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Biomedical subjects

M Tryba

Publications and source records attributed to M Tryba.

At least 55 records · Page 3Linked to original sources
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↗
PubMed1994

Plasma aluminum concentrations in long-term mechanically ventilated patients receiving stress ulcer prophylaxis with sucralfate.

OBJECTIVES: To determine plasma aluminum concentrations and 24-hr urine aluminum excretion rate in long-term mechanically ventilated patients treated with 6 g of sucralfate daily for stress ulcer prophylaxis. DESIGN: Prospective study in long-term mechanically ventilated critically ill patients. SETTING: A surgical intensive care unit at a university hospital. PATIENTS: Eleven long-term mechanically ventilated patients (multiple trauma [n = 8], abdominal surgery [n = 3]) were included in the study. The mean age of the patients was 57.2 +/- 10.8 yrs and the mean duration of treatment was 11.3 +/- 4.2 days. INTERVENTIONS: 1 g of sucralfate suspension intragastrically six times daily. MEASUREMENTS AND MAIN RESULTS: Baseline plasma aluminum concentrations were determined at the beginning of the study. Patients received 1 g of sucralfate suspension given intragastrically six times daily via a nasogastric tube. Daily plasma aluminum concentration was measured 3 hrs after the morning dose of sucralfate. The urine aluminum excretion rate was determined from the 24-hr urine samples. Determinations of plasma and urine aluminum concentrations were carried out by flameless atomic absorption spectrophotometry. Renal function was compromised in eight patients (maximum plasma creatinine concentration 2.7 mg/dL [238.7 mumol/L]; normal value < 1.4 mg/dL [< 123.8 mumol/L]). Mean daily plasma aluminum concentration varied between 7.5 +/- 1.6 micrograms/L (278 +/- 59.3 nmol/L) and 21.1 +/- 7.1 micrograms/L (782 +/- 263.1 nmol/L) (normal value < 10 micrograms/L [< 371 nmol/L]). The 24-hr urine aluminum excretion rate varied between 25.7 +/- 18.1 and 53.4 +/- 87.2 micrograms/L (952.4 +/- 671 and 1979 +/- 3232 nmol/L) (normal value < 12.2 micrograms/L [< 452 nmol/L]). Aluminum accumulation did not occur in any of the patients. CONCLUSIONS: The administration of 6 g of sucralfate daily in long-term mechanically ventilated surgical patients did not result in an increase in the plasma aluminum concentration. Sucralfate can be administered safely for a period of at least 2 wks, even in critically ill patients with impaired renal function.

Adult↗
PubMed1994

Oropharyngeal decontamination with gentamicin for long-term ventilated patients on stress ulcer prophylaxis with sucralfate?

The incidence of nosocomial pneumonia in long-term ventilated patients has been reduced by stress ulcer prophylaxis with sucralfate. In a double-blind trial we studied whether gentamicin administered topically to the oropharynx (OPG) had additional clinical benefits in these patients. 67 critically ill adult patients fulfilled entry criteria for > or = 5 days on ventilation. The OPG group received 40 mg gentamicin, the control group received 5% dextrose topically administered to the oropharynx 4 times a day. During OPG, pharyngeal colonization rate (21 vs 44%) and tracheal secretion colonization rate (12 vs 41%) were significantly lower than during placebo (p < 0.05). Despite these differences nosocomial pneumonia rate (3 vs 12%), duration of mechanical ventilation [15.8 +/- 11.1 vs 19.9 +/- 37.5 days (means +/- SD)] and mortality (27 vs 41%) were not significantly affected by OPG. Moreover, 13 of 15 bacteria (87%) that occurred during OPG were resistant to gentamicin. Despite its reduction of bacterial colonization rates of pharyngeal and tracheal secretions, OPG did not seem to offer additional clinical benefits in long-term mechanically ventilated patients on stress ulcer prophylaxis with sucralfate.

Administration, Topical↗
PubMed1993

Critical care pharmacotherapy. A review.

During recent years, research in critical care medicine has focused on the role of the gastrointestinal tract in the pathogenesis of multiple organ failure and nosocomial infection, and on preventive measures. Gram-negative bacterial overgrowth of the oropharynx and stomach has been proved to be a cause of nosocomial pneumonia. Topical application of antibiotics into the oropharynx and stomach, and preservation of gastric acidity have been shown to be effective prophylaxis in ventilated patients. Recent studies have demonstrated that gastric alkalinisation is no longer necessary for the prevention of stress ulcer bleeding in critically ill patients. Tissue hypoxaemia, not gastric acidity, is the underlying pathomechanism of stress ulcer bleeding. In experimental investigations, pirenzepine and sucralfate improved gastric mucosal oxygen supply. Both compounds effectively prevent bleeding without increasing gastric pH. In mechanically ventilated patients, significantly lower rates of pneumonia occur with both of these drugs compared with antacids or histamine H2-receptor antagonists. Topical antibiotics (selective digestive decontamination) are most effective in patients with alkaline gastric juice, but of only marginal clinical relevance in those with acidic gastric contents. Isoflurane, propofol and clonidine have been recently investigated for sedation of ventilated patients. Isoflurane may lead to fluoride accumulation after more than 1 day. Propofol dosage has to be increased more often after 4 to 7 days, leading to fat overload and significantly increased costs. Clonidine was highly effective in patients with 'sympathetic overshoot', e.g. those experiencing alcohol or opioid withdrawal. Wound infections are an important problem in burn patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Critical Care↗
PubMed1993

Inotropic support of the critically ill patient. A review of the agents.

Intensive care patients often require inotropic support to stabilise circulation and to optimise oxygen supply. In this context, the catecholamines norepinephrine (noradrenaline), epinephrine (adrenaline), dopamine and dobutamine are still the mainstay of therapy. They provide, to different extents, a variety of adrenoceptor-mediated actions comprising vasoconstriction (via alpha-receptors) as well as vasodilatation (via beta 1-receptors), and an increase in cardiac output by enhancing inotropy and heart rate (again via beta 1-receptors). Because of their favourable pharmacokinetic profile (plasma half-lives of about 2 minutes) their actions can easily be controlled. Combinations of different catecholamines with each other or with other drugs such as phosphodiesterase inhibitors or nitrates lead to a broad spectrum of possible haemodynamic actions. However, the use of catecholamines is limited by side effects like tachycardia, hypertension and disturbances of organ perfusion caused by vasoconstriction. Furthermore, as a result of receptor downregulation during long term therapy, the efficacy of catecholamine treatment decreases. These shortfalls stimulated the search for alternatives to catecholamine treatment. Among these, phosphodiesterase inhibitors (e.g. enoximone and amrinone) appear to be the most promising drugs which have been introduced into acute clinical practice up to now. They act via inhibition of the phosphodiesterase isoenzyme III, leading to higher intracellular calcium levels by increasing cyclic adenosine monophosphate (cAMP) levels. These agents improve cardiac performance by enhancing contractility, reducing left ventricular afterload and improve diastolic relaxation. In cases of failing catecholamine therapy due to receptor downregulation, treatment with phosphodiesterase inhibitors may still be effective since their action is not receptor-mediated. Inhibition of the phosphodiesterase enzyme in vascular smooth muscle leads to vasodilatation. Therefore, in low cardiac output states combined with increased total peripheral or pulmonary vascular resistance, phosphodiesterase inhibitor therapy is particularly effective. Depending on the dosage and the speed of intravenous administration, the use of phosphodiesterase inhibitors sometimes results in pronounced decrease of blood pressure which may require vasopressor therapy. Other drugs including histamine H2-agonists are currently under investigation. Their value in the treatment of intensive care patients has still to be evaluated.

Cardiotonic Agents↗
PubMed1993

[Does clonidine modify the hypnotic effect of propofol?].

The administration of alpha 2-adrenoceptor agonists before the induction of anaesthesia leads to a significant reduction in the amount of anaesthetic medication required, probably due to an attenuation of haemodynamic stress responses in centrally mediated sympathicolysis. However, it is not yet known whether alpha 2-adrenoceptor agonists influence the hypnotic action of anaesthetics. Therefore, this study was performed to evaluate the influence of the alpha 2-adrenoceptor agonist clonidine on the potency and the duration of the hypnotic action of anaesthetic agents. METHOD. The study was approved by the local ethical committee. To study the effect of clonidine on the potency of propofol we determined the ED50 of propofol with and without clonidine pretreatment. To this end, 100 unpremedicated patients (ASA I or II) were randomly assigned to receive 4 micrograms/kg body weight clonidine or placebo, each of which was dissolved in 100 ml NaCl and infused over a period of 15 min starting 30 min before the induction of anaesthesia. According to the results of a pilot study, patients who had been treated with clonidine received either 0.25, 0.5, 0.75, 1 or 1.25 mg/kg propofol for anaesthesia induction. Patients in the placebo group received 0.5, 1, 1.5, 2 or 2.5 mg/kg propofol. The success of anaesthesia induction was evaluated clinically (eye opening on command, eyelid reflex). On the basis of these data the ED50 of propofol with and without clonidine pretreatment was calculated using the modified probit analysis according to Spearman and Kärber. The effect of clonidine on the duration of anaesthesia was compared in six groups of 10 patients each, who received 1, 1.5 or 2 mg/kg propofol for anaesthesia induction with and without prior clonidine treatment. RESULTS. In the placebo group a dose of 0.5 mg propofol per kg did not produce a hypnotic effect in any patient, while 2.5 mg propofol per kilogram of body weight was effective in all patients. In the clonidine group 0.25 mg propofol per kilogram of body weight had no hypnotic effect, while 1.25 mg propofol per kilogram of body weight was effective in all patients. Increasing the dose of propofol resulted in an increasing number of successful anaesthesia inductions in the placebo as well as in the clonidine group. According to these data, the ED50 of propofol with clonidine was calculated at 0.675 +/- 0.23 mg/kg with clonidine and 1.5 +/- 0.58 mg/kg without clonidine pretreatment. Increasing the dose of propofol did not result in a significant increase in the duration of anaesthesia (1 mg/kg: 260 +/- 114 s; 1.5 mg/kg: 270 +/- 103 s; 2 mg/kg: 295 +/- 152 s). However, premedication with clonidine almost doubled the duration of the hypnotic action of propofol (1 mg/kg: 457 +/- 239 s; 1.5 mg/kg: 501 +/- 249 s; 2 mg/kg: 582 +/- 254 s) (P < 0.01). CONCLUSION. According to these findings the administration of clonidine prior to anaesthesia induction significantly increases the potency and the duration of the hypnotic action of propofol. From our data we conclude that the influence of clonidine on the hypnotic action of anaesthetics is an important factor in the reduction of anaesthetic requirements observed after clonidine pretreatment.

Adrenergic alpha-Agonists↗
PubMed1993

[Does the mixture of bupivacaine and prilocaine as opposed to bupivacaine afford a clinical advantage in epidural anesthesia?].

Local anaesthetic mixtures are often used to shorten the onset of regional anaesthesia. However, the results of these mixtures of epidural anaesthesia (EDA) are controversial. Alkalinisation of bupivacaine shortens the onset of EDA. Since mixing prilocaine with bupivacaine results in a local anaesthetic mixture with a pH of 6.8, we investigated whether this mixture can shorten the onset of EDA compared to plain bupivacaine. METHOD. In a randomised, double-blind study, 60 patients received single-shot EDA with a standardised amount of local anaesthetic (1 ml/segment for 150 cm body height +0.1 ml/segment for each further 5 cm). Group A received plain bupivacaine 0.5%, group B bupivacaine 0.5% and prilocaine 2% in a 1:1 ratio. Sensory (loss of warm/cold and pinprick sensation) and motor blockade (modified Bromage score) were studied 5, 10, 15, 20, 30, and 40 min after injection of the local anaesthetic. RESULTS. There was no difference in the onset of sensory blockade: loss of warm/cold and pinprick sensation developed in the same manner in both groups. Ten minutes after injection all patients showed changes in the perception of warm and cold stimuli. In group A this ranged from T 8.1 +/- 2.14 to L 4.36 +/- 1.79 and in group B from T 8.8 +/- 2.0 to L 4.4 +/- 1.55. Forty minutes after injection loss of warm/cold sensation ranged from T 6.6 +/- 2.89 to L 5.4 +/- 1.42 in group B and from T 7.2 +/- 1.24 to L 5.7 +/- 0.88 in group A. Nearly the same results were obtained for the pinprick test. Motor blockade developed more rapidly and intensely in group B. At the end of the observation period there were still 5 patients without any motor blockade in group A, while all patients in group B showed signs of motor blockade. DISCUSSION. Shortening of the onset times has been observed when alkalinized local anaesthetic solutions with a pH above 7.0 are used for EDA. In the present study the mixture of prilocaine and bupivacaine did not shorten the onset of EDA, most likely because the pH of this mixture is only 6.8. In contrast to peripheral nerve blocks, mixtures of local anaesthetics for EDA do not offer a clinical advantage with respect to onset time compared to plain local anaesthetics.

Adolescent↗
PubMed1993

[Fentanyl-TTS for postoperative pain therapy. A new alternative?].

Treatment of postoperative pain is often insufficient. It normally consists of systemic application of an analgesic drug or a regional technique of analgesia. Fentanyl-TTS may be a new approach for postoperative pain therapy. Fentanyl is incorporated into a transdermal system; after application to the skin continuous release of therapeutic doses is achieved for a period of 72 h. Serum peak levels are obtained 8-16 h after application; the serum half-life is about 16-21 h because of the dermal depot. Fentanyl-TTS was administered in several clinical studies for therapy of postoperative pain. The efficacy of this new form of application could be demonstrated. For the first 12 h the patients needed supplementary doses of analgesic drugs in the same range as the placebo groups because of the lag time of fentanyl-TTS. In the following 12 h the need for supplementary analgesics was significantly reduced. After removal of the patch, the need for analgesics was still reduced for 12 h. In 21 of 341 patients respiratory depression occurred under therapy with fentanyl-TTS; no respiratory depression was observed in the placebo groups. Thus, respiratory depression might occur in up to 9% of postoperative patients treated with fentanyl-TTS. Other adverse effects were nausea (62%), vomiting (26%), sedation (22%), urinary retention (11%), headache (5%), and dizziness (8%). Local reactions under the patch were erythema (39%) or pruritus (9%). These phenomena disappeared within a few hours. The pharmacokinetics of fentanyl-TTS have two major drawbacks: during the first 12-15 h the patients need supplementary analgesics, usually opioids.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Cutaneous↗
PubMed1992

Long-term oral opioid therapy in patients with chronic nonmalignant pain.

In contrast to the use of opioids for the treatment of acute and chronic cancer pain, the administration of chronic opioid therapy for pain not due to malignancy remains controversial. We describe 100 patients who were chronically given opioids for treatment of nonmalignant pain. Most patients experienced neuropathic pain or back pain. We used sustained-release dihydrocodeine, buprenorphine, and sustained-release morphine. Pain reduction was measured with visual analogue scales (VAS), and the Karnofsky Performance Status Scale was used to assess the patient's function. Good pain relief was obtained in 51 patients and partial pain relief was reported by 28 patients. Only 21 patients had no beneficial effect from opioid therapy. There was a close correlation between the sum and the peak VAS values (r = 0.983; p less than 0.0001) and pain reduction was associated with an increase in performance (p less than 0.0001). The most common side effects were constipation and nausea. There were no cases of respiratory depression or addiction to opioids. Our results indicate that opioids can be effective in chronic nonmalignant pain, with side effects that are comparable to those that complicate the treatment of cancer pain.

Adult↗
PubMed1992

Conservative treatment of stress ulcer bleeding: a new approach.

Stress ulcer prophylaxis diminishes but does not eliminate the risk of severe bleeding from this complication. In 70-80% of the cases the source of bleeding is hemorrhagic gastritis. No controlled studies exist which have in particular investigated conservative therapy in patients with stress-induced hemorrhage. Even effective measures to suppress gastric acid secretion or to reduce splanchnic blood flow are ineffective in 10-40% of intensive care unit patients with stress-induced bleeding. In these cases total gastrectomy has so far often been the only therapeutic approach. We report our experience with a new approach in treating severe stress-induced hemorrhagic gastritis after ineffective primary treatment with H2-receptor antagonists, pirenzepine and somatostatin. Continuous gastric lavage with 5-10 l ice-cold Ringer's solution was used until complete cessation of bleeding, as evident from clear lavage. Repeated administration of 12 g sucralfate (60 ml) at 2-h intervals for 24 h through a gastric tube was used to prevent recurrence of bleeding and to promote healing. Sucralfate was reduced on the 2nd and 3rd day to 20 ml 2-hourly and later to 10 ml 4-hourly. In four patients this treatment was used as an ultima ratio when the patients were already scheduled for total gastrectomy. A total of 23 patients were treated during a 7-year period; all of them responded successfully, and no patient required surgery.

Adult↗