurement techniques increased significantly on CPB after aprotinin administration (T4-T6; 89+/-152 s, P=0.032). Correlation of ACT measurements with anti-Xa activity was unchanged for SaiACT before and after aprotinin administration (r2=0.473 and 0.487, respectively; P=0.794), but was lower for HkACT after aprotinin administration (r2=0.481 and 0.361, respectively; P=0.041). On CPB after administration of aprotinin, 96% of all ACT values were classified as therapeutic by HkACT, but only 86% of all values were classified therapeutic if ACT was determined by SaiACT. Test variability was comparable for SaiACT and HkACT. CONCLUSIONS The use of SaiACT may result in more consistent heparin management that is less affected by aprotinin and a corresponding increase in heparin administration for patients receiving aprotinin.
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Affiliation(s)
- Michael T Ganter
- Institute of Anesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Switzerland
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Tucci MA, Ganter MT, Hamiel CR, Klaghofer R, Zollinger A, Hofer CK. Platelet function monitoring with the Sonoclot analyzer after in vitro tirofiban and heparin administration. J Thorac Cardiovasc Surg 2006; 131:1314-22. [PMID: 16733164 DOI: 10.1016/j.jtcvs.2006.01.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [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: 10/16/2005] [Revised: 12/20/2005] [Accepted: 01/12/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Reliable platelet function monitoring is desirable in patients treated with glycoprotein IIb/IIIa receptor inhibitors. The aim of the present laboratory-based study was to assess platelet function after administration of clinically relevant doses of the glycoprotein IIb/IIIa antagonist tirofiban with or without heparin by using Sonoclot (Sienco Inc) and platelet aggregometry. METHODS Tirofiban (0-100 ng x mL(-1)) and heparin (0 or 1 U x mL(-1)) were added to blood samples obtained from 20 healthy volunteers. Coagulation analysis was performed on citrated whole blood by using the Sonoclot analyzer. The glass bead-activated test and the new glass bead test with heparinase were used. The results were compared with adenosine-5'-diphosphate-activated platelet aggregometry. RESULTS Administration of tirofiban showed a similar increase of platelet inhibition detected with the Sonoclot glass bead-activated test and glass bead test with heparinase, as well as by means of aggregometry. Bias between the different techniques was comparable; Spearman rank correlation was strong (glass bead-activated test vs aggregometry: rho = 0.823, P < .001; glass bead test with heparinase vs aggregometry: rho = 0.856, P < .001). After additional administration of heparin, platelet inhibition was only comparable for the glass bead test with heparinase and aggregometry, and the correlation coefficient remained unchanged for the glass bead test with heparinase versus aggregometry (rho = 0.878, P < .001). By contrast, the glass bead-activated test showed a nearly complete platelet inhibition with a significant bias compared with the glass bead test with heparinase and aggregometry. Correlation was weak for the glass bead-activated test versus aggregometry (rho = 0.407, P = .004). CONCLUSIONS When compared with platelet aggregometry, the glass bead-activated test from Sonoclot reliably detects glycoprotein IIb/IIIa receptor inhibition with tirofiban in unheparinized whole blood. However, in heparinized blood the glass bead test with heparinase is essential to accurately assess platelet function.
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Affiliation(s)
- Michael A Tucci
- Institute of Anaesthesiology, University Hospital Lausanne, Lausanne, Switzerland
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Abstract
BACKGROUND In order to improve perioperative subjective quality of care it seems desirable to shorten preoperative fasting times as much as possible within acceptable safety limits. These efforts should result in a measurable reduction of preoperative thirst and hunger as well as in improvements of patient well-being. It is unknown to what extent preoperative patient comfort is limited by thirst and hunger from a patient point of view. The purpose of this study was to determine the impact of a traditional fasting regimen on preoperative patient discomfort. PATIENTS AND METHODS We conducted a survey on preoperative thirst and hunger in 412 adult American Society of Anesthesiologists ASA I and II patients scheduled for minor elective surgery. RESULTS Of the patients 33% complained of moderate to strong thirst, whereas 19% had moderate to strong hunger, 47% of the participants would have liked to have been able to drink and 72% would have appreciated a light breakfast before surgery. Mean preoperative fasting times were 12.8+/-3.4 h for fluids and 15.5+/-4.4 h for solids. "Thirst" was named by 3.3% and "hunger" by 0.8% of patients as the most important factor for preoperative discomfort but "long wait" (8.5%), "tenseness" (6.5%) and "anxiety" (4.8%) were the most frequently named factors. Answers were independent of the duration of preoperative fasting. CONCLUSION Patient comfort is compromised by traditional fasting rules and liberalization of these policies is desired by patients. However, efforts to reduce preoperative anxiety and tenseness might have an additional, important potential to improve perioperative quality of care from a patient's perspective.
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Affiliation(s)
- L Furrer
- Institut für Anästhesiologie und Intensivmedizin, Stadtspital Triemli, Birmensdorferstrasse 497, 8063 Zürich
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Ganter MT, Ware LB, Howard M, Roux J, Gartland B, Matthay MA, Fleshner M, Pittet JF. Extracellular heat shock protein 72 is a marker of the stress protein response in acute lung injury. Am J Physiol Lung Cell Mol Physiol 2006; 291:L354-61. [PMID: 16679378 PMCID: PMC2765126 DOI: 10.1152/ajplung.00405.2005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Previous studies have shown that heat shock protein 72 (Hsp72) is found in the extracellular space (eHsp72) and that eHsp72 has potent immunomodulatory effects. However, whether eHsp72 is present in the distal air spaces and whether eHsp72 could modulate removal of alveolar edema is unknown. The first objective was to determine whether Hsp72 is released within air spaces and whether Hsp72 levels in pulmonary edema fluid would correlate with the capacity of the alveolar epithelium to remove alveolar edema fluid in patients with ALI/ARDS. Patients with hydrostatic edema served as controls. The second objective was to determine whether activation of the stress protein response (SPR) caused the release of Hsp72 into the extracellular space in vivo and in vitro and to determine whether SPR activation and/or eHsp72 itself would prevent the IL-1beta-mediated inhibition of the vectorial fluid transport across alveolar type II cells. We found that eHsp72 was present in plasma and pulmonary edema fluid of ALI patients and that eHsp72 was significantly higher in pulmonary edema fluid from patients with preserved alveolar epithelial fluid clearance. Furthermore, SPR activation in vivo in mice and in vitro in lung endothelial, epithelial, and macrophage cells caused intracellular expression and extracellular release of Hsp72. Finally, SPR activation, but not eHsp72 itself, prevented the decrease in alveolar epithelial ion transport induced by exposure to IL-1beta. Thus SPR may protect the alveolar epithelium against oxidative stress associated with experimental ALI, and eHsp72 may serve as a marker of SPR activation in the distal air spaces of patients with ALI.
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Affiliation(s)
- Michael T Ganter
- Department of Anesthesia, University of California, San Francisco, 94110, USA.
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Tang JF, Pittet JF, Ganter MT. Bring Rapidly Degradable Hydroxyethyl Starch to the United States. Anesthesiology 2006; 104:1105-6; author reply 1106. [PMID: 16645466 DOI: 10.1097/00000542-200605000-00032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hofer CK, Ganter MT, Matter-Ensner S, Furrer L, Klaghofer R, Genoni M, Zollinger A. Volumetric assessment of left heart preload by thermodilution: comparing the PiCCO-VoLEF system with transoesophageal echocardiography. Anaesthesia 2006; 61:316-21. [PMID: 16548948 DOI: 10.1111/j.1365-2044.2006.04537.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [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: 11/29/2022]
Abstract
The new Volumetric Ejection Fraction monitoring system (VoLEF), when combined with the Pulse Contour Cardiac Output monitoring system (PiCCO) system, allows measurement of left and right heart end-diastolic volumes by thermodilution. The aim of this study was to evaluate whether the left heart end-diastolic volume index determined by the VoLEF system (LHEDI) better reflects left ventricular end-diastolic area index (LVEDAI) measured by transoesophageal echocardiography than does global end-diastolic volume index (GEDI) measured by the PiCCO system alone. Following induction of anaesthesia, PiCCO, VoLEF and transoesophageal echocardiography measurements were performed before and after a fluid challenge in 20 patients scheduled for elective cardiac surgery. Both left ventricular end-diastolic area index and global end-diastolic volume index, but not left heart end-diastolic volume index, significantly increased after fluid administration. Mean bias +/- 2 SD for DeltaLHEDI-DeltaLVEDAI was -2.2 +/- 32.0% and for DeltaGEDI-DeltaLVEDAI -0.6 +/- 16.8%. In contrast to global end-diastolic volume index, the use of left heart end-diastolic volume index determined by the VoLEF system cannot be recommended as an estimate of left ventricular preload.
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Affiliation(s)
- C K Hofer
- Consultant, Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Birmensdorferstr. 497, 8063 Zurich, Switzerland.
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Hofer CK, Ganter MT, Zollinger A. Evaluation of a modified ThermoWrap for the Allon warming system in patients undergoing elective off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2006; 131:929-30. [PMID: 16580465 DOI: 10.1016/j.jtcvs.2005.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Revised: 11/05/2005] [Accepted: 11/16/2005] [Indexed: 11/30/2022]
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Dalbert S, Ganter MT, Furrer L, Klaghofer R, Zollinger A, Hofer CK. Effects of heparin, haemodilution and aprotinin on kaolin-based activated clotting time: in vitro comparison of two different point of care devices. Acta Anaesthesiol Scand 2006; 50:461-8. [PMID: 16548858 DOI: 10.1111/j.1399-6576.2006.00990.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND During cardiopulmonary bypass (CPB), measurement of kaolin-based activated clotting time (kACT) is a standard practice in monitoring heparin-induced anticoagulation. Despite the fact that the kACT test from the Sonoclot Analyzer (SkACT) has been commercially available for several years, no published data on the performance of SkACT are available. Thus, the aim of this in vitro study was to compare SkACT with an established kACT from Hemochron (HkACT). METHODS Blood was withdrawn from 25 patients before elective cardiac surgery. SkACT and HkACT were measured in duplicate after in vitro administration of heparin (0, 1, 2 and 3 U/ml), calcium-free lactated Ringer's solution (25% and 50% haemodilution) and aprotinin (200 kIU/ml). RESULTS A total of 600 duplicate kACT measurements were obtained from 25 cardiac surgery patients. Overall, mean bias +/- SD between SkACT and HkACT was 7 +/- 70 s (1.3% +/- 14.1%). Administration of heparin, haemodilution and aprotinin induced a comparable effect on both activated clotting time (ACT) tests. Mean bias ranged from -4 +/- 39 s (-1.7% +/- 12.9%) to 4 +/- 78 s (3.2% +/- 15.6%) for heparinzed blood samples after haemodilution or aprotinin application and increased after combined aprotinin administration and haemodilution. After haemodilution and administration of aprotinin, both ACT tests were less reliable for values >480 s in heparinized blood samples. CONCLUSION Accuracy and performance of SkACT and HkACT were comparable after in vitro administration of heparin, aprotinin and haemodilution. Both ACT tests were considerably affected by aprotinin and haemodilution.
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Affiliation(s)
- S Dalbert
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Zurich, Switzerland
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