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Mittal AM, Nowicki KW, Mantena R, Cao C, Rochlin EK, Dembinski R, Lang MJ, Gross BA, Friedlander RM. Advances in biomarkers for vasospasm - Towards a future blood-based diagnostic test. World Neurosurg X 2024; 22:100343. [PMID: 38487683 PMCID: PMC10937316 DOI: 10.1016/j.wnsx.2024.100343] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 02/21/2024] [Indexed: 03/17/2024] Open
Abstract
Objective Cerebral vasospasm and the resultant delayed cerebral infarction is a significant source of mortality following aneurysmal SAH. Vasospasm is currently detected using invasive or expensive imaging at regular intervals in patients following SAH, thus posing a risk of complications following the procedure and financial burden on these patients. Currently, there is no blood-based test to detect vasospasm. Methods PubMed, Web of Science, and Embase databases were systematically searched to retrieve studies related to cerebral vasospasm, aneurysm rupture, and biomarkers. The study search dated from 1997 to 2022. Data from eligible studies was extracted and then summarized. Results Out of the 632 citations screened, only 217 abstracts were selected for further review. Out of those, only 59 full text articles met eligibility and another 13 were excluded. Conclusions We summarize the current literature on the mechanism of cerebral vasospasm and delayed cerebral ischemia, specifically studies relating to inflammation, and provide a rationale and commentary on a hypothetical future bloodbased test to detect vasospasm. Efforts should be focused on clinical-translational approaches to create such a test to improve treatment timing and prediction of vasospasm to reduce the incidence of delayed cerebral infarction.
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Affiliation(s)
- Aditya M. Mittal
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | | | - Rohit Mantena
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Catherine Cao
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Emma K. Rochlin
- Loyola University Stritch School of Medicine, Maywood, IL, USA
| | - Robert Dembinski
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Michael J. Lang
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Bradley A. Gross
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Robert M. Friedlander
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
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Gilmore R, Chen J, Dembinski R, Reissis Y, Milek D, Cadena L, Habibi M. Cost minimization in breast conserving surgery: a comparative study of radiofrequency spectroscopy and full cavity shave margins. Cost Eff Resour Alloc 2023; 21:66. [PMID: 37716980 PMCID: PMC10504787 DOI: 10.1186/s12962-023-00477-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full Cavity Shave (FCS) approach or adding the MarginProbe Radiofrequency Spectroscopy System. OBJECTIVE We sought to create a functioning Pro-Forma for use by facilities and payers to evaluate and compare the cost savings of implementing FCS or MarginProbe based on personalized variable inputs. METHODS A decision tree demonstrating three possible surgical pathways, BCS, BCS + FCS, and BCS + MarginProbe was developed with clinical inputs for re-excision rate, mastectomy as 2nd surgery, rate of reconstruction, and rate of 3rd surgery derived by a literature review. A surgical pathway cost formula was created using the decision tree and financial inputs derived by utilizing the nation's largest database of privately billed health insurance claims and Medicare claims data (fairhealth.org). Using the surgical pathway formula and financial inputs, a customizable Pro-Forma was created for immediate cost savings analysis of BCS + FCS and BCS + Marginprobe using variable inputs. Costs are from the perspective of third-party payers. RESULTS Utilizing MarginProbe to reduce re-excisions for positive margins can be associated with better cost-savings than FCS due to the increased pathology processing costs by using an FCS approach. The reduction in re-excision provided by both FCS and MarginProbe offset their increased expense to various degrees with cost savings of each method improving as baseline re-excisions rates increase, until ultimately each may become cost-neutral or cost-prohibitive when compared to BCS alone. Our data suggest that in the privately insured population, MarginProbe provides a cost-savings over BCS alone when baseline re-excision rates are over 20% and that FCS becomes cost-saving when baseline re-excision rates are over 29%. For Medicare patients, MarginProbe provides a cost-savings when baseline re-excision rates exceed 34%, and FCS becomes cost-saving for re-excision rates over 52%. Our Pro-Forma allows an individual provider or institution to evaluate the cost savings of the FCS approach and/or utilization of the MarginProbe device such that the additional cost or cost-savings of utilizing one or both of these methods can be quickly calculated based on their facility's volume and baseline re-excision rate. CONCLUSIONS Our data suggest that utilizing either an FCS approach or the MarginProbe radiofrequency spectroscopy system may be a cost-saving solution to reducing the rate of re-excisions depending on a facility or practice's surgical volume and baseline re-excision rate. The degree to which each of these interventions provides an added cost or cost-savings to healthcare payers can be evaluated by utilizing the Pro-Forma outlined herein with customizable variable inputs.
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Affiliation(s)
- Richard Gilmore
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Jennifer Chen
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Robert Dembinski
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Yannis Reissis
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - David Milek
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Lisa Cadena
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Mehran Habibi
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA.
- Department of Surgery, Northwell Health, Zucker School of Medicine, New York, United States.
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Alan N, Deng H, Muthiah N, Vodovotz L, Dembinski R, Guha D, Agarwal N, Ozpinar A, Hamilton DK, Kanter AS, Okonkwo DO. Graft subsidence and reoperation after lateral lumbar interbody fusion: a propensity score-matched and cost analysis of polyetheretherketone versus 3D-printed porous titanium interbodies. J Neurosurg Spine 2023:1-9. [PMID: 37178027 DOI: 10.3171/2023.4.spine22492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 04/03/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Lumbar interbody cage subsidence has a multifactorial etiology. Cage material, although well studied after transforaminal lumbar interbody fusion, has not been investigated as a contributing factor to subsidence after lateral lumbar interbody fusion (LLIF). In this study the authors compared rates of subsidence and reoperation after LLIF between polyetheretherketone (PEEK) and 3D-printed porous titanium (pTi) in an institutional propensity score-matched and cost analysis. METHODS This is a retrospective observational cohort analysis of adult patients who underwent LLIF with pTi versus PEEK between 2016 and 2020. Demographic, clinical, and radiographic characteristics were collected. Propensity scores were calculated and 1:1 matching without replacement of surgically treated levels was performed. The primary outcome of interest was subsidence. The Marchi subsidence grade was determined at the time of last follow-up. Chi-square or Fisher's exact tests were used to compare subsidence and reoperation rates between lumbar levels treated with PEEK versus pTi. Modeling and cost analysis were performed using TreeAge Pro Healthcare. RESULTS The authors identified a total of 192 patients; 137 underwent LLIF with PEEK (212 levels) and 55 had LLIF with pTi (97 levels). After propensity score matching, a total of 97 lumbar levels remained in each treatment group. After matching, there were no statistically significant differences between groups in baseline characteristics. Levels treated with pTi were significantly less likely to exhibit subsidence (any grade) compared to those treated with PEEK (8% vs 27%, p = 0.001). Five (5.2%) levels treated with PEEK required reoperation for subsidence, but only 1 (1.0%) level treated with pTi required reoperation for subsidence (p = 0.12). Given subsidence and revision rates experienced in the cohorts in this study, the pTi interbody device is economically superior to PEEK in a single-level LLIF as long as its cost is at least $1185.94 lower than that of PEEK. CONCLUSIONS The pTi interbody device was associated with less subsidence, but statistically similar revision rates after LLIF. pTi is potentially a superior economic choice at this study's reported revision rate.
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Affiliation(s)
- Nima Alan
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Hansen Deng
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Nallammai Muthiah
- 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lena Vodovotz
- 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert Dembinski
- 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Daipayan Guha
- 3Department of Neurological Surgery, University of Toronto, Ontario, Canada; and
| | - Nitin Agarwal
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Alp Ozpinar
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - D Kojo Hamilton
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Adam S Kanter
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - David O Okonkwo
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
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Abstract
Although the Berlin definition of the acute respiratory distress syndrome (ARDS) is generally recognized, the differentiation from other diseases with severe gas exchange disturbances is often difficult in clinical practice. In particular, the assessment of radiological findings and identification of primary noncardiogenic lung edema pose problems. In ARDS typical inflammatory processes can be found with involvement of activated neutrophilic granulocytes. Anti-inflammatory treatment strategies were unsuccessful. Lung protective ventilation strategies and prone positioning are the only evidence-based treatment options. Identifying ARDS phenotypes according to the etiology or disease progression can possibly provide a targeted individualized treatment option. The control of various biomarkers for assessment and treatment is the main focus of scientific interest. The results of appropriate studies remain to be seen.
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Affiliation(s)
- R Dembinski
- Klinik für Intensivmedizin und Notfallmedizin, Klinikum Bremen Mitte, St. Jürgen-Str. 1, 28177, Bremen, Deutschland.
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Sweren E, Aravind P, Dembinski R, Klein C, Habibi M, Kerns ML. Radiation recall dermatitis following letrozole administration in patient with a remote history of radiation therapy. NPJ Breast Cancer 2021; 7:62. [PMID: 34039983 PMCID: PMC8155087 DOI: 10.1038/s41523-021-00271-3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 04/19/2021] [Indexed: 11/29/2022] Open
Abstract
We report the case of letrozole-induced radiation recall dermatitis (RRD) in a patient with a remote history of radiation therapy. There is only one previously known case of RRD triggered by letrozole in a patient with a recent (<3 month) history of radiation. Previously, only four other cases of aromatase-inhibitor-induced RRD have been reported. This case is significant for cancer care teams considering personalized treatments. In addition, improved long-term outcomes in cancer patients may lead to increases in and underdiagnoses of RRD. Likewise, RRD is patient specific, exacerbating health concerns, and can be difficult to recognize without proper awareness, documentation, and classification of triggering drugs. The authors hope to address these issues in this report.
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Affiliation(s)
- Evan Sweren
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pathik Aravind
- Department of Surgery, Johns Hopkins Hospital, Bayview Campus, Baltimore, MD, USA
| | - Robert Dembinski
- Department of Surgery, Johns Hopkins Hospital, Bayview Campus, Baltimore, MD, USA
| | - Catherine Klein
- Department of Surgery, Johns Hopkins Hospital, Bayview Campus, Baltimore, MD, USA
| | - Mehran Habibi
- Department of Surgery, Johns Hopkins Hospital, Bayview Campus, Baltimore, MD, USA
| | - Michelle L Kerns
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Dembinski R, Prasath V, Bohnak C, Siotos C, Sebai ME, Psoter K, Gani F, Canner J, Camp MS, Azizi A, Jacobs L, Habibi M. Estrogen Receptor Positive and Progesterone Receptor Negative Breast Cancer: the Role of Hormone Therapy. Discov Oncol 2020; 11:148-154. [PMID: 32519274 DOI: 10.1007/s12672-020-00387-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/01/2020] [Indexed: 11/26/2022] Open
Abstract
ER+/PR- (estrogen receptor positive and progesterone receptor negative) tumors constitute only a small portion of the breast cancer population. Patients with ER+/PR- tumors, however, are characterized by worse survival compared to patients with ER+/PR+ (estrogen receptor positive and progesterone receptor positive) tumors. Controversy exists regarding the efficacy of hormone blocking therapy for patients with ER+/PR- tumors. The NCDB was queried between 2004 and 2015, and patients with invasive ER+/PR- tumors were identified. We employed univariate Cox proportional hazards to compare outcomes among patients that did or did not receive hormone blocking therapy. We identified 138,398 patients with invasive ER+/PR- tumors, 32,044 (23%) of whom did not receive hormone blocking therapy. The reasons for not receiving hormone blocking therapy included contraindications to treatment, death, patient refusal, and unknown. There were no significant differences in race, income quartile, or education quartile between patients who did and did not receive hormone blocking therapy. Patients who did not receive hormone blocking therapy underwent surgical assessment of the axilla more frequently than those who did receive hormone therapy. Our analysis demonstrated that hormone blocking therapy administration was associated with increased overall survival for up to 10 years of follow up (HR: 0.58; 95% CI: 0.56-0.59, p < 0.001). Hormone blocking therapy may be associated with increased survival for breast cancer patients with ER+/PR- tumors. Although this benefit may last for years after completion of the course, up to 25% of patients do not receive this treatment. Strategies to increase the utilization and adherence to hormone blocking therapy regimens may improve patient survival outcomes.
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Affiliation(s)
- Robert Dembinski
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Vishnu Prasath
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Carisa Bohnak
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Charalampos Siotos
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Mohamad E Sebai
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Kevin Psoter
- Department of Pediatrics, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Joe Canner
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Melissa S Camp
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Armina Azizi
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Lisa Jacobs
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Mehran Habibi
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Bayview Campus, Building A, 5th Floor, 4940 Eastern Avenue, Baltimore, MD, 21224, USA.
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7
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Dembinski R, Scholtyschik D. Die Larynxmaske – Schritt für Schritt. Pneumologie 2019; 73:686-691. [DOI: 10.1055/a-0947-3446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Sommerer A, Dembinski R, Max M, Kuhlen R, Kaisers U, Rossaint R. Effects of combined high-dose partial liquid ventilation and almitrine on pulmonary gas exchange and hemodynamics in an animal model of acute lung injury. Intensive Care Med 2014; 27:574-9. [PMID: 11355128 DOI: 10.1007/s001340000847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine possible additive effects of combined high-dose partial liquid ventilation (PLV) and almitrine bismesylate (ALM) on pulmonary gas exchange and hemodynamics in an animal model of acute lung injury (ALI). DESIGN AND SETTING Prospective, controlled animal study in an animal research facility of a university hospital. INTERVENTIONS ALI was induced in 12 anesthetized and mechanically ventilated pigs by repeated wash-out of surfactant. After initiation of PLV with 30 ml/kg perfluorocarbon the animals were randomly assigned to receive either accumulating doses of ALM (0.5, 1.0, 2.0, 4.0, 8.0, and 16.0 micrograms/kg per minute) for 30 min each (n = 6) or the solvent malic acid (n = 6). MEASUREMENT AND RESULTS Pulmonary gas exchange and hemodynamics were measured at the end of each infusion period. Compared to ALI, PLV alone significantly increased arterial oxygen partial pressure (PaO2) and decreased venous admixture (QVA/QT) and mean pulmonary artery pressure (MPAP). Administration of ALM did not result in a further improvement in PaO2, QVA/QT or MPAP compared to PLV alone but decreased PaO2 and increased QVA/QT and MPAP when 16 micrograms/kg per min ALM was compared to PLV alone. CONCLUSIONS In an animal model of surfactant depletion induced ALI the combined treatment of PLV and ALM induced no significant improvement in pulmonary gas exchange or hemodynamics when compared to PLV alone. Moreover, high-dose ALM significantly impaired gas exchange and pulmonary hemodynamics.
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Affiliation(s)
- A Sommerer
- Klinik für Anästhesiologie, Universitätsklinikum, RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
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Abstract
Treatment of patients suffering from acute lung injury is a challenge for the treating physician. In recent years ventilation of patients with acute hypoxic lung injury has changed fundamentally. Besides the use of low tidal volumes, the most beneficial setting of positive end-expiratory pressure (PEEP) has been in the focus of researchers. The findings allow adaption of treatment to milder forms of acute lung injury and severe forms. Additionally computed tomography techniques to assess the pulmonary situation and recruitment potential as well as bed-side techniques to adjust PEEP on the ward have been modified and improved. This review gives an outline of recent developments in PEEP adjustment for patients suffering from acute hypoxic and hypercapnic lung injury and explains the fundamental pathophysiology necessary as a basis for correct treatment.
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Affiliation(s)
- C S Bruells
- Klinik für Anästhesiologie, Universitätsklinikum Aachen, Aachen, Deutschland.
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10
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Bickenbach J, Fries M, Offermanns V, Von Stillfried R, Rossaint R, Marx G, Dembinski R. Impact of early vs. late tracheostomy on weaning: a retrospective analysis. Minerva Anestesiol 2011; 77:1176-1183. [PMID: 21617598] [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: 05/30/2023]
Abstract
BACKGROUND Early tracheostomy has been advocated for a number of reasons. Especially in association with weaning from mechanical ventilation, it is known that an early timepoint can help patients being weaned more rapidly from the ventilator. However, timing of tracheostomy is still unknown and evidence is lacking. The effects of early tracheostomy compared with intermediate and late tracheostomy were assessed in critically ill patients. METHODS Data collected from January 2005 to December 2007 were conducted for retrospective analysis. All patients needing tracheostomy due to extubation failure and/or weaning failure were included (N.=296). Early tracheostomy (ET) was defined as ≤4 days, intermediate tracheostomy (IT) as tracheostomy within 5-9 days, and late tracheostomy (LT) was defined as ≥10 days after endotracheal intubation. After proving normal distribution, significant changes between the three groups were tested by ANOVA followed by post hoc tests for multiple comparisons (Bonferroni's test). RESULTS Intensive care unit (ICU) mortality was significantly higher in the LT group when being compared with the ET but not when being compared with the IT group (40.7% vs. 24.8% vs. 17.1%). Further, a significantly reduced incidence of VAP and sepsis, a smaller amount of ventilator days and a shorter ICU length of stay could be observed for the ET group. Length of weaning was not significantly different between the groups. CONCLUSION The length of weaning after tracheostomy is not affected by the timing. It seems beneficial to favour early tracheostomy in order to reduce the time of mechanical ventilation and its associated risks.
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Affiliation(s)
- J Bickenbach
- Department of Intensive Care, University Hospital Aachen, RWTH Aachen University, Aachen, Germany.
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Bickenbach J, Fries M, Rex S, Stitz C, Heussen N, Rossaint R, Marx G, Dembinski R. Outcome and mortality risk factors in long-term treated ICU patients: a retrospective analysis. Minerva Anestesiol 2011; 77:427-438. [PMID: 21483387] [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: 05/30/2023]
Abstract
BACKGROUND Little is known about the prognosis and outcome of critically ill patients with a prolonged length of stay (LOS). The aim of this study was to examine mortality and its risk factors in patients requiring intensive care therapy for more than 30 days. METHODS A retrospective, single-center analysis of data collected in a surgical intensive care unit (ICU) of a university hospital in Germany from 2005 to 2007 was conducted. All demographic data and clinical variables were collected. A univariate analysis followed by multivariate regression was performed to detect the relevant risk factors for short and long-term mortality. RESULTS Altogether, 10 737 patients were admitted to the ICU; 136 patients fulfilled the criteria for long-term treatment, 75% (N=102) of whom were discharged from ICU. The one-year survival rate was 61.8% (N=60). The most significant risk factors were pulmonary compromise with prolonged mechanical ventilation and infectious disorders leading to sepsis. However, sepsis was not a predictor of outcome. Weaning failure was present in 67.6% (N=92) at day 30 but was reduced to 37.5% of the cases (N=51) over the total course of the stay. Acute and long-term prognoses were determined by a successful weaning. CONCLUSION Although the long-term treatment of critically ill patients requires significant effort, the outcome for this particular cohort was reasonably favorable. Prolonged mechanical ventilation and weaning are the factors that influence mortality independently of sepsis. Because reasonable improvements can be shown even after a prolonged LOS, further attention should be paid to weaning processes.
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Affiliation(s)
- J Bickenbach
- Department of Intensive Care, University Hospital Aachen, RWTH Aachen University, Germany.
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12
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Beckers SK, Rex S, Kopp R, Bickenbach J, Sopka S, Rossaint R, Dembinski R. [Intensive care medicine as a component of the compulsory medical curriculum. Evaluation of a pilot curriculum at the University Hospital Aachen]. Anaesthesist 2009; 58:273-9, 282-4. [PMID: 19189064 DOI: 10.1007/s00101-008-1501-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In order to provide early achievement of practical experience during medical education, the medical faculty of the university Aachen has developed a new medical school curriculum which was offered in 2003 for the first time. In this curriculum anaesthesiology became a compulsory subject with practical training both in the operation theatre and in emergency medicine. Accordingly, a practical course in the field of intensive care medicine has also been designed with respect to the planned schedule and personnel resources. This course was evaluated by both students and teaching staff in a written, anonymous form as a quality control. METHODS A dedicated course was developed for medical students of the 8th and 9th semesters. In this course comprised of 6 students and lasting 1 week, practical training is provided by intensive care physicians and accompanied by theoretical lessons focusing on the definition, diagnosis, therapy and prophylaxis of sepsis, essentials of mechanical ventilation and patient presentation at the bedside during daily rounds. On the last day of training students were required to present patients by themselves thereby recapitulating the acquired knowledge. In the summer semester 2007 this intensive care training course was offered for the first time. All participating 83 students and 23 physicians involved in teaching evaluated the course with marks from 1 to 6 according to the standard German school grading system using an online questionnaire. RESULTS Students rated the course with 1.6+/-0.7 (mean +/- SD) for comprehensibility, with 1.6+/-0.7 for structural design, and with 1.7+/-0.7 for agreement between teachers. They graded their personal learning success with 1.7+/-0.7. With a cumulative mark of 1.7+/-0.6, the course was ranked as 1 of the top 3 courses of the medical faculty from the very beginning. The majority of the teaching staff (80%) appreciated the focus on few selected teaching subjects. However, comprehensibility, structural design, agreement between teachers and personal learning success were graded one mark worse than by the students. CONCLUSIONS According to the results, efficiency and acceptance of intensive care training courses were high. Major criteria for the high grading were a limited number of participants, the focus on few subjects, and a clear structural design. However, according to several personal notes from the students, simulation-based sessions and written teaching material might further improve success of this course.
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Affiliation(s)
- S K Beckers
- Klinik für Anästhesiologie, Universitätsklinikum Aachen, Rheinisch-Westfälische Technische Hochschule (RWTH), Aachen.
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Krüger S, Frechen D, Das M, Dembinski R, Noll E. Dyspnea lusoria. Pneumologie 2009; 63:205-6. [DOI: 10.1055/s-0028-1119677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in critical care medicine and has been shown to be an independent risk factor for mortality. However, ventilator induced lung injury itself is probably only a minor factor predisposing to VAP. In contrast, invasive ventilation using an endotracheal tube is obviously a more important measure. Thus, microaspiration of potentially infectious secretion from the oropharynx into the trachea along the tube has been suggested to be the most critical pathophysiological event in the process of VAP development. Accordingly, non-invasive ventilation provides a decreased risk of VAP. Therefore, all measures aimed at averting microaspiration or shorten the duration of mechanical ventilation are appropriate to prevent VAP. Moreover, oropharyngeal decontamination may be helpful by reducing bacterial colonisation. Effectiveness of therapy depends on early treatment and therefore requires early diagnosis. With this aim combined clinical, radiologic, and microbiological parameters should be taken into account. Adequate antimicrobial therapy in due consideration for individual risk factors and local antibiotic resistance is the most important therapeutic measure.
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Affiliation(s)
- R Dembinski
- Abteilung für Operative Intensivmedizin, Universitätsklinikum der RWTH-Aachen, Pauwelsstrasse 30, 52074, Aachen, Deutschland.
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Bickenbach J, Rossaint R, Autschbach R, Dembinski R. A new technique to visualize alveolar dynamics in a rabbit model. Thorac Cardiovasc Surg 2009. [DOI: 10.1055/s-0029-1191737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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16
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Kuhlen R, Dembinski R. [Mechanical ventilation of acute lung injury]. Pneumologie 2007; 61:249-55. [PMID: 17455139 DOI: 10.1055/s-2007-959172] [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] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute lung injury (ALI) is of paramount importance for modern intensive care since it is one of the most frequent conditions necessitating admission to an ICU. ALI is characterised by severe life threatening hypoxemia which is based on ventilation perfusion mismatching within the lung. This is mostly resulting from atelectasis formation due to primary or secondary inflammation of lung tissue. Many studies showed that this inflammatory process is not restricted to the respiratory system but might result in non pulmonary organ failure and hemodynamic compromise as well. Mechanical ventilation is considered the hallmark treatment for ALI patients aimed to recruit lung tissue and thereby reverse hypoxemia without causing additional lung injury potentially resulting from overdistention or cycling collapse during expiration. Scientific evidence shows us that prevention of ventilator induced lung injury by protective ventilation with reduced tidal volumes is resulting in better clinical outcomes. Moreover, different technologies and adjunctive therapies have been suggested based on their pathophysiology. All these treatment options will be summarized in this article. Given the clear evidence for protective ventilation and bearing in mind that clinical application of this easy concept is still not widespread we will focus on this aspect.
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Affiliation(s)
- R Kuhlen
- Klinik für Intensivmedizin, Helios Klinikum Berlin Buch.
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17
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Dembinski R, Kopp R, Kuhlen R. Beatmung bei Sepsis. Dtsch Med Wochenschr 2006; 131:2223-8. [PMID: 17021992 DOI: 10.1055/s-2006-951357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- R Dembinski
- Abteilung für Operative Intensivmedizin für Erwachsene, Universitätsklinikum Aachen, RWTH Aachen
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Kopp R, Dembinski R, Kuhlen R. Role of extracorporeal lung assist in the treatment of acute respiratory failure. Minerva Anestesiol 2006; 72:587-95. [PMID: 16682933] [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: 05/09/2023]
Abstract
For patients with most severe acute respiratory distress syndrome (ARDS) conservative treatment with lung protective ventilation is often not sufficient to prevent life-threatening hypoxemia and additional strategies are necessary. Extracorporeal lung assist (ECLA) or extracorporeal membrane oxygenation (ECMO) using capillary membrane oxygenators can provide sufficient gas exchange and lung rest. In 2 randomized trials mortality was unchanged for ECMO. Today an technically enhanced ECMO is used for most severe ARDS using clinical algorithm and different case studies demonstrated a survival rate about 56%. Today miniaturized ECMO with optimized blood pumps and oxygenators are available and could enhance safety and clinical management. Another approach is an arterio-venous pumpless interventional lung assist (ILA) with a low resistance oxygenator. Advantages seem a simplified clinical management and less blood trauma. At present new devices are developed for chronic respiratory failure or bridge to lung transplant. Oxygenators with even less flow resistance could be implanted paracorporeal using the right ventricle as driving force. An intravascular oxygenator has been developed using the combination of a miniaturized blood pump and an oxygenator for implantation in the vena cava. Well designed clinical trials are necessary to demonstrate a clinical benefit for these experimental devices.
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Affiliation(s)
- R Kopp
- Department of Surgical Intensive Care Medicine University Hospital Aachen RWTH Aachen University, Aachen, Germany
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19
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Dembinski R. [Pulmonary hypertension]. Anaesthesist 2006; 55:195-212; quiz 213-4. [PMID: 16463075 DOI: 10.1007/s00101-006-0980-0] [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] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pulmonary hypertension can arise in the presence of acute cardiopulmonary decompensation or develop as a chronic and progressive disease in association with connective tissue diseases, infectious diseases, or metabolic diseases, or in the form of idiopathic pulmonary hypertension. Impaired regulation of endogenous vasoactive mediators, growth factors, and thrombotic factors leads to pulmonary artery vasoconstriction, endothelial and epithelial proliferation, and thrombotic vascular obstruction, with resulting right heart failure. There is no curative treatment for chronic pulmonary hypertension, and the immediate objective of palliative treatment is to relieve right heart stress by reducing pulmonary arterial pressure with the aid of pulmonary vasodilators. Depending on the severity of the illness, perioperative mortality is high, which must be borne in mind by both anesthetists and intensivists. Chronic medical treatment for these patients must be optimized before any surgery is undertaken. In the perioperative period, it is essential that anything that could lead to worsening of pulmonary hypertension is avoided, or at least recognized and treated at an early stage. Intraoperatively, imminent acute right heart decompensation is treated by improving right-ventricular contractility and reducing right-ventricular afterload. In the postoperative period, monitoring and optimization of the cardiopulmonary status, adequate analgesia and sedation, and careful anticoagulation must be ensured.
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Affiliation(s)
- R Dembinski
- Abteilung für Operative Intensivmedizin, Universitätsklinikum, RWTH, Aachen.
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Lotfi S, Brackhahn W, Christiansen S, Kuhlen R, Autschbach R, Dembinski R. Cardiopulmonary effects of inhaled and i.v. administered Iloprost in experimental acute lung injury in pigs. Thorac Cardiovasc Surg 2006. [DOI: 10.1055/s-2006-925739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bensberg R, Dembinski R, Kopp R, Kuhlen R. Artificial lung and extracorporeal gas exchange. Panminerva Med 2005; 47:11-7. [PMID: 15985973] [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: 05/03/2023]
Abstract
Over the last years, several observational studies have suggested that extracorporeal lung assist (ECLA) may be an important contribution to clinical algorithms for the treatment of most severe acute respiratory distress syndrome (ARDS). Today ECLA is used only as a rescue therapy in life threatening gas exchange disorders if maximal conventional therapy fails to prevent from hypoxemia. With subsequent reduction of complications and improvement of biocompability, extracorporeal membrane oxygentation (ECMO) indications may be extendend to treat patients earlier and not only in rescue situations along the original idea to buy the lung some time to heal by avoiding further ventilator associated lung injury. Veno-venous ECMO therapy at present is an important therapeutic option in severe ARDS with persisiting life threatening gas exchange disorder as a rescue therapy. The development of smaller, less complex and more secure ECMO or pumpless veno-arterial ECLA systems has the potential to perform controlled studies of its use in ARDS and potentially expand indications.
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Affiliation(s)
- R Bensberg
- Department of Intensive Care Medicine, University Hospital Aachen, Aachen, Germany.
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22
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Abstract
Iloprost, a prostacyclin analogue with a prolonged plasma half-life has beneficial effects in chronic pulmonary hypertension, whereas the effects in acute lung injury (ALI) are unknown. The present study was performed to evaluate the cardiopulmonary effects of iloprost in experimental ALI. ALI was induced in 18 pigs by repeated lung lavage. Animals were randomised to controls, i.v. or inhaled iloprost for 15 min. Haemodynamics, gas exchange and ventilation-perfusion distribution were measured at the end of iloprost application and after 1 and 2 h. As a short-term effect, both i.v. and inhaled iloprost significantly decreased pulmonary artery pressure without major effects on gas exchange or systemic haemodynamics. After 1 and 2 h, a reduction of pulmonary hypertension was no longer present. As a long-term effect, inhaled, but not i.v., iloprost decreased pulmonary shunt and significantly improved gas exchange after 1 and 2 h. In conclusion, the single application of iloprost revealed short-term pulmonary vasodilation without other major cardiopulmonary effects. However, inhaled iloprost improved gas exchange due to a decrease of pulmonary shunt as a long-term effect, possibly as a result of a reduction of lung oedema formation.
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Affiliation(s)
- R Dembinski
- Dept of Anaesthesiology, University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany.
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Koh JL, Harrison D, Myers R, Dembinski R, Turner H, McGraw T. A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion. Paediatr Anaesth 2004; 14:977-82. [PMID: 15601345 DOI: 10.1111/j.1460-9592.2004.01381.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Topical anesthetics may help reduce discomfort associated with procedures involving needle-puncture, such as intravenous (i.v.) insertions, in children. EMLA cream has become a common, noninvasive therapy for topical anesthesia in children. ELA-Max is a recently introduced topical anesthetic cream marketed as being as effective in producing topical anesthesia after a 30-min application as EMLA is after a 60-min application. The purpose of this research was to compare ELA-Max at 30 min with EMLA at 60 min for providing topical anesthesia for i.v. insertions in children. METHODS Sixty children, ages 8-17 years, requiring an i.v. were randomized to receive either the 30 min application of ELA-Max (n = 30) or the 60 min application of EMLA (n = 30). Children rated any pain associated with the i.v. insertion using a 100-mm Visual Analog Scale (VAS). The anesthesiologist assessed the presence of blanching at the site and rated the difficulty of placing the i.v. RESULTS There was no clinically or statistically significant difference in pain ratings (P = 0.87) between the ELA-Max (mean = 25.7) and the EMLA (mean = 26.8) groups. ELA-Max caused significantly (P = 0.04) less blanching than EMLA, however there was no difference in the anesthesiologists' rating of the difficulty of the i.v. placement between the groups (P = 0.73). CONCLUSION Results from this study support the claim that a 30-min application of ELA-Max (with occlusion) is as effective as a 60-min application of EMLA (with occlusion) for producing topical anesthesia for i.v. insertion in children.
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Affiliation(s)
- Jeffrey L Koh
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR 97239, USA.
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24
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Henzler D, Dembinski R, Kopp R, Hawickhorst R, Rossaint R, Kuhlen R. [Treatment of acute respiratory distress syndrome in a treatment center. Success is dependent on risk factors]. Anaesthesist 2004; 53:235-43. [PMID: 14999396 DOI: 10.1007/s00101-004-0653-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
SUBJECT Mortality rates remain high for the acute respiratory distress syndrome (ARDS) despite standardised treatment algorithms. Little is known about prognostic factors and exclusion criteria for advanced treatment including extracorporeal membrane oxygenation (ECMO). METHODS In an observational study design a cohort of 93 patients with severe ARDS admitted to a referral centre were analysed according to ventilatory and vital parameters. RESULTS Overall survival rate was 70% and in patients who received ECMO treatment it was 67%. In patients exhibiting relevant co-morbidity the odds ratio for fatal outcome increased to 4.7 (95% CI: 3.3-24.9), and patients with multiple organ failure had a 7.5-fold increase (95% CI: 2.3-25.2) for risk of death. Survivors demonstrated a more pronounced improvement in oxygenation ( p<0.05) and CO(2) removal ( p<0.05) than non-survivors. CONCLUSIONS Advanced treatment of ARDS including ECMO represents a therapeutic option if none of the currently considered contraindications are present. An improvement in gas exchange parameters, but not a defined value per se may be useful as a prognostic factor for favourable outcome.
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Affiliation(s)
- D Henzler
- Klinik für Anästhesiologie, Universitätsklinikum Aachen.
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25
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Henzler D, Dembinski R, Kuhlen R, Rossaint R. Anesthetic considerations in patients with chronic pulmonary diseases. Minerva Anestesiol 2004; 70:279-84. [PMID: 15181404] [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: 04/29/2023]
Abstract
AIM Increasing age and co-morbidities of patients admitted for surgery impose new challenges on the anesthesiologist. METHODS Review of current literature regarding the perioperative management of patients with chronic pulmonary disease. RESULTS If patients are treated adequately, surgery can be safely performed under regional and general anaesthesia. Major risk factors include type of surgery, type and duration of anesthesia, general health status and smoking history, but not certain lung function parameters. Regional anesthesia remains the first choice for intra- and postoperative care, and if general anesthesia is necessary, early extubation should be achieved. Non-invasive ventilation could be a possible alternative in weaning failure. CONCLUSION Assessing the functional status of patients admitted to surgery remains a difficult task, and in patients identified at risk by clinical examination additional spirometry and blood gases may be helpful. If there are signs of respiratory failure, the anaesthetist should monitor the patient closely and invasively, yet there is no reason to deny any patient a substantially beneficial operation.
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Affiliation(s)
- D Henzler
- Department of Anesthesiology, University Hospital, RWTH Aachen, Aachen, Germany.
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26
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Abstract
After various observational studies demonstrated a benefit of extracorporeal membrane oxygenation (ECMO) in the therapy of severe acute respiratory distress syndrome (ARDS), ECMO now represents an important contribution for ARDS therapy using clinical algorithms despite a lack of positive controlled studies. In specialized centers patients with severe ARDS and imminent hypoxia despite intensive conventional therapy, are treated with ECMO using blood pumps and artificial membrane lungs (oxygenators) for extracorporeal lung assist. The development of new surface modifications, optimized oxygenators and miniaturized blood pumps should increase hemocompatibility and lead to simplified treatment as well as less complications. New oxygenators with significantly decreased blood resistance allow the clinical application of pumpless arteriovenous extracorporeal lung assist (ECLA). After these new developments indications for ECMO could be extended from use not only as ultimate ratio but to less severe ARDS to enable lung protective, less invasive mechanical ventilation.
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Affiliation(s)
- R Kopp
- Klinik für Anästhesiologie, Universitätsklinikum der RWTH Aachen.
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27
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Dembinski R, Henzler D, Rossaint R. Modulating the pulmonary circulation: an update. Minerva Anestesiol 2004; 70:239-43. [PMID: 15173703] [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: 04/29/2023]
Abstract
Pulmonary hypertension is a common finding in pulmonary circulatory disorders of different origin. Chronic pulmonary hypertension may develop due to either cardiopulmonary or systemic diseases whereas acute and acute-on-chronic pulmonary hypertension often occur in the course of cardiothoracic surgery. Right heart failure is the major risk particularly in the course of acute pulmonary hypertension. Thus, besides basic treatment of the underlying disease the use of vasodilators is a valuable therapeutic option to decrease right ventricular afterload, but intravenous vasodilators may provoke systemic arterial hypotension and impair gas exchange due to vasodilation of pulmonary shunt areas. Therefore, inhaled vasodilators such as nitric oxide and prostacyclin have been suggested for the treatment of pulmonary hypertension especially when concomitant hypoxemia is present due to a ventilation-perfusion mismatch. However, randomised controlled trials performed to evaluate long-term effects revealed different results: thus, in chronic pulmonary hypertension inhaled vasodilators improved outcome whereas the results for the treatment of the acute respiratory distress syndrome revealed beneficial effects only when used as a rescue and/or bridging therapy in severe hypoxemia. In cardiothoracic surgery, inhaled vasodilators have been shown to improve pulmonary circulation when severe pulmonary hypertension is present. Although effective in experimental studies no clear recommendation can be made in view to the use of other vasodilators such as phosphodiesterase inhibitors or endothelin antagonists. Likewise, the combination of different vasodilators merit further investigations to prove efficacy in randomised controlled trials.
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Affiliation(s)
- R Dembinski
- Department of Anesthesiology, University Hospital, RWTH, Aachen, Germany.
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Kuhlen R, Max M, Dembinski R, Terbeck S, Jürgens E, Rossaint R. Breathing pattern and workload during automatic tube compensation, pressure support and T-piece trials in weaning patients. Eur J Anaesthesiol 2003; 20:10-6. [PMID: 12553382 DOI: 10.1017/s0265021503000024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Automatic tube compensation has been designed as a new ventilatory mode to compensate for the non-linear resistance of the endotracheal tube. The study investigated the effects of automatic tube compensation compared with breathing through a T-piece or pressure support during a trial of spontaneous breathing used for weaning patients from mechanical ventilation of the lungs. METHODS Twelve patients were studied who were ready for weaning after prolonged mechanical ventilation (10.2 +/- 8.4 days) due to acute respiratory failure. Patients with chronic obstructive pulmonary disease were excluded. Thirty minutes of automatic tube compensation were compared with 30 min periods of 7 cmH2O pressure support and T-piece breathing. Breathing patterns and workload indices were measured at the end of each study period. RESULTS During T-piece breathing, the peak inspiratory flow rate (0.65 +/- 0.20 L s(-1)) and minute ventilation (8.9 +/- 2.7L min(-1)) were lower than during either pressure support (peak inspiratory flow rate 0.81 +/- 0.25 L s(-1) minute ventilation 10.2 +/- 2.3 L min(-1), respectively) or automatic tube compensation (peak inspiratory flow rate 0.75 +/- 0.26L s(-1); minute ventilation 10.8 +/- 2.7 L min(-1)). The pressure-time product as well as patients' work of breathing were comparable during automatic tube compensation (pressure-time product 214.5 +/- 104.6 cmH2O s(-1) min(-1), patient work of breathing 1.1 +/- 0.4 J L(-1)) and T-piece breathing (pressure-time product 208.3 +/- 121.6 cmH2O s(-1) min(-1), patient work of breathing 1.1 +/- 0.4 J L(-1)), whereas pressure support resulted in a significant decrease in workload indices (pressure-time product 121.2 +/- 64.1 cmH2O s(-1) min(-1), patient work of breathing 0.7 +/- 0.4 J L(-1)). CONCLUSIONS In weaning from mechanical lung ventilation, patients' work of breathing during spontaneous breathing trials is clearly reduced by the application of pressure support 7 cmH2O, whereas the workload during automatic tube compensation corresponded closely to the values during trials of breathing through a T-piece.
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Affiliation(s)
- R Kuhlen
- University of Aachen Medical School, Department of Anesthesiology, Aachen, Germany.
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Dembinski R, Max M, López F, Kuhlen R, Kurth R, Rossaint R. Effect of Inhaled Prostacyclin in Combination with Almitrine on Ventilation–Perfusion Distributions in Experimental Lung Injury. Anesthesiology 2001; 94:461-7. [PMID: 11374607 DOI: 10.1097/00000542-200103000-00017] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background
Inhaled prostacyclin and intravenous almitrine have both been shown to improve pulmonary gas exchange in acute lung injury (ALI). This study was performed to investigate a possible additive effect of prostacyclin and almitrine on pulmonary ventilation-perfusion (VA/Q) ratio in ALI compared with inhaled prostacyclin or intravenous almitrine alone.
Methods
Experimental ALI was established in 24 pigs by repeated lung lavage. Animals were randomly assigned to receive either 25 ng.kg(-1).min(-1) inhaled prostacyclin alone, 1 microg.kg(-1).min(-1) almitrine alone, 25 ng.kg(-1).min(-1) inhaled prostacyclin in combination with 1 microg.kg(-1).min(-1) almitrine, or no specific treatment (controls) for 30 min. For each intervention, pulmonary gas exchange and hemodynamics were analyzed and VA/Q distributions were calculated using the multiple inert gas elimination technique. The data was analyzed within and between the groups by analysis of variance for repeated measurements, followed by the Student-Newman-Keuls test for multiple comparison when analysis of variance revealed significant differences.
Results
All values are expressed as mean +/- SD. In controls, pulmonary gas exchange, hemodynamics, and VA/Q distribution remained unchanged. With prostacyclin alone and almitrine alone, arterial oxygen partial pressure (PaO2) increased, whereas intrapulmonary shunt (QS/QT) decreased (P < 0.05). Combined prostacyclin and almitrine also increased PaO2 and decreased QS/QT (P < 0.05). When compared with either prostacyclin or almitrine alone, the combined application of both drugs revealed no additional effect in gas exchange or VA/Q distribution.
Conclusions
The authors conclude that, in this experimental model of ALI, the combination of 25 ng.kg(-1).min(-1) prostacyclin and 1 microg.kg(-1).min(-1) almitrine does not result in an additive improvement of pulmonary gas exchange or VA/Q distribution when compared with prostacyclin or almitrine alone.
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Affiliation(s)
- R Dembinski
- Department of Anesthesiology, Universitaetsklinikum der RWTH Aachen, Germany.
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Max M, Nowak B, Dembinski R, Schulz G, Kuhlen R, Buell U, Rossaint R. Changes in pulmonary blood flow during gaseous and partial liquid ventilation in experimental acute lung injury. Anesthesiology 2000; 93:1437-45. [PMID: 11149439 DOI: 10.1097/00000542-200012000-00016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [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: 11/25/2022]
Abstract
BACKGROUND It has been proposed that partial liquid ventilation (PLV) causes a compression of the pulmonary vasculature by the dense perfluorocarbons and a subsequent redistribution of pulmonary blood flow from dorsal to better-ventilated middle and ventral lung regions, thereby improving arterial oxygenation in situations of acute lung injury. METHODS After induction of acute lung injury by repeated lung lavage with saline, 20 pigs were randomly assigned to partial liquid ventilation with two sequential doses of 15 ml/kg perfluorocarbon (PLV group, n = 10) or to continued gaseous ventilation (GV group, n = 10). Single-photon emission computed tomography was used to study regional pulmonary blood flow. Gas exchange, hemodynamics, and pulmonary blood flow were determined in both groups before and after the induction of acute lung injury and at corresponding time points 1 and 2 h after each instillation of perfluorocarbon in the PLV group. RESULTS During partial liquid ventilation, there were no changes in pulmonary blood flow distribution when compared with values obtained after induction of acute lung injury in the PLV group or to the animals submitted to gaseous ventilation. Arterial oxygenation improved significantly in the PLV group after instillation of the second dose of perfluorocarbon. CONCLUSIONS In the surfactant washout animal model of acute lung injury, redistribution of pulmonary blood flow does not seem to be a major factor for the observed increase of arterial oxygen tension during partial liquid ventilation.
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Affiliation(s)
- M Max
- Klinik für Anaesthesie, Rheinisch-Westfaelische Technische Hochschule Aachen, Germany.
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Affiliation(s)
- M Max
- Universitätsklinikum der Rheinisch-Westfälischen Technischen Hochschule Aachen
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Sommerer A, Kaisers U, Dembinski R, Bubser HP, Falke KJ, Rossaint R. Dose-dependent effects of almitrine on hemodynamics and gas exchange in an animal model of acute lung injury. Intensive Care Med 2000; 26:434-41. [PMID: 10872136 DOI: 10.1007/s001340051178] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine the dose-response relationship of almitrine (Alm) on pulmonary gas exchange and hemodynamics in an animal model of acute lung injury (ALI). DESIGN Prospective, randomized, controlled study. METHODS Twenty anesthetized, tracheotomized and mechanically ventilated (FIO2 1.0) pigs underwent induction of ALI by repeated saline washout of surfactant. Animals were randomly assigned to either receive cumulating doses of Alm intravenously (0.5, 1.0, 2.0, 4.0, 8.0 and 16.0 micrograms.kg-1.min-1) for 30 min each (treatment; n = 10) or to receive the solvent malic acid (controls; n = 10). MEASUREMENTS AND RESULTS Measurements of pulmonary gas exchange and hemodynamics were performed at the end of each infusion period. Alm < 4.0 micrograms.kg-1.min-1 improved arterial oxygen pressure (PaO2) (105 +/- 9 mmHg for Alm 1.0 vs 59 +/- 5 mmHg) and decreased intrapulmonary shunt (Qs/Qt) (32 +/- 4% for Alm 1.0 vs 46 +/- 4%) (P < 0.05). Alm > or = 8.0 micrograms.kg-1.min-1 did not improve pulmonary gas exchange compared to controls. When compared to low doses of Alm < 4.0 micrograms.kg-1.min-1, high doses > or = 8.0 micrograms.kg1.min-1 decreased PaO2 (58 +/- 11 mmHg for Alm 16.0) and increased Qs/Qt (67 +/- 10% for Alm 16.0) (P < 0.05). CONCLUSIONS In experimental ALI, effects of almitrine on oxygenation are dose-dependent. Almitrine is most effective when used at low doses known to mimic hypoxic pulmonary vasoconstriction.
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Affiliation(s)
- A Sommerer
- Abteilung X, Anaesthesiologie und Intensivmedizin, Bundeswehrkrankenhaus Berlin, Germany
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Max M, Kuhlen R, Falter F, Reyle-Hahn M, Dembinski R, Rossaint R. Effect of PEEP and inhaled nitric oxide on pulmonary gas exchange during gaseous and partial liquid ventilation with small volumes of perfluorocarbon. Acta Anaesthesiol Scand 2000; 44:383-90. [PMID: 10757569 DOI: 10.1034/j.1399-6576.2000.440405.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Partial liquid ventilation, positive end-expiratory pressure (PEEP) and inhaled nitric oxide (NO) can improve ventilation/perfusion mismatch in acute lung injury (ALI). The aim of the present study was to compare gas exchange and hemodynamics in experimental ALI during gaseous and partial liquid ventilation at two different levels of PEEP, with and without the inhalation of nitric oxide. METHODS Seven pigs (24+/-2 kg BW) were surfactant-depleted by repeated lung lavage with saline. Gas exchange and hemodynamic parameters were assessed in all animals during gaseous and subsequent partial liquid ventilation at two levels of PEEP (5 and 15 cmH2O) and intermittent inhalation of 10 ppm NO. RESULTS Arterial oxygenation increased significantly with a simultaneous decrease in cardiac output when PEEP 15 cmH2O was applied during gaseous and partial liquid ventilation. All other hemodynamic parameters revealed no relevant changes. Inhalation of NO and instillation of perfluorocarbon had no additive effects on pulmonary gas exchange when compared to PEEP 15 cmH2O alone. CONCLUSION In experimental lung injury, improvements in gas exchange are most distinct during mechanical ventilation with PEEP 15 cmH2O without significantly impairing hemodynamics. Partial liquid ventilation and inhaled NO did not cause an additive increase of PaO2.
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Affiliation(s)
- M Max
- Klinik für Anästhesie, Medizinische Einrichtungen der RWTH Aachen, Germany.
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Dembinski R, Max M, Lopez F, Kuhlen R, Sünner M, Rossaint R. Effect of inhaled nitric oxide in combination with almitrine on ventilation-perfusion distributions in experimental lung injury. Intensive Care Med 2000; 26:221-8. [PMID: 10784314 DOI: 10.1007/s001340050051] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate a possible additive effect of combined nitric oxide (NO) and almitrine bismesylate (ALM) on pulmonary ventilation-perfusion (V(A)/Q) ratio. DESIGN Prospective, controlled animal study. SETTING Animal research facility of a university hospital. INTERVENTIONS Three conditions were studied in ten female pigs with experimental acute lung injury (ALI) induced by repeated lung lavage: 1) 10 ppm NO, 2) 10 ppm NO with 1 microg/kg per min ALM, 3) 1 microg/ kg per min ALM. For each condition, gas exchange, hemodynamics and V(A)/Q distributions were analyzed using the multiple inert gas elimination technique (MIGET). MEASUREMENT AND RESULTS With NO + ALM, arterial oxygen partial pressure (PaO2) increased from 63 +/- 18 mmHg to 202 +/- 97 mmHg while intrapulmonary shunt decreased from 50 +/- 15 % to 26 +/- 12% and blood flow to regions with a normal V(A)/Q ratio increased from 49 +/- 16 % to 72 +/- 15 %. These changes were significant when compared to untreated ALI (p < 0.05) and NO or ALM alone (p < 0.05), although improvements due to NO or ALM also reached statistical significance compared to ALI values (p < 0.05). CONCLUSIONS We conclude that NO + ALM results in an additive improvement of pulmonary gas exchange in an experimental model of ALI by diverting additional blood flow from non-ventilated lung regions towards those with normal V(A)/Q relationships.
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Affiliation(s)
- R Dembinski
- Klinik für Anästhesie, Medizinische Einrichtungen der Rheinisch-Westfälischen Technischen, Hochschule Aachen, Germany.
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Max M, Kuhlen R, Dembinski R, Rossaint R. Time-dependency of improvements in arterial oxygenation during partial liquid ventilation in experimental acute respiratory distress syndrome. Crit Care 2000; 4:114-9. [PMID: 11056747 PMCID: PMC29038 DOI: 10.1186/cc665] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/1999] [Revised: 11/15/1999] [Accepted: 12/02/1999] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The mechanisms by which partial liquid ventilation (PLV) can improve gas exchange in acute lung injury are still unclear. Therefore, we examined the time- and dose-dependency of the improvements in arterial oxygen tension (PaO2) due to PLV in eight pigs with experimental lung injury, in order to discriminate increases due to oxygen dissolved in perfluorocarbon before its intrapulmonary instillation from a persistent diffusion of the respiratory gas through the liquid column. RESULTS Application of four sequential doses of perfluorocarbon resulted in a dose-dependent increase in PaO2. Comparison of measurements 5 and 30 min after instillation of each dose revealed a time-dependent decrease in PaO2 for doses that approximated the functional residual capacity of the animals. CONCLUSION Although oxygen dissolved in perfluorocarbon at the onset of PLV can cause a short-term improvement in arterial oxygenation, diffusion of oxygen through the liquid may not be sufficient to maintain the initially observed increase in PaO2.
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Affiliation(s)
- M Max
- Medizinische Einrichtungen der Rheinisch-Westfälischen Technischen Hochschule Aachen, Aachen, Germany.
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Max M, Kuhlen R, Dembinski R, Rossaint R. Effect of aerosolized prostacyclin and inhaled nitric oxide on experimental hypoxic pulmonary hypertension. Intensive Care Med 1999; 25:1147-54. [PMID: 10551974 DOI: 10.1007/s001340051027] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [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: 10/28/2022]
Abstract
OBJECTIVE To compare the effect of different concentrations of inhaled nitric oxide and doses of nebulized prostacyclin on hypoxia-induced pulmonary hypertension in pigs. DESIGN Prospective, controlled animal study. SETTING Animal research facilities of an university hospital. INTERVENTIONS After reducing the fraction of inspired oxygen (FIO(2)) from 1.0 to 0.1, two groups of five pigs each were submitted to inhalation of three concentrations of nitric oxide (5, 10 and 20 ppm) or three doses of prostacyclin (2.5, 5, 10 ng x kg(-1) x min(-1)). RESULTS All doses of prostacyclin and concentrations of nitric oxide resulted in a decrease in mean pulmonary arterial pressure and pulmonary vascular resistance when compared to hypoxic ventilation (p < 0.001) which was independent of the dose or concentration of either drug used. While inhalation of nitric oxide caused a reduction in mean pulmonary arterial pressure back to values obtained during ventilation with FIO(2) 1.0, values achieved with prostacyclin were still significantly higher when compared to measurements prior to the initiation of hypoxic ventilation. However, direct comparison of the effect of 20 ppm nitric oxide and 10 ng x kg(-1) x min(-1) prostacyclin on mean pulmonary arterial pressure revealed no differences between the drugs. All other hemodynamic and gas exchange parameters remained stable throughout the study. CONCLUSIONS Inhalation of clinically used concentrations of nitric oxide and doses of prostacyclin can decrease elevated pulmonary arterial pressure in an animal model of hypoxic pulmonary vasoconstriction without impairing systemic hemodynamics or gas exchange.
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Affiliation(s)
- M Max
- Klinik für Anästhesie, Medizinische Einrichtungen der Rheinisch-Westfälischen Technischen Hochschule Aachen, Pauwelsstrasse 30, 52 074 Aachen, Germany.
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Max M, Reyle-Hahn M, Kuhlen R, Dembinski R, Rossaint E. Nitric oxide--is there a future? Acta Anaesthesiol Scand Suppl 1997; 111:64-68. [PMID: 9420958] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- M Max
- Klinik für Anästhesiologie und operative Intensivmedizin, Virchow-Klinikum, Medizinischen Fakultät, Humboldt-Universität zu Berlin
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Dembinski R, skowronska A. The Simple Synthesis of Tetra-Alkyl Sym-Monothiopyrophosphates. PHOSPHORUS SULFUR 1990. [DOI: 10.1080/10426509008544256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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