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Biomedical subjects

M Tryba

Publications and source records attributed to M Tryba.

At least 37 records · Page 2Linked to original sources
PubMed1996

[Anesthesia and intensive care management of severely burned children of Jehovah's Witnesses].

A 3.5-year-old girl suffered from a thermal injury affecting 37% of the body surface area. The parents, being Jehovah's witnesses, refused permission for their child to receive blood transfusions. As the haemoglobin level was only 7.5% and a necrectomy was planned, the patient was likely to need blood transfusions. Indications for transfusion were defined as clinical signs of hypoxia and/or cardiovascular instability. A judicial declaration was proposed. Hb decreased during the therapy. To stimulate the erythropoiesis erythropoietin and iron were administered. During the clinical course the anaemia worsened. First, a conservative treatment with polyvidoniodine ointment for tanning was started, to avoid an operation during the acute phase after the injury, as in this case it was thought a blood transfusion would definitely be necessary. On the 19th day after the injury a necrectomy of 10% of the body surface was necessary because of fever and leucocytosis not responding to antibiotics. The most likely cause of the symptoms was an infection of the burned area. Hb was 4.6 g/dl%. General anaesthesia was performed with midazolam, ketamine and vecuronium and mechanical ventilation. No blood transfusion was required during the operation. Vital signs were stable during the preoperative period, during anaesthesia and following the operation. There were no signs of tissue hypoxia. Peripheral oxygen saturation ranged between 98% and 100%, lactate and arterial blood gas samples were normal, and the child was awake and cooperative before and after anaesthesia. The lowest Hb was 3.3 g/dl on the 22th day after injury (3rd postoperative day). In this phase the patient was still playing and riding a tricycle. On the 45th day after injury the child was discharged home with Hb of 10.9 g/dl and reticulocytosis of 33%.

Anemia↗
PubMed1996

Preoperative alpha2-adrenergic receptor agonists prevent the deterioration of renal function after cardiac surgery: results of a randomized, controlled trial.

OBJECTIVE: To evaluate the influence of the alpha2-adrenergic receptor agonist clonidine on creatinine clearance as a measure of renal function. DESIGN: Prospective, double-blind, randomized, placebo-controlled clinical trial. SETTING: University hospital. PATIENTS: Patients undergoing coronary artery bypass graft surgery (n = 48) with normal risk. INTERVENTIONS: Administration of clonidine (4 micrograms/kg iv)) or placebo 1 hr before induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Induction and maintenance of anesthesia (etomidate, midazolam, and fentanyl) and cardiopulmonary bypass technique (nonpulsatile, normothermic, intermittent cold blood cardioplegia) were standardized in all patients. The night before surgery and the first and third night after surgery, creatinine clearance was calculated from a 12-hr urine collection period. Venous blood samples for determination of plasma antidiuretic hormone (ADH) concentrations were taken the evening before surgery, immediately before induction of anesthesia and the evening after surgery (n = 16). Arterial catecholamine plasma concentrations were determined (high-performance liquid chromatography) before induction, 15 mins after induction of anesthesia, immediately after sternotomy, before initiation of cardiopulmonary bypass, as well as 5, 15, and 30 mins after initiation of cardiopulmonary bypass (n = 16). The total amount of anesthetics, infusions, transfusions, diuresis, and blood loss was not different between the groups. Creatinine clearance decreased over the first postoperative night from 98 +/- 18 (preoperatively) to 68 +/- 19 mL/min (p < .05) in placebo-treated patients. Creatinine clearance remained unchanged in clonidine-treated patients (90 +/- 19 [preoperatively] to 92 +/- 17 mL/min). There was a significant difference in creatinine clearance between the groups during the first postoperative night (p < .05; Mann-Whitney U test). In the third postoperative night, mean creatinine clearance of both groups was not different (75 +/- 31 vs. 86 +/- 28 mL/min). ADH concentrations were not different between the groups at any time, while plasma catecholamine concentrations were always significantly lower in clonidine-treated patients. CONCLUSIONS: Preoperative treatment with clonidine (4 microgram/kilogram) prevents the deterioration of renal function after cardiac surgery. This effect might be due to clonidine-induced reduction in the sympathetic nervous system response to coronary artery bypass graft surgery.

Adrenergic alpha-Agonists↗
PubMed1996

Choices in sedation: the balanced sedation technique.

Patients undergoing surgery under regional anaesthesia may be anxious, uncomfortable or in pain. Therefore, effective sedation throughout the procedure is an important aspect of patient management. The balanced sedation technique uses combinations of sedatives to meet the anxiolytic and analgesic needs of the individual patient. For example, benzodiazepines are effective anxiolytics, while propofol can be used to provide a suitable level of sedation, especially in patients who have expressed a wish to remain asleep during the procedure. Analgesics should be considered only in those patients who are likely to experience pain during the procedure. Basic measures to increase the comfort of the patient and to facilitate the effect of pharmacological methods include supplementary non-pharmacological techniques, for example the use of a soft mattress to prevent back pain, infusion of warmed fluids and a warm operating atmosphere. This may extend to the opportunity for patients to listen to music if they have a fear of the sounds associated with the operating room, such as technical discussions by surgical staff or the sound of surgical instruments being used and discarded. The balanced sedation technique can, therefore, help to achieve the ideal goal of a comfortable patient who is free from anxiety and pain, and can sleep if desired.

Anesthesia, Conduction↗
PubMed1996

Epoetin alfa plus autologous blood donation in patients with a low hematocrit scheduled to undergo orthopedic surgery.

A low predonation hematocrit (Hct) can preclude the collection of sufficient autologous blood (AB) to meet the transfusion requirements of patients scheduled for orthopedic surgery. Subcutaneous (s.c.) administration of epoetin alfa, in conjunction with intravenous (i.v.) iron supplementation, has proved effective for the facilitation of AB donation by such patients. Compared with untreated controls and patients treated with i.v. iron alone, epoetin alfa 50 to 150 IU/kg SC plus i.v. iron twice weekly for 3 weeks prior to surgery significantly increased total red blood cell (RBC) production (P < .01) and the volume of RBCs donated (P < .05). Epoetin alfa was particularly effective in females and patients with a predicted blood volume (PBV) less than 5 L. Treatment with epoetin alfa led to an increase (albeit nonsignificant) in the number of AB units predonated compared with i.v. iron alone. However, in patients with a PBV less than 5 L, a substantially greater percentage of epoetin alfa-treated patients donated > or = 4 AB units (80% v 30%). Allogeneic blood requirements were reduced, albeit not significantly (P = .051), in patients treated with epoetin alfa. However, in comparison with untreated controls, there was a significant reduction in the mean volume of allogeneic blood transfused per transfused patient in the epoetin alfa groups. The optimum s.c. dose of epoetin alfa in patients with a low predonation Hct scheduled for orthopedic surgery appears to be between 100 and 150 IU/kg twice weekly for 3 weeks.

Anemia↗
PubMed1996

Epoetin alfa plus autologous blood donation and normovolemic hemodilution in patients scheduled for orthopedic or vascular surgery.

In previous studies, treatment with epoetin alfa facilitated preoperative donation of autologous blood (AB). However, some patients may not be able to donate sufficient AB to meet their surgical blood requirements when the time to surgery is short. In this multicenter, double-blind, placebo-controlled study, the ability of epoetin alfa combined with normovolemic hemodilution (NVHD) to facilitate the collection of > or = 4 AB units within 2 weeks of surgery was investigated in 112 nonanemic patients scheduled for elective orthopedic or vascular surgery. All patients received oral iron supplementation and were treated with three intravenous (i.v.) injections of epoetin alfa (300 or 600 IU/kg) on days 1,4, and 7; surgery, in combination with NVHD, was performed on day 13. A total of 4 units of AB were predeposited if the patient's hemoglobin (Hb) level exceeded 11 g/dL at each donation. Compared with placebo, epoetin alfa dose-dependently increased reticulocyte counts prior to surgery and significantly minimized the decrease in hematocrit (Hct) associated with AB donation, although there were no significant differences between dosages. While significantly more patients treated with epoetin alfa were able to donate > or = 4 AB units compared with placebo, there was no difference between the groups in exposure to allogeneic blood. This effect of epoetin alfa was particularly apparent in female patients. I.v. epoetin alfa 300 IU/kg, administered three times within 1 week, appears to be the optimum dose for facilitating the collection of > or = 4 units of AB in nonanemic patients scheduled for elective surgery and NVHD within 2 weeks.

Administration, Oral↗
PubMed1995

[Stress bleeding. 2. Prophylaxis].

Preventive strategies aim to reduce gastric acidity (H2-antagonists, antacids), to strengthen mucosal defence mechanisms (sucralfate, antacids, pirenzepine) and to normalize gastric mucosal microcirculation (sucralfate, pirenzepine). Thus, the most important prophylactic measure is an optimized emergency and ICU regime aiming to improve oxygenation and microcirculation. All specific drugs used for stress ulcer prophylaxis have been shown to be effective in prospective controlled studies. Furthermore, pirenzepine has been found to be superior to H2-antagonists, at least in neurosurgical patients. Insufficient or no data exist to support the use of prostaglandins or omeprazole for stress ulcer prophylaxis. The most important adverse effect of stress ulcer prophylaxis is nosocomial pneumonia due to gastric alkalinization. This may occur in long-term ventilated patients with a gastric pH > 4 and may account for up to 50% of all nosocomial pneumonias in certain groups of patients. Mortality is not influenced by antacids or H2-antagonists, while sucralfate has been shown to reduce mortality, most probably by inhibition of bacterial translocation.

Animals↗
PubMed1995

Severe undertreatment of cancer pain: a 3-year survey of the German situation.

The aim of this survey was to determine the prescribing patterns of German physicians in the treatment of cancer pain. The computerized patient records of 330 practices, which treated a total number of 1,104,435 patients over a 3-year period, were analyzed. "Strong" opioids, widely accepted in the management of severe cancer pain, were prescribed to just 322 of 16,630 cancer patients (1.9%). Only 99 (0.6%) patients received more than three prescriptions during more than 3 weeks of treatment. Additionally, many prescriptions mandated inadequate time intervals for the dosing, and 12% of the prescriptions were given "as required." From these data, it can be concluded that the majority of cancer patients in Germany are not treated for pain at all, and that those patients who receive treatment are treated inadequately. Germany is still a developing country in terms of pain therapy. This situation is symptomatic of many countries and reflects the continuing prejudice against opioids.

Analgesics, Opioid↗
PubMed1995

Dose-response effects of intravenous clonidine on stress response during induction of anesthesia in coronary artery bypass graft patients.

This study was designed to evaluate the dose-response effects of different doses of clonidine on the stress response to laryngoscopy and endotracheal intubation. In a randomized, double-blind study, 48 coronary artery bypass grafting (CABG) patients received 0, 2, 4, or 6 micrograms/kg clonidine as an intravenous (IV) infusion during a 15-min period 30 min prior to induction of anesthesia with etomidate (0.3 mg/kg), fentanyl (5-7 micrograms/kg), and pancuronium (0.1 mg/kg). Sedation was assessed prior to induction of anesthesia. Cardiovascular variables and catecholamine plasma levels were measured at predefined intervals. Additional bolus doses of etomidate and fentanyl for suppression of stress-induced reactions were administered if predefined limits of heart rate and blood pressure were exceeded. Clonidine 4 and 6 micrograms/kg significantly attenuated hemodynamic and adrenergic reactions to stress, reduced pharmacologic interventions, and increased sedation. However, clonidine 6 micrograms/kg was not more effective than 4 micrograms/kg, and clonidine 2 micrograms/kg was equally effective as placebo. We conclude that clonidine 4 micrograms/kg IV is the appropriate dose to attenuate the stress response to laryngoscopy in CABG patients. Side effects limiting the use of IV clonidine were not observed.

Blood Pressure↗
PubMed1995

Gastric alkalinization, pneumonia, and systemic infections: the controversy.

BACKGROUND: Gastric alkalinization has been suspected as a cause of pneumonia in critically ill patients. Although meta-analysis of the available data confirms an association between the administration of antacids/H2-antagonists and the risk of pneumonia, controversy remains whether stress ulcer prophylaxis with sucralfate reduces the risk of pneumonia. We hypothesized that the conflicting study results may be due to differences in patient population and general treatment regimens. RISK FACTORS: Microbiological studies have shown that a gastric pH > 4 is crucial for overgrowth of gastric gram-negative but not gram-positive bacteria. Sucralfate mainly influences the growth of gram-negative bacteria. Thus, in patient groups with a high frequency of gram-positive pneumonia, preservation of gastric acidity does not influence the pneumonia rate. Since 40-60% of critically ill patients show gastric pH values > 4 even without administration of acid-neutralizing agents, an increased risk of nosocomial pneumonia with antacids/H2-antagonists can only be expected if these agents substantially increase the frequency of patients with gastric pH > 4. No influence of stress ulcer prophylaxis on the pneumonia rate can be expected in patients on enteral nutrition, especially if administered continuously. In non-ventilated patients or in those with a short duration of ventilation no significant influence of stress ulcer prophylaxis on nosocomial pneumonia rate can be expected. The same is true for patient groups where regurgitation of gastric content is prevented, e.g. head-up position in neurosurgical patients. Furthermore, in patient groups with primary lung injury nosocomial pneumonia occurs due to specific pathomechanisms, e.g. lung contusion or inhalation injury. Based on these factors we have developed a scoring system and have performed a regression analysis between the sum of the risk scores and the odds ratio of nosocomial pneumonia of all available stress ulcer studies dealing with nosocomial pneumonia. RESULTS: A highly significant correlation (p < 0.0001) could be demonstrated between the sum of the risk score and the odds ratio for pneumonia. An increased risk of nosocomial pneumonia due to stress ulcer prophylaxis with antacids/H2-antagonists occurred in patient groups with a risk score of > or = 2. CONCLUSIONS: This analysis supports the hypothesis that gastric alkalinization significantly increases the risk of nosocomial pneumonia in long-term ventilated patients. However, this analysis also shows that only specific subgroups of patients benefit from acid-independent stress ulcer prophylaxis relative to nosocomial pneumonia. Furthermore, recent experimental and clinical studies support the hypothesis that gastric alkalinization may increase the risk of systemic infections and that sucralfate may have significant protective effects.

Acid-Base Equilibrium↗
PubMed1994

[Stress bleeding. 1. Pathogenesis, clinical picture and therapy].

Acute upper gastrointestinal bleeding in ICU patients has many possible causes: ulcer, adverse drug effects, gastric tube lesion, acute renal or liver failure, or stress-induced gastric mucosal lesion. Stress-induced gastric mucosal lesions typically are multiple superficial erosions, while ulcerations typically occur in patients with head trauma, neurosurgical operation or severe burns. Head trauma and neurosurgical patients are the only ones with increases gastric acid secretion; in general reduced acid secretion can be observed in ICU patients. An active acid secreting stomach has been shown to be more resistant against mucosal damage than a stomach with basal activity. Active acid secretion depends on sufficient oxygen supply and mucosal ATP content. Hypotension and shock results in gastric mucosal ischaemia. These are the most important risk factors of stress bleeding.

Critical Care↗
PubMed1994

[Preventing blood transfusion in a severely burned Jehovah's witness].

The treatment rationale of a burn victim (35% TBSA) who was child of Jehova's witnesses is described. Following a combined approach including erythropoetin and blood saving surgical techniques we were able to excise and graft the burn areas without blood transfusion. An extremely low hemoglobin of 3.4 g/dl was tolerated postoperatively and showed an increase to 10.9 g/dl 25 days later when the child was dismissed from the burn unit in stable condition. Possibilities to minimize blood loss and to avoid blood transfusions are discussed.

Blood Loss, Surgical↗
PubMed1994

Rapid-sequence orotracheal intubation with rocuronium: a randomized double-blind comparison with suxamethonium--preliminary communication.

Eighty ASA I-III patients were randomly assigned to four groups. Group I patients received rocuronium 0.6 mg kg-1 immediately prior to thiopentone, while patients in group II received the same dose immediately after the induction agent. In groups III and IV a priming dose of rocuronium 0.04 mg kg-1 was administered prior to induction. Group III patients received rocuronium immediately prior to thiopentone. In group IV, suxamethonium 1.5 mg kg-1 was administered immediately after thiopentone. Intubation conditions were scored by a blinded investigator. An intubation time of > 60 s was defined as a failure. All patients could be intubated within 60 s. Priming with rocuronium did not improve intubation conditions. Total intubation scores > 6 occurred significantly more often in group II (P < 0.01 vs. all other groups). A single bolus dose of rocuronium 0.6 mg kg-1 (2 x ED95) administered immediately prior to thiopentone 6 mg kg-1 offers the same intubation conditions as suxamethonium 1.5 mg kg-1.

Adult↗