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Şentürk M, El Tahan MR, Shelley B, Szegedi LL, Piccioni F, Licker MJ, Karzai W, Gil MG, Neskovic V, Vanpeteghem C, Pelosi P, Cohen E, Sorbello M, MBChB JB, Stoica R, Mourisse J, Brunelli A, Jimenez MJ, Drnvsek-Globoikar M, Yapici D, Morsy AS, Kawagoe I, Végh T, Navarro-Ripoll R, Marczin N, Paloczi B, Unzueta C, Gregorio GD, Wouters P, Rex S, Mukherjee C, Paternoster G, Guarracino F. Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee. J Cardiothorac Vasc Anesth 2021; 35:3528-3546. [PMID: 34479782 PMCID: PMC8313821 DOI: 10.1053/j.jvca.2021.07.027] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/09/2021] [Accepted: 07/11/2021] [Indexed: 02/07/2023]
Abstract
The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.
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Affiliation(s)
- Mert Şentürk
- Dep. of Anesthesiology & Reanimation, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Mohamed R El Tahan
- Cardiothoracic Anesthesiology, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Ben Shelley
- Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital/West of Scotland Heart and Lung Centre, University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care, Scotland
| | - Laszlo L Szegedi
- Department of Anesthesiology, CUB Hôpital Erasme, ULB Université Libre de Bruxelles, Brussels, Belgium
| | - Federico Piccioni
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marc-Joseph Licker
- Anesthesia, Pharmacology and Intensive Care, University Hospital Geneva, Geneva, Switzerland
| | - Waheedullah Karzai
- Chefarzt, Zentralklinik Bad Berka GmbH, Robert-Koch-Allee, Bad Berka, Germany
| | | | - Vojislava Neskovic
- Anesthesia and Intensive Care, Military Medical Academy Belgrade, Belgrade, Serbia
| | | | - Paolo Pelosi
- Università degli Studi di Genova, UNIGE, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC), Genoa, Italy
| | - Edmond Cohen
- Anesthesiology, Perioperative & Pain Medicine, Thoracic Surgery Specialty, Anesthesiology Icahn School of Medicine at Mount Sinai, New York, NY; Anesthesia and Intensive Care, AOU Policlinico Vittorio Emanuele San Marco, Catania, Italy
| | - Massimiliano Sorbello
- Anesthesia, Pharmacology and Intensive Care, University Hospital Geneva, Geneva, Switzerland
| | - Johan Bence MBChB
- Cardiothoracic Anaesthesiology, University Hospitals of Leicester Glenfield Hospital, Leicester, UK
| | - Radu Stoica
- Faculty of Medicine, Titu Maiorescu, Bucharest; Anesthesia and Intensive Care, Military Medical Academy Belgrade, Belgrade, Serbia
| | - Jo Mourisse
- Anesthesiology and ICU, Monza Oncolgy Hospital, Bucharest; Department of Anesthesia, Pain and Palliative Medicine, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Alex Brunelli
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, UK
| | - Maria-José Jimenez
- Anesthesiology, Centro Medico Teknon, Universitat de Barcelona, Barcelona, Spain
| | | | - Davud Yapici
- Anesthesia and Intensive Care, Mersin University School of Medicine, Mersin, Turkey
| | - Ahmed Salaheldin Morsy
- Department of Anesthesia, King Fahd Hospital of the Imam Abdulrahman bin Faisal University, Al Khober, Saudi Arabia
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Tokyo, Japan; Outcomes Research Consortium, Cleveland, OH
| | - Tamás Végh
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | | | - Nandor Marczin
- Department of Anesthesiology, Ljubjljana University Medical Centre, Ljubljana, Slovenia; Section of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Department of Anesthesia, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Balazs Paloczi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Carmen Unzueta
- Department of Anesthesiology, Hospital de la Santa Creu i San Pau, Barcelona, Spain
| | - Guido Di Gregorio
- Anesthesia and Critical Care Azienda Ospedaliera Università di Padova, Padova, Italy
| | - Patrick Wouters
- Department of Anesthesia and Perioperative Medicine, Ghent University, Ghent, Belgium
| | - Steffen Rex
- Clinic Department of Anesthesiology, University Hospitals Leuven, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Chirojit Mukherjee
- Department of Anaesthesia & Intensive Care, Helios Clinic for Cardiac Surgery, Karlsruhe, Germany
| | - Gianluca Paternoster
- Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care San Carlo Hospital (Potenza) Italy Via Potito Petrone, Italy
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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2
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Şentürk M, El Tahan MR, Szegedi LL, Marczin N, Karzai W, Shelley B, Piccioni F, Granell Gil M, Rex S, Sorbello M, Bence J, Cohen E, Gregorio GD, Kawagoe I, Globokar MD, Jimenez MJ, Licker MJ, Mourisse J, Mukherjee C, Navarro R, Neskovic V, Paloczi B, Paternoster G, Pelosi P, Salaheldeen A, Stoica R, Unzueta C, Vanpeteghem C, Vegh T, Wouters P, Yapici D, Guarracino F. Thoracic Anesthesia of Patients With Suspected or Confirmed 2019 Novel Coronavirus Infection: Preliminary Recommendations for Airway Management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee. J Cardiothorac Vasc Anesth 2020; 34:2315-2327. [PMID: 32414544 PMCID: PMC7151284 DOI: 10.1053/j.jvca.2020.03.059] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/29/2020] [Indexed: 01/27/2023]
Abstract
The novel coronavirus has caused a pandemic around the world. Management of patients with suspected or confirmed coronavirus infection who have to undergo thoracic surgery will be a challenge for the anesthesiologists. The thoracic subspecialty committee of European Association of Cardiothoracic Anaesthesiology (EACTA) has conducted a survey of opinion in order to create recommendations for the anesthetic approach to these challenging patients. It should be emphasized that both the management of the infected patient with COVID-19 and the self-protection of the anesthesia team constitute a complicated challenge. The text focuses therefore on both important topics.
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Affiliation(s)
- Mert Şentürk
- Department of Anaesthesiology & Intensive care of Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
| | - Mohamed R El Tahan
- Department of Anaesthesia, Intensive Care and Pain Medicine, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Laszlo L Szegedi
- Department of Anesthesiology, CUB Hôpital Erasme, ULB Université Libre de Bruxelles, Brussels, Belgium
| | - Nandor Marczin
- Department of Surgery & Cancer, Section of Anaesthetics, Imperial College London, London, UK; Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Harefield, UK; Department of Anesthesia and Intensive Care, Semmelweis University, Budapest, Hungary
| | | | - Ben Shelley
- Golden Jubilee National Hospital/West of Scotland Heart and Lung Centre, University of Glasgow Academic Unit of Anesthesia, Pain, and Critical Care, Glasgow, Scotland
| | - Federico Piccioni
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, AOU Policlinico Vittorio Emanuele San Marco, Catania, Italy
| | - Johan Bence
- Department of Anesthesia, Glenfield Hospital Leicester, Leicester, England, UK
| | - Edmond Cohen
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Guido Di Gregorio
- Anesthesia and Critical Care, Azienda Ospedaliera Università di Padova, Padova, Italy
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University, Tokyo, Japan
| | - Mojca Drnovšek Globokar
- Department of Anesthesiology, Ljubjljana University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Marc-Joseph Licker
- Anesthesia, Pharmacology and Intensive Care, University Hospital Geneva, Geneva, Switzerland
| | - Jo Mourisse
- Department of Anesthesia, Pain, and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Chirojit Mukherjee
- Department of Anesthesia and Intensive Care, Helios Clinic for Cardiac Surgery, Karlsruhe, Germany
| | - Ricard Navarro
- Department of Anesthesiology and Critical Care, Hospital Clinic Barcelona, Barcelona, Spain
| | | | - Balazs Paloczi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Gianluca Paternoster
- Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Ahmed Salaheldeen
- Department of Anesthesia, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Radu Stoica
- Department of Thoracic Anesthesia, Institute of Pulmonology "Marius Nasta," Bucharest, Romania
| | - Carmen Unzueta
- Department of Anesthesiology, Hospital de la Santa Creu i San Pau, Barcelona, Spain
| | | | - Tamas Vegh
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Patrick Wouters
- Anesthesia and Perioperative Medicine, Ghent University, Ghent, Belgium
| | - Davud Yapici
- Mersin University School of Medicine, Mersin, Turkey
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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3
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Kiss T, Wittenstein J, Becker C, Birr K, Cinnella G, Cohen E, El Tahan MR, Falcão LF, Gregoretti C, Granell M, Hachenberg T, Hollmann MW, Jankovic R, Karzai W, Krassler J, Loop T, Licker MJ, Marczin N, Mills GH, Murrell MT, Neskovic V, Nisnevitch-Savarese Z, Pelosi P, Rossaint R, Schultz MJ, Neto AS, Severgnini P, Szegedi L, Vegh T, Voyagis G, Zhong J, de Abreu MG, Senturk M. Correction to: Protective ventilation with high versus low positive end-expiratory pressure during one-lung ventilation for thoracic surgery (PROTHOR): study protocol for a randomized controlled trial. Trials 2019; 20:259. [PMID: 31068212 PMCID: PMC6505178 DOI: 10.1186/s13063-019-3371-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/23/2022] Open
Affiliation(s)
- T Kiss
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - J Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - C Becker
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - K Birr
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - G Cinnella
- Department of Anesthesia and Intensive Care, OO Riuniti Hospital, University of Foggia, Foggia, Italy
| | - E Cohen
- Department of Anesthesiology, The Mount Sinai Hospital, New York, USA
| | - M R El Tahan
- Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - L F Falcão
- Federal University of São Paulo, Sao Paulo, Brazil
| | - C Gregoretti
- UOC Anestesia e Rianimazione A.O.Universitaria "P. Giaccone", Dipartimento Di.Chir.On.S, Università degli Studi di Palermo, Palermo, Italy
| | - M Granell
- Hospital General Universitario de Valencia, Valencia, Spain
| | - T Hachenberg
- University Hospital Magdeburg, Magdeburg, Germany
| | - M W Hollmann
- Department of Anesthesiology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - R Jankovic
- Clinic for Anesthesia and Intensive Therapy, Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia
| | - W Karzai
- Zentralklinik Bad Berka, Bad Berka, Germany
| | | | - T Loop
- Department of Anesthesiology and Intensive Care Medicine Clinic, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - M J Licker
- University Hospital Geneva, Geneva, Switzerland
| | - N Marczin
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK.,Centre of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary
| | - G H Mills
- Department of Anaesthesia and Intensive Care Medicine, Sheffield Teaching Hospitals, Sheffield University, Sheffield, UK
| | - M T Murrell
- Department of Anesthesiology, Weill Cornell Medicine, New York, USA
| | - V Neskovic
- Military Medical Academy, Belgrade, Serbia
| | | | - P Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,IRCCS San Martino Policlinico Hospital, Genoa, Italy
| | - R Rossaint
- Department of Anaesthesiology, University Hospital Aachen, Aachen, Germany
| | - M J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - A Serpa Neto
- Department of Critical Care, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - P Severgnini
- Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell'Insubria, Varese, Italy
| | - L Szegedi
- Department of Anesthesiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - T Vegh
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary.,Outcomes Research Consortium, Cleveland, USA
| | - G Voyagis
- Department of Anaesthesia, Postoperative ICU, Pain Relief & Palliative Care Clinic, "Sotiria" Chest Diseases Hospital, Athens, Greece.,Department of Anaesthesiology and Critical Care Medicine, University of Patras, Patra, Greece
| | - J Zhong
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - M Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M Senturk
- Department of Anaesthesiology and Intensive Care, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey
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4
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Kiss T, Wittenstein J, Becker C, Birr K, Cinnella G, Cohen E, El Tahan MR, Falcão LF, Gregoretti C, Granell M, Hachenberg T, Hollmann MW, Jankovic R, Karzai W, Krassler J, Loop T, Licker MJ, Marczin N, Mills GH, Murrell MT, Neskovic V, Nisnevitch-Savarese Z, Pelosi P, Rossaint R, Schultz MJ, Serpa Neto A, Severgnini P, Szegedi L, Vegh T, Voyagis G, Zhong J, Gama de Abreu M, Senturk M. Protective ventilation with high versus low positive end-expiratory pressure during one-lung ventilation for thoracic surgery (PROTHOR): study protocol for a randomized controlled trial. Trials 2019; 20:213. [PMID: 30975217 PMCID: PMC6460685 DOI: 10.1186/s13063-019-3208-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [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: 10/21/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Postoperative pulmonary complications (PPC) may result in longer duration of in-hospital stay and even mortality. Both thoracic surgery and intraoperative mechanical ventilation settings add considerably to the risk of PPC. It is unclear if one-lung ventilation (OLV) for thoracic surgery with a strategy of intraoperative high positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM) reduces PPC, compared to low PEEP without RM. METHODS PROTHOR is an international, multicenter, randomized, controlled, assessor-blinded, two-arm trial initiated by investigators of the PROtective VEntilation NETwork. In total, 2378 patients will be randomly assigned to one of two different intraoperative mechanical ventilation strategies. Investigators screen patients aged 18 years or older, scheduled for open thoracic or video-assisted thoracoscopic surgery under general anesthesia requiring OLV, with a maximal body mass index of 35 kg/m2, and a planned duration of surgery of more than 60 min. Further, the expected duration of OLV shall be longer than two-lung ventilation, and lung separation is planned with a double lumen tube. Patients will be randomly assigned to PEEP of 10 cmH2O with lung RM, or PEEP of 5 cmH2O without RM. During two-lung ventilation tidal volume is set at 7 mL/kg predicted body weight and, during OLV, it will be decreased to 5 mL/kg. The occurrence of PPC will be recorded as a collapsed composite of single adverse pulmonary events and represents the primary endpoint. DISCUSSION PROTHOR is the first randomized controlled trial in patients undergoing thoracic surgery with OLV that is adequately powered to compare the effects of intraoperative high PEEP with RM versus low PEEP without RM on PPC. The results of the PROTHOR trial will support anesthesiologists in their decision to set intraoperative PEEP during protective ventilation for OLV in thoracic surgery. TRIAL REGISTRATION The trial was registered in clinicaltrials.gov ( NCT02963025 ) on 15 November 2016.
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Affiliation(s)
- T. Kiss
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - J. Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - C. Becker
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - K. Birr
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - G. Cinnella
- Department of Anesthesia and Intensive Care, OO Riuniti Hospital, University of Foggia, Foggia, Italy
| | - E. Cohen
- Department of Anesthesiology, The Mount Sinai Hospital, New York, USA
| | - M. R. El Tahan
- Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - L. F. Falcão
- Federal University of São Paulo, Sao Paulo, Brazil
| | - C. Gregoretti
- UOC Anestesia e Rianimazione A.O.Universitaria “P. Giaccone”, Dipartimento Di.Chir.On.S., Università degli Studi di Palermo, Palermo, Italy
| | - M. Granell
- Hospital General Universitario de Valencia, Valencia, Spain
| | | | - M. W. Hollmann
- Department of Anesthesiology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - R. Jankovic
- Clinic for Anesthesia and Intensive Therapy, Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia
| | - W. Karzai
- Zentralklinik Bad Berka, Bad Berka, Germany
| | | | - T. Loop
- Department of Anesthesiology and Intensive Care Medicine Clinic, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - N. Marczin
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
- Centre of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary
| | - G. H. Mills
- Department of Anaesthesia and Intensive Care Medicine, Sheffield Teaching Hospitals, Sheffield University, Sheffield, UK
| | - M. T. Murrell
- Department of Anesthesiology, Weill Cornell Medicine, New York, USA
| | | | | | - P. Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS San Martino Policlinico Hospital, Genoa, Italy
| | - R. Rossaint
- Department of Anaesthesiology, University Hospital Aachen, Aachen, Germany
| | - M. J. Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - A. Serpa Neto
- Department of Critical Care, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - P. Severgnini
- Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell’Insubria, Varese, Italy
| | - L. Szegedi
- Department of Anesthesiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - T. Vegh
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
- Outcomes Research Consortium, Cleveland, USA
| | - G. Voyagis
- Department of Anaesthesia, Postoperative ICU, Pain Relief & Palliative Care Clinic, “Sotiria” Chest Diseases Hospital, Athens, Greece
- Department of Anaesthesiology and Critical Care Medicine, University of Patras, Patra, Greece
| | - J. Zhong
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - M. Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M. Senturk
- Department of Anaesthesiology and Intensive Care, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey
| | - the Research Workgroup PROtective VEntilation Network (PROVEnet) of the European Society of Anaesthesiology (ESA)
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Anesthesia and Intensive Care, OO Riuniti Hospital, University of Foggia, Foggia, Italy
- Department of Anesthesiology, The Mount Sinai Hospital, New York, USA
- Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Federal University of São Paulo, Sao Paulo, Brazil
- UOC Anestesia e Rianimazione A.O.Universitaria “P. Giaccone”, Dipartimento Di.Chir.On.S., Università degli Studi di Palermo, Palermo, Italy
- Hospital General Universitario de Valencia, Valencia, Spain
- University Hospital Magdeburg, Magdeburg, Germany
- Department of Anesthesiology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Clinic for Anesthesia and Intensive Therapy, Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia
- Zentralklinik Bad Berka, Bad Berka, Germany
- Thoracic Center Coswig, Coswig, Germany
- Department of Anesthesiology and Intensive Care Medicine Clinic, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- University Hospital Geneva, Geneva, Switzerland
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
- Centre of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary
- Department of Anaesthesia and Intensive Care Medicine, Sheffield Teaching Hospitals, Sheffield University, Sheffield, UK
- Department of Anesthesiology, Weill Cornell Medicine, New York, USA
- Military Medical Academy, Belgrade, Serbia
- Penn State Hershey Anesthesiology & Perioperative Medicine, Hershey, USA
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS San Martino Policlinico Hospital, Genoa, Italy
- Department of Anaesthesiology, University Hospital Aachen, Aachen, Germany
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Critical Care, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell’Insubria, Varese, Italy
- Department of Anesthesiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
- Outcomes Research Consortium, Cleveland, USA
- Department of Anaesthesia, Postoperative ICU, Pain Relief & Palliative Care Clinic, “Sotiria” Chest Diseases Hospital, Athens, Greece
- Department of Anaesthesiology and Critical Care Medicine, University of Patras, Patra, Greece
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Anaesthesiology and Intensive Care, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey
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Spaeth J, Ott M, Karzai W, Grimm A, Wirth S, Schumann S, Loop T. Double-lumen tubes and auto-PEEP during one-lung ventilation. Br J Anaesth 2016; 116:122-30. [DOI: 10.1093/bja/aev398] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Schwarzkopf K, Hueter L, Schreiber T, Preussler NP, Loeb V, Karzai W. Oxygenation during one-lung ventilation with propofol or sevoflurane. Middle East J Anaesthesiol 2009; 20:397-400. [PMID: 19950733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
60 patients, ASA I-III, underwent one-lung ventilation for open or video-assisted thoracic surgery randomized either with intravenous anesthesia with propofol or with inhalational anesthesia with 1 MAC sevoflurane. Propofol was titrated during one-lung ventilation to achieve a mean arterial pressure of 75-80 mmHg. Blood gas analyses, hemodynamic and respiratory parameters were measured during two-lung ventilation at the beginning of the surgical procedure and 10 min, 20 min and 30 min after start of one-lung ventilation. At all time points, hemodynamic and respiratory parameters were comparable in both groups. Oxygenation did not differ between groups at comparable mean arterial blood pressures.
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Affiliation(s)
- Konrad Schwarzkopf
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Saarbrueken, Winterberg 1, 66119 Saarbruecken, Germany.
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Karzai W, Schmidt J, Jung A, Kröger R, Clausner G, Presselt N. Delayed emergence and acute renal failure after pneumonectomy: tumor emboli complicating postoperative course. J Cardiothorac Vasc Anesth 2008; 23:219-22. [PMID: 18834843 DOI: 10.1053/j.jvca.2008.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2007] [Indexed: 11/11/2022]
Affiliation(s)
- Waheedullah Karzai
- Department of Anesthesia and Intensive Care Medicine, Zentralklinik Bad Berka, Bad Berka, Germany
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Schreiber T, Hueter L, Gaser E, Schmidt B, Schwarzkopf K, Karzai W. Effects of a catecholamine-induced increase in cardiac output on lung injury after experimental unilateral pulmonary acid instillation. Crit Care Med 2007; 35:1741-8. [PMID: 17522573 DOI: 10.1097/01.ccm.0000269374.85160.bf] [Citation(s) in RCA: 11] [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
OBJECTIVES Increasing pulmonary blood flow aggravated ventilation-associated lung injury in ex vivo animal experiments, but data were less consistent in an in vivo animal model and do not reflect redistributed lung perfusion seen in clinical acute lung injury. We sought to determine the effects of increased cardiac output on markers of lung injury in an in vivo model of inhomogeneous lung perfusion and injury. DESIGN Prospective, controlled animal study. SETTING Experimental research laboratory of a university hospital. SUBJECTS A total of 50 anesthetized, mechanically ventilated, male Wistar rats. INTERVENTIONS Unilateral lung injury was induced in rats by left lung acid instillation. After 24 hrs, animals were anesthetized and subjected to mechanical ventilation (tidal volume, 8 mL/kg; positive end-expiratory pressure, 7 cm H2O; FIO2, 0.4) and continuous infusion of either 10 microg x kg x min dobutamine or isotonic saline (control) for 4 hrs. MEASUREMENTS AND MAIN RESULTS Cardiac output and differential lung perfusion were recorded throughout the ventilation period. Right and left lung wet-to-dry weight ratio, cytokines and inflammatory cells in lung lavage, and histologic lung injury were measured postmortem. After acid injury, lung perfusion was preferentially distributed to the noninjured lung. Dobutamine increased baseline cardiac output (>70%) and perfusion of both lungs (left, acid-instilled lung: from 16 +/- 2 to 29 +/- 6 mL/min; right, non-acid-instilled lung: from 54 +/- 3 to 98 +/- 7 mL/min). There was no difference in left lung injury between dobutamine- and saline-infused animals, but right lung injury was aggravated in dobutamine-infused animals, as indicated by increased lung edema, histologic lung injury, and cell counts in lavage. CONCLUSIONS In the setting of unilateral lung injury and uneven lung perfusion, a dobutamine-induced increase in cardiac output has potentially detrimental effects on the opposite lung.
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Affiliation(s)
- Torsten Schreiber
- Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-Universität Jena, Jena, Germany.
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Abstract
Mechanical ventilation (MV) with large tidal volumes (V(T)) causes ventilator induced lung injury. Whereas immediate effects of short-term injurious ventilation are well studied, little is known about its long-term effects. We aimed to establish an animal model of selective injurious MV, permitting assessment of the long-term course of ventilation-induced lung injury. In anesthetized and instrumented rats (n = 26), laryngoscopy was performed, and one cannula for MV was placed in the left main bronchus and a second one in the trachea. Two ventilators were used to ventilate the left lung with high (20 mL/kg) and the right lung with low (4 mL/kg) V(T). In control animals, both lungs received low V(T). After 2 h of MV, animals were extubated and observed for 24 h and then killed. Left and right lungs were excised and sampled for further investigations. Survival in animals ventilated with the high V(T) was 90%. Twenty-four hours after MV, alveolar levels of humoral (tumor necrosis factor alpha, interleukin 6) and cellular (polymorphonuclear leukocytes) inflammatory markers were increased, and histological alterations were present in lungs ventilated with high V(T). A delayed decrease in PaO2 was noted 24 h after MV, with high V(T) delivered to one lung as compared with low V(T) delivered to both lungs. This animal model permits assessment of the long-term course of ventilation-induced lung injury and shows that pulmonary inflammation and histological alterations are present 24 h after unilateral injurious ventilation.
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Affiliation(s)
- Torsten Schreiber
- Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-Universitaet Jena, Jena, Germany.
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Schreiber T, Hueter L, Gaser E, Schmidt B, Schwarzkopf K, Rek H, Karzai W. PEEP has beneficial effects on inflammation in the injured and no deleterious effects on the noninjured lung after unilateral lung acid instillation. Intensive Care Med 2006; 32:740-9. [PMID: 16534568 DOI: 10.1007/s00134-006-0117-6] [Citation(s) in RCA: 15] [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] [Subscribe] [Scholar Register] [Received: 06/25/2005] [Accepted: 02/14/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE In clinical lung injury areas of inflammation and structural alveolar alteration are unevenly distributed and interspaced between healthy or less injured lung areas. Positive end-expiratory pressure (PEEP) applied with mechanical ventilation (MV) may affect injured and healthy lung areas differently. We compared the effects of PEEP on the inflammatory response in injured and noninjured regions of the lung in an animal model of unilateral lung acid instillation. SUBJECTS Anesthetized, paralyzed, and ventilated rats. INTERVENTIONS Rats underwent left-endobronchial instillation with either hydrochloric acid or isotonic saline and were randomized 24 h later to MV using constant tidal volume (16 ml/kg) with either ZEEP, PEEP at 5 mmHg, or PEEP at 10 mmHg. After 4 h of MV the animals (n=9 or 10 per group) were killed and inflammatory markers assessed in left- and right-lung lavage fluid samples. In four additional animals per group differential lung perfusion was assessed. RESULTS Unilateral acid injury alone worsened oxygenation, decreased left-lung perfusion, and increased left-lung lavage neutrophil and macrophage counts and cytokine levels. MV with ZEEP further impaired oxygenation and further decreased left-lung perfusion in acid-injured animals. MV with high PEEP preserved oxygenation and significantly decreased left-lung lavage protein content and cell counts in acid-injured animals and had no deleterious effect on the right (noninjured) lung. CONCLUSION In this model of unilateral lung acid injury high PEEP attenuates the inflammatory cell response in the acid-injured lung, preserved oxygenation and has no deleterious effects in the opposite lung.
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Affiliation(s)
- Torsten Schreiber
- Department of Anesthesiology and Intensive Care Medicine, Friedrich Schiller University, Erlanger Allee 101, 07747, Jena, Germany.
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Schreiber T, Hueter L, Schwarzkopf K, Hohlstein S, Schmidt B, Karzai W. Increased susceptibility to ventilator-associated lung injury persists after clinical recovery from experimental endotoxemia. Anesthesiology 2006; 104:133-41. [PMID: 16394699 DOI: 10.1097/00000542-200601000-00019] [Citation(s) in RCA: 12] [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 Endotoxin, when delivered shortly before or during mechanical ventilation, increases susceptibility to ventilation-associated lung injury. However, it is unclear whether increased susceptibility to ventilator-associated lung injury is still present after clinical recovery from a transient endotoxin challenge. METHODS Anesthetized rats were submitted to a 4-h period of mechanical ventilation with low (8 ml/kg) or high (24, 27, or 30 ml/kg) tidal volumes (VTs) 24 h after transient illness had been provoked by a single nonlethal intravenous injection of Escherichia coli endotoxin. Control animals were injected with phosphate-buffered saline and underwent the same protocol. RESULTS At 24 h, endotoxin-treated nonventilated animals showed no symptoms of clinical illness, and oxygenation was comparable with that of controls, but lung neutrophil counts were increased. Compared with controls, mechanical ventilation with high VT induced a stronger pulmonary inflammatory response and more severe lung injury in endotoxin-treated animals, as indicated by impaired oxygenation, increased lung wet-to-dry weight ratio, and increased levels of protein, neutrophils, and cytokines in lung lavage fluid. In addition, the highest VT resulted in increased mortality in endotoxin-treated animals. Low VT after endotoxin treatment did not cause functional pulmonary impairment but induced an inflammatory response. CONCLUSIONS In this animal model, a 24-h delay after a single systemic injection of endotoxin resulted in clinical recovery and preserved pulmonary function but did not prevent increased susceptibility to ventilator-associated lung injury provoked by high VT. Residual pulmonary inflammation and neutrophilic infiltration at initiation of mechanical ventilation probably contribute to these findings.
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Affiliation(s)
- Torsten Schreiber
- Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-Universitaet, Jena, Germany.
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Karzai W, Cui X, Heinicke N, Niemann C, Gerstenberger EP, Correa R, Banks S, Mehlhorn B, Bloos F, Reinhart K, Eichacker PQ. Neutrophil Stimulation with Granulocyte Colony-stimulating Factor Worsens Ventilator-induced Lung Injury and Mortality in Rats. Anesthesiology 2005; 103:996-1005. [PMID: 16249674 DOI: 10.1097/00000542-200511000-00014] [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] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background
Based on the association between the neutrophil and ventilator-induced lung injury, the authors hypothesized that neutrophil inhibition with fucoidin would be beneficial and stimulation with granulocyte colony-stimulating factor (G-CSF) would be harmful in a rat model of lethal ventilator-induced lung injury.
Methods
Animals (n = 111) were randomly assigned to be pretreated with fucoidin, G-CSF, or placebo (control) before 4 h of low-tidal-volume (10 ml/kg) or high-tidal-volume (40 ml/kg) mechanical ventilation.
Results
All low-volume animals survived. With high volumes, compared with controls, fucoidin did not improve survival (3 of 20 control animals and 5 of 20 fucoidin animals died; P = 0.51) but G-CSF significantly worsened it (18 of 22 animals died; P < 0.001). Circulating neutrophils were increased early with G-CSF and late with fucoidin with low and high tidal volumes (P < 0.05 for each treatment and tidal volume). Fucoidin decreased lung neutrophils, but these were only significant with high tidal volumes, whereas G-CSF increased lung neutrophils but only significantly with low tidal volumes (P < or = 0.01 for each). Fucoidin did not alter any cardiopulmonary measure significantly. Compared with control, G-CSF increased airway pressures with high tidal volumes and worsened lung edema and arterial oxygen with both tidal volumes (P < 0.05 for each).
Conclusions
In this model, neutrophil stimulation by G-CSF increased lung dysfunction and with high tidal volumes worsened survival rates. Extrapolated clinically, neutrophil stimulation either by agents such as G-CSF or conditions such as sepsis may aggravate ventilator-induced lung injury.
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Affiliation(s)
- Waheedullah Karzai
- Department of Anesthesiology and Critical Care Medicine, Friedrich-Schiller-University Hospital, Jena, Germany.
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Abstract
Extravasation is an unintentional injection or leakage of fluid in the perivascular or subcutaneous space. Extravasation injury results from a combination of factors, including solution cytotoxicity, osmolality, vasoconstrictor properties, infusion pressure, regional anatomical peculiarities, and other patient factors. We reviewed the hospital files of patients who had sustained a significant extravasation injury in the perioperative setting at two German hospitals. These cases highlight the risk of devastating consequences from extravasation injury. Vasoactive drugs and hyperosmolar and concentrated electrolyte solutions are the predominant vesicants in the perioperative setting. Prompt and appropriate intervention is important for avoiding or minimizing extensive tissue injury.
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Affiliation(s)
- Wolfram Schummer
- Departments of *Anesthesiology and Intensive Care Medicine and †Otolaryngology, Friedrich-Schiller University of Jena, Jena, Germany; ‡Department of Kinesiology, University of Wisconsin-Eau Claire, Eau Claire, Wisconsin; and §Department of Anesthesia and Intensive Care Medicine, Zentralklinik Bad Berka, Bad Berka, Germany
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Schwarzkopf K, Schreiber T, Gaser E, Preussler NP, Hueter L, Schubert H, Rek H, Karzai W. The effects of xenon or nitrous oxide supplementation on systemic oxygenation and pulmonary perfusion during one-lung ventilation in pigs. Anesth Analg 2005; 100:335-339. [PMID: 15673852 DOI: 10.1213/01.ane.0000142118.84049.80] [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: 11/05/2022]
Abstract
During experimental one-lung ventilation (OLV), the type of anesthesia may alter systemic hemodynamics, lung perfusion, and oxygenation. We studied whether xenon (Xe) or nitrous oxide (N(2)O) added to propofol anesthesia would affect oxygenation, lung perfusion, and systemic and pulmonary hemodynamics during OLV in a pig model. Nine pigs were anesthetized, tracheally intubated, and mechanically ventilated. After placement of arterial and pulmonary artery catheters, a left-sided double-lumen tube was placed via tracheotomy. IV anesthesia with propofol was supplemented in random order with N(2)O/O(2) 60:40 or Xe/O(2) 60:40 or N(2)/O(2) 60:40. All measurements were made after stabilization at each concentration. Differential lung perfusion was measured with colored microspheres. Oxygenation (Pao(2): 90 +/- 17, 95 +/- 20, and 94 +/- 20 mm Hg for N(2)/O(2), N(2)O/O(2), and Xe/O(2)) and left lung perfusion (16% +/- 5%, 14% +/- 6%, and 18.8% for N(2)/O(2), N(2)O/O(2), and Xe/O(2)) during OLV did not differ among the 3 groups. However, mean arterial blood pressure (78 +/- 25, 62 +/- 23, and 66 +/- 23 mm Hg for N(2)/O(2), N(2)O/O(2), and Xe/O(2)) and mixed venous saturation (55% +/- 12%, 48% +/- 12%, and 50% +/- 12% for N(2)/O(2), N(2)O/O(2), and Xe/O(2)) were reduced during N(2)O/O(2) as compared with the control group (N(2)/O(2)). Supplementation of IV anesthesia with Xe or N(2)O does not impair oxygenation nor alter lung perfusion during experimental OLV.
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Affiliation(s)
- Konrad Schwarzkopf
- *Department of Anesthesiology and Intensive Care Medicine and †Institute for Experimental Animals, University of Jena; and ‡Department of Anesthesiology and Intensive Care Medicine, Zentralklinik Bad Berka, Germany
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Hüter L, Schwarzkopf K, Preussler NP, Gaser E, Schubert H, Karzai W, Schreiber T. Measuring cardiac output in one-lung ventilation: a comparison of pulmonary artery and transpulmonary aortic measurements in pigs. J Cardiothorac Vasc Anesth 2004; 18:190-3. [PMID: 15073710 DOI: 10.1053/j.jvca.2004.01.026] [Citation(s) in RCA: 15] [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] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The agreement between cardiac output measurements via pulmonary artery thermodilution (CO[PA]) and transpulmonary aortic thermodilution (CO[AT]) during one-lung ventilation was studied. DESIGN Animal study with repeated simultaneous measurements comparing 2 cardiac output measurement techniques. SETTING Experimental animal facility of a university department. PARTICIPANTS Forty-eight female pigs (26-42 kg). INTERVENTIONS The pigs were anesthetized, tracheally intubated, and mechanically ventilated. After placement of an aortic thermistor catheter via the femoral artery and a pulmonary artery catheter, a double-lumen tube was placed via tracheotomy. During one-lung ventilation in each animal, 3 measurements with pulmonary artery thermodilution and transpulmonary aortic thermodilution were performed in different hemodynamic states. Both thermistors were connected to 1 computer system, and 144 simultaneous cardiac output measurements were analyzed. MEASUREMENTS AND MAIN RESULTS Linear regression analyses revealed a close relationship between the 2 methods: CO(AT) = 0.81 CO(PA) + 1.04 (L/min) (r = 0.96, p < 0.0001). Bland-Altman analysis showed that CO(AT) was slightly higher than the CO(PA) with a bias of 0.2 +/- 0.5 L/min. However, in higher CO states, an inversion of this relationship was found, possibly because of indicator loss and recirculation. CONCLUSIONS The pulmonary artery thermodilution and the transpulmonary aortic thermodilution techniques both accurately measure cardiac output during one-lung ventilation.
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Affiliation(s)
- Lars Hüter
- Department of Anaesthesiology and Intensive Care Medicine, University of Jena, Jena, Germany
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Schummer W, Schummer C, Müller A, Karzai W. [Extravasation: a rare complication of central venous cannulation? Case report of an imminent erosion of the common carotid artery]. Anaesthesist 2003; 52:711-7. [PMID: 12955273 DOI: 10.1007/s00101-003-0521-z] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Extravasation is the non-intentional leakage of substances/solutions into the perivascular or subcutaneous space that can result in significant tissue damage. The extent of destruction depends on the properties of the substance, its concentration, and the amount applied. Substances known to cause severe tissue damage include certain chemotherapeutic agents, vasoactive substances, concentrated electrolytes, and other hyperosmolar solutions. Extravasation can be avoided by meticulous monitoring of venous access. When extravasation occurs, the infusion should be stopped immediately. Substances known to cause tissue damage should be removed from perivascular or subcutaneous space within 24 hours by local incision and irrigation. A delay in early treatment may necessitate more extensive surgical debridement and skin coverage operations. Since the extent of deep soft tissue damage is difficult to predict and is often underestimated, a magnetic resonance imaging should be performed before surgery. We report here on a 73-year-old patient, in whom extravasation of potassium-chloride from a dislocated multi-lumen central venous catheter led to a life-threatening skin and soft-tissue necrosis of the neck. This article provides an overview of common vesicants, theories of tissue destruction, potential risk factors, guidelines for prevention, and current treatment strategies.
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Affiliation(s)
- W Schummer
- Klinik für Anästhesiologie und Intensivtherapie, Friedrich-Schiller-Universität Jena.
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Karzai W, Cui X, Mehlhorn B, Straube E, Hartung T, Gerstenberger E, Banks SM, Natanson C, Reinhart K, Eichacker PQ. Protection with antibody to tumor necrosis factor differs with similarly lethal Escherichia coli versus Staphylococcus aureus pneumonia in rats. Anesthesiology 2003; 99:81-9. [PMID: 12826846 DOI: 10.1097/00000542-200307000-00016] [Citation(s) in RCA: 26] [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: 11/27/2022]
Abstract
BACKGROUND Differing factors may alter the effects of antibody to tumor necrosis factor (TNF) in infection and sepsis. The authors tested whether bacteria type or treatment route alters antibody to TNF in a rat model of bacterial pneumonia. METHODS Rats (n = 231) received similarly lethal doses of either intratracheal Escherichia coli or Staphylococcus aureus followed by treatment with either intratracheal or intraperitoneal antibody to TNF or control serum. Animals received antibiotics (cefotiam daily dose, 100 mg/kg) starting 4 h after inoculation and were studied for up to 96 h. RESULTS Compared with S. aureus, E. coli increased serum TNF and interleukin-6 concentrations, lung lavage TNF concentrations, neutrophil counts, and alveolar-to-arterial oxygen gradients and decreased circulating neutrophils and lymphocytes (P > or = 0.05 for all). Compared with controls, with both bacteria, except for lung lavage TNF concentrations (which decreased with intratracheal but not with intraperitoneal antibody to TNF), treatment route did not alter the effects of antibody to TNF on any parameter (P = not significant for all). Antibody to TNF reduced mortality rates (relative risk of death +/- SEM) with both E. coli (-1.6 +/- 0.6; P = 0.006) and S. aureus (-0.5 +/- 0.04; P = 0.185), but these reductions were greater with E. coli than with S. aureus in a trend approaching statistical significance (P = 0.09). Compared with controls, similarly (P = not significant) with both bacteria, antibody to TNF decreased lung lavage and tissue bacteria concentrations (both P < 0.05) and serum TNF concentration (P < 0.09) and increased circulating neutrophils and lymphocytes (both P < or = 0.01). Compared with S. aureus, with E. coli antibody to TNF decreased alveolar-to-arterial oxygen gradients (P = 0.04) and increased serum interleukin-6 concentrations (P = 0.003). CONCLUSION Antibody to TNF improved host defense and survival rates with both lethal E. coli and S. aureus pneumonia, but protection was greater with E. coli, where TNF concentrations were higher than with S. aureus. The efficacy of antiinflammatory agents in sepsis may be altered by bacteria type.
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MESH Headings
- Administration, Inhalation
- Animals
- Antibodies/administration & dosage
- Antibodies/therapeutic use
- Bronchoalveolar Lavage Fluid/chemistry
- Cefotiam/therapeutic use
- Cephalosporins/therapeutic use
- Escherichia coli/pathogenicity
- Escherichia coli Infections/immunology
- Escherichia coli Infections/microbiology
- Escherichia coli Infections/prevention & control
- Injections, Intraperitoneal
- Interleukin-6/blood
- Intubation, Intratracheal
- Leukocyte Count
- Lymphocyte Count
- Male
- Neutrophils/immunology
- Oxygen/blood
- Oxygen Consumption/physiology
- Pneumonia, Bacterial/immunology
- Pneumonia, Bacterial/microbiology
- Pneumonia, Bacterial/prevention & control
- Pneumonia, Staphylococcal/immunology
- Pneumonia, Staphylococcal/microbiology
- Pneumonia, Staphylococcal/prevention & control
- Rats
- Rats, Wistar
- Sepsis/immunology
- Staphylococcus aureus/pathogenicity
- Survival Analysis
- Tumor Necrosis Factor-alpha/immunology
- Tumor Necrosis Factor-alpha/metabolism
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Affiliation(s)
- Waheedullah Karzai
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Jena, Germany.
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Karzai W, Priebe HJ. Aspirin and mortality from coronary bypass surgery. N Engl J Med 2003; 348:1057-9; author reply 1057-9. [PMID: 12638576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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Preussler NP, Schreiber T, Hüter L, Gottschall R, Schubert H, Rek H, Karzai W, Schwarzkopf K. Percutaneous transtracheal ventilation: effects of a new oxygen flow modulator on oxygenation and ventilation in pigs compared with a hand triggered emergency jet injector. Resuscitation 2003; 56:329-33. [PMID: 12628564 DOI: 10.1016/s0300-9572(02)00402-1] [Citation(s) in RCA: 24] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The application of percutaneous transtracheal jet ventilation for emergency ventilation depends on special equipment which is often not available outside the operating room. The oxygen flow modulator is a new specially designed device for emergency ventilation using a low pressure oxygen supply. We studied the effects of the new device in comparison with a hand triggered emergency jet injector on oxygenation and ventilation in six pigs (21+/-1 kg). The animals were anaesthetized, tracheally intubated, and mechanically ventilated. Following central venous and pulmonary artery catheterization, a Paratrend 7 sensor was placed in the left femoral artery for continuous measurements of PaO(2) and PaCO(2). Then an emergency transtracheal airway catheter was inserted into the trachea after surgical exposure. In randomized order each animal was ventilated via the transtracheal airway catheter with the hand triggered emergency jet injector (inspiratory/expiratory (I/E) ratio of 1:1; respiratory rate of 60 min(-1); driving pressure 1.5 bar; FjetO(2) 1.0) and the oxygen flow modulator (FiO(2) 1.0 at an oxygen flow of 15 l min(-1); respiratory rate of 60 min(-1); I/E ratio of approximately 1:1) for 15 min each. After each phase of the experiment respiratory and hemodynamic variables were measured. Whereas PaO(2) was not significantly different between the two devices, PaCO(2) was higher during the hand-triggered jet ventilation. Thus, the efficacy of the oxygen flow modulator during the experiment was comparable with the efficacy of the hand triggered emergency jet injector.
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Affiliation(s)
- Niels-Peter Preussler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, 07740 Jena, Germany
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Schwarzkopf K, Schreiber T, Preussler NP, Gaser E, Hüter L, Bauer R, Schubert H, Karzai W. Lung perfusion, shunt fraction, and oxygenation during one-lung ventilation in pigs: the effects of desflurane, isoflurane, and propofol. J Cardiothorac Vasc Anesth 2003; 17:73-5. [PMID: 12635064 DOI: 10.1053/jcan.2003.13] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [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: 11/11/2022]
Abstract
OBJECTIVE To study how desflurane, isoflurane, and propofol affect pulmonary perfusion, shunt fraction, and systemic oxygenation during one-lung ventilation (OLV) in vivo. DESIGN Prospective animal study with a crossover design. SETTING Animal laboratory of a university hospital. PARTICIPANTS Twelve female pigs. INTERVENTIONS The pigs were anesthetized, tracheally intubated, and mechanically ventilated. After placement of femoral arterial and thermodilution pulmonary artery catheters, a left-sided, double-lumen tube (DLT) was placed via tracheotomy. After DLT placement, F(I)O(2) was adjusted at 0.8, and anesthesia was continued in random order with 1 minimal alveolar concentration of desflurane, 1 minimal alveolar concentration of isoflurane, or propofol. MEASUREMENTS AND MAIN RESULTS Measurements of respiratory and hemodynamic parameters were made after stabilization at each anesthetic. During OLV, perfusion of the nonventilated lung and shunt fraction were comparable during all 3 anesthetics. PaO(2) was lower during desflurane and isoflurane anesthesia as compared with propofol anesthesia. Mixed venous PO(2) and cardiac output were lower with desflurane and isoflurane as compared with propofol. CONCLUSIONS In a clinically relevant model of OLV cardiac output, PaO(2) and mixed venous PO(2) decreased during desflurane and isoflurane as compared with propofol, whereas perfusion of the nonventilated lung and shunt fraction remained comparable.
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Affiliation(s)
- Konrad Schwarzkopf
- Department of Anesthesiology and Intensive Care Medicine, University of Jena, Germany
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Abstract
UNLABELLED In a previous study we have shown that the antihypertensive drug, urapidil, stops postanesthetic shivering. One possible mechanism in the inhibition of postanesthetic shivering by urapidil may be alterations in thermoregulatory thresholds. We therefore studied the effects of urapidil on vasoconstriction and shivering thresholds during cold-induced shivering in volunteers. Seven healthy male volunteers were cooled by an infusion of saline at 4 degrees C on two study days separated by 48 h. Thermoregulatory vasoconstriction was estimated using forearm minus fingertip skin-temperature gradients, and values exceeding 0 degrees C were considered to represent significant vasoconstriction. The rectal core temperatures at the beginning of shivering and at vasoconstriction were considered the thermoregulatory thresholds. Before cooling, either 25 mg of urapidil or placebo was administered randomly and blindly to each volunteer. When shivering occurred continuously for 10 min, another 25 mg of urapidil was administered IV to completely stop shivering. Urapidil led to a decrease in core temperature at vasoconstriction and shivering threshold by 0.4 degrees C plus/minus 0.2 degrees C (P < 0.001) and 0.5 degrees C plus/minus 0.3 degrees C (P < 0.01), respectively. Oxygen consumption increased during shivering by 70% plus/minus 30% (P < 0.01) in comparison with baseline and decreased levels after shivering stopped, despite the continued low core temperature. Our investigation shows that urapidil stops postanesthetic shivering by decreasing important thermoregulatory thresholds. This means that shivering, not hypothermia, is treated, and hypothermia will need more attention in the postanesthesia care unit. IMPLICATIONS In this study we show that the antihypertensive drug urapidil stops cold-induced shivering and decreases normal thermoregulatory responses, i.e., the thresholds for vasoconstriction and shivering, in awake volunteers.
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Affiliation(s)
- Harald G Fritz
- Klinik fuer Anaesthesiologie und Intensivtherapie Klinikum and Apotheke des Klinikums, Friedrich-Schiller-Universitaet, Jena, Germany.
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Abstract
Early diagnosis of the different severities of septic inflammation is important for early implementation of specific therapies. Sepsis and severe sepsis are accompanied by clinical and laboratory signs of systemic inflammation. However, patients suffering from non-infectious inflammation may present with similiar signs and symptoms making it difficult to diagnose infection based on clinical findings alone. Bacteriological evidence of sepsis, though definitive and specific, may not be obtainable, is time-consuming and even may not occur concurrently with clinical signs of sepsis. It is therefore important to identify markers, which, by enabling an early diagnosis of sepsis and organ dysfunction, would allow early specific therapeutic interventions. Wheras C-reactive Protein is a more sensitive parameter for the diagnosis of non-systemic infections, Procalcitonin seems to be a useful parameter to improve the diagnosis and monitoring of therapy in patients with severe sepsis and septic shock.
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Affiliation(s)
- F M Brunkhorst
- Klinik für Anästhesiologie und Intensivtherapie, Klinikum der Friedrich Schiller Universität Jena, Germany
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Schreiber T, Schwarzkopf K, Schmidt B, Karzai W. Crit Care 2002; 6:P8. [DOI: 10.1186/cc1783] [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: 11/10/2022] Open
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Karzai W, Klein U. [Avoidance of hypoxemia during one lung ventilation]. Anasthesiol Intensivmed Notfallmed Schmerzther 2002; 37:51-6. [PMID: 11845383 DOI: 10.1055/s-2002-20083] [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: 10/17/2022]
Affiliation(s)
- W Karzai
- Klinik für Anästhesie und Intensivmedizin, Zentralklinik Bad Berka GmbH.
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Schreiber T, Schwarzkopf K, Preussler N, Schubert H, Gaser E, Hüter L, Karzai W. Crit Care 2002; 6:P9. [DOI: 10.1186/cc1794] [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: 11/10/2022] Open
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Schwarzkopf K, Schreiber T, Bauer R, Schubert H, Preussler NP, Gaser E, Klein U, Karzai W. The effects of increasing concentrations of isoflurane and desflurane on pulmonary perfusion and systemic oxygenation during one-lung ventilation in pigs. Anesth Analg 2001; 93:1434-8, table of contents. [PMID: 11726419 DOI: 10.1097/00000539-200112000-00017] [Citation(s) in RCA: 23] [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: 11/25/2022]
Abstract
UNLABELLED During one-lung ventilation (OLV), hypoxic pulmonary vasoconstriction (HPV) reduces venous admixture and attenuates the decrease in arterial oxygen tension by diverting blood from the nonventilated lung to the ventilated lung. In vitro, desflurane and isoflurane depress HPV in a dose-dependent manner. Accordingly, we studied the effects of increasing concentrations of desflurane and isoflurane on pulmonary perfusion, shunt fraction, and PaO(2) during OLV in vivo. Fourteen pigs (30-42 kg) were anesthetized, tracheally intubated, and mechanically ventilated. After placement of femoral arterial and thermodilution pulmonary artery catheters, a left-sided double-lumen tube (DLT) was placed via tracheotomy. After DLT placement, FIO(2) was adjusted at 0.8 and anesthesia was continued in random order with 3 concentrations (0.5, 1.0, and 1.5 minimal alveolar concentrations) of either desflurane or isoflurane. Differential lung perfusion was measured with colored microspheres. All measurements were made after stabilization at each concentration. Whereas mixed venous PO(2), mean arterial pressure, cardiac output, nonventilated lung perfusion, and shunt fraction decreased in a dose-dependent manner, PaO(2) remained unchanged with increasing concentrations of desflurane and isoflurane during OLV. In conclusion, increasing concentration of desflurane and isoflurane did not impair oxygenation during OLV in pigs. IMPLICATIONS In an animal model of one-lung ventilation, increasing concentrations of desflurane and isoflurane dose-dependently decreased shunt fraction and perfusion of the nonventilated lung and did not impair oxygenation. The decreases in shunt fraction are likely the result of anesthetic-induced marked decreases in cardiac output and mixed venous saturation.
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Affiliation(s)
- K Schwarzkopf
- Department of Anesthesiology, Institute for Experimental Animals, University of Jena, Germany
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Schreiber T, Hüter L, Schwarzkopf K, Schubert H, Preussler N, Bloos F, Gaser E, Karzai W. Lung perfusion affects preload assessment and lung water calculation with the transpulmonary double indicator method. Intensive Care Med 2001; 27:1814-8. [PMID: 11810127 DOI: 10.1007/s00134-001-1122-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2001] [Accepted: 09/03/2001] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The transpulmonary double indicator method uses intra- and extravascular indicators to calculate cardiac output, intrathoracic blood volume, global end-diastolic volume, and extravascular lung water content. Since lung perfusion may be of importance during these measurements, we studied the effects of pulmonary blood flow occlusion on measurements obtained with this method. SETTING Experimental animal facility of a University department. METHODS AND INTERVENTIONS In seven pigs, the branch of the pulmonary artery perfusing the lower and middle lobe of the right lung was occluded. Measurements before, during, and after the occlusion were made with a pulmonary artery catheter and a commonly used transpulmonary double indicator catheter and device. MEASUREMENTS AND RESULTS Occlusion of the right lower and middle lobe branch of the pulmonary artery increased mean pulmonary pressure (before occlusion: 24+/-1, during occlusion: 32+/-2, after reopening 25+/-1 mmHg; P<0.05), increased right ventricular end-diastolic volume (172+/-34, 209+/-21, 174+/-32 ml, respectively; P<0.05), decreased intrathoracic blood volume (998+/-39, 894+/-48, 1006+/-49 ml, respectively; P<0.05), and decreased extravascular lung water (7.2+/-0.5, 4.2+/-0.4, 6.9+/-0.4 ml/kg, respectively; P<0.05) without causing significant changes in cardiac output. All changes were reversible upon reopening the vessel. CONCLUSIONS These data show that the transpulmonary double indicator method may underestimate extravascular lung water and right ventricular preload when the perfusion to parts of the lung is obstructed.
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Affiliation(s)
- T Schreiber
- Department of Anesthesiology and Intensive Care Medicine, University of Jena, Jena, Germany
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Quezado Z, Parent C, Karzai W, Depietro M, Natanson C, Hammond W, Danner RL, Cui X, Fitz Y, Banks SM, Gerstenberger E, Eichacker PQ. Acute G-CSF therapy is not protective during lethal E. coli sepsis. Am J Physiol Regul Integr Comp Physiol 2001; 281:R1177-85. [PMID: 11557626 DOI: 10.1152/ajpregu.2001.281.4.r1177] [Citation(s) in RCA: 18] [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] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We investigated whether decreases in circulating polymorphonuclear neutrophils (PMN) during lethal Escherichia coli (E. coli) sepsis in canines are related to insufficient host granulocyte colony-stimulating factor (G-CSF). Two-year-old purpose-bred beagles had intraperitoneal E. coli-infected or -noninfected fibrin clots surgically placed. By 10 to 12 h following clot, both infected survivors and nonsurvivors had marked increases (P = 0.001) in serum G-CSF levels (mean peak G-CSF ng/ml +/- SE, 1,931 +/- 364 and 2,779 +/- 681, respectively) compared with noninfected controls (134 +/- 79), which decreased at 24 to 48 h. Despite increases in G-CSF, infected clot placement caused delayed (P = 0.06) increases in PMN (mean +/- SE change from baseline in cells x 10(3)/mm(3) at 24 and 48 h) in survivors (+3.9 +/- 3.9 and +13.8 +/- 3.6) compared with noninfected controls (+13.1 +/- 2.8 and +9.1 +/- 2.5). Furthermore, infected nonsurvivors had decreases in PMN (-1.4 +/- 1.0 and -1.1 +/- 2.3, P = 0.006 compared with the other groups). We next investigated whether administration of G-CSF immediately after clot placement and continued for 96 h to produce more rapid and prolonged high levels of G-CSF after infection would alter PMN levels. Although G-CSF caused large increases in PMN compared with control protein from 2 to 48 h following clot in noninfected controls, it caused much smaller increases in infected survivors and decreases in infected nonsurvivors (P = 0.03 for the ordered effect of G-CSF comparing the three groups). Thus insufficient host G-CSF is unlikely the cause of decreased circulating PMN in this canine model of sepsis. Other factors associated with sepsis either alone or in combination with G-CSF itself may reduce increases or cause decreases in circulating PMN.
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Affiliation(s)
- Z Quezado
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892, USA
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Abstract
OBJECTIVE Tumor necrosis factor (TNF) is an important mediator involved in the pathogenesis of sepsis. We review clinical studies investigating the efficacy of anti-TNF therapy in decreasing mortality rates in septic patients. DATA SOURCES We conducted a computerized bibliographic search of randomized, clinical, multicenter trials studying the effects of anti-TNF therapy in the treatment of sepsis. We included all primary studies, reviewed all published meta-analyses, and contacted primary investigators of multicenter trials where necessary. DATA SYNTHESIS Almost all randomized studies targeting TNF during sepsis show a small, albeit nonsignificant, benefit in decreasing mortality. Strategies using monoclonal antibodies are more effective than are strategies using TNF receptor proteins. Analysis of randomized multicenter trials shows a small but significant benefit with anti-TNF therapeutic strategies. Furthermore, a recent study in 2634 septic patients using a murine anti-TNF antibody shows a 3.6% significant benefit in reducing mortality. CONCLUSIONS Anti-TNF strategies are only partially effective in patients with sepsis. Although individual studies show small, nonsignificant benefits, analysis of all trial data as well as data from a recent trial in a large population of septic patients show that anti-TNF strategies may confer a small survival benefit. Better characterization of patients and a more multimodal approach by concomitantly targeting other mediators involved in sepsis may be helpful in enlarging the clinical benefit of anti-TNF therapy.
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Affiliation(s)
- K Reinhart
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Jena, Germany.
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Karzai W, Hüttemann E. Noninvasive ventilation in immunosuppressed patients. N Engl J Med 2001; 344:2027; author reply 2028. [PMID: 11430336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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Karzai W, Klein U. Lobectomy for cavitating lung abscess. Br J Anaesth 2001; 86:735-6. [PMID: 11575357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
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Schwarzkopf K, Klein U, Schreiber T, Preussetaler NP, Bloos F, Helfritsch H, Sauer F, Karzai W. Oxygenation during one-lung ventilation: the effects of inhaled nitric oxide and increasing levels of inspired fraction of oxygen. Anesth Analg 2001; 92:842-7. [PMID: 11273912 DOI: 10.1097/00000539-200104000-00009] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED We studied whether inhaled nitric oxide (NO) would improve arterial oxygen tension (PaO(2)) and reduce the occurrence of oxygen saturation of hemoglobin (O(2)Hb) < 90% during one-lung ventilation (OLV). One-hundred-fifty-two patients were ventilated either with or without NO (20 ppm) with an inspired fraction of oxygen (FIO(2)) of either 0.3, 0.5, or 1.0 during OLV. Anesthesia was induced and maintained with propofol, remifentanil, and rocuronium IV, and lung separation was achieved with a double-lumen tube. During OLV, we set positive end-expiratory pressure at 5 cm H(2)O, peak pressure at 30 cm H(2)O, and end-tidal CO(2) at 30 mm Hg. The nonventilated lung was opened to room air and collapsed. During OLV, three consecutive measurements were performed every 10 min. The operated lung was temporarily ventilated if pulse oximetric saturation (SpO(2)) decreased to < 91%. SpO(2) <9 1% occurred in 2 of the 152 patients. SpO(2) overestimated O(2)Hb by 2.9% +/- 0.1%. NO failed to improve oxygenation or alter occurrence of O(2)Hb < 90% during OLV across all time points and all levels of FIO(2). Increasing FIO(2) increased oxygenation and decreased occurrence of O(2)Hb < 90% (P: < 0.001). At FIO(2) = 1, PaO(2) was higher (P < 0.01) and O(2)Hb < 90% rate tended to be lower (P = 0.1) during right versus left lung ventilation. PaO(2) was higher in patients undergoing pneumonectomy and lobectomy than in those undergoing metastasectomy or video-assisted operations (P < 0.05). IMPLICATIONS Inhaled nitric oxide failed to improve oxygenation during one-lung ventilation. Oxygenation during one-lung ventilation was improved with increasing levels of FIO(2) during ventilation of the right versus the left lung and with increasing pathology of the nonventilated lung.
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Affiliation(s)
- K Schwarzkopf
- Department of Anesthesiology and Intensive Care Therapy , University Hospital, 07740 Jena, Germany
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Linnemann G, Reinhart K, Parade U, Philipp A, Pfister W, Straube E, Karzai W. The effects of inhibiting leukocyte migration with fucoidin in a rat peritonitis model. Intensive Care Med 2000; 26:1540-6. [PMID: 11126269 DOI: 10.1007/s001340000642] [Citation(s) in RCA: 18] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To study the effects of fucoidin on leukocyte rolling and emigration and bacterial colonization in a peritonitis sepsis model in rats. DESIGN AND INTERVENTIONS A controlled study in 64 male Wistar rats, anesthetized and rendered septic by cecal ligation and puncture (CLP). Immediately after CLP 32 animals received a continuous infusion of fucoidin and 32 a continuous infusion of Ringer's lactate. MEASUREMENTS AND MAIN RESULTS Systemic leukocyte counts were determined every 2 h after CLP. Surviving animals were anesthetized 24 h after CLP, and intravital measurements of leukocyte rolling in venules in the cremaster muscle were performed. The animals were then killed and their organs harvested for histological and microbiological examinations. The 24-h survival was comparable in the two groups. Fucoidin-treated animals had higher leukocyte counts in the systemic circulation and lower counts in the lungs, liver, abdominal cavity, and brain than control animals. The number of bacterial colony forming units in the abdominal cavity, lungs, liver, brain and blood did not differ in the two groups. Fucoidin treatment changed the type of bacteria predominantly found in the examined organs from Escherichia coli to Pseudomonas aeruginosa. CONCLUSIONS In an intra-abdominal model of sepsis we found that treatment with fucoidin induces leukocytosis inhibits leukocyte rolling and reduces leukocyte emigration in the abdominal cavity, lungs, and liver. Reduction in the number of emigrating leukocytes was not associated with an increase in bacterial counts found in the examined organs.
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Affiliation(s)
- G Linnemann
- Department of Anesthesiology and Intensive Care Therapy, University Hospital Jena, Germany
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Affiliation(s)
- K Reinhart
- Klinik für Anästhesiologie und Intensivtherapie, Friedrich-Schiller-Universität Jena, Germany
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Weyandt D, Karzai W. Total parenteral nutrition for critically ill patients. JAMA 1999; 282:1424; author reply 1425. [PMID: 10535430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
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Oberhoffer M, Karzai W, Meier-Hellmann A, Bögel D, Fassbinder J, Reinhart K. Sensitivity and specificity of various markers of inflammation for the prediction of tumor necrosis factor-alpha and interleukin-6 in patients with sepsis. Crit Care Med 1999; 27:1814-8. [PMID: 10507603 DOI: 10.1097/00003246-199909000-00018] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.0] [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: 11/25/2022]
Abstract
OBJECTIVES To determine correlations and predictive strength of surrogate markers (body temperature, leukocyte count, C-reactive protein [CRP], and procalcitonin [PCT]) with elevated levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in septic patients. DESIGN Prospective consecutive case series. SETTING Surgical intensive care unit (ICU) of a university hospital. PATIENTS A total of 175 patients experiencing intensive care unit stays >48 hrs categorized for sepsis according to ACCP/ SCCM Consensus Conference criteria. MEASUREMENTS AND MAIN RESULTS CRP and PCT were both significantly correlated with TNF-alpha and IL-6. Based on the area-under-the-curve of the receiver operating characteristics curves, predicting capability was highest for PCT (0.814 for TNF-alpha >40 pg/mL and 0.794 for IL-6 >500 pg/mL), moderate with CRP (0.732 and 0.716, respectively), and lowest for leukocyte count (0.493 and 0.483, respectively) and body temperature (0.587 and 0.589, respectively). Sensitivity, specificity, positive, and negative predictive values and test effectiveness all followed this same pattern of being highest for PCT followed by CRP, with leukocyte count and body temperature being lowest. CONCLUSION PCT may be an early and better marker of elevated cytokines than the more classic criteria of inflammation.
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Affiliation(s)
- M Oberhoffer
- Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-University, Jena, Germany
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Karzai W, Haberstroh J, Priebe HJ. The Effects of Increasing Concentrations of Desflurane on Systemic Oxygenation During One-Lung Ventilation in Pigs. Anesth Analg 1999. [DOI: 10.1213/00000539-199907000-00039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [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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Abstract
UNLABELLED During one-lung ventilation (OLV), hypoxic pulmonary vasoconstriction reduces venous admixture and attenuates the decrease in arterial O2 tension by diverting blood from the nonventilated to the ventilated lung. In vitro, increasing concentrations of desflurane depresses hypoxic pulmonary vasoconstriction in a dose-dependent manner. Accordingly, we investigated the effects of increasing concentrations of desflurane on oxygenation during OLV in vivo. Thirteen pigs (25-30 kg) were anesthetized (induction: propofol 2-3 mg/kg IV; maintenance: N2O/O2 50%/50%, desflurane 3%, propofol 50 microg x kg(-1) min(-1), and vecuronium 0.2 mg x kg(-1) x h(-1) IV), orotracheally intubated, and mechanically ventilated. After placement of femoral arterial and thermodilution pulmonary artery catheters, a leftsided, 28F, double-lumen tube was placed via tracheotomy. After double-lumen tube placement, N2O and desflurane were discontinued, propofol was increased to 200 microg x kg(-1) x min(-1), and the fraction of inspired oxygen was adjusted at 0.8. Anesthesia was then continued in random order with desflurane 5%, 10%, or 15% end-tidal concentrations while propofol was discontinued. Whereas mixed venous PO2, mean arterial pressure, cardiac output, and shunt fraction decreased in a dose-dependent manner, PaO2 remained unchanged with increasing concentrations of desflurane during OLV. These findings indicate that, in vivo, increasing concentrations of desflurane do not necessarily worsen oxygenation during OLV. IMPLICATIONS Oxygenation during one-lung ventilation depends on reflex vasoconstriction in the nonventilated lung. In vitro, desflurane inhibits this reflex dose-dependently. Our results indicate that, in vivo, this does not necessarily translate to dose-dependent decreases in oxygenation during one-lung ventilation.
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Affiliation(s)
- W Karzai
- Department of Anesthesia, University Hospital Freiburg, Germany.
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Karzai W, von Specht BU, Parent C, Haberstroh J, Wollersen K, Natanson C, Banks SM, Eichacker PQ. G-CSF during Escherichia coli versus Staphylococcus aureus pneumonia in rats has fundamentally different and opposite effects. Am J Respir Crit Care Med 1999; 159:1377-82. [PMID: 10228098 DOI: 10.1164/ajrccm.159.5.9806082] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [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: 11/16/2022] Open
Abstract
We investigated if bacteria type alters outcome with prophylactic granulocyte colony stimulating factor (G-CSF) therapy during pneumonia. Rats received G-CSF or placebo daily for 6 d and after the third dose were intrabronchially inoculated with either Escherichia coli or Staphylococcus aureus. Without G-CSF, E. coli and S. aureus produced similar (p = NS) mortality rates (36 versus 38%) and serial changes in mean circulating neutrophil counts (CNC), but differing mean (+/- SE) tumor necrosis factor (TNF) levels (E. coli, 259 +/- 104 versus S. aureus, 51 +/- 17 pg/ml, p = 0.01). G-CSF prior to bacteria increased mean CNC more than six times compared with placebo (p = 0.001). However, with G-CSF in the first 6 h after E. coli, there was a greater than 20-fold decrease in mean (+/- SE) CNC (x 10(3)/ mm3) to below placebo (0.5 +/- 0.1 versus 0.8 +/- 0.1), whereas with G-CSF after S. aureus, there was only a fivefold decrease in mean CNC and CNC were greater than placebo (1.8 +/- 0.2 versus 0.8 +/- 0.1) (E. coli versus S. aureus decrease in CNC with G-CSF, p = 0.001). With E. coli, G-CSF worsened oxygenation and increased bacteremia and mortality, whereas with S. aureus, G-CSF improved oxygenation and decreased bacteremia and mortality (G-CSF therapy, E. coli versus S. aureus, p = 0.03, 0.05, and 0.001, respectively). Thus, during S. aureus pneumonia with low TNF levels, G-CSF increased CNC and bacterial clearance, resulting in less pulmonary injury and decreased death. During E. coli pneumonia with high TNF levels, G-CSF paradoxically decreased CNC, resulting in impaired bacterial clearance and worsened pulmonary injury and death. Bacterial species and the associated inflammatory mediator response can alter outcome with prophylactic G-CSF therapy during pneumonia.
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Affiliation(s)
- W Karzai
- Departments of Anesthesiology and Surgical Research, University Hospital, Freiburg, Germany; and Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland, USA
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Klein U, Karzai W, Gottschall R, Gugel M, Bartel M. Respiratory gas monitoring during high-frequency jet ventilation for tracheal resection using a double-lumen jet catheter. Anesth Analg 1999; 88:224-6. [PMID: 9895097 DOI: 10.1097/00000539-199901000-00042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- U Klein
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Jena, Germany.
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Karzai W, Reinhart K. Editorial comment. Crit Care 1999; 3:17-18. [PMID: 11056718 PMCID: PMC29008 DOI: 10.1186/cc301] [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: 05/13/1998] [Accepted: 02/11/1999] [Indexed: 11/10/2022] Open
Affiliation(s)
- Waheedullah Karzai
- Department of Anesthesiology and Intensive Care Medicine,
University Hospital, Friedrich-Schiller-University Jena, 07740 Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine,
University Hospital, Friedrich-Schiller-University Jena, 07740 Jena, Germany
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Klein U, Karzai W, Gottschall R, Gugel M, Bartel M. Respiratory Gas Monitoring During High-Frequency Jet Ventilation for Tracheal Resection Using a Double-Lumen Jet Catheter. Anesth Analg 1999. [DOI: 10.1213/00000539-199901000-00042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [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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Klein U, Karzai W, Zimmermann P, Hannemann U, Koschel U, Brunner JX, Remde H. Changes in pulmonary mechanics after fiberoptic bronchoalveolar lavage in mechanically ventilated patients. Intensive Care Med 1998; 24:1289-93. [PMID: 9885882 DOI: 10.1007/s001340050764] [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: 10/28/2022]
Abstract
OBJECTIVE We prospectively assessed the impact of bronchoalveolar lavage (BAL) on respiratory mechanics in critically ill, mechanically ventilated patients. STUDY DESIGN Mechanically ventilated patients underwent BAL of one lung segment using 5 x 20 ml of sterile, physiologic saline with a temperature of 25-28 degrees C. The fractional inspired oxygen was increased to 1.0, but ventilator settings were otherwise left unchanged. Static pulmonary compliance, pulmonary resistance, alveolar ventilation, and serial dead space were measured 60 min and 2 min before and 8, 60, and 180 min after BAL to assess the consequences of the procedure. In addition, blood gases [partial pressure of carbon dioxide in arterial blood (PaCO2) and arterial oxygen tension (PaO2)], hemodynamic variables (heart rate, systolic and diastolic blood pressure), and body temperature were recorded at the same time points. SETTING Intensive care unit of a university hospital. PATIENTS 18 consecutive critically ill, mechanically ventilated patients. RESULTS Pulmonary compliance decreased by 23% (p < 0.05) and pulmonary resistance increased by 22% (p < 0.05) shortly after BAL. The changes in pulmonary compliance and resistance were more than 30% in one third of the patient population. One hour after the procedure, PaO2 was significantly lower and PaCO2 significantly higher than before the procedure. Three hours after the procedure, pulmonary resistance returned to pre-BAL values but compliance remained 10% below baseline values (p < 0.05). CONCLUSION BAL in mechanically ventilated patients is associated with deterioration of pulmonary mechanics and function.
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Affiliation(s)
- U Klein
- Department of Anesthesiology and Intensive Care Medicine, Friedrich Schiller University Jena, Germany
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Pascual C, Bredle D, Karzai W, Meier-Hellmann A, Oberhoffer M, Reinhart K. Effect of plasma and LPS on respiratory burst of neutrophils in septic patients. Intensive Care Med 1998; 24:1181-6. [PMID: 9876981 DOI: 10.1007/s001340050742] [Citation(s) in RCA: 13] [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: 10/28/2022]
Abstract
OBJECTIVE To compare the respiratory burst of neutrophils in sepsis and control patients using lipopolysaccharide (LPS), autologous plasma, and a combination of the two. DESIGN Prospective, consecutive case study. SETTING A 16-bed intensive care unit (ICU) in a university teaching hospital. INTERVENTIONS None. PATIENTS Plasma was obtained from 23 healthy patients scheduled for minor surgery immediately prior to induction of anesthesia (controls) and from 23 ICU patients within 24 h of diagnosis of sepsis or septic shock. MEASUREMENTS AND MAIN RESULTS Respiratory burst was determined by lucigenin chemiluminescence expressed as mean +/- SEM of peak values of relative light units per neutrophil. There were no significant differences between neutrophils of septic patients and controls for the stimuli saline, phorbol myristate acetate, formyl-methionyl-leucyl-phenylalanine, and LPS alone. Septic patients showed a lower respiratory burst than controls (p < 0.05) under the following stimuli: plasma alone (5911 +/- 803 vs 15,397 +/- 3038) and LPS and plasma combined (13,857 +/- 1537 vs 23,026 +/- 2640). However, when stimulated with plasma after priming with LPS, septic patients elicited a higher value than control subjects (11,373 +/- 1758 vs 5987 +/- 1234, p < 0.05). CONCLUSIONS (1) Some components of the plasma of septic patients may have a profound effect on neutrophil response; (2) plasma as a respiratory burst stimulus differentiates between sepsis and non-sepsis samples better than other common stimuli; (3) precautions must be taken when using plasma together with LPS because of the different response depending on whether LPS-priming precedes the plasma stimulus or both are introduced simultaneously and whether septic or nonseptic plasma is used.
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Affiliation(s)
- C Pascual
- Department of Anesthesiology and Intensive Care Medicine, Friedrich Schiller University, Jena, Germany.
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Reinhart K, Karzai W. Re: Procalcitonin: a new parameter for the diagnosis of bacterial infection in the perioperative period. Oczenski et al., Eur J Anaesthesiol 1998; 15: 129-132. Ugeskr Laeger 1998; 15:618-9. [PMID: 9785086 DOI: 10.1017/s0265021598271122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
OBJECTIVES Cardiopulmonary bypass (CPB) can be successfully performed in patients on hemodialysis. However, ischemic complications occur more often in these patients. This could partly be because of shunting through the arteriovenous (AV) fistula during CPB, resulting in reduced peripheral flow and oxygen (O2) delivery. Inadequate oxygen delivery during CPB should be reflected in a lower oxygen consumption (VO2) compared with patients without an AV fistula. DESIGN To test the hypothesis, the authors analyzed VO2 in three groups of patients retrospectively. Group 1 included 14 patients with end-stage renal failure (creatinine level 9.1 +/- 0.3 mg/dL, urea level 126 +/- 8 mg/dL) requiring hemodialysis through an AV fistula. Group 2 included 13 patients with compensated renal insufficiency (creatinine level 3.1 +/- 0.4 mg/dL, urea level 106 +/- 10 mg/dL) without an AV fistula. Group 3 included 14 patients with normal renal function (creatinine level 1.0 +/- 0.1 mg/dL, urea level 44 +/- 4 mg/dL). SETTING An operating room of a university hospital. PARTICIPANTS Patients undergoing cardiac surgery requiring CPB. MEASUREMENTS AND MAIN RESULTS VO2 was calculated from the recorded hemodynamic and blood gas data using standard formulae. Data were analyzed using a two-way analysis of variance with a repeated measurement on one factor. Before undergoing CPB, VO2 was similar in all three groups. VO2 decreased in all three groups during hypothermic CPB (standard flow rate 2.2 L/min/m2, standard temperature 29 degrees C) and returned to prebypass levels during rewarming. There was no difference in VO2 among the three groups during hypothermic CPB or during rewarming. Only base excess decreased more in group 1 patients compared with the other groups (p < 0.001). CONCLUSION During hypothermic CPB at a flow rate of 2.2 L/min/m2, shunting through an AV fistula is unlikely to lead to decreased VO2 in dialysis patients.
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Affiliation(s)
- W Karzai
- Department of Anesthesiology, University Hospital Freiburg, Germany
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