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Biomedical subjects

H Metzler

Publications and source records attributed to H Metzler.

At least 19 recordsLinked to original sources
PubMed2007

Influence of acute normovolaemic haemodilution on the dose-response relationship and time course of action of cisatracurium besylate.

BACKGROUND: Acute normovolaemic haemodilution (ANH) is an efficacious blood conservation strategy aiming at avoiding allogeneic blood transfusion. ANH was shown to increase the potency of vecuronium, atracurium, and rocuronium. The aim of our study was to investigate whether cisatracurium potency is altered with ANH. METHODS: Using the Relaxometer mechanomyograph, we compared cisatracurium dose-response relationship and time course of action in 60 patients randomly allocated to the ANH or control groups. Patients in each group were randomly allocated to receive one of three cisatracurium doses (30, 40, 50 microg kg(-1)) followed by a second supplemental dose to reach a total of 100 microg kg(-1). RESULTS: ANH did not result in a significant shift in cisatracurium log dose-probit dose-response curve. There was no significant difference in mean (95% confidence intervals) ED(50), ED(90), and ED(95) (effective doses required for 50, 90, and 95% first twitch depression) between the ANH group [29.5 (27-32), 50.4 (47.4-53.4), 58.7 (55.3-62) microg kg(-1)] and the control group [28.2 (25.3-31), 47.6 (44.9-50.3), 55.3 (52.5-58.1) microg kg(-1)], whereas there was no difference in mean (SD) Dur(25) and Dur(0.8) (time until 25% first twitch and 0.8 train-of-four ratio recoveries) between the ANH group [40.8 (5.9), 64.7 (8.4) min] and the control group [42.2 (7.6), 66.5 (10.7) min]. CONCLUSIONS: Our results demonstrated that unlike other previously reported neuromuscular blocking drugs, ANH did not alter cisatracurium potency. Thus, cisatracurium would be the neuromuscular blocking drug of choice in patients who undergo surgery with ANH, as no dose adjustments are required.

Adult↗
PubMed2006

Influence of acute normovolaemic haemodilution on the dose-response relationship, time-course of action and pharmacokinetics of rocuronium bromide.

BACKGROUND: Acute normovolaemic haemodilution (ANH) is an effective strategy for avoiding or reducing allogeneic blood transfusion. We aimed to study its effect on the pharmacological profile of rocuronium. METHODS: In two study centres, 28 patients undergoing major surgery with ANH were matched with 28 control patients. In the dose-response groups, using the mechanomyograph, neuromuscular block of six consecutive incremental doses of rocuronium 50 microg kg(-1), followed by 300 microg kg(-1), was evaluated. In the pharmacokinetics groups, serial arterial blood samples were withdrawn for rocuronium assay after a single dose of rocuronium 600 microg kg(-1). RESULTS: ANH resulted in a shift to the left of rocuronium dose-response curve. Rocuronium effective dose(95) (ED(95)) was 26% lower (P<0.05) in the ANH group [283.4 (92.0) microg kg(-1)] compared with the control group [383.5 (127.3) microg kg(-1)]. Times from administration of last incremental dose until 25% of first response of train-of-four (TOF) recovery (Dur(25)) and 0.8 TOF ratio recovery (Dur(0.8)) were 28% longer in the ANH group [39.9 (8.4), 66.7 (14.2) min] compared with the control group [31.1 (6.6), 52.1 (15.8) min] (P<0.01, P<0.05), respectively. Volume of distribution was higher (P<0.01), central clearance was lower (P<0.05) and terminal elimination half-life was longer (P<0.0001) in the ANH group [234.97 (47.11) ml kg(-1), 4.70 (0.94) ml kg(-1) min(-1), 77.29 (12.25) min] compared with the control group [181.22 (35.73) ml kg(-1), 5.71 (1.29) ml kg(-1) min(-1), 56.86 (10.05) min, respectively]. CONCLUSION: ANH resulted in prolongation of rocuronium time-course of action, thus careful monitoring of neuromuscular block is recommended in patients who undergo ANH.

Aged↗
PubMed2006

Procalcitonin for early prediction of survival outcome in postoperative critically ill patients with severe sepsis.

BACKGROUND: Identification of postoperative patients at high risk of dying early after intensive care unit (ICU) admission through a fast and readily available parameter may help in determining therapeutic interventions or further diagnostic procedures that could have an impact on patients' outcome. The aim of our study was to assess the utility of procalcitonin (PCT) and other readily available parameters, as useful early (days 1-3) predictors of mortality in postoperative patients diagnosed with severe sepsis within 24 h preceding their operation. METHODS: More than a period of 2 yr, subsets of 69 postoperative patients admitted with severe sepsis and 890 non-septic ICU patients were investigated. PCT, C-reactive protein (CRP) and sequential organ failure assessment (SOFA) score were recorded over the duration of ICU stay. RESULTS: PCT area under receiver operating characteristic (ROC) curve was 0.78 on day 3 and was highly predictive of fatal outcome (0.90) at day 6. Area under ROC curve of SOFA score was 0.85 on day 3 and remained in this range until day 6. Area under ROC curves on day 3 of CRP (0.61) was non-predictive and remained non-predictive over the duration of ICU stay. CONCLUSIONS: PCT exhibited no discriminative power early after ICU admission for prediction of mortality in critically ill patients with severe sepsis, compared with a high predictive power of SOFA score on day 3. However, using PCT could still serve as a useful complementary comparator for prediction of survival outcome using the SOFA score.

Adult↗
PubMed2006

Coronary artery stenting and non-cardiac surgery--a prospective outcome study.

BACKGROUND: A 45% complication rate and a mortality of 20% were reported previously in patients undergoing non-cardiac surgery after coronary artery stenting. Discontinuation of antiplatelet drugs appeared to be of major influence on outcome. Therefore we undertook a prospective, observational multicentre study with predefined heparin therapy and antiplatelet medication in patients undergoing non-cardiac procedures after coronary artery stenting. METHODS: One hundred and three patients from three medical institutions were enrolled prospectively. Patients received coronary artery stents within 1 yr before non-cardiac surgery (urgent, semi-urgent or elective). Antiplatelet drug therapy was not, or only briefly, interrupted. Heparin was administered to all patients. All patients were on an intensive/intermediate care unit after surgery. Main outcome was the combined (cardiac, bleeding, surgical, sepsis) complication rate. RESULTS: Of 103 patients, 44.7% (95% CI 34.9-54.8) suffered complications after surgery; 4.9% (95% CI 1.6-11.0) of the patients died. All but two (bleeding only) adverse events were of cardiac nature. The majority of complications occurred early after surgery. The risk of suffering an event was 2.11-fold greater in patients with recent stents (<35 days before surgery) as compared with percutaneous cardiac intervention more than 90 days before surgery. CONCLUSIONS: Despite heparin and despite having all patients on intensive/intermediate care units, cardiac events are the major cause for new perioperative morbidity/mortality in patients undergoing non-cardiac surgery after coronary artery stenting. The complication rate exceeds the re-occlusion rate of stents in patients without surgery (usually <1% annually). Patients with coronary artery stenting less than 35 days before surgery are at the greatest risk.

Adult↗
PubMed2006

Haemodynamic and catecholamine stress responses to the Laryngeal Tube-Suction Airway and the Proseal Laryngeal Mask Airway.

Supraglottic airway devices such as the ProSeal Laryngeal Mask Airway (PLMA) and Laryngeal Tube-Suction Airway (LTS) that provoke the least stress responses could be beneficial in many situations, especially in patients with cardiovascular disease. We compared the haemodynamic and catecholamine stress response of the LTS and PLMA in a randomised study of 36 patients. Mean arterial pressure, heart rate, epinephrine and norepinephrine levels were all reduced following induction of anaesthesia with no significant differences between the two groups. Following insertion of LTS, mean arterial pressure, heart rate, epinephrine and norepinephrine levels increased to pre-induction levels. However, following the insertion of the PLMA, mean arterial pressure, heart rate, epinephrine and norepinephrine levels remained significantly lower than pre-induction values. Mean arterial pressure, heart rate and epinephrine were significantly greater in the LTS group than in the PLMA group. We conclude that the LTS produces a greater and more sustained haemodynamic and catecholamine stress response than does the PLMA.

Adolescent↗
PubMed2006

Beneficial outcome after prostaglandin-induced post-partum cardiac arrest using levosimendan and extracorporeal membrane oxygenation.

BACKGROUND: Administration of high doses of prostaglandins is a frequently performed and effective method for the treatment of atonic uterine haemorrhage in order to increase uterine muscle tone. Rarely, however, these drugs may cause life-threatening complications including bronchospasm, acute pulmonary oedema and myocardial infarction caused by coronary spasms. METHODS: We discuss the management of a patient suffering post-partum atonic uterine bleeding, catecholamine-resistant cardiac arrest and fulminant pulmonary failure due to deleterious side-effects of treatment with prostaglandins. RESULTS: During therapy resistant cardiopulmonary resuscitation, the addition of levosimendan to standard medications resulted in a prompt stabilization of haemodynamics. Subsequent treatment of pulmonary failure was successfully managed with ECMO. CONCLUSION: Although levosimendan is not approved for pharmacological treatment of cardiopulmonary arrest, the beneficial effects in this patient suggest an important role of calcium sensitization and vasodilation during prostaglandin-induced cardiac arrest.

Adult↗
PubMed2004

Endotoxin pretreatment modifies peristalsis and attenuates the antipropulsive action of adrenoceptor agonists in the guinea-pig small intestine.

The action of endotoxin to alter gastrointestinal motility in vivo may reflect a direct effect on the gut or result from vascular and other systemic manifestations of this sepsis model. Here we examined whether in vivo pretreatment of guinea-pigs with endotoxin modifies peristalsis in the isolated gut and influences the antipropulsive action of adrenoceptor agonists. Distension-induced peristalsis was recorded in fluid-perfused segments of the small intestine taken from animals pretreated intraperitoneally with endotoxin (1 mg kg(-1)Escherichia coli lipopolysaccharide) or vehicle 4 or 20 h before. Clonidine, adrenaline, noradrenaline, dopamine and dobutamine inhibited peristalsis with differential potency. Endotoxin pretreatment lowered the peristaltic pressure threshold and altered other parameters of baseline peristalsis in a time-related manner. The potency and efficacy of clonidine to inhibit peristalsis were markedly decreased after endotoxin administration, while the potency of the other test drugs was less attenuated. The antipropulsive action of clonidine in control segments was reduced by yohimbine and prazosin, whereas in segments from endotoxin-pretreated animals it was antagonized by yohimbine but not prazosin. We conclude that systemic endotoxin pretreatment of guinea-pigs modifies baseline peristalsis by an action on the gut and inhibits the antipropulsive action of adrenoceptor agonists through changes in adrenoceptor activity.

Adrenergic Agonists↗
PubMed2004

Different effects of abciximab and cytochalasin D on clot strength in thrombelastography.

Maximum amplitude (MA) in thrombelastography (TEG) consists of a plasmatic and a platelet component. To assess the magnitude of the plasmatic component, pharmacological approaches have been proposed to eliminate the platelet component. We evaluated the individual and combined effects of abciximab and cytochalasin D on the MA of TEG. Whole blood, platelet-rich plasma (PRP) and homologous platelet-poor plasma (PPP) from 20 healthy volunteers were spiked with abciximab or cytochalasin D or a combination of both and TEGs performed. Abciximab and cytochalasin D decreased MA in all samples. MA of whole blood (18.6 +/- 3.1 mm) and PRP (33.7 +/- 3.5 mm) spiked with abciximab or cytochalasin D alone (15.0 +/- 2.9 mm and 25.0 +/- 4.0 mm) were significantly higher when compared with abciximab and cytochalasin D combined (10.4 +/- 3.0 and 20.2 +/- 3.5 mm). While MA of PRP and homologous PPP were significantly (P < 0.001) different after individual administration of abciximab and cytochalasin D, combination of both abolished this difference (20.2 +/- 3.5 mm and 20.4 +/- 3.7 mm, P = 0.372). In whole blood of critically ill patients or patients undergoing major surgery there was also a significant difference of MA between abciximab alone and in combination with cytochalasin D (16.5 +/- 11.3 mm and 11.3 +/- 7.7 mm, P < 0.001). This indicates that in contrast to individual administration of abciximab or cytochalasin D, a combination of both compounds eliminates the platelet-specific effect on MA of TEG tracings.

Abciximab↗
PubMed2003

Lowering cardiac risk by preoperative interventions.

Postoperative myocardial infarction still represents a serious complication in patients with coronary artery disease, after the first 48 hours following non cardiac surgery (NCS). To reduce the incidence, patient's status should be optimised, including CABG, PTCA and stenting, before the NCS. Indications for CABG, PTCA and stenting suggested by ACC/AHA are in general applicable also for NCS. Patients undergoing low and intermediate risk procedures would not benefit from extensive testing and CABG, while a potential benefit exists for high risk surgery in severe CAD patients. Revascularisation by means of PTCA seems to decrease the risk only if it is performed more than 90 days before the NCS. By the contrary, the combination of PTCA and stenting reduces incidence of coronary re-stenosis, but it increases bleeding, thrombosis and distal embolisation, especially if not supported by an anti-platelet or combined pharmacological schedule; therefore, perioperative stenting is not recommended to increase safety. Moreover, if NCS is urgent, despite a recent stenting, the patient should be included in a high risk group.

Angioplasty, Balloon, Coronary↗
PubMed2002

First clinical experience with the rapid-, short-acting amiodarone derivative E 047/1 after cardiac surgery.

BACKGROUND AND OBJECTIVE: Amiodarone is very effective against a variety of dysrhythmias but has poor pharmacodynamic properties and many undesired side-effects. Its short- and rapid-acting derivative E 047/1 may circumvent some of these drawbacks. It is easier to titrate while retaining the high efficacy of amiodarone and may have acceptable influences on haemodynamics and cardiac conduction in patients who develop serious, destabilizing ventricular tachydysrhythmias after cardiac surgery. METHODS: Testing E 047/1 was performed prospectively in two consecutive phase II open, clinical studies. Out of 504 patients scheduled for surgery using cardiopulmonary bypass for coronary artery grafting and/or valve repair, 35 developed serious, haemodynamically destabilizing ventricular dysrhythmias (Lown 2-Lown 4b) after surgery and were treated with a 1 mg kg(-1) (pilot study, n = 15) or randomized to a 2 or 3 mg kg(-1) bolus of E 047/1, followed by a 1 mg kg(-1) h(-1) continuous infusion for 2 h (n = 10 in each group). Dysrhythmias, PQ, QTc intervals and haemodynamics using the thermodilution technique were evaluated for up to 24 h after drug initiation. RESULTS: At the time of final inclusion the patients had between 6 and 12 (or more) ventricular ectopics per minute. Within the first 2-3 min of application in the pilot trial E 047/1 induced a decrease of ventricular dysrhythmias to between 0 and 4 per min, a decrease that held for the duration of treatment. The area under the curve decreased from 434 (322, 855; median, quartiles) to 114 (9, 477, P < 0.01) events per hour. In the randomized trial, E 047/1 administered in either dose rapidly reduced ventricular dysrhythmias at least as effectively as in the pilot trial 565 (478, 701) to 33 (8, 238, P < 0.05) after a 2 mg bolus; 482 (339, 482) to 95 (13, 540, P < 0.01) events per hour after a 3 mg bolus. Approximately 4-6 h after drug termination, dysrhythmias reappeared in the majority of patients. In only three patients did the incidence of dysrhythmias return to inclusion criteria levels. In contrast to the pilot trial, in the randomized trial there was a slight increase of mean pulmonary artery pressure, central venous pressure and pulmonary arterial wedge pressure and a slight decrease of LCWI in both groups. E 047/1 did not cause QTc prolongation. CONCLUSIONS: E 047/1 appears to be a safe alternative to amiodarone in the perioperative setting of cardiac surgery when serious, destabilizing dysrhythmias occur.

Aged↗
PubMed2001

Sufentanil potentiates the inhibitory effect of epinephrine on intestinal motility.

OBJECTIVE: The aim of our study was to evaluate the effect of the combination of different catecholamines and sufentanil on peristalsis of the isolated guinea pig small bowel in vitro. DESIGN: In vitro study on excised guinea pig small-bowel segments (8-10 segments per substance tested). SETTING: Laboratory for experimental studies at the University. SUBJECTS: Isolated guinea pig small-bowel segments. INTERVENTIONS: Excised segments of guinea pig small bowel were mounted in a tissue bath (37 degrees C) in Tyrode's solution and bubbled with carbogen (95% O2/5% CO2). The lumina were perfused with Tyrode's solution at 0.5 ml/min. The test drugs (epinephrine, norepinephrine, dobutamine, sufentanil, and a combination of these catecholamines with sufentanil) were added to the tissue bath and peristalsis recorded via changes in the intraluminal pressure. One-way and two-way ANOVA were used for statistical analysis. MEASUREMENTS AND RESULTS: All the tested substances, both individually and in combination, inhibited intestinal peristalsis in a dose-dependent manner. High doses resulted in a complete blockade of peristalsis. Preexposure of the segments to sufentanil at 0.1 nM barely influenced the effects of the catecholamines on peristalsis. However, sufentanil at 0.3 nM enhanced the antiperistaltic activity of epinephrine in a supraadditive manner, whereas the effect on norepinephrine and dobutamine was less pronounced. CONCLUSIONS: Our experimental data suggest that the combination of epinephrine and sufentanil might be the worst choice for the intensive care setting. This is due to its pronounced inhibitory effect on peristalsis in vitro at moderate and higher concentrations.

Adrenergic Agents↗
PubMed2001

[Coronary arterial stent implantation proceeding noncardiac surgical procedures. Is it safe; can we recommend it?].

Patients undergoing non-cardiac surgical procedures who carry coronary artery stents have to be classified as high risk patients. Perioperative myocardial infarction and severe bleeding are possible. Therefore, anaesthetic management directed by invasive monitoring, ECG ST analysis, transesophageal echocardiography and referral to an intensive care unit are absolutely justified. The urgency of the surgical procedure, perioperative risk and an antiplatelet regimen have to be discussed with the patient and the surgeon in advance. In the case of cardiac complications, rapid therapy by an interventional cardiologist must be available.

Anesthesia↗
PubMed2001

Thromboelastography for monitoring prolonged hypercoagulability after major abdominal surgery.

UNLABELLED: Despite clinical and laboratory evidence of perioperative hypercoagulability, there are no consistent data evaluating the extent, duration, and specific contribution of platelets and procoagulatory proteins by in vitro testing. We tested the hypothesis that the parallel use of standard and abciximab-cytochalasin D-modified thromboelastography (TEG) can assess 7 days' postoperative hypercoagulability and can estimate the independent contribution of procoagulatory proteins and platelets. Thromboelastograms were performed before surgery, at the end of surgery, 6 h after surgery, and on postoperative days 1, 2, 3, and 7; they were analyzed for the reaction time and the maximal amplitude (MA). We calculated the elastic shear modulus of standard MA (G(t)) and modified MA (G(c)), which reflect total clot strength and procoagulatory protein component, respectively. The difference was an estimate of the platelet component (G(p)). There was a 10% perioperative increase of standard MA, corresponding to a 50% increase of G(t) (P < 0.0001) and an 86%-90% contribution of the calculated G(p) to G(t). We conclude that serial standard and modified thromboelastography may reveal prolonged postoperative hypercoagulability and the independent contribution of platelets and procoagulatory proteins to clot strength. IMPLICATIONS: Postoperative hypercoagulability, occurring for at least 1 wk after major abdominal surgery, may be demonstrated by standard and modified thromboelastography. This hypercoagulability is not reflected by standard coagulation monitoring and seems to be predominantly caused by increased platelet reactivity.

Abdomen↗
PubMed2001

Coronary artery plaque burden and perioperative cardiac risk.

BACKGROUND: Electron-beam computed tomography-derived coronary calcium score correlates with the morphologic severity of coronary artery disease, reflecting both global atherosclerotic plaque formation and coronary artery luminal narrowing. The current study examines the impact of coronary atherosclerotic plaque burden, measured by coronary calcium score, on the potential for perioperative myocardial cell injury, as assessed by cardiac troponin T elevations in patients undergoing elective vascular surgery. The authors further investigated whether perioperative myocardial cell injury in those patients adversely affects noninvasive measures of left ventricular systolic function, such as ejection fraction and wall motion score. METHODS: Fifty-one consecutive patients scheduled for vascular surgery were enrolled in this prospective study. In addition to standard preoperative evaluation, including patient history and physical examination, electron-beam computed tomography scan, 12-lead electrocardiography, and transthoracic echocardiography were performed on the day before surgery. Subsequent evaluations on postoperative days 2 and 7 included transthoracic echocardiography and 12-lead electrocardiography. Cardiac troponin T determinations were performed on the day before surgery, immediately preoperatively, and on postoperative days 1, 2, 3, and 7. RESULTS: The median coronary calcium score of the 51 patients was 997.0 (25th percentile, 202.5; 75th percentile, 1,949.5). Cardiac troponin T elevations exclusively occurred in patients with a coronary calcium score greater than 1,000. The six patients (12%) with perioperative cardiac troponin T elevations had a 2.5-fold higher coronary calcium score than those without cardiac troponin T elevation (P = 0.021). In these patients, the ejection fraction decreased from 61 +/- 10% to 52 +/- 13% (mean +/- SD) on postoperative day 2 and was 54 +/- 16% on postoperative day 7 (P = 0.022). CONCLUSION: A high electron-beam computed tomography coronary calcium score, reflecting substantial coronary plaque burden, carries an increased risk for myocardial cell injury after vascular surgery. In these patients, myocardial damage may result in deterioration of global systolic left ventricular function.

Aged↗
PubMed2000

Successful treatment of massive arterial air embolism during open heart surgery.

We report a case of a 5-year-old girl who suffered a massive arterial air embolism during surgical closure of an atrial septal defect. The risk of permanent neurologic deficits or even fatal outcome is significant (mortality rate, 31%). We successfully treated a proven arterial air embolism with intraoperative (retrograde cerebral perfusion) combined with postoperative procedures (deep barbiturate anesthesia and hyperbaric oxygenation). At discharge the girl had fully recovered from the initial neurologic defects.

Child, Preschool↗