Biomedical subjects

Bernhard Kumle

Publications and source records attributed to Bernhard Kumle.

12 recordsLinked to original sources

PubMed2004

Influence of different volume replacement strategies on inflammation and endothelial activation in the elderly undergoing major abdominal surgery.

OBJECTIVE: Adequate restoration of intravascular volume remains an important maneuver in the management of the surgical patient. Influence of different volume replacement regimens on inflammation/endothelial activation in elderly surgical patients was assessed. DESIGN: Prospective, randomized study. SETTING: Surgical intensive care unit of a university-affiliated hospital. PATIENTS: Sixty-six patients >65 years undergoing major abdominal surgery. INTERVENTIONS: Ringer's lactate (RL; n=22), normal saline solution (NS; n=22) or a low-molecular HES (mean molecular weight 130 kD) with a low degree of substitution (0.4; HES 130/0.4; n=22) were administered after induction of anesthesia until the 1st postoperative day (POD) to keep central venous pressure between 8-12 mmHg. MEASUREMENTS AND RESULTS: C-reactive protein, interleukins (IL-6, IL-8), adhesion molecules [endothelial leukocyte adhesion molecule-1 (ELAM-1) and intercellular adhesion molecule-1 (ICAM-1)] were measured prior to volume therapy at the end of surgery, 5 h after surgery and at the morning of the 1st POD. RL patients received 10,150+/-1,660 ml of RL, NS patients 10,220+/-1,770 ml of NS and the HES-treated group 2,850+/-300 ml of HES 130/0.4 and 2,810+/-350 ml of RL. Hemodynamics were similar in all groups. CRP, IL-6 and IL-8 plasma levels increased significantly higher in both crystalloid groups (IL-6 in the NS group: increase to 407+/-33 pg/ml; RL: increase to 377+/-35 pg/dl) than in the HES-130 treated group (IL-6: increase to 197+/-20 pg/dl). Plasma levels of ELAM-1 and ICAM remained almost unchanged in the HES 130-, but significantly increased in the RL- and NS-treated patients. CONCLUSIONS: In elderly patients, markers of inflammation and endothelial injury and activation were significantly higher after crystalloid- than after HES 130/0.4-based volume replacement regimens.

Abdomen↗

PubMed2004

The influence of allogeneic red blood cell transfusion compared with 100% oxygen ventilation on systemic oxygen transport and skeletal muscle oxygen tension after cardiac surgery.

In this study we investigated the effects of allogeneic red blood cell (RBC) transfusion on tissue oxygenation compared with those of 100% oxygen ventilation by using systemic oxygen transport variables and skeletal muscle oxygen tension (PtiO2). Fifty-one volume-resuscitated, mechanically ventilated patients with a nadir hemoglobin concentration in the range from 7.5 to 8.5 g/dL after elective coronary artery bypass grafting were allocated randomly to receive 1 unit (transfusion 1; n = 17) or 2 units (transfusion 2; n = 17) of allogeneic RBCs and ventilation with 40% oxygen or pure oxygen ventilation (100% oxygen; n = 17) and no allogeneic blood for 3 hours. Invasive arterial and pulmonary artery pressures and calculations of oxygen delivery (oxygen delivery index) and consumption indices (oxygen consumption index) were documented at 30-min intervals. PtiO2 was measured continuously by using implantable polarographic microprobes. Systemic oxygen transport variables and PtiO2 were similar between groups at baseline. The oxygen delivery index increased significantly with transfusion of allogeneic RBCs and 100% oxygen ventilation, whereas the oxygen consumption index remained unchanged. Oxygen 100% ventilation increased PtiO2 significantly (from 24.0 +/- 5.1 mm Hg to 34.2 +/- 6.2 mm Hg), whereas no change was found after transfusion of allogeneic RBCs. Peak PtiO2 values were 25.2 +/- 5.2 mm Hg and 26.3 +/- 6.5 mm Hg in the transfusion 1 and 2 groups, respectively. Transfusion of stored allogeneic RBCs was effective only in improving systemic oxygen delivery index, whereas 100% oxygen ventilation improved systemic oxygen transport and PtiO2. This improved oxygenation status was most likely due to an increase in convective oxygen transport with a large driving gradient for diffusion of plasma-dissolved oxygen into the tissue.

Aged↗

PubMed2003

Influence of two different volume replacement regimens on renal function in elderly patients undergoing cardiac surgery: comparison of a new starch preparation with gelatin.

OBJECTIVE: There is continuing concern on the influence of hydroxethyl starch (HES) on renal function. DESIGN: Prospective, randomized study. SETTING: University-affiliated medical center. PATIENTS: Forty consecutive patients aged >70 years undergoing cardiac surgery using cardiopulmonary bypass. INTERVENTIONS: Either low-molecular HES (mean molecular weight: 130 kD) with low degree of substitution (0.4) (6% HES 130/0.4) (n=20) or gelatin ( n=20) was given after induction of anesthesia until the 2nd postoperative day (POD) to keep central venous pressure between 12-14 mmHg. MEASUREMENTS AND RESULTS: Creatinine clearance (CC) and fractional sodium clearance (FSC) were measured. N-acetyl-beta-D-glucosamidase, alpha-1-microglobulin, glutathione transferase-pi, and glutathione transferase-alpha were measured from urine specimens. Measurements were made after induction of anesthesia, at the end of surgery, and at the first and the second POD. More gelatin (total: 4150+/-490 ml) than HES 130/0.4 (total: 3450+/-450 ml) was infused within the study. CC and FSC were without differences between the two groups. All measured kidney-specific proteins were almost within normal range at baseline. They increased significantly after surgery, however, without significant group differences. At the 2nd POD, kidney-specific proteins had returned almost to normal values. None of the patients developed acute renal failure. CONCLUSIONS: Sensitive markers of kidney dysfunction increased in our elderly patients indicating moderate alterations in kidney integrity during cardiac surgery. The two volume replacement regimens did not differ with regard to kidney integrity in elderly patients undergoing cardiac surgery.

Aged↗

PubMed2003

Diltiazem may preserve renal tubular integrity after cardiac surgery.

PURPOSE: To evaluate the influence of dopamine and diltiazem on renal function and markers for acute renal failure, including urinary alpha-glutathion s-transferase (alpha-GST), alpha-1-microglobulin (alpha(1)-MG) and N-acetyl-ss-glucosaminidase (ss-NAG) after extracorporeal circulation. METHODS: In a randomized, placebo-controlled, double-blind trial we evaluated the efficacy of dopamine (2.5 micro g x kg(-1) x min(-1)), diltiazem (2 micro g x kg(-1) x min(-1)) or placebo administered over 48 hr postoperatively to maintain renal tubular integrity in 60 elective cardiac surgery patients. alpha-GST, alpha(1)-MG, ss-NAG, and creatinine clearance were measured from urine collected during surgery (T0), the first four hours (T1), 24 hr (T2) and 48 hr (T3) postoperatively. RESULTS: Cumulative urine output in the diltiazem group (9.0 +/- 2.8 L) increased significantly compared with placebo (7.0 +/- 1.6 L), but not compared with dopamine (7.8 +/- 1.8 L). Creatinine clearance showed no significant intergroup differences. In all groups alpha(1)-MG increased from T0 to T3, but we found no significant intergroup differences. alpha-GST increased significantly from T0 to T3 in the placebo (2.1 +/- 1.8 to 11.4 +/- 8.6 micro g x L(-1)) and in the dopamine groups (2.7 +/- 1.8 to 13.6 +/- 14.9 micro g x L(-1)), but not in the diltiazem group (1.8 +/- 1.4 to 3.2 +/- 3.2 micro g x L(-1)). Forty-eight hours postoperatively alpha-GST was significantly lower in the diltiazem group than in both other groups. CONCLUSIONS: Diltiazem stimulates urine output, reduces excretion of alpha-GST and ss-NAG and may be useful to maintain tubular integrity after cardiac surgery.

Acetylglucosaminidase↗

PubMed2003

Volume replacement with HES 130/0.4 may reduce the inflammatory response in patients undergoing major abdominal surgery.

PURPOSE: To investigate the effects of intravascular volume replacement therapy on the inflammatory response during major surgery. METHODS: Thirty-six patients scheduled for elective abdominal surgery were randomized to receive either 6% hydroxyethylstarch (130,000 Dalton mean molecular weight, degree of substitution 0.4; n = 18, HES-group) or lactated Ringer's solution (RL-group; n = 18) for intravascular volume replacement. Fluid therapy was given perioperatively and continued for 48 hr in the intensive care unit. Volume replacement was guided by physiological parameters. Serum concentrations of interleukin (IL)-6, IL-8 and IL-10 and soluble adhesion molecules (sELAM-1 and sICAM-1) were measured after induction of anesthesia, four hours after the end of surgery, as well as 24 hr and 48 hr postoperatively. RESULTS: Biometric and perioperative data, hemodynamics and oxygenation were similar between groups. On average, 4470 +/- 340 mL of HES 130/0.4 per patient were administered in the HES-group compared to 14310 +/- 750 mL of RL in the RL-group during the study period. Release of pro-inflammatory cytokines IL-6 and IL-8 was significantly lower in the HES-group [(peak values) 47.8 +/- 12.1 pg*dL(-1) of IL-6 and 35.8 +/- 11.2 pg*mL(-1) of IL-8 (HES-group) vs 61.2 +/- 11.2 pg*dL(-1) of IL-6 and 57.9 +/- 9.7 pg*mL(-1) of IL-8 (RL-group); P < 0.05]. Serum concentrations of sICAM-1 were significantly higher in the RL-group [(peak values) 1007 +/- 152 ng*mL(-1) (RL-group) vs 687 +/- 122 ng*mL(-1), (HES group); P < 0.05)]. Values of sELAM-1 were similar in both groups. CONCLUSION: Intravascular volume replacement with HES 130/0.4 may reduce the inflammatory response in patients undergoing major surgery compared to a crystalloid-based volume therapy. We hypothesize that this is most likely due to an improved microcirculation with reduced endothelial activation and less endothelial damage.

Abdomen↗

PubMed2003

Is kidney function altered by the duration of cardiopulmonary bypass?

BACKGROUND: Cardiopulmonary bypass (CPB) is considered responsible for kidney damage. By using sensitive markers of kidney damage we assessed whether the length of CPB influences kidney function. METHODS: In a prospective study, 50 consecutive cardiac operation patients with CPB times of less than 70 minutes were compared with 50 consecutive patients showing CPB times of more than 90 minutes. Aside from creatinine clearance and fractional excretion of sodium, urine concentrations of N-acetyl-beta-D-glucosaminidase, alpha1-microglobulin, glutathione transferase-pi, and glutathione transferase-alpha were measured after induction of anesthesia at the end of the operation, and on the first and second postoperative days in the intensive care unit. RESULTS: CPB times were 58 +/- 12 minutes and 116 +/- 18 minutes, respectively. Hemodynamics, volume replacement, and use of catecholamines during cardiopulmonary bypass (CPB) were without significant differences between groups. Concentrations of all kidney-specific proteins increased significantly after CPB, showing the highest significant increases in the CPB more than 90 minutes group (eg, glutathione transferase-alpha CPB > 90 minutes from 3.0 +/- 1.0 to 12.9 +/- 2.9 microg/L; glutathione transferase-alpha CPB < 70 minutes from 2.4 +/- 0.5 to 5.5 +/- 1.2 microg/L). By the second postoperative day, urine concentrations of kidney-specific proteins had returned to almost baseline in the CPB less than 70 minutes patients, but remained slightly elevated in the other group. CONCLUSIONS: Patients with CPB times more than 90 minutes showed more pronounced kidney damage than patients with CPB times less than 70 minutes as assessed by sensitive kidney-specific proteins. Whether patients with preexisting renal dysfunction undergoing prolonged CPB times would profit from renal protection strategies needs to be elucidated.

Acute Kidney Injury↗

PubMed2003

Influence of prolonged cardiopulmonary bypass times on splanchnic perfusion and markers of splanchnic organ function.

BACKGROUND: Cardiopulmonary bypass (CPB) is known to have considerable negative impact on perfusion and organ function. The effects of the duration of CPB on markers of splanchnic organ function was studied. METHODS: Consecutive patients undergoing elective aorto-coronary bypass grafting with CPB times (CPBT) of either less than 70 minutes (n = 15) or more than 80 minutes (n = 15) were prospectively studied. Splanchnic perfusion was assessed by measuring arterial and gastric mucosal PCO2 and calculating PCO2gap. Hepatic function was evaluated by monoethylglycinexylidide (MEGX) test and by measuring alpha-glutathione S-transferase (alpha-GST). Concentration of pancreatitis-associated protein was measured to assess pancreatic integrity. Measurements were performed after induction of anesthesia, at the end of surgery, 4 hours after arrival in the intensive care unit, and on postoperative day 1. RESULTS: The mean (+/- standard deviation) CPBT were 54 +/- 12 minutes and 99 +/- 16 minutes, respectively. PCO2gap increased significantly more in the group with CPBT of more than 80 minutes than in that with CPBT of less than 70 minutes, at +15 +/- 4 mm Hg versus +8 +/- 3 mm Hg, respectively, indicating reduction in splanchnic perfusion by longer CPBTs. Postoperative MEGX concentrations were significantly lower and postoperative alpha-GST concentrations were significantly higher in the group with CPBT of more than 80 minutes than in that with CPBT of less than 70 minutes. Plasma levels of pancreatitis-associated protein remained similar in both groups throughout the study period. CONCLUSIONS: In our patients with CPBT of more than 80 minutes, splanchnic perfusion and hepatocelluar integrity were moderately affected, whereas pancreatic function remained almost unchanged. Studies including a larger patient population are necessary to assess whether protective approaches would be helpful in patients undergoing complex cardiac surgery with very long CPBT.

Aged↗

PubMed2003

Kidney-specific proteins in elderly patients undergoing cardiac surgery with cardiopulmonary bypass.

UNLABELLED: In cardiac surgery, acute renal failure (ARF) is more likely in elderly patients than in younger patients. We assessed whether kidney function is different between elderly and younger cardiac surgery patients by measuring kidney-specific proteins. Forty consecutive patients aged <60 yr and 40 patients aged >70 yr without preoperative kidney dysfunction undergoing elective cardiac surgery with cardiopulmonary bypass (CPB) were included. Creatinine clearance and fractional excretion of sodium, as well as urine concentrations of N-acetyl-beta-D-glucosaminidase, alpha-1-microglobulin, glutathione transferase-pi (GST-pi), and glutathione transferase-alpha (GST-alpha) were measured after induction of anesthesia, at the end of surgery, and at the first and second postoperative days (PODs) on the intensive care unit. Patients' ages were 54 +/- 4 and 77 +/- 3 yr, respectively. Preoperative creatinine concentrations were without significant differences between the two groups. Fractional excretion of sodium was significantly higher after bypass in the elderly than in the younger patients. Urine concentrations of all kidney-specific proteins increased after CPB in the elderly (e.g., GST-pi from 16.2 +/- 3.4 to 27.7 +/- 3.9 microg/L), whereas they remained almost unchanged in the younger patients. Concentrations of all kidney-specific proteins were significantly larger in the elderly than in the younger patients even at the second POD. Although none of our patients suffered ARF requiring dialysis, increased post-CPB urine concentrations of kidney-specific proteins in the elderly suggest discrete and transient alterations in kidney integrity in comparison with a younger patient population undergoing cardiac surgery. IMPLICATIONS: Measurement of kidney-specific proteins demonstrated that patients >70 yr (mean, 77 +/- 3 yr) undergoing cardiac surgery with cardiopulmonary bypass had moderate and transient alterations in kidney integrity compared with patients aged <60 yr (mean, 54 +/- 4 yr). These abnormalities were not detected with standard measures of kidney function (e.g., creatinine concentrations).

Acetylglucosaminidase↗

PubMed2002

Does coagulation differ between elderly and younger patients undergoing cardiac surgery?

OBJECTIVE: Multiple improvements allow cardiac surgery in an increasingly older population. It is still unclear whether perioperative hemostasis differs between elderly and younger patients. DESIGN: Prospective, observational study. SETTING: Single institutional study at an urban, university-affiliated hospital. PATIENTS: Twenty-one consecutive patients aged over 80 years and 21 consecutive patients aged under 60 years undergoing first-time elective aortocoronary bypass grafting. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Modified thromboelastography (TEG) using different activators [intrinsic TEG (InTEG); extrinsic TEG (ExTEG); fibrinogen TEG (fibTEG)] was carried out to measure coagulation time [CT = reaction time (r)], clot formation time [CFT = coagulation time (k)], and maximum clot firmness [MCF = maximal amplitude (MA)]. Measurements were performed before surgery, at the end and 5 h after surgery on the intensive care unit (ICU), and on the morning of the 1st postoperative day (POD). Blood loss was slightly higher in the elderly than in the younger patients. Most TEG data were already significantly different between elderly and younger patients at baseline, indicating altered coagulation in the elderly prior to surgery (hypocoagulability). After surgery and on the ICU, elderly patients showed similar alterations in TEG to those of the younger patients (e.g. InTEG-CT: from 183+/-21 to 239+/-28 s versus from 146+/-15 to 186+/-26 s). On the 1st POD, most TEG data had returned almost to baseline values, however, they were still different between elderly and younger patients. CONCLUSIONS: Elderly cardiac surgery patients already showed moderately altered coagulation prior to surgery. Thus elderly patients may be at risk of developing postoperative alterations in hemostasis on the ICU. The exact reasons for the impaired coagulation in the elderly remains to be determined.

Age Factors↗

PubMed2002

The influence of hyperoxic ventilation during sodium nitroprusside-induced hypotension on skeletal muscle tissue oxygen tension.

BACKGROUND: Increasing inspired oxygen concentrations might provide a simple and effective intervention to increase oxygen tension in tissues during controlled hypotension. To test this hypothesis, the influence of hyperoxic ventilation (100% O2) on skeletal muscle oxygen partial pressure (Ptio2) in patients receiving sodium nitroprusside-induced controlled hypotension was studied. METHODS: Forty-two patients undergoing radical prostatectomy were prospectively studied and randomly divided into three groups as follows: (1) Controlled hypotension induced by sodium nitroprusside (mean arterial blood pressure, 50 mmHg) and hyperoxic ventilation (CH-100%; n = 14); (2) controlled hypotension and ventilation with 50% O2 in nitrous oxide (CH-50%; n = 14); and (3) standard normotensive anesthesia with 50% O2 in nitrous oxide (control; n = 14). Ptio2 values were measured continuously in all patients using implantable polarographic microprobes. Arterial blood gases and lactate concentrations were analyzed in 30-min intervals. RESULTS: Surgical blood loss and transfusion requirements were significantly reduced in both groups receiving hypotensive anesthesia. During surgery, arterial partial pressure of oxy-gen and arterial oxygen content were significantly higher in patients of the CH-100% group. Baseline values of Ptio2 were comparable between the groups (CH-50%: 25.0 +/- 0.7 mmHg; CH-100%: 25.2 +/- 0.2 mmHg; control: 24.5 +/- 0.2 mmHg). After a transient increase in Ptio2 in the CH-100% group during normotension, Ptio2 values returned to baseline and remained unchanged in the control group. Ptio2 decreased significantly during the hypotensive period in the CH-50% group. The lowest mean Ptio2 values were 15.0 +/- 4.1 mmHg in the CH-50% group, 24.2 +/- 4.9 mmHg in the CH-100% group, and 23.5 +/- 3.8 mmHg in the control group. There were no significant changes in lactate plasma concentrations in any group throughout the study period. CONCLUSIONS: Hyperoxic ventilation improved skeletal muscle tissue oxygenation during sodium nitroprusside-induced hypotension. This improved local tissue oxygenation seems to be most likely due to an increase in convective oxygen transport and the attenuation of hyperoxemia-induced arteriolar vasoconstriction by sodium nitroprusside.

Aged↗

PubMed2002

Pharmacoeconomic considerations in anaesthetic use.

Healthcare costs are rising in all areas of medicine, especially in high technology specialities such as anaesthesia. Therefore, cost containment and reduction have become major goals in many hospitals and anaesthesia departments. One area that has received substantial attention is the cost of pharmaceutical products, in particular the cost of newer, shorter-acting inhaled and intravenous anaesthetics, analgesics and neuromuscular blocking agents. Numerous pharmacoeconomic studies have been published on the theoretical analysis of anaesthetic drug costs and the potential benefit of various anaesthesia techniques. However, the results are not conclusive and anaesthesia departments continue to seek ways to reduce costs. In this review, we intend to discuss cost terminology, common areas of cost containment in anaesthesia and the relationship of anaesthesia care costs to total perioperative costs.

Anesthesia, Inhalation↗

PubMedDate not supplied

Robotic surgery using Zeus MicroWrist technology: the next generation.

BACKGROUND: The use of computer-animated surgical instruments for various cardiac operations has been shown to be feasible, but to date, the available information regarding the operative and technical details of these procedures is still inadequate. METHODS: We used the Zeus (Computer Motion Inc., Goleta, Calif, USA) telemanipulation system to perform the internal mammary artery (IMA) takedown in 56 patients, in 12 of whom we used the newest model with MicroWristTM (Computer Motion Inc., Goleta, Calif, USA) technology. Port orientation was based on thoracic anatomy, the decisive landmarks being the mammillary line and the axillary line. The distance between ports was at least 9 cm, and the patient's arm was positioned with the left shoulder raised and angulated by not more than 90 degrees. RESULTS: Mean setup time was 44 +/- 18 minutes for the first five patients and 16 +/- 7 minutes for the last five patients, with an overall average of 24 +/- 12 minutes. IMA harvest time at the beginning reached a mean of 95 +/- 23 minutes and decreased to 44 +/- 18 minutes in the last five cases. Average IMA takedown time was 58 +/- 17 minutes. The IMA was patent with a good flow in all 56 patients. CONCLUSIONS: The introduction of robotic technology into clinical routine has resulted in safe procedures with a short learning curve. However, basic training in the modality is a must in order to achieve technical excellence.

Cardiac Surgical Procedures↗