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G Schelling

Publications and source records attributed to G Schelling.

At least 37 records · Page 2Linked to original sources
PubMed1998

Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome.

OBJECTIVES: Despite considerable progress in intensive care management of the acute respiratory distress syndrome (ARDS), little is known about health-related quality of life in long-term survivors. In addition, intensive care treatment can be extremely stressful, and many survivors of ARDS report adverse experiences such as respiratory distress, anxiety, or pain during intensive care unit (ICU) treatment. This study was performed to assess health-related quality of life in survivors of ARDS and to test the hypothesis that adverse experiences during ICU treatment result in posttraumatic stress disorder (PTSD) and negative effects on health-related quality of life. DESIGN: Retrospective, cohort, case-controlled analyses. SETTING: A 12-bed multidisciplinary ICU of a tertiary care university hospital, capable of providing extracorporeal life support for adults with severe ARDS. PATIENTS: We studied 80 patients who were admitted to our hospital from 1985 to 1995 and who survived an episode of ARDS. ARDS was defined according to the criteria of the American-European Consensus Conference on ARDS. INTERVENTIONS: Health-related quality of life was measured using the Health Status Questionnaire of the self-administered Medical Outcomes Study Short Form Survey that consists of 36 questions (SF-36) and the German version of the Post Traumatic Stress Syndrome 10-Questions Inventory (PTSS-10), a self-report scale for the diagnosis of posttraumatic stress disorder based on the Diagnostic and Statistical Manual (Third Edition) criteria (American Psychiatric Association). The number of adverse experiences (anxiety, respiratory distress, pain, and nightmares) during intensive care was evaluated by means of a structured questionnaire. For each patient with ARDS, three age- and gender-comparable controls were randomly selected from databases providing normal values for the SF-36 and PTSS-10 scores in populations at risk for posttraumatic stress disorder. MEASUREMENTS AND MAIN RESULTS: Survivors of ARDS showed statistically significant impairments in all eight health dimensions of the SF-36 when compared with normal controls (median reduction 21.3%, p < .006) with maximal impairments in physical function (median reduction 28.9%, p = .000) and a 38% higher frequency of chronic pain (p = .0001). Three of 34 patients reporting none, or one, adverse experience had evidence of posttraumatic stress disorder vs. 19 of 46 patients remembering multiple traumatic episodes (p = .007). Patients reporting multiple adverse experiences described the lowest health-related quality of life, with maximal impairments in psychosocial functioning (p < .005) and only small limitations in physical function. CONCLUSIONS: Long-term survivors of ARDS describe a good overall health-related quality of life. Major impairments in mental health domains of health-related quality of life are associated with the development of posttraumatic stress disorder and are a possible result of traumatic experiences during ICU therapy.

Adolescent↗
PubMed1997

[Generalized gas gangrene infection with rhabdomyloysis following cholecystectomy].

We report a rare case of spontaneously developing generalised gas gangrene with massive rhabdomyolysis after a cholecystectomy and drainage of a hepatic abscess. On preoperative physical examination the patient appeared severely ill and was icteric and oliguric. Laboratory evaluation showed signs of systemic inflammation, elevated lactate levels, evidence of disseminated intravascular coagulation (DIC), and increased levels of serum creatine kinase (CK) activity. Abdominal ultrasound and endoscopic retrograde cholangiography showed a gallbladder perforation and a hepatic abscess. Cholecystectomy and drainage of the abscess was performed immediately and without technical problems. After postoperative admission to the intensive care unit, the patient showed evidence of generalised myonecrosis with subcutaneous gas formation and acute renal failure. Initially, there were few other signs of systemic toxicity; the patient was not hypotensive and the pulmonary gas exchange was normal. Within hours diffuse swelling of his right leg developed with cutaneous gangrene and a compartment syndrome. After fasciectomy and extensive surgical debridement, uncontrollable bleeding due to DIC developed from the fasciectomy site, which finally required exarticulation of the leg at the hip joint. At this point, multiple organ failure including severe adult respiratory distress syndrome was present. Two days after cholecystectomy, the patient died from hypoxic cardiocirculatory failure. Clostridium perfringens was repeatedly isolated from the wounds. Besides gas gangrene, the differential diagnosis of such infections includes localised clostridial cellulitis, nonclostridial anaerobic cellulitis caused by mixed aerobes and anaerobes, and type I or type II necrotising fasciitis. Patients with systemic necrotising infections should be treated with broad-spectrum antimicrobial regimens (penicillin G, 3rd generation cephalosporins, clindamycin, and aminoglycosides). An otherwise unexplained elevation of serum CK activity in the presence of acute cholecystitis may suggest haematologic spread of an aggressive myolytic agent and the beginning of myonecrosis. This should prompt immediate surgical exploration after establishing broad-spectrum antibiotic coverage. The role of hyperbaric oxygen treatment in this situation remains to be established. If hyperbaric oxygen is to be employed, it should neither delay surgical exploration nor jeopardize the patient with the hazards of an interhospital transport.

Cholecystectomy↗
PubMed1997

[ARDS and Wegener granulomatosis].

UNLABELLED: Wegener's granulomatosis is a distinct clinicopathologic entity characterized by granulomatous vasculitis of the upper and lower respiratory tract and glomerulonephritis. This disease can present as a clinical picture which resembles sepsis and adult respiratory distress syndrome (ARDS). Wegener's disease requires immunosuppression which can have detrimental consequences when used in sepsis. The following case report illustrates the diagnostic difficulties encountered by intensive care physicians treating severe pulmonary failure and multiple organ dysfunction in Wegener's granulomatosis appearing as ARDS with sepsis. CASE REPORT: A 19-year-old female patient had developed acute respiratory and renal failure after a prolonged period (many months) of antibiotic resistant otitis, sinusitis and mastoiditis. The patient had required intubation at another hospital and there was a history of tension pneumothorax and cardiopulmonary resuscitation during mechanical ventilation. Emergency extracorporeal membrane oxygenation (ECMO) for acute hypercapnic and hypoxic respiratory failure was instituted and the patient was transported to our institution while on ECMO. The patient was treated empirically for suspected pulmonary and systemic infection and received hydrocortisone (0.18 mg/kg/h) as part of a protocol-driven treatment of septic shock in addition to antibiotic and antimycotic regime. The use of ECMO was required for 10 and mechanical ventilation for another 50 days after admission. After successful extubation, central nervous system dysfunction became evident with a somnolent and generally unresponsive patient. When the hydrocortisone dose was gradually tapered, the clinical status of the patient further deteriorated, pulmonary gas exchange worsened and she developed renal failure with proteinura and hematuria. A renal biopsy was performed demonstrating vasculitis and focal segmental glomerulonephritis, a systemic granulomatous vasculitis was suspected; the serum was tested for anti-proteinase 3 antibodies (PR3-ANCA) and turned out to be positive (17.5 U/ml; normal range < 7 U/ml). The morphologic findings from renal biopsy, the positive test for antiproteinase 3 antibodies and the pulmonary-renal involvement with evidence of multisystem disease established the diagnosis of Wegener's granulomatosis. Immunosuppressive therapy with cyclophosphamide and prednisolone was instituted resulting in rapid improvement with recovery of pulmonary, renal and central nervous system function within two weeks. The use of ECMO in this patient served as a life-saving immediate measure usefull to "buy time" until a definite diagnosis could be established. ARDS represents an uniform pulmonary reaction to a large number of different noxious stimuli and disease entities. This case demonstrates that intensive care physicians caring for critically ill patients with ARDS should include even rare causes of pulmonary injury into their differential diagnosis.

Acute Kidney Injury↗
PubMed1996

A comparison of the adrenocortical response during septic shock and after complete recovery.

OBJECTIVE: To compare the adrenocortical response to corticotropin during septic shock and after complete recovery. DESIGN: Prospective clinical study. SETTING: Multidisciplinary intensive care unit in a university hospital. PATIENTS: 20 consecutive patients surviving septic shock. All patients met the American College of Chest Physicians/Society of Critical Care Medicine criteria for septic shock. In addition, the presence of high-output circulatory failure with a cardiac index > 41/min per m2 was a criterion for enrollment in the study. Complete recovery from septic shock was defined as discontinuation of any supportive therapies. Severity of illness during septic shock and after recovery was graded using the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system. INTERVENTIONS: In each patient, two short corticotropin stimulation tests were done during septic shock and after recovery. MEASUREMENTS AND RESULTS: Basal cortisol levels recorded during septic shock and after recovery did not differ (medians: 18.8 vs 18.9 micrograms/dl). However, the response to corticotropin was significantly attenuated during septic shock when compared with the response after recovery (medians: 7.7 vs 14.7 micrograms/dl; p = 0.02). After recovery, patients' stress response was less, as indicated by a reduction in APACHE II scores (medians: 21 vs 5 points; p < 0.01). CONCLUSIONS: Adrenocortical response to corticotropin is attenuated in patients with septic shock and high-output circulatory failure compared to the response in the much less stressful condition after recovery. The attenuated adrenocortical responsiveness may be explained by effects of circulating mediators from the systemic inflammatory response.

APACHE↗
PubMed1996

Patient controlled analgesia for shock wave lithotripsy: the effect of self-administered alfentanil on pain intensity and drug requirement.

PURPOSE: Second generation lithotriptors offer immersion-free treatment and a decrease in shock wave induced pain. Pain sensations caused by advanced lithotriptors vary widely and have a significant impact on clinical management. We tested patient controlled analgesia during extracorporeal shock wave lithotripsy (ESWL) and quantified analgesic requirements by means of patient controlled analgesia during ESWL of renal stones. MATERIALS AND METHODS: Patients with renal stone disease undergoing ESWL were randomized prospectively to receive an alfentanil infusion titrated by 4 different anesthesiologists not otherwise involved in the study (22 controls) or to self-administer alfentanil via a patient controlled infusion pump (22 patients). As a measure of individual pain sensitivity the detection, pain and tolerance thresholds of electrocutaneous sensitivity were determined in all patients. RESULTS: Alfentanil was used more often in the patient controlled analgesia group than in the control patients (12 versus 8 required the narcotic, respectively, p = 0.226). Patients using patient controlled analgesia needed less drug (0.5 versus 2.15 mg., p = 0.005, median values), tolerated higher discharge voltages and pain intensities, needed significantly fewer shock waves to complete stone fragmentation (1,612 versus 2,105, p = 0.014) and had shorter treatment times (36.9 versus 46.2 minutes, p = 0.069). There was a significant correlation between the duration of shock wave exposure tolerated without analgesia, and pain (p = 0.0009) and tolerance (p = 0.0020) thresholds but not with regard to detection thresholds (p = 0.1400). Male patients showed significantly higher tolerance thresholds to electrocutaneous stimulation (10.2 versus 6.9 mA., p = 0.0238), which corresponded to longer analgesia-free treatment times in male versus female patients (31.7 versus 19.4 minutes, p = 0.0510). CONCLUSIONS: Patient controlled analgesia increases pain tolerance, decreases narcotic requirements, simplifies ESWL as an outpatient procedure and can be used to quantify analgesic requirements during lithotripsy. Pain and tolerance thresholds of electrocutaneous sensitivity are sensitive markers of pain tolerance during lithotripsy, which may be more pronounced in male patients.

Alfentanil↗
PubMed1995

Long-term evaluation of a continuous intra-arterial blood gas monitoring system in patients with severe respiratory failure.

OBJECTIVE: The purpose of this study was to evaluate the reliability and accuracy of a new continuous intra-arterial blood gas monitoring system (IABG; PB3300, Puritan Bennett) over a prolonged period of time (> 7 days). DESIGN: Prospective criterion standard study. SETTING: Anesthesiological intensive care unit in a university hospital. PATIENTS: 11 sensors were tested in 10 mechanically ventilated patients with severe respiratory failure. INTERVENTIONS: PO2, PCO2, and pH measured using IABG were compared to values obtained from 2 conventional blood gas analyzers. The quality of blood pressure tracings was assessed using a scoring system consisting of 5 grades. RESULTS: The median study period was 205h/sensor (range: 169-506h). 320 blood samples were obtained. The ranges of measured parameters were: PO2 = 46-433 mmHg, PCO2 = 25-79 mmHg, pH = 7.25-7.55. The mean (SD) differences for the whole study period were: -4.3 (11.9) mmHg for PO2, for the clinically important range (PO2 < 150 mmHg) -1.9 (5.4) mmHg, -2.8 (4.5) mmHg for PCO2, and -0.03 (0.04) for the pH value. The MD (SD) in relation to the sensor lifetime were for days 1-3: -1.1 (5.1) mmHg for PO2, -0.4 (3.9) mmHg for PCO2, and -0.01 (0.03) for the pH value; for days 4-6: -1.5 (6.0) mmHg for PO2, -3.3 (4.0) mmHg for PCO2, and -0.03 (0.03) for the pH value; for days 7-9: -2.5 (4.7) mmHg for PO2, -5.1 (4.6) mmHg for PCO2, and -0.04 (0.04) for the pH value; for days > 9: -4.9 (4.4) mmHg for PO2, -5.3 (4.1) mmHg for PCO2, and -0.05 (0.03) for the pH value. CONCLUSIONS: The IABG reliably measured blood gases and pH values with acceptable clinical performance based on the overall results. There was, however, a decline in the agreement of the sensors and conventional values with increasing sensor lifetime. The mean differences (bias) and the standard deviation of differences (precision) of PO2, PCO2 and the pH values were acceptable for clinical purposes up to day 6. The arterial blood pressure tracings and blood withdrawal were not adversely affected. No side effects due to the sensors occurred. In summary, a prolonged sensor use for a period of up to 6 days appears to be reasonable. This system offers on-line information on oxygenation, ventilation, and acid-base status and allows immediate detection of acute and potentially life-threatening events.

Adult↗
PubMed1994

Fat embolism syndrome.

Explore the source record for details and available documents.

Echocardiography, Transesophageal↗
PubMed1994

Extracorporeal shock waves stimulate frog sciatic nerves indirectly via a cavitation-mediated mechanism.

Shock waves (SWs) are single pressure pulses with amplitudes up to over 100 MPa, a rise time of only a few nanoseconds, and a short duration of approximately 2 microseconds. Their clinical application for stone destruction causes pain, indicating nerve stimulation by SWs. To examine this phenomenon, sciatic nerves of frogs were exposed to SWs in an organ bath. The SWs were generated with an experimental Dornier lithotripter model XL1 at an operating voltage of 15 kV. The nerves were mounted in a chamber which allowed electrical nerve stimulation and the registration of electrically and SW-induced compound action potentials (SWCAPs). The chamber was filled with frog Ringer's solution. In a standardized protocol. The first experiment established that 95.0 +/- 4.7% of administered SWs induced action potentials which were lower in amplitude (1.45 +/- 1.14 versus 1.95 +/- 0.95 mV, p = 0.004) but similar in shape to electrically induced compound action potentials. In a second experiment, it was shown that the site of origin of the SWCAPs could be correctly determined by simultaneous recording of action potentials at both ends of the nerve. The mechanism of shock wave stimulation was examined by experiments 3 and 4. In experiment 3, in contrast to the previous experiments, SW exposure of the nerves was performed 6 cm outside the shock wave focus. This resulted in a mean probability of inducing a SWCAP of only 4%. After gas bubble administration, this probability increased to 86% for the first SW released immediately after bubble application and declined to 56% for the second, 21% for the third, to 0 for the 10th SW after fluid injection. This indicates that cavitation, the interaction between shock waves and gas bubbles in fluid or tissues, was involved in SWCAP generation. In experiment 4, nerves were again exposed in the focus, however, the Ringer's solution surrounding the nerve was replaced by polyvinyl alcohol (PVA). PVA is a solution with low cavitation activity.In PVA, the excitability was markedly diminished to 11.0 +/- 5.1% compared with 96.0 +/- 4.4% in control nerves exposed in Ringer's solution. In conclusion, bioeffects of SWs on nervous tissue appear to result from cavitation. It is suggested that cavitation is also the underlying mechanism of SW-related pain during extracorporeal SW lithotripsy in clinical medicine.

Animals↗
PubMed1991

The Munich Gallbladder Lithotripsy Study. Results of the first 5 years with 711 patients.

OBJECTIVE: To evaluate the long-term results of three types of shock wave treatment in patients with radiolucent gallbladder stones. DESIGN: Cohort study. SETTING: Single-center trial. PATIENTS: Of 5824 patients with gallstones, 19% were eligible; 711 patients were treated. INTERVENTIONS: Patients received extracorporeal shock wave lithotripsy as well as adjuvant therapy with bile acids. RESULTS: Lithotripsy was done in three ways, using a water-tank lithotriptor (group A), a water-cushion lithotriptor at low energy levels (group B), and a water-cushion lithotriptor at high energy levels (group C). The rate of complete fragment clearance 9 to 12 months after lithotripsy was done differed significantly among the three groups: Among patients with single stones of 20 mm or less in diameter, the rate of fragment clearance for group A was 76%; for group B, it was 60%; and for group C, it was 83% (P = 0.03). Among patients with single stones of 21 to 30 mm, the rate of fragment clearance for group A was 63%; for group B, it was 32%; and for group C, it was 58% (P less than 0.005). Among patients with two or three stones, the rate of fragment clearance for group A was 38%; for group B, it was 16%; and for group C, it was 46% (P = 0.01). Patients with fragments of 3 mm or less 24 hours after lithotripsy was done showed a higher probability of fragment disappearance than did those with larger fragments (P less than 0.001). The clearance rate was higher in patients who were compliant than in those who were noncompliant with bile acid therapy (P less than 0.001). Adverse effects included liver hematoma in 1 patients, biliary pain attacks in 253 patients (36%), mild biliary pancreatitis in 13 patients (2%), and cholestasis in 7 patients (1%). Elective cholecystectomy was done in 16 patients (2%), and endoscopic sphincterotomy was done in 4 patients (1%). CONCLUSIONS: The rate of complete disappearance of stones after shock wave therapy depends on the size and the number of the initial stones, the diameter of the largest fragment, and the mode of shock wave treatment. Adjuvant therapy with bile acids appears to be important for complete fragment clearance.

Actuarial Analysis↗
PubMed1989

[Opioid analgesia during extracorporeal shockwave lithotripsy of gallstones].

Gallstone lithotripsy is a new and noninvasive therapeutic option for approximately 20% of patients who harbor cholesterol gallstones. Technologically advanced second-generation lithotripters such as the Dornier MPL 9000 device have greatly simplified biliary lithotripsy with a consecutive reduction in anesthetic requirements. Despite these technical improvements, patients still can experience considerable pain and discomfort during biliary ESWL. Due to its relatively predictable pharmacokinetic profile and its short duration of action, alfentanil appeared to be a suitable drug for pain relief during stone fragmentation. In order to analyze the degree and distribution of pain during gallstone lithotripsy and to evaluate pain control by alfentanil, 44 consecutive patients (ASA I-II) with no previous ESWL therapy were studied. Pain intensity and degree of opioid-induced sedation during shock wave application were evaluated according to 5-point verbal scales that ranged from 0 = no pain to 4 = unbearable pain and 0 = patient awake to 4 = patient asleep. All patients were treated while in the prone position and received oxygen at 6 l/min. After stone focusing, an alfentanil infusion at an initial rate of 2.5 micrograms/kg min was started. Single shock waves were released as test shocks after approximately 2 min. If they were well tolerated, stone fragmentation was begun. If not, more alfentanil was allowed to accumulate until continuous treatment was tolerated. Further in- or decreases of the infusion rate were titrated according to patient response. Registered variables included the required alfentanil loading dose, maintenance and total doses, and the applied shock wave energy approximated by multiplication of shock wave number and voltage squared.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

Application of a fibrinogen-thrombin-collagen-based hemostyptic agent in experimental injuries of liver and spleen.

FTCH is a recently developed material which consists of a collagen fleece containing fibrinogen, thrombin, and aprotinin integrated into its surface. FTCH is highly effective in sealing of tissues and in establishing hemostasis. We evaluated FTCH in experimentally produced liver (n = 6) and splenic (n = 12) injuries in 18 adult mongrel dogs. The stability of the parenchymal seal of the splenic injuries was tested by splenic tissue pressure elevation after temporary ligation of the splenic vein. No breakthrough bleeding occurred up to a parenchymal pressure of 16.3 +/- 5 mm Hg. Complete hemostasis was easily achieved in all animals before closure. When the dogs were re-explored postoperatively at intervals of either 14 or 30 days, there was no gross evidence of recurrent bleeding. Histologic examinations demonstrated a partially regenerated capsule covering an unspecific fibrovascular granulation tissue and progressive resorption of FTCH without significant inflammatory response. We conclude the following: FTCH provides adequate hemostatic control of experimental liver and splenic injuries. FTCH has excellent tissue compatibility and can be applied easily and safely to hemorrhaging parenchymal wounds. It will not replace adequate surgical techniques, but could be useful as a quickly available and easily applicable hemostatic means in diffuse or acute bleeding of liver and spleen.

Animals↗
PubMed1987

The effectiveness of a fibrinogen-thrombin-collagen-based hemostatic agent in an experimental arterial bleeding model.

The hemostyptic agent used in this study is a recently developed material that consists of a collagen fleece containing fibrinogen, thrombin, and aprotinin integrated into its surface (FTCH) with excellent topical hemostyptic properties. The potential use of this substance for cardiovascular surgery was evaluated in a canine arterial bleeding model, which allowed comparison of the new agent with previously used pure collagen (CHF) as well as study of the hemostyptic under elevated blood pressure conditions. The results revealed that FTCH induced reliable hemostasis in 10-mm injuries of the canine hypogastric artery up to a systolic blood pressure of 260 mmHg, whereas bleeding control by CHF alone was impossible. To assess the long-term reliability of FTCH, the dogs were re-explored at intervals of 14 and 31 days after operation. At relaparotomy, the arteries were patent and there was no evidence of recurrent bleeding, thrombosis formation, or aneurysmatic changes. Histologic examinations showed well-healed vascular lesions covered by cell-depleted collagen tissue and a partially resorped hemostyptic. FTCH will not replace adequate surgical techniques but could be useful as a quickly available and easily applicable hemostatic means in otherwise uncontrollable diffuse or acute bleeding in cardiovascular surgery.

Animals↗
PubMedDate not supplied

The relationship between cognitive performance and employment and health status in long-term survivors of the acute respiratory distress syndrome: results of an exploratory study.

Survivors of acute respiratory distress syndrome (ARDS) are at risk for long-lasting cognitive decline due to hypoxemia, sepsis and/or psychological sequelae associated with aggressive supportive care in the intensive care unit (ICU). We conducted an exploratory study to assess cognitive performance in long-term survivors of ARDS and to investigate how cognitive functioning is related to employment status and health-related quality of life (HRQOL). At median time of 6.0 years after ICU discharge, forty-six ARDS survivors were tested with SKT, a short cognitive performance test for assessing deficits of memory and attention. A measure of HRQOL (SF-36 Health Status Questionnaire) was also administered, and in a brief psychiatric interview, employment status was rated. 23.9% (n=11) of the patients showed cognitive impairments. However, no extreme and severe cognitive deficits were recorded. They primarily revealed low levels of cognitive function in various tasks assessing attention skills. Disability was found in 41.3% (n=19) of the patients. All ARDS survivors with cognitive deficits were disabled, whereas only 22.9% (n=8) of the cognitively not impaired patients gave evidence of disability. The SF-36 values of the ARDS survivors indicated impaired health status on seven out of eight domains when compared to normative population data. Patients with cognitive deficits described the lowest HRQOL with major limitations in the domains role-physical and social functioning when compared to patients without cognitive impairments. In conclusion, long-term ARDS survivors exhibit impaired health status and the presence of cognitive deficits is associated with disability and considerable impairments in HRQOL. More detailed psychiatric research is required to establish the etiology of these cognitive impairments.

Acute Disease↗