Biomedical subjects

B Kumle

Publications and source records attributed to B Kumle.

36 records · Page 2Linked to original sources

PubMed2000

Electroencephalogram bispectral index predicts hemodynamic and arousal reactions during induction of anesthesia in patients undergoing cardiac surgery.

OBJECTIVE: To evaluate hemodynamic and clinical responses to induction of anesthesia and intubation at 3 different values of the electroencephalogram bispectral index (BIS). DESIGN: Prospective randomized trial. SETTING: University-affiliated hospital. PARTICIPANTS: Forty-five patients undergoing elective coronary artery bypass graft surgery. INTERVENTIONS: Patients were assigned to 3 groups (n = 15 for each group). Anesthesia was induced with midazolam, sufentanil, and pancuronium. In each group, sufentanil was titrated to a BIS value of 60, 50, or 40 before intubation. Mean arterial blood pressure, heart rate, incidence of coughing, tearing, and need for fluid replacement or injections of norepinephrine were recorded before intubation as well as immediately and 1 and 2 minutes after intubation. MEASUREMENTS AND MAIN RESULTS: Thirteen patients intubated at a BIS value of 60 coughed and 14 experienced tearing after intubation, whereas no patient of the other groups showed signs of arousal. Mean arterial blood pressure remained stable in the BIS 60 and 50 groups, whereas in the BIS 40 group it decreased significantly to lower values before and after intubation. Patients in the BIS 40 group needed significantly more fluid replacement and injections of norepinephrine compared with the other groups. No significant changes in heart rate were detected. CONCLUSIONS: Electroencephalogram BIS predicts hemodynamic and arousal reaction resulting from induction of anesthesia and endotracheal intubation. BIS value should be kept at 50 before intubation to ensure safe hemodynamic conditions during induction of anesthesia in cardiac surgical patients.

Anesthesia, Inhalation↗

PubMed2000

Economic aspects of different muscle relaxant regimens.

OBJECTIVE: At a time of cost reduction in medical care efforts to manage the ever-increasing costs of new pharmaceutical drugs become increasingly important. Costs of four different muscle relaxant regimens including the new intermediate-acting neuromuscular blocking drugs (NMBD) cisatracurium and rocuronium will be analyzed. METHODS: Eighty patients undergoing laparoscopic cholecystectomy were prospectively studied. All patients received standardized general anaesthesia with desflurane/fentanyl. Muscle relaxation was achieved with atracurium, cisatracurium, vecuronium, or rocuronium with 20 patients in each group. Intraoperatively muscle relaxants were added to maintain two twitches of the train-of-four (TOF) assessment. RESULTS: There were no differences among the four groups regarding biometric data, duration of surgery and anesthesia, number of patients with reversal of neuromuscular blockade, and time of extubation. Length of stay in the postanesthesia care unit (PACU) and the incidence of side effects were similar in all groups. Total costs of used drugs were significantly lowest in the atracurium-treated patients (per patient: 18.27 Euro) and significantly highest in the cisatracurium group (26.71 Euro) compared with the other groups (vecuronium: 22.61 Euro; rocuronium: 22.63 Euro). CONCLUSION: It is summarized that the use of cisatracurium was associated with higher costs compared to a standard muscle relaxant regimen using atracurium, whereas patient outcome was the same in all study groups. The routine use of the newer NMBDs can only be justified economically, if considerable improvements to clinical practice can be demonstrated.

Adult↗

PubMed2000

[Anesthesiologic management in the treatment of patients with cystic fibrosis].

OBJECTIVE: Improvements in the management of patients with cystic fibrosis (CF) result in increased life expectancy. Thus it is likely that anesthetists will see this patients with increasing frequency. This study describes our experiences in the anesthetic management of CF patients. METHODS: We descriptively and retrospectively reviewed the records of all CF patients from 1981 until 1997 who underwent elective surgery in our department of ear, nose and throat and in whom general anesthesia was required. RESULTS: 199 anesthetics in 53 patients were reviewed. Premedication with midazolam (0.4 +/- 0.07 mg/kg) were given orally in 163 of the 199 anesthetics (82%). In 45 anesthetics the induction was performed by Inhalation with halothane (23%). Atropine (0.21 +/- 0.11 mg/kg) was used in 69 cases for induction. 57 pulmonary function tests were performed preoperatively mostly showing no severe abnormalities. We documented 10 perioperative respiratory complications (5%) in 199 procedures. No patient died at hospital. CONCLUSION: In patients with cystic fibrosis undergoing minor ear, nose and throat surgery who do not show significant reduction in pulmonary function anesthesia can be safely carried out.

Adult↗

PubMed2000

Influence of different colloids on molecular markers of haemostasis and platelet function in patients undergoing major abdominal surgery.

Synthetic colloids have been reported to cause haemorrhagic complications. The effects of perioperative volume replacement with 4% gelatin (n = 20), 6% low-molecular weight (LMW) hydroxyethyl starch (HES) (Mw: 70,000 dalton; HES 70/0.5; n = 20) and 6% medium-molecular weight (MMW) HES (Mw: 200,000 dalton; HES 200/0.5; n = 20) on haemostasis were assessed in patients undergoing major abdominal surgery. Volume was administered to keep central venous pressure (CVP) between 10 and 14 mm Hg. Conventional global coagulation tests, molecular markers of coagulation, and platelet function (using a platelet function analyser (PFA-100) with ADP as inductor) were monitored prior to surgery (T0), at the end of surgery (T1), 4 h after the end of surgery (T2), and on the morning of the first postoperative day (T3). Significantly more gelatin (2900 (SD 320) ml) than HES 200 (2150 (312) ml) was given during the study period. Bleeding and the use of allogeneic blood-blood products were similar in all groups. Markers of thrombin generation (F1 + 2), of thrombin neutralization (TAT III complex), and of fibrin formation and its degradation (D-dimer) increased significantly during and after surgery without showing significant group differences. Factor VIII and von Willebrand factor (vWF) also increased in all groups beyond the normal range, showing the significantly highest increase in the gelatin-treated group (VIII: from 173 (36) to 266 (33) U dl-1; vWF: from 164(33) to 238 (31) U dl-1). Platelet function remained within the normal range and without group differences throughout the study period. We can conclude that all three solutions can be used safely in patients undergoing major abdominal surgery with regard to the haemostatic process.

Abdomen↗

PubMed2000

Low-flow desflurane and sevoflurane anesthesia minimally affect hepatic integrity and function in elderly patients.

UNLABELLED: Hepatic blood flow is reduced in a dose-related manner by all inhaled anesthetics now in use. We assessed hepatic function in elderly patients anesthetized with desflurane or sevoflurane. We measured the cytosolic liver enzyme alpha glutathione S-transferase (alpha GST), the formation of the lidocaine metabolite monoethylglycinexylidide (MEGX), and gastric mucosal tonometry-derived variables as sensitive markers of hepatic function and splanchnic perfusion. Thirty patients, 70 to 90 yr old, were allocated randomly to receive desflurane or sevoflurane anesthesia. Anesthetic exposure ranged from 2.1-4.5 minimum alveolar concentration hours. No significant changes in standard liver enzyme markers were seen throughout the study. In both anesthetic groups, tonometric measurements showed a significant decrease from baseline in regional PCO(2), regional to arterial difference in PCO(2), and intramucosal pH at 90 min after skin incision. alpha GST concentrations increased significantly in both groups (desflurane: median peak concentrations 5.8 microg/L [25th, 75th percentile 5.3 microg/L, 7.2 microg/L]; sevoflurane: 7.0 microg/L [5.8 microg/L, 7.3 microg/L]) without showing differences between both anesthetic groups. A return to baseline values in tonometric values and alpha GST levels was seen 24 h postoperatively. MEGX formation did not change significantly after surgery. Median MEGX concentrations postoperatively were 70.0 ng/mL (56.2 ng/mL, 102.0 ng/mL) and 70.0 ng/mL (60.0 ng/mL, 94.2 ng/mL) in the desflurane and sevoflurane groups, respectively. We conclude that, overall, liver function in elderly patients is well preserved during desflurane and sevoflurane anesthesia. Increased serum levels of alpha GST and changes of gastric tonometry-derived variables imply a reduction in splanchnic perfusion, leading to a temporary impairment of hepatocyte oxygenation. IMPLICATIONS: We measured the lidocaine metabolite monoethylglycinexylidide, the cytosolic liver enzyme, alpha glutathione S-transferase, and gastric mucosal tonometry-derived variables to evaluate the effects of desflurane and sevoflurane on hepatic function in elderly patients. Liver function was well preserved, whereas increased alpha glutathione S-transferase levels and changes in tonometry-derived variables indicated a reduction in splanchnic blood flow and a temporary impairment of hepatocyte oxygenation for both anesthetics.

Aged↗

PubMed2000

Changes of the hemostatic network in critically ill patients--is there a difference between sepsis, trauma, and neurosurgery patients?

OBJECTIVE: To study the time course of coagulation data in intensive care patients. DESIGN: Prospective, descriptive study. SETTING: Clinical investigation on a surgical and neurosurgical intensive care unit of a university hospital. PATIENTS: Fifteen patients with severe trauma (injury severity score, 15 to 25), 15 sepsis patients secondary to major surgery, and 15 neurosurgery patients (cancer surgery) were studied. INTERVENTIONS: Standardized intensive care therapy. MEASUREMENTS AND MAIN RESULTS: Standard coagulation data and molecular markers of coagulation activation and fibrinolytic activity (soluble thrombomodulin, protein C, free protein S, thrombin/antithrombin III complex, plasmin-alpha 2-antiplasmin complex, tissue plasminogen activator, platelet factor 4, beta-thromboglobulin were measured from arterial blood samples on the day of admission to the intensive care unit (trauma/neurosurgery patients) or on the day of diagnosis of sepsis (baseline value) and serially during the next 5 days. Antithrombin III, fibrinogen, and platelet counts were highest in neurosurgery patients but without significant differences between sepsis and trauma patients. Thrombin/antithrombin III complex increased in the sepsis patients (from 22.6+/-4.2 microg/L to 39.9+/-6.8 microg/L), but decreased in trauma (from 40.2+/-5.1 microg/L to 17.6+/-4.0 microg/L) and neurosurgery patients (from 28.2+/-4.2 microg/L to 16.2+/-3.8 microg/L). Tissue plasminogen activator increased in the sepsis patients (from 14.4+/-3.9 microg/L to 20.7+/-3.8 microg/mL) and remained almost unchanged in the other two groups. Soluble thrombomodulin plasma concentration increased significantly in the sepsis group (max, 131.8+/-22.5 ng/mL), while it remained elevated in the trauma (max, 75.5+/-5.9 ng/mL) and was almost normal in the neurosurgery patients. Protein C and free protein S remained decreased only in the sepsis group. CONCLUSIONS: Alterations of the hemostatic network were seen in all three groups of critically ill patients. Hemostasis normalized in the neurosurgery patients and posttraumatic hypercoagulability recovered within the study period. By contrast, monitoring of molecular markers of the coagulation process demonstrated abnormal hemostasis in the sepsis patients during the entire study period indicating ongoing coagulation disorders and abnormalities in fibrinolysis in these patients.

Adult↗

PubMed1999

Nefopam and clonidine in the prevention of postanaesthetic shivering.

Postanaesthetic shivering affects up to 70% of patients after general anaesthesia, and may be very distressing. Various drugs have been used to treat or prevent postanaesthetic shivering, but the ideal one has not yet been found. Sixty patients undergoing elective abdominal or orthopaedic surgery under general anaesthesia were included in a randomised, double-blind study. Patients received clonidine (3 microgram.kg-1), nefopam (0.15 mg.kg-1) or saline 0.9% as a placebo at the end of surgery, prior to extubation. Nefopam and clonidine significantly reduced the incidence and severity of shivering in comparison with the placebo. The recovery time, between the end of anaesthesia and extubation, was significantly longer in the clonidine-treated patients [13.6 (5.2) min] than in either the nefopam [9.6 (2.8) min] or the placebo [10.0 (5.4) min] groups. Mean arterial blood pressure and heart rate were significantly lower in the clonidine group compared with both other groups. Our results suggest that nefopam and clonidine are effective in the prevention of postanaesthetic shivering. However, following clonidine administration the recovery time was prolonged and hypotension was significantly greater than after nefopam.

Adult↗

PubMed1999

Cost analysis of target-controlled infusion-based anesthesia compared with standard anesthesia regimens.

UNLABELLED: With the development of new computer-assisted target-controlled infusion (TCI) systems and the availability of short-acting anesthetics, total IV anesthesia (TIVA) has become increasingly popular. The aim of this study was to compare costs of TCI-based anesthesia with two standard anesthesia regimens. Sixty patients undergoing elective laparoscopic cholecystectomy were randomly divided into three groups. Group 1 (TIVA/TCI) received TIVA using a propofol-based TCI system and continuous administration of remifentanil; Group 2 (isoflurane) underwent inhaled anesthesia with isoflurane, fentanyl, and N2O; Group 3 (standard propofol) received fentanyl and N2O and a continuous infusion of propofol using a standard delivery system. Maintenance doses for anesthetics were adjusted according to the patient's need. Isoflurane consumption was measured by weighing the vaporizer by using a precision weighing machine. Duration of surgery and of anesthesia was similar in the three groups. Time from stopping administration of anesthetics until tracheal extubation (6+/-2 min) and stay in the postanesthesia care unit (PACU; 70+/-12 min) were shorter in Group 1 than in the Groups 2 (15+/-3 and 87+/-13 min, respectively) and 3 (10+/-4 and 81+/-14 min, respectively) (P < 0.05). Episodes of postoperative nausea and vomiting in the PACU and on the surgical ward were less common in Group 1 than in the other two groups. Intraoperative costs were higher in Group 1 ($62.19/patient; $0.55/min of anesthesia) than in Groups 2 ($16.97/patient; $0.13/min of anesthesia) and 3 ($34.68/patient; $0.32/min of anesthesia). Cost for discarded anesthetic drugs accounted for almost 18% of total intraoperative costs in Group 1. We conclude that TIVA/TCI anesthesia using propofol/remifentanil was associated with the highest intraoperative costs but the fewest postoperative side effects. An overall cost-effectiveness analysis of new anesthetic regimens must balance the direct cost of anesthetics and beneficial effects leading to improved patients' comfort. IMPLICATIONS: In today's climate of cost-consciousness, careful economic evaluation of new anesthetic regimens is necessary. A target-controlled infusion (TCI)-based total IV anesthesia (TIVA) regimen using propofol and remifentanil was compared with a standard propofol anesthesia regimen and an inhaled anesthetic technique using isoflurane. Target-controlled infusion/total IV anesthesia was associated with the largest intraoperative costs but allowed the most rapid recovery from anesthesia, was associated with fewest postoperative side effects, and permitted earlier discharge from the postanesthesia care unit.

Adult↗

PubMed1999

The effects of sodium nitroprusside-induced hypotension on splanchnic perfusion and hepatocellular integrity.

UNLABELLED: The purpose of our study was to investigate the effects of sodium nitroprusside-induced hypotension on splanchnic perfusion and hepatocellular integrity. Thirty patients undergoing radical prostatectomy were allocated randomly to a sodium nitroprusside (SNP) or control group (control). Regional pco2 was measured using gastric tonometry, and the regional to arterial difference in partial pressure of CO2 and intramucosal pH were calculated. The cytosolic liver enzyme alpha-glutathione S-transferase and standard liver enzyme markers (alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyltransferase) were also measured. Mean arterial pressure in the SNP group was 50 mm Hg for 97 min during surgery. A significant increase from baseline in regional pco2 (from 40.0+/-4.2 mm Hg to 45.3+/-1.3 mm Hg) and regional to arterial difference in partial pressure of CO2 (from 4.1+/-1.1 mm Hg to 9.7+/-1.4 mm Hg) was seen at 90 min after skin incision only in the SNP group. Intramucosal pH decreased significantly from 7.40+/-0.02 to 7.35+/-0.03 during the same period in this group. Tonometric variables returned to baseline values within 2 h postoperatively. Alpha-glutathione S-transferase concentrations increased significantly in the SNP group from baseline to peak concentrations at the end of surgery (SNP: 9.93+/-4.94 microg/L; control: 5.85+/-1.86 microg/L). A return to baseline values was seen 24 h postoperatively. No significant changes in standard liver enzyme markers were seen throughout the study period. It is concluded, that splanchnic perfusion was transiently impaired during controlled hypotension. This is supported by significant changes in tonometric data. Increased serum levels of alpha-glutathione S-transferase may indicate a disturbance in hepatocellular integrity. IMPLICATIONS: We studied gastric mucosal tonometry and the cytosolic liver enzyme alpha-glutathione S-transferase to evaluate the effects of controlled hypotension induced by sodium nitroprusside on splanchnic perfusion and hepatocellular integrity. Splanchnic perfusion decreased and alpha-glutathione S-transferase increased during and after a hypotensive period, but returned to baseline values within the first postoperative day, indicating a transient impairment of splanchnic perfusion and hepatocellular integrity.

Antihypertensive Agents↗

PubMed1999

The influence of different intravascular volume replacement regimens on renal function in the elderly.

UNLABELLED: Elderly patients are at risk of developing renal dysfunction. Synthetic colloids are often used perioperatively, but they may have detrimental effects on renal function. In a prospective, randomized study, we assessed the influence of different intravascular volume replacement regimens on renal function in elderly (>65 yr) and younger (< 65 yr) patients without preoperative renal dysfunction who were undergoing major abdominal surgery. Either 6% low molecular weight hydroxyethyl starch (HES) solution (mean molecular weight 70,000 D, degree of substitution 0.5; HES 70/0.5) [each group n = 10]), 6% medium-molecular weight HES (molecular weight 200,000 D, degree of substitution 0.5 (HES 200/0.5) [each group n = 10]), or modified gelatin (molecular weight 35,000 D [each group n = 10]) was administered to maintain mean arterial blood pressure >65 mm Hg and central venous pressure between 10 and 14 mm Hg. After the induction of anesthesia (T0); at the end of surgery (T1); 4 h after surgery (T2); and on the first (T3), second (T4), and third postoperative days (T5), alpha1-microglobulin (alpha1-M), N-acetyl-beta-glucosaminidase, fractional sodium clearance, and creatinine clearance (CC) were measured. Colloids (1300-3000 mL) were infused until the first postoperative day. At T0, urine concentrations of alpha1-M were higher in the elderly than in the younger patients in all groups (P < 0.05). alpha1-M remained increased only in the gelatin group. N-acetyl-beta-glucosaminidase and fractional sodium clearance were not affected during the study period in any groups. At baseline, CC was significantly higher in the younger than in the elderly patients, but CC did not decrease in any of the intravascular volume replacement groups. We conclude that intravascular volume therapy with gelatin and two different HES preparations did not adversely affect renal function in elderly patients without preoperative renal malfunction. IMPLICATIONS: We studied the influence of three different intravascular volume replacement regimens on renal function in elderly patients without renal dysfunction who were undergoing major abdominal surgery. Two hydroxyethyl starch and one gelatin preparation were administered perioperatively to maintain stable hemodynamics. As assessed by sensitive markers of renal function, all three regimens can be used safely for volume replacement without risking significant renal dysfunction.

Abdomen↗

PubMed1998

Volume replacement strategies on intensive care units: results from a postal survey.

OBJECTIVE: To assess volume replacement strategies on intensive care units (ICUs) in Germany. DESIGN: A postal survey questionnaire of 18 questions was sent to 451 ICUs in Germany. The questionnaire was sent to general, surgical, anesthesiology, neurosurgery, cardiac surgery, and medical ICUs of hospital with more than 200 beds. RESULTS: 286 questionnaires (64%) were returned and analysed. Hydroxyethylstarch (HES) solution is the solution most often used for volume replacement (total: 193 ICUs, exclusively HES: 93 ICUs), crystalloids are next (crystalloids exclusively: 61 ICUs), and human albumin is used rarely as a first choice. Clinical experience is a very important argument for administering volume. Diagnostic tools, e.g. measurement of central venous pressure or pulmonary capillary wedge pressure, also play an important role. Albumin/total protein and colloid osmotic pressure (COP) are measured often on ICUs (albumin measured routinely: 173 ICUs; COP measured routinely: 33 ICUs). Critical values for albumin/total protein are defined in most ICUs. Reduced plasma levels of albumin/total protein was the indication most often cited for administering human albumin. Only 149 ICUs (52%) have a financial budget for their unit. Costs still do not play a major role in the choice of volume replacement on 30 ICUs (10%). CONCLUSIONS: The kind of volume therapy differs widely among the different ICUs. This questionnaire supported the supposition that no standards exist for volume therapy in intensive care patients. New results concerning the abuse of albumin in the critically ill have not yet influenced strategies of volume replacement.

Albumins↗

PubMed1998

Point-of-care (POC) measurement of coagulation after cardiac surgery.

OBJECTIVE: Two different point-of-care (POC) systems for the monitoring of coagulation variables at the bedside were evaluated with regard to practicability, accuracy and costs. DESIGN: Prospective, descriptive study. SETTING: Single-institutional, clinical investigation on an intensive care unit (ICU) of an urban, university-affiliated hospital. PATIENTS: Eighty cardiac surgery patients were studied postoperatively. INTERVENTIONS: Arterial blood samples were drawn postoperatively on the ICU at different data points. MEASUREMENTS AND RESULTS: Activated partial thromboplastin time (aPTT) and prothrombin time (PT) were measured using two POC systems (Thrombolytic Assessment System [TAS] and CoaguCheck Plus). At the same time coagulation parameters were measured by the central laboratory of the hospital. Measurements were carried out at different data points after cardiac surgery on the ICU. The direct and indirect costs of measuring aPTT/PT were also assessed. Bias analyses revealed good agreement of the POC-based monitoring of aPTT/PT with laboratory-based monitoring of coagulation (e. g. aPTT CoaguCheck: bias of -2.8 s with +/- 2 SD [limits of agreement] of +13.7 and -19.1 s). Mean turn-around time (TAT; time from blood sampling until availability of data for the ICU physicians) was significantly longer for the central laboratory-based coagulation monitoring (130 +/- 38 min) than for the two POC systems (aPTT-TAS: 9.6 +/- 2.7 min; aPTT-CoaguCheck: 6.5 +/- 1.9 min). Blood sampling at unfavorable times increased the TAT for laboratory-based measurements considerably. The direct costs for measuring aPPT and PT were significantly higher using both POC systems (aPTT-TAS: $4.84; aPTT-CoaguCheck: $4.34) than for the central laboratory ($1.59). Costs for transportation increased the laboratory-based monitoring considerably ($3.77). CONCLUSIONS: Both POC analyzers may reduce the potential for preanalytical errors associated with coagulation measurements at the central laboratory, hasten TAT significantly and may improve patient therapy by reducing inappropriate administration of blood products.

Aged↗

PubMed1998

Are circulating adhesion molecules specifically changed in cardiac surgical patients?

BACKGROUND: Soluble adhesion molecules are considered to be markers of inflammation, endothelial activation, or damage. This study was designed to assess whether adhesion molecules are specifically altered in patients undergoing cardiac surgical procedures. METHODS: Three groups of 20 patients each were prospectively studied: patients undergoing elective coronary artery bypass grafting; patients scheduled for a Whipple pancreatoduodenectomy; and patients undergoing elective pneumonectomy for lung cancer. Plasma levels of soluble adhesion molecules (endothelial leukocyte adhesion molecule-1, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and granule membrane protein 140) were measured from arterial blood samples after induction of anesthesia (baseline), at the end of the operation, 2 hours and 5 hours after operation, and on the morning of the first postoperative day. RESULTS: Duration of operation was longest in the group having a Whipple operation (289 +/- 50 minutes) and did not differ between the other two groups. Plasma levels of all measured adhesion molecules at baseline were within normal ranges. After cardiopulmonary bypass, levels of adhesion molecules were significantly increased in the cardiac surgical patients (soluble endothelial leukocyte adhesion molecule-1, from 38 +/- 11 ng/mL at baseline to 68 +/- 12 ng/mL; soluble intercellular adhesion molecule-1, from 241 +/- 50 ng/mL to 498 +/- 78 ng/mL; and granule membrane protein 140, from 69 +/- 12 ng/mL to 150 +/- 25 ng/mL). On the morning of the first postoperative day, all levels had returned to baseline except that of soluble vascular cell adhesion molecule-1, which was still elevated (p < 0.05). In both the other groups, concentrations of adhesion molecules remained almost unchanged. CONCLUSIONS: Cardiac operation was associated with increased plasma levels of soluble adhesion molecules, a finding indicating endothelial activation or dysfunction. In contrast, in patients undergoing complex, long-lasting abdominal or lung operations, soluble adhesion molecules remained unchanged. Activation of proinflammatory cascades, ischemia/reperfusion phenomenon, and microcirculatory dysfunction appear to be the most likely reasons for this difference between groups. Whether modulation of adhesion molecules may influence organ function after cardiopulmonary bypass remains to be elucidated in further studies.

Aged↗

PubMed1998

[Prophylactic nefopam administration for post-anesthetic shivering].

PURPOSE: Shivering is a frequent postanaesthetic complication. Its definite reason is unknown. Patients with cardiovascular or pulmonary diseases are endangered by postanaesthetic shivering. The aim of this study was to assess the efficacy of nefopam in prophylaxis of shivering. Additionally we investigated the influence of nefopam on haemodynamic parameters and on the time until extubation. METHODS: 30 patients (ASA I-II) were randomly allocated in a double-blind fashion to one of two groups to receive directly after the end of isoflurane application either nefopam (0.15 mg/kg) or placebo (0.9% saline). The period of anaesthesia had to be longer than 60 minutes. All patients received a premedication with lorazepam (0.02 mg/kg) 30-45 minutes prior to surgery. Induction of anaesthesia was standardised: fentanyl (3 micrograms/kg), thiopentone (5 mg/kg), atracurium (0.4 mg/kg). Intraoperatively a mixture of isoflurane, nitrous oxide (60%) and oxygen was used to maintain anaesthesia. The following parameters were evaluated: Age, sex, duration of operation and anaesthesia and the time between the end of application of volatiles and extubation. Heart rate (HR), mean arterial blood pressure (MAP), rectal temperature and O2-saturation were measured at predefined data points. Postoperatively the consumption of analgesic was documented. The severity of shivering was classified in five grades. RESULTS: In the control-group nine patients shivered (60%), whereas in the nefopam group only one patient (6.6%) shivered (p < 0.05). In comparison to the placebo group we observed in the nefopam group a significantly decreased HR 30 and 60 minutes postoperatively (p < or = 0.007 and p < or = 0.002). We did not observe prolonged awakening in the nefopam-treated patients. MAP and O2-saturation showed similar reactions in both groups. CONCLUSION: The data indicate that prophylactic administration of nefopam can suppress postanaesthetic shivering. Prolonged awakening was not observed.

Analgesics, Non-Narcotic↗

PubMed1998

Economic considerations of the use of new anesthetics: a comparison of propofol, sevoflurane, desflurane, and isoflurane.

UNLABELLED: Cost control in anesthesia is no longer an option; it is a necessity. New anesthetics have entered the market, but economic differences in comparison to standard anesthetic regimens are not exactly known. Eighty patients undergoing either subtotal thyroidectomy or laparoscopic cholecystectomy were randomly divided into four groups, with 20 patients in each group. Group 1 received propofol 1%/sufentanil, Group 2 received desflurane/sufentanil, Group 3 received sevoflurane/sufentanil, and Group 4 received isoflurane/sufentanil (standard anesthesia) for anesthesia. A fresh gas flow of 1.5-2 L/min and 60% N2O in oxygen was used for maintenance of anesthesia, and atracurium was given for muscle relaxation. Concentrations of volatile anesthetics, propofol, and sufentanil were varied according to the patient's perceived need. Isoflurane, desflurane, and sevoflurane consumption was measured by weighing the vaporizers with a precision weighing machine. Biometric data, time of surgery, and time of anesthesia were similar in the four groups. Times for extubation and stay in the postanesthesia care unit (PACU) were significantly longer in the isoflurane group. Use of sufentanil and atracurium did not differ among the groups. Propofol patients required fewer additional drugs in the PACU (e.g., antiemetics), and thus showed the lowest additional costs in the PACU. Total (intra- and postoperative) costs were significantly higher in the propofol group ($30.73 per patient; $0.24 per minute of anesthesia). The costs among the inhalational groups did not differ significantly (approximately $0.15 per minute of anesthesia). We conclude that in today's climate of cost savings, a comprehensive pharmacoeconomic approach is needed. Although propofol-based anesthesia was associated with the highest cost, it is doubtful whether the choice of anesthetic regimen will lower the costs of an anesthesia department. IMPLICATIONS: Cost analysis of anesthetic techniques is necessary in today's economic climate. Consumption of the new inhaled drugs sevoflurane and desflurane was measured in comparison to a standard anesthetic regimen using isoflurane and an IV technique using propofol. Propofol-based anesthesia was associated with the highest costs, whereas the costs of the new inhaled anesthetics sevoflurane and desflurane did not differ from those of a standard, isoflurane-based anesthesia regimen.

Anesthetics, Inhalation↗

PubMed1998

Influence of angiotensin-converting enzyme inhibitor enalaprilat on endothelial-derived substances in the critically ill.

OBJECTIVE: To assess the effects of the angiotensin-converting enzyme inhibitor enalaprilat on endothelial cells in septic patients. DESIGN: Prospective, randomized, placebo-controlled, blinded study. SETTING: Clinical investigation on a surgical intensive care unit of a university hospital. PATIENTS: Forty surgical septic patients (noncardiac/nonneurosurgical patients). INTERVENTIONS: After inclusion in the study and after baseline data were obtained, either 0.25 mg/hr (enalaprilat group, n = 20) or saline solution as placebo (control group, n = 20) was continuously given and continued throughout the following 5 days. MEASUREMENTS AND MAIN RESULTS: Extensive hemodynamic monitoring was carried out in all patients. Plasma concentrations of endothelin-1, angiotensin II, soluble thrombomodulin, and soluble adhesion molecules (endothelial leukocyte adhesion molecule-1, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and granule membrane protein-140) were measured from arterial blood samples. All measurements were carried out before the start of the infusion ("baseline" values) and daily during the following 5 days. All endothelial-derived substances (thrombomodulin, endothelin-1, and all soluble adhesion molecules) were similarly increased beyond normal in both group. Endothelin-1 increased only in the untreated control patients (from 6.9 +/- 0.7 to 14.3 +/- 1.4 mg/mL). Soluble thrombomodulin increased in the untreated control patients (from 58 +/- 9 to 79 +/- 14 ng/mL [p < .05]), but significantly decreased in the enalaprilat-treated patients. Soluble adhesion molecules increased in the untreated control group (endothelial leukocyte adhesion molecule from 92 +/- 14 to 192 +/- 29 ng/mL; intercellular adhesion molecule-1 from 480 +/- 110 to 850 +/- 119 ng/ mL) and returned almost to normal values in the enalaprilat patients. The survival rate did not differ significantly between the two groups. Control patients developed severe sepsis and septic shock more often than the enalaprilat-treated group. CONCLUSIONS: The complex pathogenesis of endothelial function abnormalities in sepsis may offer a large number of pharmacologic interventions. Administration of the angiotensin-converting enzyme inhibitor enalaprilat resulted in a reduced release of soluble endothelial-derived substances into the circulating blood, which may indicate an improved endothelial function. The specific actions of enalaprilat on the endothelium have to be elucidated in further studies.

Aged↗

PubMed1997

[Resuscitation of a near-drowning patient by the use of a portable extracorporeal circulation device].

We report on a 21-year old patient who nearly drowned in cold water under inexplicable circumstances. About 1/2 hour later he was found with cardiac arrest. Immediate cardiopulmonary resuscitation remained unsuccessfully but was continued. After transportation to the nearest hospital a core temperature of 26.1 degrees C was recorded. A team of our hospital arrived 2 1/2 hours after start of cardiopulmonary resuscitation. After introducing a femo-femoral bypass the patient was rapidly rewarmed and oxygenated using a portable extracorporeal circulation and membrane oxygenation. Defibrillation succeeded at a core temperature of 34.4 degrees C. A severe ARDS developed the same day which was successfully treated by membrane oxygenation. 41 days later the patient left the hospital fully recovered.

Adult↗

PubMed1992

Immunotoxins directed against the high-molecular-weight melanoma-associated antigen. Identification of potent antibody-toxin combinations.

To study factors influencing the cytotoxicity of immunotoxins (ITs), we compared the in vitro cytotoxicity of conjugates in which the plant toxin abrin and the bacterial toxin Pseudomonas exotoxin A (PE) were coupled by 2 different procedures to 2 MAbs, 9.2.27 and NR-ML-05, which bind to different epitopes on the melanoma-associated antigen p250. The individual target cell lines differed widely in sensitivity to the different ITs, as assessed by measurement of protein synthesis inhibition. The action of the ITs was highly specific, as the toxicity of abrin and PE conjugates was respectively 20-540 and 2,200-550,000 times higher in antigen-positive cell lines (FEMX, SESX, OHS) than in the antigen-negative line KPDX. The PE conjugates prepared with the 2 different MAbs differed in potency by factors of 16-126 in the target-cell lines, but were consistently more toxic than the abrin ITs. The results demonstrate that the cytotoxicity of ITs varies with the nature of both of its moieties and that optimal results require that toxins and MAbs be matched. Moreover, the 2 coupling procedures affected differentially the binding and potency of some ITs. Each of the 2 toxins was conjugated to a sheep anti-mouse antibody (SAM) and the toxicity of these 2 conjugates was tested in an indirect approach using 9.2.27 and NR-ML-05 as primary MAbs. The results showed that the indirect procedure would have correctly predicted the most potent antibody-toxin pair, indicating that the approach may be valid for selecting suitable combinations of MAbs and toxins for use as direct ITs.

ADP Ribose Transferases↗