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Biomedical subjects

A E Goetz

Publications and source records attributed to A E Goetz.

At least 19 recordsLinked to original sources
PubMed2007

[Severe accidental hypothermia with cardiac arrest and extracorporeal rewarming. A case report of a 2-year-old child].

In patients with severe hypothermia and cardiac arrest, active rewarming is recommended by extracorporeal circulation with cardiopulmonary bypass. The current guidelines for resuscitation of the European Resuscitation Council now include the recommendation regarding patients with hypothermia remaining comatose after initial resuscitation to accomplish an active rewarming only up to a temperature of 32-34 degrees C and to maintain a mild hypothermia for 12-24 h. We report the case of a 2-year-old boy who suffered from severe hypothermia after falling into ice-cold water. On discovery cardiac arrest with asystole was present and the first measured temperature was 23.8 degrees C. Resuscitation led to restoration of spontaneous circulation. The patient was rewarmed by extracorporeal circulation with cardiopulmonary bypass to 33 degrees C then mild hypothermia was maintained for a further 12 h. On the third day after the accident the patient was extubated and after a further 9 days was discharged without any sequelae.

Accidents↗
PubMed2006

The influence of PEEP and tidal volume on central blood volume.

BACKGROUND AND OBJECTIVE: Measurement of central blood volumes (CBV), such as global end-diastolic volume (GEDV) and right ventricular end-diastolic volume (RVEDV) are considered appropriate estimates of intravascular volume status. However, to apply those parameters for preload assessment in mechanically ventilated patients, the influence of tidal volume (TV) and positive endexpiratory airway pressure (PEEP) on those parameters must be known. METHODS: In 13 mechanically ventilated piglets, the effect of low (10 mL kg(-1)) and high (20 mL kg(-1)) TVs on CBV was investigated in absence and presence of PEEP (0 and 15 cm H(2)O). GEDV, RVEDV, right heart (RHEDV) and left heart end-diastolic volume (LHEDV) were measured by thermodilution. Blood flow on the descending thoracic aorta measured with an ultrasonic flow-probe served to determine stroke volume (SV). Measurements were performed during baseline conditions, after volume loading with previously extracted haemodilution blood (20 mL kg(-1)) and following haemorrhage (30 mL kg(-1)). RESULTS: Application of PEEP decreased GEDV and SV significantly (P < 0.05). Augmenting TV did not reduce GEDV systematically, but significantly reduced SV (P < 0.05). Changes in ventilator settings only influenced RVEDV following volume loading (P < 0.05). RHEDV and LHEDV decreased following application of PEEP, but only RHEDV decreased after augmenting TV at baseline and following volume loading. Correlation of SV with parameters of CBV was r = 0.487 (P < 0.01) for GEDV, r = 0.553 (P < 0.01) for RVEDV, r = 0.596 (P < 0.01) for RHEDV and r = 0.303 (P < 0.01) for LHEDV. CONCLUSION: Application of PEEP decreases CBV and SV. Augmenting TV reduces SV but not CBV. There is a moderate correlation between parameters of CBV and cardiac performance.

Animals↗
PubMed2006

[The use of diagnosis-related-groups data for external benchmarking of anesthesia and intensive care services].

Measurement and assessment of the economic efficiency of clinical departments is still an unresolved, yet important problem in hospital management. Benchmarking with other providers can help to evaluate one's own efficacy in anaesthesia and intensive care services. In this article we describe a method for using the diagnosis-related-groups (DRG) cost breakdown data, to achieve a case mix adjusted comparison of own costs for anaesthesia and intensive care services with the average costs in German hospitals. On the basis of 19,401 cases from 10 different surgical departments, we compared our own costs with the German-wide benchmark. Major factors for profit optimisation are discussed. Special attention is given to the close interaction of surgical, anaesthesiological and intensive care process performance and costs and its impact on benchmarking studies.

Anesthesia↗
PubMed2006

[Severe anaphylaxis from rocuronium].

Muscle relaxant drugs are the most frequent cause of anaphylactic and anaphylactoid reactions during anaesthesia. We report a case of a life-threatening anaphylactic reaction during induction of anaesthesia with severe bronchospasm as the first clinical symptom. Mechanical ventilation was nearly impossible. The patient required a multimodal antiallergic therapy and a high-dose catecholamine therapy for stabilization. Rocuronium was identified as the allergic agent using intradermal testing.

Anaphylaxis↗
PubMed2006

[Public access defibrillation. Limited use by trained first responders and laymen].

As ventricular fibrillation is the most frequent initial heart rhythm causing out-of-hospital sudden cardiac arrest, defibrillation is of essential significance. Automated external defibrillators (AEDs) have been available for some years and as a result defibrillation can be carried out by individuals other than physicians and healthcare providers such as trained first responders and untrained lay rescuers. This so-called public access defibrillation nourished hope of progress in the treatment of sudden cardiac arrest. However, several limitations exist, such as low frequency of sudden cardiac arrest in public, rare use of publicly placed AEDs, low cost effectiveness, legal requirements and insufficient public willingness to help. Due to these restrictions of public access defibrillation other measures are more promising than the attempt at general distribution of AEDs. These measures are primary or secondary prophylaxis of sudden cardiac arrest, general knowledge of adequate activation of emergency medical services, implementation of first responder teams equipped with AEDs and particularly a better education in and application of the well-established principles of cardiopulmonary resuscitation.

Cost-Benefit Analysis↗
PubMed2005

[Accuracy of pulse contour cardiac index measurements during changes of preload and aortic impedance].

BACKGROUND: Cardiac index obtained by arterial pulse contour analysis (CI(PC)) demonstrated good agreement with arterial or pulmonary arterial thermodilution derived cardiac index (CI(TD), CI(PA)) in cardiac surgical or critically ill patients. However as the accuracy of pulse contour analysis during changes of the aortic impedance is unclear, we compared CI(PC), CI(TD) and CI(PA) during changes of preload and the aortic impedance as occurring during sternotomy. PATIENTS AND METHODS: CI(PC) und CI(TD), were compared in 28 patients, (and CI(PA) in 6 patients) undergoing elective coronary artery bypass grafting, before and after sternotomy. The relative changes DeltaCI(PC) und DeltaCI(PC) were calculated. RESULTS: Sternotomy resulted in a significant increase in CI in 25 out of 28 patients. Regression analysis was performed between CI(PC) and CI(TD) before and after sternotomy (r(2) = 0.87, p<0.0001, r(2) = 0.88, p<0.0001) as well as between CI(PC) and CI(PA), before and after sternotomy (r(2) = 0.85, p<0.0001, r(2) = 0.93, p<0.01) and between DeltaCI(PC) and DeltaCI(TD) (r(2) = 0.72, p<0.0001). Bland Altman-Analysis for determining bias (m) and precision (2SD) between CI(PC) and CI(TD) before and after sternotomy and between DeltaCI(PC) and DeltaCI(TD) resulted in m = -0.03 L/min/m(2), 2SD = -0.34 to 0.28 L/min/m(2), m = -0.06 L/min/m(2), 2SD = -0.45 to 0.33 L/min/m(2) and m = -0.02 L/min/m(2), SD = -0.47 to 0.44 L/min/m(2). CONCLUSION: Pulse contour analysis derived CI(PC) accurately reflects thermodilution derived CI(TD) or CI(PA) during changes of preload and the aortic impedance as occurring during sternotomy.

Aged↗
PubMed2005

[Measurement of cardiac output].

Diagnosis and therapy of hemodynamic instability are of the utmost importance in the treatment of critically ill patients during surgery and in intensive care. For both diagnosis and therapy, adequate and preferably continuous hemodynamic monitoring is essential. Besides the assessment of cardiac preload and blood pressure, cardiac output represents an important clinical marker of cardiac performance and global perfusion. Since its clinical introduction by Swan and Ganz in 1970, the standard technique for measuring cardiac output has been the pulmonary arterial thermodilution technique using a pulmonary artery catheter. The ongoing discussion on the risk-benefit ratio of such a pulmonary artery catheter has led to the introduction of several less invasive methods for determining cardiac output. The aim of this review is to provide background information on these alternative methods and to discuss the individual advantages and disadvantages of each method in the context of their clinical applicability.

Algorithms↗
PubMed2005

[Fast-track surgery in radical retropubic prostatectomy. First experiences with a comprehensive program to enhance postoperative convalescence].

Fast-track surgery is a comprehensive program for the optimization of perioperative care in elective surgery reducing potential postoperative complications and speeding up convalescence. Recent data from randomized colon resection trials emphasize that fast-track surgery is possible in most major operations. Our initial results in radical retropubic prostatectomy fast-track surgery have been encouraging. Fast-track surgery in major urological operations needs validation using randomized trials.

Clinical Trials as Topic↗
PubMed2004

Assessing fluid responsiveness during open chest conditions.

BACKGROUND: Measurement of ventilation-induced left ventricular stroke volume variations (SVV) or pulse pressure variations (PPV) is useful to optimize preload in patients after cardiac surgery. The aim of this study was to investigate the ability of SVV and PPV measured by arterial pulse contour analysis to assess fluid responsiveness in patients undergoing coronary artery bypass surgery during open-chest conditions. METHODS: We studied 22 patients immediately after midline sternotomy. We determined SVV, PPV, left ventricular end-diastolic area index by transoesophageal echocardiography, global end-diastolic volume index and cardiac index by thermodilution before and after removal of blood 500 ml and after volume substitution with hydroxyethyl starch 6%, 500 ml. RESULTS: Blood removal resulted in a significant increase in SVV from 6.7 (2.2) to 12.7 (3.8)%. PPV increased from 5.2 (2.5) to 11.9 (4.6)% (both P<0.001). Cardiac index decreased from 2.9 (0.6) to 2.3 (0.5) litres min(-1) m(-2) and global end-diastolic volume index decreased from 650 (98) to 565 (98) ml m(-2) (both P<0.025). Left ventricular end-diastolic area index did not change significantly. After fluid loading SVV decreased significantly to 6.8 (2.2)% and PPV decreased to 5.4 (2.1)% (both P<0.001). Concomitantly, cardiac index increased significantly to 3.3 (0.5) litres min(-1) m(-2) (P<0.001) and global end-diastolic volume index increased significantly to 663 (104) ml m(-2) (P<0.005). Left ventricular end-diastolic area index did not change significantly. We found a significant correlation between the increase in cardiac index caused by fluid loading and SVV as well as PPV before fluid loading (SVV, R=0.74, P<0.001; PPV, R=0.61, P<0.005). No correlations were found between values of global end-diastolic volume index or left ventricular end-diastolic area index before fluid loading and the increase in cardiac index. CONCLUSION: Measurement of SVV or PPV allows assessment of fluid responsiveness in hypovolaemic patients under open-chest and open-pericardium conditions. Thus, measuring heart-lung interactions may improve haemodynamic management during surgical procedures requiring mid-line sternotomy.

Adult↗
PubMed2004

Effects of mid-line thoracotomy on the interaction between mechanical ventilation and cardiac filling during cardiac surgery.

BACKGROUND: Mid-line thoracotomy is a standard approach for cardiac surgery. However, little is known how this surgical approach affects the interaction between the circulation and mechanical ventilation. We studied how mid-line thoracotomy affects cardiac filling volumes and cardiovascular haemodynamics, particularly variations in stroke volume and pulse pressure caused by mechanical ventilation. METHODS: We studied 19 patients during elective coronary artery bypass surgery. Before and after mid-line thoracotomy, we measured arterial pressure, cardiac index (CI) and global end-diastolic volume index (GEDVI) by thermodilution, left ventricular end-diastolic area index (LVEDAI) by transoesophageal echocardiography and the variations in left ventricular stroke volume and pulse pressure during ventilation by arterial pulse contour analysis. RESULTS: After thoracotomy, CI increased from 2.3 (0.4) to 2.9 (0.6) litre min(-1) m(-2), GEDVI increased from 605 (110) to 640 (94) litre min(-1) m(-2), and LVEDAI increased from 9.2 (3.7) to 11.2 (4.1) cm(2) m(-2). All these changes were significant. In contrast, stroke volume variation (SVV) decreased from 10 (3) to 6 (2)% and pulse pressure variation (PPV) decreased from 11 (3) to 5 (3)%. Before thoracotomy, SVV and PPV significantly correlated with GEDVI (both P<0.01). When the chest was open, similar significant correlations of SVV (P<0.001) and PPV (P<0.01) were found with GEDVI. CONCLUSION: Thoracotomy increases cardiac filling and preload. Further, thoracotomy reduces the effect of mechanical ventilation on left ventricular stroke volume. However, also under open chest conditions, SVV and PPV are preload-dependent.

Adult↗
PubMed2003

[Assessment of volume responsiveness in mechanically ventilated patients].

Monitoring and management of intravascular volume status is of crucial importance in critically ill patients. Hypovolemia, induced by hemorrhage or pathologic fluid shifts in the presence of systemic inflammation, is frequently the cause for hemodynamic instability and hypotension. This deficit of central blood volume leads to a reduction in biventricular cardiac preload. With respect to the Frank-Starling mechanism, this causes an alteration in left ventricular stroke volume. If this reduction in stroke volume cannot be compensated by an increase in heart rate, this finally results in a decline of cardiac output. In this clinical situation fluid loading is the treatment of choice. However, insufficient peripheral vascular resistance and thus reduced cardiac afterload as well as impaired myocardial contractility also have to be taken in account to be causative for hypotension. Potential hazards of fluid loading specifically in the latter situation include pulmonary edema, worsening of pulmonary gas exchange and myocardial failure. Thus, prediction of fluid responsiveness, i.e. the prediction of the hemodynamic response to fluid loading is of utmost importance in critically ill patients. Several conventional parameters of systemic hemodynamic monitoring such as the cardiac filling pressures CVP and PAOP, the estimation of the left ventricular end-diastolic area (LVEDA) by echocardiography and measurement of central blood volumes as the right-ventricular end-diastolic volume (RVEDV) or the global end-diastolic volume (GEDV) by thermodilution are frequently used for preload monitoring. Further, functional preload parameters such as the left ventricular stroke volume variation (SW), describing the specific interactions of the heart and the lungs under mechanical ventilation, have been recently proposed to be useful for predicting fluid responsiveness. Thus, it is the aim of the present article to analyze these different concepts of hemodynamic monitoring regarding their usefulness and clinical applicability to predict fluid responsiveness at the bedside.

Blood Volume↗
PubMed2003

Trendelenburg positioning after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance.

BACKGROUND AND OBJECTIVE: The efficacy of the Trendelenburg position, a common first step to treat suspected hypovolaemia, remains controversial. We evaluated its haemodynamic effects on cardiac preload and performance in patients after cardiac surgery. METHODS: Twelve patients undergoing mechanical ventilation of the lungs who demonstrated left ventricular 'kissing papillary muscles' by transoesophageal echocardiography, thus suggesting hypovolaemia, were positioned 30 degrees head down for 15 min immediately after cardiac surgery. Cardiac output by thermodilution, central venous pressure, pulmonary artery occlusion pressure, left ventricular end-diastolic area by transoesophageal echocardiography and intrathoracic blood volume by thermo- and dye dilution were determined before, during and after this Trendelenburg manoeuvre. RESULTS: Trendelenburg's manoeuvre was associated with increases in central venous pressure (9 +/- 2 to 12 +/- 3 mmHg) and pulmonary artery occlusion pressure (8 +/- 2 to 11 +/- 3 mmHg). The intrathoracic blood volume index increased slightly (dye dilution from 836 +/- 129 to 872 +/- 112 mL m(-2); thermodilution from 823 +/- 129 to 850 +/- 131 mL m(-2)) as did the left ventricular end-diastolic area index (7.5 +/- 2.1 to 8.1 +/- 1.7 cm2 m(-2)), whereas mean arterial pressure and the cardiac index did not change significantly. After supine repositioning, the cardiac index decreased significantly below baseline (3.0 +/- 0.6 versus 3.5 +/- 0.8 L min(-1) m(-2)) as did mean arterial pressure (76 +/- 12 versus 85 +/- 11 mmHg), central venous pressure (8 +/- 2 mmHg) and pulmonary artery occlusion pressure (6 +/- 4 mmHg). The intrathoracic blood volume index and left ventricular end-diastolic area index did not differ significantly from baseline. CONCLUSIONS: Trendelenburg's manoeuvre caused only a slight increase of preload volume, despite marked increases in cardiac-filling pressures, without significantly improving cardiac performance.

Blood Volume↗
PubMed2002

Orthogonal polarisation spectral imaging as a new tool for the assessment of antivascular tumour treatment in vivo: a validation study.

Tumour angiogenesis plays a key role in tumour growth, formation of metastasis, detection and treatment of malignant tumours. Recent investigations provided increasing evidence that quantitative analysis of tumour angiogenesis is an indispensable prerequisite for developing novel treatment strategies such as anti-angiogenic and antivascular treatment options. Therefore, it was our aim to establish and validate a new and versatile imaging technique, that is orthogonal polarisation spectral imaging, allowing for non-invasive quantitative imaging of tumour angiogenesis in vivo. Experiments were performed in amelanotic melanoma A-MEL 3 implanted in a transparent dorsal skinfold chamber of the hamster. Starting at day 0 after tumour cell implantation, animals were treated daily with the anti-angiogenic compound SU5416 (25 mg kg x bw(-1)) or vehicle (control) only. Functional vessel density, diameter of microvessels and red blood cell velocity were visualised by both orthogonal polarisation spectral imaging and fluorescence microscopy and analysed using a digital image system. The morphological and functional properties of the tumour microvasculature could be clearly identified by orthogonal polarisation spectral imaging. Data for functional vessel density correlated excellently with data obtained by fluorescence microscopy (y=0.99x+0.48, r2=0.97, R(S)=0.98, precision: 8.22 cm(-1) and bias: -0.32 cm(-1)). Correlation parameters for diameter of microvessels and red blood cell velocity were similar (r2=0.97, R(S)=0.99 and r2=0.93, R(S)=0.94 for diameter of microvessels and red blood cell velocity, respectively). Treatment with SU5416 reduced tumour angiogenesis. At day 3 and 6 after tumour cell implantation, respectively, functional vessel density was 4.8+/-2.1 and 87.2+/-10.2 cm(-1) compared to values of control animals of 66.6+/-10.1 and 147.4+/-13.2 cm(-1), respectively. In addition to the inhibition of tumour angiogenesis, tumour growth and the development of metastasis was strongly reduced in SU5416 treated animals. This new approach enables non-invasive, repeated and quantitative assessment of tumour vascular network and the effects of antiangiogenic treatment on tumour vasculature in vivo. Thus, quantification of tumour angiogenesis can be used to more accurately classify and monitor tumour biologic characteristics, and to explore aggressiveness of tumours.

Angiogenesis Inhibitors↗
PubMed2002

Impact of sepsis, lung injury, and the role of lipid infusion on circulating prostacyclin and thromboxane A(2).

OBJECTIVE: To investigate whether plasma levels of prostacyclin (PGI2) and thromboxane A(2) (TxA2) are a function of the infusion rate of soybean-based fat emulsions, severity of systemic inflammation, and pulmonary organ failure. DESIGN: Prospective, randomized, crossover study. SETTING: Intensive care unit of a university hospital. PATIENTS: Eighteen critically ill patients, ten presenting with severe sepsis, eight with SIRS or sepsis complicated with ARDS. INTERVENTIONS: Patients were randomly assigned to receive rapid fat infusion over 6 h (rFI) or slow fat infusion over 24 h (sFI) along with parenteral nutrition. MEASUREMENTS AND RESULTS: The stable prostanoids 6-keto-PGF1alpha and TxB2 were measured in arterial and mixed venous blood samples, and at 6-h periods trans-pulmonary balances (TPB) were calculated. Free linoleic acid fraction was determined in arterial blood. rFI induced greater increase of linoleic acid than sFI in both groups. Enhanced prostanoid levels and correlations with linoleic acid availabilities were found, however, in ARDS patients only, revealing the highest sepsis- and lung injury scores. Averaged TPB per 24 h was positive in the sepsis group and negative in the ARDS group as rFI induced lowest TPB values for TxB2 at 6 h. CONCLUSION: The quantity of prostanoids formed and their subsequent utilization are dependent on the availability of precursor linoleic acid and are probably affected by the severity of SIRS or sepsis and the existence of pulmonary organ failure, respectively. Because TxA2 might be extracted by the injured lung, rapid infusion of soybean-based fat emulsions should be avoided in patients suffering from severe pulmonary organ failure.

Adult↗
PubMed2002

[Transesophageal echocardiography: perioperative evaluation of valvular function].

Since its introduction into the operating room, transesophageal echocardiography (TEE) has proven to be an invaluable diagnostic tool for perioperative patient management. TEE allows direct visualization of structural and functional cardiac abnormalities. Therefore, it has become the most important imaging technique to evaluate valular function. Pressure gradients across a stenotic valve can be calculated by measuring the blood flow velocity within the valve. Additionally, the area of the valve can be estimated by using the continuity equation. The severity of regurgitant blood flow across an incompetent valve can be assessed using color flow, continuous or pulsed-wave Doppler. Surgical patients experience significant changes in blood pressure, intrathoracic pressures and volume status in the perioperative period. Therefore, the interaction between these parameters and valvular function is the focus of recent clinical studies and might in future contribute to the perioperative as well as anesthesiological management of patients with valvular dysfunction.

Algorithms↗
PubMed2002

Optimizing fluid therapy in mechanically ventilated patients after cardiac surgery by on-line monitoring of left ventricular stroke volume variations. Comparison with aortic systolic pressure variations.

BACKGROUND: Mechanical ventilation causes changes in left ventricular preload leading to distinct variations in left ventricular stroke volume and systolic arterial pressure. Retrospective off-line quantification of systolic arterial pressure variations (SPV) has been validated as a sensitive method of predicting left ventricular response to volume administration. We report the real-time measurement of left ventricular stroke volume variations (SVV) by continuous arterial pulse contour analysis and compare it with off-line measurements of SPV in patients after cardiac surgery. METHODS: SVV and SPV were determined before and after volume loading with colloids in 20 mechanically ventilated patients. RESULTS: SVV and SPV decreased significantly after volume loading and were correlated (r=0.89; P<0.001). Changes in SVV and changes in SPV as a result of volume loading were also significantly correlated (r=0.85; P<0.005). Changes in SVV correlated significantly with changes in stroke volume index (SVI) (r=0.67; P<0.005) as did changes in SPV (r=0.56; P<0.05). SVV determined before volume loading correlated significantly with changes in SVI (R=0.67; P <0.005). Using receiver operating characteristics curves, the area under the curve was statistically greater for SVV (0.824; 95% confidence interval: [CI] 0.64-1.0) and SPV (0.81; CI: 0.62-1.0) than for central venous pressure (0.451; CI: 0.17-0.74). CONCLUSIONS: Monitoring of SVV enables real-time prediction and monitoring of the left ventricular response to preload enhancement in patients after cardiac surgery and is helpful for guiding volume therapy.

Aorta, Abdominal↗