[A single nighttime trauma helicopter does not represent a significant improvement in emergency assistance].
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Air Ambulances↗
Biomedical subjects
G J Scheffer
Publications and source records attributed to G J Scheffer.
Quantitative acid-base physiology using the Stewart model. Does it improve our understanding of what is really wrong?
Traditional theories of acid-base balance are based on the Henderson-Hasselbalch equation to calculate proton concentration. The recent revival of quantitative acid-base physiology using the Stewart model has increased our understanding of complicated acid-base disorders, but has also led to several new controversies. With the help of three patient histories, we show that the Henderson-Hasselbalch equation should be regarded as a simplified version of the more general Stewart model and not as something completely different. Therefore, both models may be useful at the bedside.
Journal Article↗
Thoracic epidural analgesia and antihypertensive therapy: a matter of timing?
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Aged↗
Chronic post-thoracotomy pain: a retrospective study.
BACKGROUND: Chronic pain is common after thoracotomy. The primary goal of this study was to investigate the incidence of chronic post-thoracotomy pain. The secondary goal was to identify possible risk factors associated with the development of chronic post-operative pain. METHODS: We contacted 255 patients who had undergone a classic postero-lateral thoracotomy at our institution in the period between January 2001 and December 2003. All patients received a letter requesting participation; a questionnaire was included with the letter. One week later patients were contacted by telephone to obtain the answers to the questionnaire. RESULTS: We ultimately obtained results from 149 patients (58% of all thoracotomies, 84% of survivors). The overall incidence of chronic post-operative pain was 52% (32% mild, 16% moderate and 3% severe chronic post-operative pain). Patients with chronic post-operative pain reported acute post-operative pain more frequently than those without (85% vs. 62%, P = 0.01), had more severe acute post-operative pain (P = 0.0001), underwent more extensive surgical procedures (P = 0.01), had more constant acute pain (vs. fluctuating pain or pain in attacks) (P = 0.0004) and reported less absence of pain during the first post-operative week (P = 0.0001). There was no significant decrease in chronic pain with time after thoracotomy. CONCLUSION: Our study confirms that chronic post-thoracotomy pain is a common problem. The results from our study suggest that chronic post-thoracotomy pain may be associated with more intensive and extensive nociceptive input due to thoracic surgery.
Acute Disease↗
Pharmacodynamics of rocuronium 0.3 mg kg(-1) in adult patients with and without renal failure.
BACKGROUND AND AIM: The neuromuscular effects of a bolus dose of rocuronium 0.6 mg kg(-1) under propofol anaesthesia in renal failure patients are prolonged compared to healthy patients. The present study aims to describe the neuromuscular effects of 0.3 mg kg(-1) rocuronium under propofol anaesthesia in patients with renal failure and to compare these effects with healthy control patients. METHODS: With institutional approval and informed consent, 18 healthy patients and 18 patients with renal failure took part in this prospective open label study. The renal failure patients were undergoing either renal transplantation or insertion of a shunt. Rocuronium 0.3 mg kg(-1) was given intravenously after induction of anaesthesia with propofol 1-2 mg kg(-1) and fentanyl 2 microg kg(-1). Propofol 6-12 mg kg(-1) h(-1) was used for maintenance of anaesthesia. Four acceleromyographic responses of the thumb after supramaximal stimulation of the ulnar nerve using surface electrodes at 2 Hz every 15 s were measured and recorded. The onset time, the time to recovery of the first twitch to 25% recovery and the time to a train-of-four ratio of 0.7 were all recorded. Wilcoxon rank sum testing was used to compare the pharmacodynamics and to see if medication, gender or electrolytes influenced the duration of the block. P < 0.05 was significant. RESULTS: No statistical differences were seen in the neuromuscular blocking effects of rocuronium between the two groups but there was a significant difference (P < 0.00001) in the variability of the total duration of the block. CONCLUSIONS: Rocuronium 0.3 mg kg(-1) is suitable for use in patients with renal failure when endotracheal intubation and neuromuscular block for a short period of time are needed. Tracheal intubation is facilitated within 4 min and the block can be antagonized within 20 min.
Adult↗
Anesthetic management in a child with Arnold-Chiari malformation and bilateral vocal cord paralysis.
We report a case of a child who was scheduled for an emergency ventriculoperitoneal shunt procedure. The patient had a type II Arnold-Chiari malformation (ACM) and associated hydrocephalus and presented with near complete respiratory obstruction from bilateral abductor vocal cord palsy. Early diagnosis and management of airway abnormalities associated with ACM may be lifesaving. Chiari malformations and anesthesia management are discussed.
Airway Obstruction↗
Cytokines and biotrauma in ventilator-induced lung injury: a critical review of the literature.
BACKGROUND: Mechanical ventilation is known to induce and aggravate lung injury. One of the underlying mechanisms is biotrauma, an inflammatory response in which cytokines play a crucial role. OBJECTIVE: To review the literature on the role of cytokines in ventilator-induced lung injury (VILI) and multiple organ dysfunction syndrome (MODS). MATERIAL AND METHODS: 57 English written, peer-reviewed articles on cytokines in in-vitro settings (n=5), ex-vivo models (n=9) in-vitro models (n=19) and clinical trials (n=24). RESULTS: Mechanical ventilation (MV) can induce cytokine upregulation in both healthy and injured lungs. The underlying mechanisms include alveolar cellular responses to stretch with subsequent decompartimentalisation due to concomitant cellular barrier damage. The cytokines involved are interleukin (IL)-8 and CXC chemokines, and probably IL-6, IL-1beta and tumour necrosis factor (TNF)-alpha. Cytokines are important for signalling between inflammatory cells and recruiting leucocytes to the lung. There is strong circumstantial evidence that the release of cytokines into the systemic circulation contributes to the pathogenesis of MODS. Multiple studies demonstrate the relation between elevated proinflammatory cytokine concentrations and mortality. CONCLUSION: Cytokines are likely to play a role in the various interrelated processes that lead to VILI and other MV-related complications, such as MODS and possibly ventilatorassociated pneumonia. Cytokines are good surrogate endpoints in exploring the pathogenesis and pathophysiology of VILI in both experimental and clinical studies.
Animals↗
Conscious sedation for endoscopic procedures.
Despite the fact that gastrointestinal endoscopy is a safe procedure, significant complications can occur. According to the literature most complications are related to sedation and compared with perioperative mortality under general anaesthesia, the mortality for this procedure appears high. Strict implementation of existing guidelines is warranted.
Anesthesia, General↗
[Intensive care medicine in the Netherlands, 1997-2001. I. Patient population and treatment outcome].
OBJECTIVE: To describe the patients admitted to intensive care units (ICUs) in the Netherlands between 1997-2001 and the treatment outcome. DESIGN: Descriptive. METHOD: For the years 1997-2001, prospective admission and discharge data as well as all data necessary for calculating prospective severity of illness scores (e.g. APACHE II and SAPS II) were collected for all patients that were admitted to 18 ICUs participating in the Dutch National Intensive Care Evaluation (NICE). Outcome measures were ICU mortality and hospital mortality, length of hospital and ICU admission, and standardised mortality ratio (SMR). RESULTS: Data from 55,016 admissions were registered. The median APACHE II score was 15 (P25-P75: 10-20) and the median SAPS II score was 29 (19-43). The median ICU length of admission for individual ICUs varied between 0.86 and 2.76 days. The occupied ICU capacity of individual ICUs varied between 220 and 1260 days per 100 patients admitted for non-cardiosurgical patients and between 110 and 330 days per 100 patients admitted for cardiosurgical patients. The ICU mortality and hospital mortality were 9.0% and 12.9% respectively. The mean SMR according to APACHE II was 0.95 (95% CI: 0.93-0.98). The SMR of the individual participating hospitals varied between 0.55 (95% CI: 0.37-0.80) and 1.20 (1.13-1.28). CONCLUSION: Hospital mortality for ICU-admitted patients in the NICE registration was 12.9%. For patients who could be evaluated with the APACHE II model, actual hospital mortality was lower than predicted by this model. Significant differences in length of admission, hospital mortality and SMR were found between individual hospitals.
APACHE↗
[Intensive care medicine in the Netherlands, 1997-2001. II. Changes over time and differences between hospitals].
OBJECTIVE: To describe efficacy (mortality) and efficiency (length of admission) of intensive care (IC) treatment after admission due to a prior cardiothoracic operation or pneumonia, based on data from the Dutch National Intensive Care Evaluation (NICE) foundation. DESIGN: Descriptive. METHOD: Data for the period 1 January 1997-31 December 2001 were extracted from the NICE databank for patients admitted after cardiothoracic surgery and for patients admitted with pneumonia. The variables changes in time, risk factors for mortality, and differences between hospitals were analysed. RESULTS: There were 25,463 admissions to 5 hospitals following cardiothoracic surgery and 1408 admissions to 18 hospitals due to pneumonia. An increase in valve surgery was noted in the cardiothoracic surgery group: from about 10% to about 25%. In the group undergoing valve operations, there was an increase in the average age of the patients and in the number of patients with comorbidity. No significant differences in mortality between hospitals were detected. However, the length of ICU treatment differed. Hospital mortality in the pneumonia group was 33.9%. Differences between hospitals with respect to mortality (both crude mortality and severity-of-illness adjusted mortality) and length of ICU admission were found. CONCLUSION: With the NICE registration it is possible to detect differences and trends. This is a valuable tool for indicating where and how quality and efficiency in intensive care medicine can be improved.
Cardiac Surgical Procedures↗
Effect of sevoflurane on the ex vivo secretion of TNF-alpha during and after coronary artery bypass surgery.
BACKGROUND AND OBJECTIVE: Sevoflurane has been used for the induction and maintenance of anaesthesia during cardiac surgery owing to its favourable haemodynamic effects. It has been suggested that it offers protection against myocardial ischaemia-reperfusion injury. METHODS: We investigated the effect of sevoflurane on plasma concentrations of tumour necrosis factor-alpha (TNF-alpha) after ex vivo stimulation of whole-blood leukocytes by lipopolysaccharide from 20 patients undergoing coronary artery bypass surgery. The patients were randomized to two groups. Group 1 patients were induced and maintained with sevoflurane; those in Group 2 were anaesthetized with moderate doses of midazolam-sufentanil. Blood samples were drawn from the patients on seven occasions from before induction of anaesthesia until 24 h after skin closure. RESULTS: Plasma concentrations of TNF-alpha were lower in Group 1 than in Group 2 after cessation of cardiopulmonary bypass (median (interquartiles): 25 (21-30) versus 37 (28-79) pg mL(-1); P < 0.05) and 24h after skin closure (196 (100-355) versus 382 (233-718) pg mL(-1); P < 0.05). Postoperatively, two cases of myocardial infarction were recorded, one in each group. Six patients in Group 2 needed continued inotropic support after the first morning to maintain haemodynamic stability versus one patient in Group 1 (P < 0.05). The length of stay in the intensive care unit was significantly lower in Group 1 than in Group 2 (mean +/- SD: 25 +/- 16 versus 54 +/- 30 h; P < 0.05). CONCLUSIONS: Sevoflurane reduces production of TNF-alpha more than total intravenous anaesthesia with midazolam-sufentanil during cardiac surgery. This may reduce cardiac morbidity and the length of stay in the intensive care unit.
Aged↗
The number of antral follicles in normal women with proven fertility is the best reflection of reproductive age.
BACKGROUND: The purpose of this study was to compare the predictive capacity of several markers of reproductive age in normal women. METHODS: Healthy female volunteers (n = 162) aged 25-46 years with proven, normal fertility and regular menstrual cycles were recruited. In this selected group, chronological age was assumed to approximate reproductive age and, therefore, was taken as the proxy-variable for reproductive age. The number of antral follicles with 2-10 mm diameter, total ovarian volume, total follicular volume, mean follicular volume, and volume of either the smallest or largest ovary were estimated by transvaginal sonography of the ovaries. Serum levels of early follicular FSH, estradiol and inhibin B, as well as the response of estradiol and inhibin B to exogenous GnRH agonist administration (GAST), were also evaluated. RESULTS: Regression analysis revealed that the antral follicle number showed the highest correlation with age (r = -0.68, P = 0.001), and explained 46% of its variance. All other variables, except inhibin B, were moderately correlated with age. Responses of estradiol and inhibin B to the GnRH agonist were moderately correlated with age, but highly correlated with the number of antral follicles. CONCLUSIONS: It is concluded that the number of antral follicles has the closest association with chronological age in normal women with proven fertility. As stimulated estradiol and inhibin B clearly reflect the size of the antral follicle cohort, the GAST may be considered the second best single test to predict reproductive age.
Adult↗
Do cycle disturbances explain the age-related decline of female fertility? Cycle characteristics of women aged over 40 years compared with a reference population of young women.
BACKGROUND: The cause of declining fertility with age, in women who still have regular menstrual cycles, is not clear. METHODS: Follicle development, endometrial growth and hormonal patterns were evaluated in cycles of older women (aged 41-46 years; n = 26) who previously were normally fertile, and these cycles were compared with a reference group of relatively young fertile women (aged 22-34 years; n = 35). RESULTS: Clearly abnormal cycles were found in only two women in the older age group, and in one woman in the younger group. The main differences between the age groups were a shorter follicular phase and cycle length in the older group, in combination with higher FSH levels in the late luteal and early follicular phase. In contrast to published data which suggest an "accelerated" follicle development in older women, sonographical and hormonal evidence was found of an "advanced" follicle growth, with an earlier start already during the luteal phase of the preceding cycle, and an advanced selection and ovulation of the dominant follicle. CONCLUSIONS: Such an earlier start of follicle growth in a possibly less favourable hormonal environment, as well as a limited oocyte pool, may contribute to a decreased follicle and oocyte quality, resulting in diminished fertility in ageing women.
Adult↗
Effect of VIMA with sevoflurane versus TIVA with propofol or midazolam-sufentanil on the cytokine response during CABG surgery.
BACKGROUND AND OBJECTIVE: Cardiac surgery with cardiopulmonary bypass triggers an inflammatory response involving pro-inflammatory cytokines such as tumour necrosis factor-alpha (TNF-alpha), interleukin 6 (IL-6) and interleukin 8 (IL-8). We investigated whether different anaesthetic techniques alter the pro-inflammatory cytokine response to cardiac surgery. METHODS: Thirty patients scheduled for elective coronary artery bypass grafting (CABG) surgery were randomized into three groups of 10 patients. They received either volatile inhalation induction and maintenance (Group 1) or total intravenous anaesthesia with propofol and a minimal dose sufentanil (Group 2) or a moderate dose midazolam-sufentanil (Group 3). The effect of the different anaesthetic techniques on plasma levels of TNF-alpha, IL-6 and IL-8 were examined during and after anaesthesia. RESULTS: Concentrations of TNF-alpha, and IL-8 were comparable in the three groups throughout all measurements. Before the start of cardiopulmonary bypass, IL-6 was significantly higher in Group 1 than in Group 2 (P = 0.009) or Group 3 (P = 0.030), but there were no differences between groups after cardiopulmonary bypass or postoperatively. In the three groups there was a positive correlation between aortic clamping time and serum concentrations of IL-6 (r = 0.54) and IL-8 (r = 0.62). Length of stay in intensive care was correlated with high levels of TNF-alpha (r = 0.78). CONCLUSIONS: Albeit there is difference between the volatile induction and maintenance of the anaesthesia method and the total intravenous anaesthesia technique on the pro-inflammatory cytokine response to surgical stimulation before starting of cardiopulmonary bypass, neither technique can modify the pro-inflammatory cytokine response to ischaemia-reperfusion or extracorporeal circulation.
Aged↗
Quantitative transvaginal two- and three-dimensional sonography of the ovaries: reproducibility of antral follicle counts.
OBJECTIVE: To assess the intra- and interobserver reproducibilities in addition to the between-method reliability of antral follicle counts using two (2D)- and three (3D)-dimensional transvaginal sonography (TVS). METHODS: Two groups of women with regular menstrual cycles were studied. One group consisted of healthy volunteers with proven fertility and the other group consisted of patients visiting the general infertility clinic. In each woman, 2D or 3D TVS was performed in the early follicular phase (day 2, 3 or 4) of the menstrual cycle to measure the number of antral follicles (2-10 mm). RESULTS: Intraobserver reproducibility was calculated from follicle counts using 3D TVS in 41 women. The intraclass correlation coefficient was 0.99 and the 95% coverage interval of the difference (CID) was -3.2 to +3.2. Interobserver reproducibility was assessed from both 2D (n = 37) and 3D (n = 49) TVS-based follicle counts. An interclass correlation coefficient of 0.98 was found for both methods. The 95% CID was -5.0 to +4.1 for 2D and -5.6 to +5.7 for 3D measurements. The latter CID appeared to increase in the higher range of counts. Finally, the degree of agreement between 2D and 3D TVS counts (n = 76) was characterized by a 95% CID of -5.3 to +8.3. This coverage interval widened when higher numbers of follicles were counted. With the exception of the between-method analysis, kappa values indicated overall that follicle counts will hardly change from one category to another when repeatedly carried out. CONCLUSIONS: Determination of antral follicle numbers by both 2D and 3D TVS is adequate with regard to the intra- and interobserver reproducibility. The between-method reproducibility of follicle counts measured both by 2D and 3D ultrasound is moderate. When higher follicle counts are observed both interobserver and between-method reproducibilities tend to decline. If used in categorical classifications, ultrasound-based follicle counts appear to have a high level of agreement between and within observers.
Female↗
Dexamethasone decreases the pro- to anti-inflammatory cytokine ratio during cardiac surgery.
BACKGROUND: Cytokines regulate inflammation associated with cardiopulmonary bypass (CPB). Pro-inflammatory cytokines may cause myocardial dysfunction and haemodynamic instability after CPB, but the release of anti-inflammatory cytokines is potentially protective. We studied the effects of dexamethasone on pro- and anti-inflammatory cytokine responses during coronary artery bypass grafting surgery. METHODS: Seventeen patients were studied: nine patients received dexamethasone 100 mg before induction of anaesthesia (group 1) and eight patients acted as controls (group 2). Plasma levels of tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8, IL-10 and IL-4 were measured perioperatively. RESULTS: TNF-alpha and IL-8 did not increase significantly in group 1 whereas they increased in group 2 to greater than preoperative values (P<0.05). IL-6 increased in both groups, with lower values in group 1 than in group 2 (P<0.05). IL-10 increased in both groups, with higher values in group 1 (P<0.05). IL-4 did not change in group 1 but decreased in group 2 compared with pre-induction values (P<0.05). After surgery, patients in group 2 had tachycardia, hyperthermia, a greater respiratory rate and higher pulmonary artery pressure, and a longer stay in the intensive care unit. CONCLUSION: Dexamethasone given before cardiac surgery changes circulating cytokines in an anti-inflammatory direction. Postoperative outcome may be improved by inhibition of the systemic inflammatory response.
Aged↗
Hormones and reproductive aging.
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Adult↗
Correlation between detection methods of Chlamydia pneumoniae in atherosclerotic and non-atherosclerotic tissues.
Polymerase chain reaction (PCR) and immunohistochemistry (IHC) have been used to detect Chlamydia (C.) pneumoniae in vascular tissues. Discrepancies between the results of these two methods have frequently been reported. However, the correlation between PCR and IHC has not been analyzed yet. This study assesses the correlation between the detection of C. pneumoniae by PCR and IHC in 45 atherosclerotic and 50 non-atherosclerotic tissue specimens. Also, the presence of Mycoplasma (M.) pneumoniae in these 95 specimens was investigated. Correlation was found between the detection of C. pneumoniae by PCR and IHC in the atherosclerotic tissues. Both tests were positive in 10 specimens and negative in 17 specimens (p = 0.003). There was no significant correlation between PCR and IHC in non-atherosclerotic specimens (p = ns). M. pneumoniae was detected, by PCR, in one atherosclerotic specimen.The results show correlation between PCR and IHC in the detection of C. pneumoniae in atherosclerotic tissues, emphasize the association between C. pneumoniae and atherosclerosis, and support the specificity of the association between C. pneumoniae and atherosclerosis.
Adult↗