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C von Heymann

Publications and source records attributed to C von Heymann.

11 recordsLinked to original sources
PubMed2006

[The role of anesthesiology in fast track concepts in colonic surgery].

In the present study the "fast-track rehabilitation" protocol of the Charité university hospital for patients undergoing elective colonic resection is described. The underlying principles, clinical pathways and outcome data from 208 patients are shown. Particularly anesthesiological aspects of this multimodal approach, such as modified preoperative and postoperative fluid management, changed guidelines for preoperative fasting, effective analgetic therapy using epidural analgesia and avoiding high systemic doses of opioids, use of short-acting anesthetic agents, and maintenance of normothermia as well as normovolemia are presented and discussed. In comparison to outcome data before "fast-track rehabilitation" was established, the duration of postoperative hospital stay has been reduced from 12 to 5 days, the number of general complications (pneumonia, duodenal ulcer bleeding, urinary tract infection, cerebral, cardiac and renal dysfunction) decreased from 20% to 7%, whereas surgical complications remained constant at 17% (8% wound infections, 3% anastomotic insufficiency).

Analgesia, Epidural↗
PubMed2006

[The influence of intraoperative fluid therapy on the postoperative outcome in "fast track" colon surgery].

OBJECTIVE: To evaluate the association between the intraoperative and postoperative application of different quantities of fluids and the incidence of postoperative complications after "fast-track"-colonic surgery. METHODS: We performed a retrospective analysis of 136 patients undergoing elective "fast-track" colonic surgery (sigma resection and right hemicolectomy). Data collection in regard of fluid administration during surgery and in the post anaesthesia care unit (PACU) was based on anaesthesia charts and a prospectively generated surgery database. Classification into three volume groups (up to 3500 ml = group 1, 3500 - 5500 ml = group 2, more than 5500 ml = group 3). Basic patient characteristics, pre-existing conditions, type and duration of surgery and anastomoses were documented. We analysed the incidence of postoperative complications such as wound infections, anastomotic leak, bleeding, bowel obstruction, cardiovascular failure, hypertension, pulmonary failure, pneumonia, renal failure, urinary tract infection, neurological and psychiatric complications in the different volume groups. RESULTS: 115 patients were infused with up to 3500 mLs of fluids, 19 patients received more than 3500 mLs, two patients were infused with 6000 ml and 7500 mLs, respectively. This was in median 36 ml/kg in the restrictive and 53 ml/kg in the higher volume groups (group 2 and 3 together), respectively. The duration of surgery and anaesthesia was significantly different between both fluid groups (p = 0,023). In a logistic regression model only intraoperative blood loss was independently associated with the volume of infused fluid (OR 0,393, 95 % CI 1.028 - 2.306, p < 0.01). The rate of postoperative complications was not different between groups (p = 0,228). CONCLUSION: The incidence of postoperative complications was not different between patients who were infused 36 ml/kg or 53 ml/kg of fluids during surgery and post anaesthesia care unit stay.

Aged↗
PubMed2006

[Bleeding after cardiac surgery: the role of recombinant factor VIIa].

Cardiac surgery carries a remarkable risk of blood loss requiring transfusion of blood products. Moreover, severe bleeding necessitating reoperation occurs in 3-5% of patients according to international studies. These patients face a significantly higher morbidity and mortality. This underscores the need for a safe and effective haemostatic therapy, which may significantly improve the outcome. Recombinant activated factor VII is approved for haemophiliacs with inhibitors and patients with thrombasthenia Glanzmann and factor VII deficiency. In the proceeding years a series of articles has been published reporting the successful and safe therapy of refractory bleeding after cardiac surgery. This review focuses at presenting the pathophysiological alterations of the haemostatic system related to the cardiopulmonary bypass. These alterations are thought to explain the high risk of bleeding after cardiopulmonary bypass. Furthermore, the use of rFVIIa in paediatric and adult cardiac surgery is reviewed and critically discussed.

Blood Coagulation↗
PubMed2005

[Quality assurance of haemotherapy in anaesthesia. Auswertung eines 3-jahrigen Erfahrungszeitraums].

BACKGROUND: The measures for quality assurance in haemotherapy developed at the Charite Campus Mitte according to the transfusion law of 1998 are introduced and discussed. METHODS: In a 3-year study period the submission of transfusion documentation and the expiration of blood products were compared to the year 2001. The potentials for improvement for 2001-2003 were compared based on evaluation of the self-inspection documentation of the transfusion clinics. RESULTS: The submission rate for the transfusion documentation increased from 90% in 2001 to 98.3% in 2002 and 2003. The expiration of blood products decreased from 5.1% in 2001 to 1.7% in 2003 resulting in a cost reduction from 140,000 Euro to 50,000 Euro. Continuous need for improvement was found for the prescribed annual further education of staff on quality management. CONCLUSIONS: The self-inspection procedure in transfusion clinics still revealed potential for improvement, although documentation of transfusions were improved and the expiration of blood products and the resulting costs were substantially reduced.

Anesthesia↗
PubMed2005

Aspirin and clopidogrel taken until 2 days prior to coronary artery bypass graft surgery is associated with increased postoperative drainage loss.

OBJECTIVE: Platelet aggregation inhibitors, such as aspirin and clopidogrel, are associated with increased bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass. We investigated the impact of time between the last intake of aspirin and clopidogrel before CABG surgery and drainage loss, transfusion requirements and rate of reoperation. PATIENTS AND METHODS: The records of patients who had coronary artery bypass graft surgery (CABG) were reviewed for intake of aspirin and clopidogrel within 7 days prior to surgery. Drainage loss, transfusion requirements and rate of reoperation for bleeding within 5 days after the operation, were recorded. RESULTS: Out of 261 analysed patients, 225 patients (86.2 %) had no anti-platelet medication and 36 patients (13.8 %) were on aspirin and clopidogrel. Aspirin and clopidogrel, taken all until 2 days prior to operation, were associated with a significantly higher postoperative blood loss (1840 mL [1230 - 3710] vs. 280 mL [185 - 765], p = 0.005 for one day and 850 mL [345 - 1725] vs. 277 mL [165 - 778], p = 0.026, for 2 days prior to surgery). The trend showed that patients in the study group received more platelet concentrates (PC: 5.3 % vs. 13.9 %, p = 0.067). The rate of reoperation for bleeding was not different ( p = 0.25). CONCLUSION: Aspirin and clopidogrel up to 2 days prior to CABG were associated with a significantly higher postoperative drainage loss.

Aged↗
PubMed2005

Torsemide versus furosemide after continuous renal replacement therapy due to acute renal failure in cardiac surgery patients.

Diuretic therapy in ARF (acute renal failure) is mainly done with loop diuretics, first of all furosemide. Torsemide has a longer duration of action and does not accumulate in renal failure. In chronic and acute renal failure, both diuretics have been effectively applied, with a more pronounced diuretic effect for torsemide. In this study, the effects of torsemide versus furosemide on renal function in cardiac surgery patients recovering from ARF after continuous renal replacement therapy (CRRT) were studied. Twenty-nine critically ill patients admitted to an intensive care unit at a university teaching hospital after cardiac surgery recovering from ARF after CRRT were included in this prospective, controlled, single-center, open-labeled, randomized clinical trial. Inclusion criteria were urine output >0.5 mL/kg/h over 6 h under CRRT. Torsemide and furosemide dosages were adjusted with the target urine output being 0.8-1.5 mL/kg/h. Hemodynamic data, urine output, volume balance, serum creatinine clearance, electrolytes, blood urea nitrogen, serum creatinine, renin, and aldosterone concentrations were measured. Fourteen patients were included in the furosemide group and 15 patients in the torsemide group. Dosages of 29 (0-160) mg torsemide and a dosage of 60 (0-240) mg furosemide were given every 6 h in each group, respectively. The dosage given at the end of the study decreased significantly in furosemide and torsemide treated patients. Urine output, 24 h balance, and serum creatinine clearance did not differ significantly between groups. Urine output decreased in both groups, mostly dose-dependent in the torsemide group. The intragroup comparison of the first time-interval after inclusion with the last time-interval showed a significant increase in serum creatinine and blood urea nitrogen in the furosemide group. Renin and aldosterone concentrations did not show significant differences. In conclusion, torsemide and furosemide were effective in increasing urine output. Torsemide might show a better dose-dependent diuretic effect in ARF patients after CRRT treatment. Serum creatinine and blood urea nitrogen elimination were less pronounced in the furosemide group.

Acute Kidney Injury↗
PubMed2005

Clopidogrel-related refractory bleeding after coronary artery bypass graft surgery: a rationale for the use of coagulation factor concentrates?

Clopidogrel, an irreversible ADP-receptor antagonist, inhibits platelet aggregation mediated by reduced activation of glycoprotein receptor IIb/IIIa. Clopidogrel in combination with aspirin has been shown to be superior to aspirin alone for treating unstable angina, but clopidogrel recipients have shown increases in blood loss, transfusion requirements, and rate of reoperation after cardiac surgery. We describe a patient who had taken clopidogrel 75 mg daily until the day prior to coronary artery bypass graft surgery. Severe postoperative bleeding developed and was refractory to conventional hemostatic therapy consisting of 19 units of packed red blood cell concentrates, 16 of fresh frozen plasma, 8 of platelet apheresis concentrates plus high-dose treatment with aprotinin (500.000 kallikrein-inhibiting units/h) and administration of 0.3 microg/kg 1-deamino-8-D-arginine vasopressin (DDAVP). Two reoperations were performed, but surgical hemostasis was not achieved, so 100 microg/kg recombinant activated factor VII was applied to generate sufficient thrombin to stop the bleeding. This treatment approach reduced the bleeding. Then, to promote clot formation and firmness, 2 g of fibrinogen and 1250 IU of factor XIII were administered, and the bleeding finally stopped. No further transfusions were required, and the patient was discharged from the hospital on day 10 after the operation. This case suggests that in clopidogrel-related bleeding refractory to conventional hemostatic therapy, hemostasis may be achieved by a stepwise administration of coagulation factor concentrates.

Clopidogrel↗
PubMed2001

Risk factors for prolonged ventilation after cardiac surgery using APACHE II, SAPS II, and TISS: comparison of three different models.

OBJECTIVE: To identify the risk for prolonged mechanical ventilation in cardiac surgical patients. DESIGN: Prospective study with retrospective combination of a second database. PATIENTS: Six hundred and eighty-seven patients after cardiac surgery over a period of 12 months. MEASUREMENTS: Demographic data were recorded preoperatively, and surgical procedures intraoperatively using a surgical database designed for quality control. Length of ICU and hospital stay, and hospital outcome were recorded. Severity of illness was assessed daily using APACHE II, SAPS II, and Organ Failure Score. Intensity of treatment and nursing care was monitored by means of the Therapeutic Intervention Scoring System (TISS). Univariate and multivariate analyses were performed using logistic regression. The predictive value of the identified variables was tested by the Wilcoxon test using the receiver operating characteristic curve. MAIN RESULTS: Sixty-two patients (9.0%) were ventilated for > 48 h and accounted for 42.8% of the total costs in the ICU. The pre- and intraoperatively collected data produced a model with weak predictive capacity for prolonged ventilation [area under curve (AUC) 73.22 and 71.08, respectively]. The use of TISS and SAPS postoperatively resulted in an effective model of prediction (AUC 93.76). Adding the occurrence of reoperation, reintubation, emergency transfusion, intraaortic balloon pumping, and need for total parenteral nutrition to the model further improved its predictive capacity (AUC 94.74). CONCLUSIONS: The present results strongly suggest that data collected postoperatively using established scoring systems as well as documented events of high clinical impact for risk assessment and quality control are reliable predictors of prolonged ventilation.

APACHE↗
PubMed2001

Hirudin versus heparin for anticoagulation in continuous renal replacement therapy.

OBJECTIVE: To compare the efficacy and safety of hirudin and heparin for anticoagulation during continuous renal replacement therapy (CRRT) in critically ill patients. DESIGN: Prospective, randomized controlled pilot study. SETTING: Single centre; interdisciplinary intensive care unit at a university hospital. PATIENTS: Seventeen patients receiving CRRT. INTERVENTIONS: Patients were randomly allocated to two groups. Heparin group (nine patients): continuous administration of 250 IU/h heparin; dose was adjusted in 125 IU/h steps with a targeted activated clotting time (ACT) of 180-210 s. Hirudin group (eight patients): continuous infusion of 10 micrograms/kg/h hirudin, dose was adjusted in 2 micrograms/kg/h steps with a targeted ecarin clotting time (ECT) of 80-100 s. Observation time was 96 h. MEASUREMENTS AND MAIN RESULTS: Measured filter run patency and haemofiltration efficacy did not significantly differ between the two groups. Three bleeding complications were observed in the hirudin group, none in the heparin group (P < 0.01). At the onset of bleeding, which occurred 60 or more hours after the start of therapy, only one patient was still under continuous hirudin administration but levels were either in therapeutic range or below. CONCLUSIONS: Hirudin can be used efficiently for anticoagulation in CRRT. Late bleeding complications may have been caused by possible hirudin accumulation, but this was not evident from hirudin plasma and ECT levels. Since bleeding complications were observed only in the presence of documented coagulation disorders, not only adequate drug monitoring but also the plasmatic and cellular coagulation status of the patient should be taken into consideration for adjusting hirudin dosage.

APACHE↗
PubMed2001

Renal replacement therapy: physical properties of hollow fibers influence efficiency.

INTRODUCTION: Physical properties of filters for continous renal replacement therapy have a great impact on biocompatibility. According to Poiseuille's law, a filter with more and shorter hollow fibers should offer a decreased pressure drop and, therefore, lower transmembrane pressure (TMP). The aim of this study was to study the effect of a new filter configuration in terms of TMP and clotting compared with the standard configuration. METHODS: In a prospective randomized cross-over study 2 polysulphone hollow fiber hemofilters, one handmade, which differed only in length and number of hollow fibers were compared. In each group 12 filters were investigated during continous venovenous hemofiltration in patients with acute renal failure due to septic shock. Pressures were measured every 3 hours and running time until filter clotting was documented. Mediators before and after the filter, at the end of treatment and in filtrate were assessed. RESULTS: The standard filter with longer hollow fibers had significantly lower TMPs (106 vs. 194 mmHg, p=0.02) and longer running times (1276 vs. 851 min, p=0.04). There were no differences in hematocrit, total protein, cellular and plasmatic coagulation or blood temperature. No significant elimination of mediators was shown. CONCLUSION: In contrast to our expectations, the filter with the longer hollow fibers had a better performance, as it ran longer and had lower TMP This may be due to slower blood flow leading to an increase in blood viscosity in a filter with a larger cross section.

Acute Kidney Injury↗