Der Ausduck „Schock“ findet haufige, ja banale Anwendung im Alltag. In der Medizin erregt seine V... more Der Ausduck „Schock“ findet haufige, ja banale Anwendung im Alltag. In der Medizin erregt seine Verwendung ofters Anstos, weil er oft als Oberbegriff fur alle moglichen akuten Zustande herhalten mus. Manches Schocksymposium der letzten Jahre endete mit dem Stosseufzer, der misverstandliche Sammelbegriff Schock moge doch endlich durch einen auf der Pathogenese der verschiedenen Schockzustande basierenden Ausdruck ersetzt werden. Der Begriff Schock hat diesen puristischen Angriffen aber erfolgreich widerstanden, und er ist in der medizinischen Terminologie fester verankert denn je — nicht zuletzt wegen der Systematisierung unseres Wissens in verschiedenen Dokumentationssystemen. Er ist heutemit ordnenden Adjektiven unterteilt, wie beispielsweise hamorrhagischer traumatischer, kardiogener, septischer oder anaphylaktischer Schock.
Procalcitonin as a Marker of Systemic Inflammation After Conventional or Minimally Invasive Coronary Artery Bypass Grafting
Thoracic and Cardiovascular Surgeon, Jun 1, 1998
Cardiac surgery using cardiopulmonary bypass (CPB) often induces a systemic inflammatory response... more Cardiac surgery using cardiopulmonary bypass (CPB) often induces a systemic inflammatory response syndrome (SIRS). The concept of minimally invasive direct coronary artery bypass (MIDCAB) eliminates cardiopulmonary bypass. We evaluated the perioperative time course of procalcitonin (PCT) to compare the inflammatory response due to these two different surgical procedures. 57 patients were studied: CABG with CPB (n = 30), MIDCAB without CPB (n = 27). The following data were measured preoperatively, after induction of anesthesia, after separation from CPB in the CABG group or after left internal mammary artery (LIMA)-to-left anterior descending artery (LAD) anastomosis in MIDCAB group, and every 3 hours for the first 42 hours in the ICU: PCT, C-reactive protein (CRP), body temperature, hemodynamic parameters, and the need for catecholamines. Leucocyte counts were measured daily. For statistical analyses the Friedmann, Wilcoxon, or Mann-Whitney U tests were used. PCT in the CABG group rose to a maximum of 2.0 ng/ml (median) at 15 hrs postoperatively. In the MIDCAB group maximal PCT concentration was 0.7ng/ml (median) (p < 0.05). CRP was elevated to 17.1 mg/dl in the CABG and 18.5mg/dl in the MIDCAB group (n.s.). The leucocyte counts were increased on day 2 in the CABG group (p < 0.05). In the CABG group about 25% of the patients needed noradrenaline, but in the MIDCAB group none (p < 0.05). Body temperature did not differ between both groups. The increase in PCT concentration was more pronounced after CABG, indicating a reduced inflammatory response after MIDCAB. CRP was increased after both procedures. PCT reflects the inflammatory response after cardiac bypass surgery with or without CPB.
„Die Wunschbarkeit interdisziplinarer Zusammenarbeit steht nicht in Frage, wohl aber ihre Machbar... more „Die Wunschbarkeit interdisziplinarer Zusammenarbeit steht nicht in Frage, wohl aber ihre Machbarkeit. Darin gleicht sie der Tugend. Und wie bei dieser hat es dann wenig Sinn, die Unvollkommenheit allgemein zu beklagen“ [9].
Background. The purpose of this study was to evaluate the course of serum markers of myocardial t... more Background. The purpose of this study was to evaluate the course of serum markers of myocardial tissue damage after two different types of minimally invasive coronary surgical procedures (MICS) as compared with conventional coronary artery bypass grafting (CABG). Methods. We enrolled 87 patients with one-or twovessel disease scheduled for one of the three procedures: minimally invasive direct coronary artery bypass grafting (MIDCABG) by lateral thoracotomy (n ؍ 29), the OCTOPUS method by median sternotomy (n ؍ 27), and CABG (n ؍ 31). Creatine kinase activity (CK), creatine kinase MB activity (CK-MB act), creatine kinase MB mass concentration (CK-MB mass), myoglobin concentration (MG), and cardiac troponin I concentration (cTnI) were measured perioperatively until the second postoperative day. Results. Creatine kinase-MB, CK-MB mass, and cTnI were significantly higher after CABG and were nearly maintained within the normal range in MICS. Creatine kinase and MG were significantly lower in the OCTOPUS group than in the MIDCABG or CABG groups. Conclusions. Minimally invasive coronary surgical procedures cause less myocardial injury than CABG as indicated by specific serum markers. However, higher CK and MG reflect more substantial skeletal muscle trauma during MIDCABG operation compared with OCTOPUS procedures.
Patienten, die thorakotomiert werden, haben oft eine Reihe von Vorerkrankungen des kardiopulmonal... more Patienten, die thorakotomiert werden, haben oft eine Reihe von Vorerkrankungen des kardiopulmonalen Systems, das wiederum durch den chirurgischen Eingriff zusatzlich beeintrachtigt wird.
Azole plasma concentrations in lung transplant recipients
European Respiratory Journal, Sep 1, 2014
Background: The absorption of azoles is subject to a high inter- and intra-individual variability... more Background: The absorption of azoles is subject to a high inter- and intra-individual variability. However, therapeutic drug monitoring [TDM] is not routinely performed. The purpose of this observation was to analyse azole plasma levels [APL] in lung transplant recipients [LTR]. Methods: 116 LTR of our lung transplantation [LTx] follow-up program who underwent TDM (65 male, 84 double-LTx, 3.1±3.5 years after LTx, age 49.7±14.9 years, underlying disease [ULD]: idiopathic pulmonary fibrosis [IPF; n=34; 29%], cystic fibrosis [CF; n=29; 25%], chronic obstructive pulmonary disease [COPD; n=28; 24%], other [n=25; 22%]) were evaluated. The target plasma levels [TPL] of azoles were defined as follows: Itraconazole [ITR] and Voriconazole [VOR] >1000µg/L, Posaconazole [POS] >700µg/L. APL were assayed using high performance liquid chromatography. Results: The mean APL for ITR, VOR, and POS were 715.4±866.1µg/L, 1649.2±1300.5µg/L and 903.4±780.9µg/L, respectively. Most frequent use was noted for ITR (n=55; 47%). The following results are classified by azole and ULD: View this table: Conclusion: Our data suggest that TDM is important to identify patients at risk for sub-therapeutic APL. Therefore, measuring plasma concentrations should be considered as part of the best practice management following LTx.
[Monitoring by measurement of gastrointestinal mucosal pH value (pHi)]
PubMed, Oct 1, 1993
Noninvasive measurement of mucosal pH by tonometry provides information on the adequacy of gastro... more Noninvasive measurement of mucosal pH by tonometry provides information on the adequacy of gastrointestinal mucosal oxygenation. The technique requires tonometer catheters (commercially available from Tonometrics) and a standard blood gas analyzer. After positioning of the catheter in the stomach or gut for at least 30 min, fluid is withdrawn from the prefilled balloon mounted on the catheter tip for pHi measurements. The pCO2 in the withdrawn fluid and bicarbonate concentration in the arterial blood are determined and pHi is calculated according to the Henderson-Hasselbalch equation. The tonometer technique has been validated in experimental studies and pHi has been shown to be a useful parameter to estimate adequacy of oxygenation of the mucosa surrounding the tonometer balloon. In surgical patients, pHi was found to be of high predictive value concerning incidence of complications; return of pHi towards higher values was found to be associated with a higher survival rate. In intensive care units, pHi-guided resuscitation proved to be superior to conventional therapy. Tonometric measurement of pHi is a useful parameter to monitor mucosal oxygenation and to provide information on the probability of complications and patient outcome. Further studies are needed in well-stratified patient groups with a present lower limit of pHi, triggering defined therapeutic interventions to improve mucosal oxygenation.
Bestimmung der Splanchnikusdurchblutung mittels Tonometrie bei der laparoskopischen und konventionellen Cholezystektomie— Präliminäre Ergebnisse
Acta chirurgica Austriaca, Mar 1, 1995
Zusammenfassung Grundlagen Der mittels Tonometrie bestimmte intramuköse pH der Intestinalschleim... more Zusammenfassung Grundlagen Der mittels Tonometrie bestimmte intramuköse pH der Intestinalschleimhaut (pHi) ist der sensibelste Parameter einer Minderdurchblutung im Splanchnikusgebiet. Der pHi bei der Cholezystektomie ist nicht bestimmt worden. Es ist denkbar, daß sich der pHi bei der laparoskopischen Cholezystektomie (LCH) anders verhält als bei der konventionellen Cholezystektomie (KCH). Methodik Bei je 10 Patienten der LCH-Gruppe und der KCH-Gruppe wird mittels Tonometrie
[Blood replacement in elective surgery: results of the Sanguis Study]
PubMed, Jun 1, 1993
The aim of the Sanguis study, a project sponsored by the European Community, is to assess the use... more The aim of the Sanguis study, a project sponsored by the European Community, is to assess the use of blood and blood components including the use of programs for autologous blood transfusion in 43 hospitals in 10 European countries. The study was inaugurated by Prof. G. Sirchia, Milan, who formed a study group of experts from 10 countries. The study group defined the study design, identified the centers, and followed the progress of the project. From October 1990 until September 1991 data were collected in the 43 hospitals from patients undergoing one of six elective surgical procedures. The results obtained from interim analysis (70% of expected data) of patients with total hip replacement revealed differences in the frequency of homologous blood transfusion between hospitals and also regional differences between different countries. There was great variation in the use of alternative programs for reduction or even avoidance of homologous blood transfusion between hospitals. For total hip replacement, the calculated probability to receive homologous blood varied between 0 and 100% in different hospitals. This observational study will provide a data base concerning the transfusion practice in 6 elective surgical procedures in 10 European countries. According to the findings of this study, recommendations for improving the transfusion practice shall be elaborated and indications for alternative programs identified. In a subsequent study (Sanguis 2), these recommendations are to be validated.
ZusammenfassungAdipositas führt zu einem besseren Überleben bei kritisch kranken Patienten. Diese... more ZusammenfassungAdipositas führt zu einem besseren Überleben bei kritisch kranken Patienten. Diese in zahlreichen Untersuchungen nachgewiesene und für den Kliniker doch überraschende Beobachtung wird als „obesity paradox“ beschrieben. Ein Teil des „obesity paradox“ beruht auf der Tatsache, dass der Body Mass Index (BMI), welcher in nahezu allen klinischen Untersuchungen zur Einteilung der Gewichtsklassen verwendet wird, kein ausreichend geeignetes Instrument ist, um die Körperkonstitution mit Fett- und Muskelverteilung kritisch kranker Patienten zu beschreiben. Zusätzlich beruht er auf den meist nicht gemessenen, sondern geschätzten Parametern Körpergröße und -gewicht. Die abdominelle Adipositas konnte bei zahlreichen Krankheitsbildern als unabhängiger Risikofaktor für ein schlechteres Outcome identifiziert werden. In der Intensivmedizin gibt es dafür erste Hinweise. Neben der Adipositas ist die Gesamtmuskelmasse eines Menschen eine das Outcome beeinflussende Variable. Die abdominelle Adipositas kann relativ einfach mittels Schublehre gemessen werden. Die Erhebung der Muskelmasse ist komplexer. Aus im Rahmen der klinischen Routine angefertigten computertomographischen (CT) Aufnahmen kann diese valide und detailliert ermittelt werden. Für künftige klinische Beobachtungs- oder auch Interventionsstudien stellt die CT-Einzelschichtanalyse ein Werkzeug dar, um die Anthropometrie des Patienten über die Vermessung mit Maßband und Schublehre hinaus zu erfassen. Das möglicherweise besonders gefährdete Kollektiv der Patienten mit sarkopenischer Adipositas kann beispielsweise nur über bildgebende Verfahren wie die CT-Einzelschichtanalyse identifiziert werden. Somit sollte der BMI als anthropometrischer Parameter in Klinik und Forschung in den Hintergrund rücken.AbstractObesity leads to better survival in critically ill patients. Although there are several studies confirming this thesis, the “obesity paradox” is still surprising from the clinician’s perspective. One explanation for the “obesity paradox” is the fact that the body mass index (BMI), which is used in almost all clinical evaluations to determine weight categories, is not an appropriate measure of fat and skeletal muscle mass and its distribution in critically ill patients. In addition, height and weight are frequently estimated rather than measured. Central obesity has been identified in many disorders as an independent risk factor for an unfavourable outcome. The first clues are to be found in intensive care. Along with obesity, an individual’s entire muscle mass is a variable that has an influence on outcome. Central obesity can be measured relatively easily with an abdominal calliper, but the calculation of muscle mass is more complex. A valid and detailed measurement of this can be obtained using computed tomography (CT) images, acquired during routine care. For future clinical observation or interventional studies, single cross-sectional CT is a more sophisticated tool for measuring patients’ anthropometry than a measuring tape and callipers. Patients with sarcopenic obesity, for example, who may be at a particular risk, can only be identified using imaging procedures such as single cross-sectional CT. Thus, BMI should take a back seat as an anthropometric tool, both in the clinic and in research.
Human Herpesvirus 6 in Bronchalveolar Lavage Fluid after Lung Transplantation: A Risk Factor for Bronchiolitis Obliterans Syndrome?
American Journal of Transplantation, Dec 1, 2005
Bronchiolitis obliterans syndrome (BOS) is the limiting factor to long-term survival after lung t... more Bronchiolitis obliterans syndrome (BOS) is the limiting factor to long-term survival after lung transplantation. Previous studies suggested respiratory viral tract infections are associated with the development of BOS. To identify the impact of virus detection in bronchoalveolar lavage (BAL) fluid, we analyzed BAL samples from 87 consecutive lung transplant recipients for human herpesvirus (HHV)-6, Epstein-Barr virus, Herpes simplex virus 1/2, Cytomegalovirus, respiratory syncytical virus and adenovirus by PCR. Acute rejection, BOS and death were recorded for a mean follow-up time of 3.27 +/- 0.47 years. Results of PCR analysis and other potential risk factors were entered into a Cox regression analysis of BOS predictors and death. Only acute rejection was a distinct risk factor for BOS of all stages, death and death from BOS. HHV-6 was detected in 20 patients. Univariate and multivariate analysis revealed that HHV-6 was associated with an increased risk to develop BOS > orb = stage 1 and death, separate from the risk attributable to acute rejection. Identification of HHV-6 DNA in BAL fluid is a potential risk factor for BOS. Our results warrant further studies to elucidate a possible causal link between HHV-6 and BOS.
Small Volume Hypertonic Resuscitation: The Conceptional Basis for Volume Therapy in Septic Shock
Springer eBooks, 1991
Early diagnosis of sepsis and endotoxemia in critically ill patients and immediate onset of thera... more Early diagnosis of sepsis and endotoxemia in critically ill patients and immediate onset of therapy is of utmost importance for prevention of multiple organ failure (MOF) [1, 2]. Besides ventilatory support, either by continuous positive airway pressure (CPAP) or by controlled ventilation with or without positive end-expiratory pressure (PEEP), cardiocirculatory support by vigorous volume therapy and vasoactive drugs are mandatory to ensure peripheral oxygen delivery [3]. The quantity of fluids required to obtain adequate cardiac filling pressures often amounts to several liters per day [4, 5]. In spite of the advanced techniques in monitoring the intensive care patient and in spite of all therapeutic efforts however, deterioration of organ function may progress and lead to MOF [2, 6, 7]. A severe deterioration of the microcirculation results in a “delivery dependent oxygen consumption”, which is in marked contrast with the normal control of oxygen metabolism and which is assumed to play a decisive role in septic shock [2, 8].
Influence of different immunosuppressive protocols with mmf and FK506 on long-term survival, acute rejection and BOS after lung transplantation: A 17 years experience of a single-centre
International Journal of Antimicrobial Agents, Oct 1, 2016
Therapeutic drug monitoring for critically ill patients receiving piperacillin/tazobactam is desc... more Therapeutic drug monitoring for critically ill patients receiving piperacillin/tazobactam is described as a useful tool. However, the minimum inhibitory concentration of piperacillin depends on a sufficiently high concentration of tazobactam in case of β-lactamase-producing strains. Therefore, the relationship between piperacillin and tazobactam concentrations was assessed in a heterogeneous group of critically ill patients. Sixty patients with severe infections receiving 4.5 g of piperacillin/tazobactam 2-3 times daily by intermittent infusion were included in this prospective observational study (NCT01793012). Over 4 days, multiple serum samples were obtained to determine the total piperacillin and tazobactam concentrations. The target ranges were defined as trough levels >16 mg/L (>22.5 mg/L) and >4 mg/L (>5.7 mg/ L) for the calculated unbound concentrations (measured total concentrations) of piperacillin and tazobactam, respectively. Despite a high correlation coefficient (r = 0.93) comparing piperacillin and tazobactam trough levels, the piperacillin/tazobactam quotients varied between ca. 1 and 10. From linear regression analysis of piperacillin versus tazobactam values, it follows that a piperacillin trough level of 22.5 mg/L might be associated with tazobactam trough levels ranging from 1.5 mg/L to 10.1 mg/L. A 70 mg/L threshold for total piperacillin trough levels would be necessary to ensure that tazobactam concentrations are >5.7 mg/ L. Because of the observed variability of piperacillin/tazobactam quotients, defining the total piperacillin target range ≥70 mg/L might be useful to ensure that tazobactam concentrations do not fall below 5.7 mg/ L. Further studies are necessary to confirm that the used therapeutic ranges are associated with optimal outcomes in critically ill patients.
Objective: To investigate the effects of noninvasive positive pressure ventilation (NPPV) on pulm... more Objective: To investigate the effects of noninvasive positive pressure ventilation (NPPV) on pulmonary gas exchange, breathing pattern, intrapulmonary shunt fraction, oxygen consumption, and resting energy expenditure in patients with persistent acute respiratory failure but without chronic obstructive pulmonary disease (COPD) after early extubation. Design: Prospective study. Setting: Multidisciplinary intensive care unit of a university hospital. Patients: 15 patients after prolonged mechanical ventilation (> 72 h) with acute respiratory insufficiency after early extubation. Interventions: Criteria for early extubation were arterial oxygen tension (PaO 2 ) L 40 mm Hg (fractional inspired oxygen 0.21), arterial carbon dioxide tension (PaCO 2 ) K 55 mm Hg, pH > 7.32, respiratory rate K 40 breaths per min, tidal volume (V T ) L 3 ml/kg, rapid shallow breathing index K 190 and negative inspiratory force L 20 cmH 2 O. After extubation, two modes of NPPV were applied [continuous positive airway pressure (CPAP) of 5 cmH 2 O and pressure support ventilation (PSV) with 15 cmH 2 O pressure support]. Measurements and main results: Oxygenation and ventilatory para-Key words Noninvasive mechanical ventilation × Pressure support ventilation × Continuous positive airways pressure × Weaning criteria × Respiratory failure Intensive Care Med (1999) 25: 1374±1380
The end-systolic pressure-volume relation (ESPVR) is accepted as a load-independent measure of ca... more The end-systolic pressure-volume relation (ESPVR) is accepted as a load-independent measure of cardiac contractility. Potential curvilinearity of the ESPVR, dependency on coronary perfusion pressure (CPP) and sensitivity to the type of loading intervention might limit its use in hemorrhagic shock. This study compared ESPVRs obtained by caval and aortic occlusion under physiological loading conditions at baseline with those obtained during hemorrhagic shock (mean arterial pressure 45 mmHg). The left ventricular (LV) pressure (tip manometer) and volume (conductance catheter) were measured in ten anesthetized pigs. ESPVRs were fitted to linear and quadratic models. Within end-systolic pressure (Pes) ranges obtained under baseline conditions, ESPVR displayed only minimal curvilinearity (second-order coefficient a<0.007) and could be accurately described by a linear model. However, nonlinearity of ESPVRs obtained over wider load ranges is suggested by negative volume axis intercepts of the linear model. Steeper ESPVR with aortic than with caval occlusion (2.28_+0.22 vs 3.41_+0.51 mmHg/ml, ns) could not be proven owing to the large interindividual variance of ESPVR slopes with both loading interventions. During shock the Pes range obtained by caval occlusion decreased to very low levels (from 49_+2 to 34_+1 mmHg), ESPVR did not adequately fit either of the two models (mean R<0.66), and critical reduction of CPP induced negative ESPVR slope in four of ten experiments. In contrast, aortic occlusion at shock resulted in linear ESPVR (R = 0.927_+0.029), Pes ranges (92-+3 to 58_+4 mmHg) comparable to the ones obtained by caval occlusion at control (113_+5 to 73_+6 mmHg), and steeper ESPVR than at control (3.41_+0.51 to 7.38_+1.0 mmHg/ml, P<0.05). Interpretation of the increased ESPVR slope obtained with aortic occlusion as due to increased contractility in shock is, however, complicated by different Pes ranges. It is concluded
Der Ausduck „Schock“ findet haufige, ja banale Anwendung im Alltag. In der Medizin erregt seine V... more Der Ausduck „Schock“ findet haufige, ja banale Anwendung im Alltag. In der Medizin erregt seine Verwendung ofters Anstos, weil er oft als Oberbegriff fur alle moglichen akuten Zustande herhalten mus. Manches Schocksymposium der letzten Jahre endete mit dem Stosseufzer, der misverstandliche Sammelbegriff Schock moge doch endlich durch einen auf der Pathogenese der verschiedenen Schockzustande basierenden Ausdruck ersetzt werden. Der Begriff Schock hat diesen puristischen Angriffen aber erfolgreich widerstanden, und er ist in der medizinischen Terminologie fester verankert denn je — nicht zuletzt wegen der Systematisierung unseres Wissens in verschiedenen Dokumentationssystemen. Er ist heutemit ordnenden Adjektiven unterteilt, wie beispielsweise hamorrhagischer traumatischer, kardiogener, septischer oder anaphylaktischer Schock.
Procalcitonin as a Marker of Systemic Inflammation After Conventional or Minimally Invasive Coronary Artery Bypass Grafting
Thoracic and Cardiovascular Surgeon, Jun 1, 1998
Cardiac surgery using cardiopulmonary bypass (CPB) often induces a systemic inflammatory response... more Cardiac surgery using cardiopulmonary bypass (CPB) often induces a systemic inflammatory response syndrome (SIRS). The concept of minimally invasive direct coronary artery bypass (MIDCAB) eliminates cardiopulmonary bypass. We evaluated the perioperative time course of procalcitonin (PCT) to compare the inflammatory response due to these two different surgical procedures. 57 patients were studied: CABG with CPB (n = 30), MIDCAB without CPB (n = 27). The following data were measured preoperatively, after induction of anesthesia, after separation from CPB in the CABG group or after left internal mammary artery (LIMA)-to-left anterior descending artery (LAD) anastomosis in MIDCAB group, and every 3 hours for the first 42 hours in the ICU: PCT, C-reactive protein (CRP), body temperature, hemodynamic parameters, and the need for catecholamines. Leucocyte counts were measured daily. For statistical analyses the Friedmann, Wilcoxon, or Mann-Whitney U tests were used. PCT in the CABG group rose to a maximum of 2.0 ng/ml (median) at 15 hrs postoperatively. In the MIDCAB group maximal PCT concentration was 0.7ng/ml (median) (p &lt; 0.05). CRP was elevated to 17.1 mg/dl in the CABG and 18.5mg/dl in the MIDCAB group (n.s.). The leucocyte counts were increased on day 2 in the CABG group (p &lt; 0.05). In the CABG group about 25% of the patients needed noradrenaline, but in the MIDCAB group none (p &lt; 0.05). Body temperature did not differ between both groups. The increase in PCT concentration was more pronounced after CABG, indicating a reduced inflammatory response after MIDCAB. CRP was increased after both procedures. PCT reflects the inflammatory response after cardiac bypass surgery with or without CPB.
„Die Wunschbarkeit interdisziplinarer Zusammenarbeit steht nicht in Frage, wohl aber ihre Machbar... more „Die Wunschbarkeit interdisziplinarer Zusammenarbeit steht nicht in Frage, wohl aber ihre Machbarkeit. Darin gleicht sie der Tugend. Und wie bei dieser hat es dann wenig Sinn, die Unvollkommenheit allgemein zu beklagen“ [9].
Background. The purpose of this study was to evaluate the course of serum markers of myocardial t... more Background. The purpose of this study was to evaluate the course of serum markers of myocardial tissue damage after two different types of minimally invasive coronary surgical procedures (MICS) as compared with conventional coronary artery bypass grafting (CABG). Methods. We enrolled 87 patients with one-or twovessel disease scheduled for one of the three procedures: minimally invasive direct coronary artery bypass grafting (MIDCABG) by lateral thoracotomy (n ؍ 29), the OCTOPUS method by median sternotomy (n ؍ 27), and CABG (n ؍ 31). Creatine kinase activity (CK), creatine kinase MB activity (CK-MB act), creatine kinase MB mass concentration (CK-MB mass), myoglobin concentration (MG), and cardiac troponin I concentration (cTnI) were measured perioperatively until the second postoperative day. Results. Creatine kinase-MB, CK-MB mass, and cTnI were significantly higher after CABG and were nearly maintained within the normal range in MICS. Creatine kinase and MG were significantly lower in the OCTOPUS group than in the MIDCABG or CABG groups. Conclusions. Minimally invasive coronary surgical procedures cause less myocardial injury than CABG as indicated by specific serum markers. However, higher CK and MG reflect more substantial skeletal muscle trauma during MIDCABG operation compared with OCTOPUS procedures.
Patienten, die thorakotomiert werden, haben oft eine Reihe von Vorerkrankungen des kardiopulmonal... more Patienten, die thorakotomiert werden, haben oft eine Reihe von Vorerkrankungen des kardiopulmonalen Systems, das wiederum durch den chirurgischen Eingriff zusatzlich beeintrachtigt wird.
Azole plasma concentrations in lung transplant recipients
European Respiratory Journal, Sep 1, 2014
Background: The absorption of azoles is subject to a high inter- and intra-individual variability... more Background: The absorption of azoles is subject to a high inter- and intra-individual variability. However, therapeutic drug monitoring [TDM] is not routinely performed. The purpose of this observation was to analyse azole plasma levels [APL] in lung transplant recipients [LTR]. Methods: 116 LTR of our lung transplantation [LTx] follow-up program who underwent TDM (65 male, 84 double-LTx, 3.1±3.5 years after LTx, age 49.7±14.9 years, underlying disease [ULD]: idiopathic pulmonary fibrosis [IPF; n=34; 29%], cystic fibrosis [CF; n=29; 25%], chronic obstructive pulmonary disease [COPD; n=28; 24%], other [n=25; 22%]) were evaluated. The target plasma levels [TPL] of azoles were defined as follows: Itraconazole [ITR] and Voriconazole [VOR] >1000µg/L, Posaconazole [POS] >700µg/L. APL were assayed using high performance liquid chromatography. Results: The mean APL for ITR, VOR, and POS were 715.4±866.1µg/L, 1649.2±1300.5µg/L and 903.4±780.9µg/L, respectively. Most frequent use was noted for ITR (n=55; 47%). The following results are classified by azole and ULD: View this table: Conclusion: Our data suggest that TDM is important to identify patients at risk for sub-therapeutic APL. Therefore, measuring plasma concentrations should be considered as part of the best practice management following LTx.
[Monitoring by measurement of gastrointestinal mucosal pH value (pHi)]
PubMed, Oct 1, 1993
Noninvasive measurement of mucosal pH by tonometry provides information on the adequacy of gastro... more Noninvasive measurement of mucosal pH by tonometry provides information on the adequacy of gastrointestinal mucosal oxygenation. The technique requires tonometer catheters (commercially available from Tonometrics) and a standard blood gas analyzer. After positioning of the catheter in the stomach or gut for at least 30 min, fluid is withdrawn from the prefilled balloon mounted on the catheter tip for pHi measurements. The pCO2 in the withdrawn fluid and bicarbonate concentration in the arterial blood are determined and pHi is calculated according to the Henderson-Hasselbalch equation. The tonometer technique has been validated in experimental studies and pHi has been shown to be a useful parameter to estimate adequacy of oxygenation of the mucosa surrounding the tonometer balloon. In surgical patients, pHi was found to be of high predictive value concerning incidence of complications; return of pHi towards higher values was found to be associated with a higher survival rate. In intensive care units, pHi-guided resuscitation proved to be superior to conventional therapy. Tonometric measurement of pHi is a useful parameter to monitor mucosal oxygenation and to provide information on the probability of complications and patient outcome. Further studies are needed in well-stratified patient groups with a present lower limit of pHi, triggering defined therapeutic interventions to improve mucosal oxygenation.
Bestimmung der Splanchnikusdurchblutung mittels Tonometrie bei der laparoskopischen und konventionellen Cholezystektomie— Präliminäre Ergebnisse
Acta chirurgica Austriaca, Mar 1, 1995
Zusammenfassung Grundlagen Der mittels Tonometrie bestimmte intramuköse pH der Intestinalschleim... more Zusammenfassung Grundlagen Der mittels Tonometrie bestimmte intramuköse pH der Intestinalschleimhaut (pHi) ist der sensibelste Parameter einer Minderdurchblutung im Splanchnikusgebiet. Der pHi bei der Cholezystektomie ist nicht bestimmt worden. Es ist denkbar, daß sich der pHi bei der laparoskopischen Cholezystektomie (LCH) anders verhält als bei der konventionellen Cholezystektomie (KCH). Methodik Bei je 10 Patienten der LCH-Gruppe und der KCH-Gruppe wird mittels Tonometrie
[Blood replacement in elective surgery: results of the Sanguis Study]
PubMed, Jun 1, 1993
The aim of the Sanguis study, a project sponsored by the European Community, is to assess the use... more The aim of the Sanguis study, a project sponsored by the European Community, is to assess the use of blood and blood components including the use of programs for autologous blood transfusion in 43 hospitals in 10 European countries. The study was inaugurated by Prof. G. Sirchia, Milan, who formed a study group of experts from 10 countries. The study group defined the study design, identified the centers, and followed the progress of the project. From October 1990 until September 1991 data were collected in the 43 hospitals from patients undergoing one of six elective surgical procedures. The results obtained from interim analysis (70% of expected data) of patients with total hip replacement revealed differences in the frequency of homologous blood transfusion between hospitals and also regional differences between different countries. There was great variation in the use of alternative programs for reduction or even avoidance of homologous blood transfusion between hospitals. For total hip replacement, the calculated probability to receive homologous blood varied between 0 and 100% in different hospitals. This observational study will provide a data base concerning the transfusion practice in 6 elective surgical procedures in 10 European countries. According to the findings of this study, recommendations for improving the transfusion practice shall be elaborated and indications for alternative programs identified. In a subsequent study (Sanguis 2), these recommendations are to be validated.
ZusammenfassungAdipositas führt zu einem besseren Überleben bei kritisch kranken Patienten. Diese... more ZusammenfassungAdipositas führt zu einem besseren Überleben bei kritisch kranken Patienten. Diese in zahlreichen Untersuchungen nachgewiesene und für den Kliniker doch überraschende Beobachtung wird als „obesity paradox“ beschrieben. Ein Teil des „obesity paradox“ beruht auf der Tatsache, dass der Body Mass Index (BMI), welcher in nahezu allen klinischen Untersuchungen zur Einteilung der Gewichtsklassen verwendet wird, kein ausreichend geeignetes Instrument ist, um die Körperkonstitution mit Fett- und Muskelverteilung kritisch kranker Patienten zu beschreiben. Zusätzlich beruht er auf den meist nicht gemessenen, sondern geschätzten Parametern Körpergröße und -gewicht. Die abdominelle Adipositas konnte bei zahlreichen Krankheitsbildern als unabhängiger Risikofaktor für ein schlechteres Outcome identifiziert werden. In der Intensivmedizin gibt es dafür erste Hinweise. Neben der Adipositas ist die Gesamtmuskelmasse eines Menschen eine das Outcome beeinflussende Variable. Die abdominelle Adipositas kann relativ einfach mittels Schublehre gemessen werden. Die Erhebung der Muskelmasse ist komplexer. Aus im Rahmen der klinischen Routine angefertigten computertomographischen (CT) Aufnahmen kann diese valide und detailliert ermittelt werden. Für künftige klinische Beobachtungs- oder auch Interventionsstudien stellt die CT-Einzelschichtanalyse ein Werkzeug dar, um die Anthropometrie des Patienten über die Vermessung mit Maßband und Schublehre hinaus zu erfassen. Das möglicherweise besonders gefährdete Kollektiv der Patienten mit sarkopenischer Adipositas kann beispielsweise nur über bildgebende Verfahren wie die CT-Einzelschichtanalyse identifiziert werden. Somit sollte der BMI als anthropometrischer Parameter in Klinik und Forschung in den Hintergrund rücken.AbstractObesity leads to better survival in critically ill patients. Although there are several studies confirming this thesis, the “obesity paradox” is still surprising from the clinician’s perspective. One explanation for the “obesity paradox” is the fact that the body mass index (BMI), which is used in almost all clinical evaluations to determine weight categories, is not an appropriate measure of fat and skeletal muscle mass and its distribution in critically ill patients. In addition, height and weight are frequently estimated rather than measured. Central obesity has been identified in many disorders as an independent risk factor for an unfavourable outcome. The first clues are to be found in intensive care. Along with obesity, an individual’s entire muscle mass is a variable that has an influence on outcome. Central obesity can be measured relatively easily with an abdominal calliper, but the calculation of muscle mass is more complex. A valid and detailed measurement of this can be obtained using computed tomography (CT) images, acquired during routine care. For future clinical observation or interventional studies, single cross-sectional CT is a more sophisticated tool for measuring patients’ anthropometry than a measuring tape and callipers. Patients with sarcopenic obesity, for example, who may be at a particular risk, can only be identified using imaging procedures such as single cross-sectional CT. Thus, BMI should take a back seat as an anthropometric tool, both in the clinic and in research.
Human Herpesvirus 6 in Bronchalveolar Lavage Fluid after Lung Transplantation: A Risk Factor for Bronchiolitis Obliterans Syndrome?
American Journal of Transplantation, Dec 1, 2005
Bronchiolitis obliterans syndrome (BOS) is the limiting factor to long-term survival after lung t... more Bronchiolitis obliterans syndrome (BOS) is the limiting factor to long-term survival after lung transplantation. Previous studies suggested respiratory viral tract infections are associated with the development of BOS. To identify the impact of virus detection in bronchoalveolar lavage (BAL) fluid, we analyzed BAL samples from 87 consecutive lung transplant recipients for human herpesvirus (HHV)-6, Epstein-Barr virus, Herpes simplex virus 1/2, Cytomegalovirus, respiratory syncytical virus and adenovirus by PCR. Acute rejection, BOS and death were recorded for a mean follow-up time of 3.27 +/- 0.47 years. Results of PCR analysis and other potential risk factors were entered into a Cox regression analysis of BOS predictors and death. Only acute rejection was a distinct risk factor for BOS of all stages, death and death from BOS. HHV-6 was detected in 20 patients. Univariate and multivariate analysis revealed that HHV-6 was associated with an increased risk to develop BOS &amp;amp;gt; orb = stage 1 and death, separate from the risk attributable to acute rejection. Identification of HHV-6 DNA in BAL fluid is a potential risk factor for BOS. Our results warrant further studies to elucidate a possible causal link between HHV-6 and BOS.
Small Volume Hypertonic Resuscitation: The Conceptional Basis for Volume Therapy in Septic Shock
Springer eBooks, 1991
Early diagnosis of sepsis and endotoxemia in critically ill patients and immediate onset of thera... more Early diagnosis of sepsis and endotoxemia in critically ill patients and immediate onset of therapy is of utmost importance for prevention of multiple organ failure (MOF) [1, 2]. Besides ventilatory support, either by continuous positive airway pressure (CPAP) or by controlled ventilation with or without positive end-expiratory pressure (PEEP), cardiocirculatory support by vigorous volume therapy and vasoactive drugs are mandatory to ensure peripheral oxygen delivery [3]. The quantity of fluids required to obtain adequate cardiac filling pressures often amounts to several liters per day [4, 5]. In spite of the advanced techniques in monitoring the intensive care patient and in spite of all therapeutic efforts however, deterioration of organ function may progress and lead to MOF [2, 6, 7]. A severe deterioration of the microcirculation results in a “delivery dependent oxygen consumption”, which is in marked contrast with the normal control of oxygen metabolism and which is assumed to play a decisive role in septic shock [2, 8].
Influence of different immunosuppressive protocols with mmf and FK506 on long-term survival, acute rejection and BOS after lung transplantation: A 17 years experience of a single-centre
International Journal of Antimicrobial Agents, Oct 1, 2016
Therapeutic drug monitoring for critically ill patients receiving piperacillin/tazobactam is desc... more Therapeutic drug monitoring for critically ill patients receiving piperacillin/tazobactam is described as a useful tool. However, the minimum inhibitory concentration of piperacillin depends on a sufficiently high concentration of tazobactam in case of β-lactamase-producing strains. Therefore, the relationship between piperacillin and tazobactam concentrations was assessed in a heterogeneous group of critically ill patients. Sixty patients with severe infections receiving 4.5 g of piperacillin/tazobactam 2-3 times daily by intermittent infusion were included in this prospective observational study (NCT01793012). Over 4 days, multiple serum samples were obtained to determine the total piperacillin and tazobactam concentrations. The target ranges were defined as trough levels >16 mg/L (>22.5 mg/L) and >4 mg/L (>5.7 mg/ L) for the calculated unbound concentrations (measured total concentrations) of piperacillin and tazobactam, respectively. Despite a high correlation coefficient (r = 0.93) comparing piperacillin and tazobactam trough levels, the piperacillin/tazobactam quotients varied between ca. 1 and 10. From linear regression analysis of piperacillin versus tazobactam values, it follows that a piperacillin trough level of 22.5 mg/L might be associated with tazobactam trough levels ranging from 1.5 mg/L to 10.1 mg/L. A 70 mg/L threshold for total piperacillin trough levels would be necessary to ensure that tazobactam concentrations are >5.7 mg/ L. Because of the observed variability of piperacillin/tazobactam quotients, defining the total piperacillin target range ≥70 mg/L might be useful to ensure that tazobactam concentrations do not fall below 5.7 mg/ L. Further studies are necessary to confirm that the used therapeutic ranges are associated with optimal outcomes in critically ill patients.
Objective: To investigate the effects of noninvasive positive pressure ventilation (NPPV) on pulm... more Objective: To investigate the effects of noninvasive positive pressure ventilation (NPPV) on pulmonary gas exchange, breathing pattern, intrapulmonary shunt fraction, oxygen consumption, and resting energy expenditure in patients with persistent acute respiratory failure but without chronic obstructive pulmonary disease (COPD) after early extubation. Design: Prospective study. Setting: Multidisciplinary intensive care unit of a university hospital. Patients: 15 patients after prolonged mechanical ventilation (> 72 h) with acute respiratory insufficiency after early extubation. Interventions: Criteria for early extubation were arterial oxygen tension (PaO 2 ) L 40 mm Hg (fractional inspired oxygen 0.21), arterial carbon dioxide tension (PaCO 2 ) K 55 mm Hg, pH > 7.32, respiratory rate K 40 breaths per min, tidal volume (V T ) L 3 ml/kg, rapid shallow breathing index K 190 and negative inspiratory force L 20 cmH 2 O. After extubation, two modes of NPPV were applied [continuous positive airway pressure (CPAP) of 5 cmH 2 O and pressure support ventilation (PSV) with 15 cmH 2 O pressure support]. Measurements and main results: Oxygenation and ventilatory para-Key words Noninvasive mechanical ventilation × Pressure support ventilation × Continuous positive airways pressure × Weaning criteria × Respiratory failure Intensive Care Med (1999) 25: 1374±1380
The end-systolic pressure-volume relation (ESPVR) is accepted as a load-independent measure of ca... more The end-systolic pressure-volume relation (ESPVR) is accepted as a load-independent measure of cardiac contractility. Potential curvilinearity of the ESPVR, dependency on coronary perfusion pressure (CPP) and sensitivity to the type of loading intervention might limit its use in hemorrhagic shock. This study compared ESPVRs obtained by caval and aortic occlusion under physiological loading conditions at baseline with those obtained during hemorrhagic shock (mean arterial pressure 45 mmHg). The left ventricular (LV) pressure (tip manometer) and volume (conductance catheter) were measured in ten anesthetized pigs. ESPVRs were fitted to linear and quadratic models. Within end-systolic pressure (Pes) ranges obtained under baseline conditions, ESPVR displayed only minimal curvilinearity (second-order coefficient a<0.007) and could be accurately described by a linear model. However, nonlinearity of ESPVRs obtained over wider load ranges is suggested by negative volume axis intercepts of the linear model. Steeper ESPVR with aortic than with caval occlusion (2.28_+0.22 vs 3.41_+0.51 mmHg/ml, ns) could not be proven owing to the large interindividual variance of ESPVR slopes with both loading interventions. During shock the Pes range obtained by caval occlusion decreased to very low levels (from 49_+2 to 34_+1 mmHg), ESPVR did not adequately fit either of the two models (mean R<0.66), and critical reduction of CPP induced negative ESPVR slope in four of ten experiments. In contrast, aortic occlusion at shock resulted in linear ESPVR (R = 0.927_+0.029), Pes ranges (92-+3 to 58_+4 mmHg) comparable to the ones obtained by caval occlusion at control (113_+5 to 73_+6 mmHg), and steeper ESPVR than at control (3.41_+0.51 to 7.38_+1.0 mmHg/ml, P<0.05). Interpretation of the increased ESPVR slope obtained with aortic occlusion as due to increased contractility in shock is, however, complicated by different Pes ranges. It is concluded
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