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Biomedical subjects

S G Sakka

Publications and source records attributed to S G Sakka.

At least 19 recordsLinked to original sources
PubMed2006

Positive end-expiratory pressure does not affect indocyanine green plasma disappearance rate or gastric mucosal perfusion after cardiac surgery.

BACKGROUND AND OBJECTIVE: Positive end-expiratory pressure (PEEP) may affect hepato-splanchnic blood flow. We studied whether a PEEP of 10 mbar may negatively influence flow-dependent liver function (indocyanine green plasma disappearance rate, ICG-PDR) and splanchnic microcirculation as estimated by gastric mucosal PCO2 (PRCO2). METHODS: In a randomized, controlled clinical study, we enrolled 28 patients after elective cardiac surgery using cardiopulmonary bypass. In 14 patients (13 male, 1 female; age 48-74, mean 63 +/- 7 yr) we assessed ICG-PDR and PRCO2 on intensive care unit admission with PEEP 5 mbar, after 2 h with PEEP of 10 mbar and again after 2 h at PEEP 5 mbar. Inspiratory peak pressure was adjusted to maintain normocapnia. Fourteen other patients (8 male, 6 female; age 46-86, mean 68 +/- 11 yr) in whom PEEP was 5 mbar throughout served as controls. All patients underwent haemodynamic monitoring by measurement of central venous pressure, left atrial pressure and cardiac index using pulmonary artery thermodilution. RESULTS: While doses of vasoactive drugs and cardiac filling pressures did not change significantly, cardiac index slightly increased in both groups. ICG-PDR remained unchanged either within or between both groups (PEEP10 group: 24.0 +/- 6.9, 22.0 +/- 7.9 and 25.5 +/- 7.7% min-1 vs. controls: 22.0 +/- 7.5, 23.8 +/- 8.4 and 21.4 +/- 6.5% min-1) (P = 0.05). The difference between PRCO2 and end-tidal PCO2 (PCO2-gap) did not change significantly (PEEP10 group: 1.1 +/- 0.9, 1.3 +/- 0.7 and 1.3 +/- 0.9 kPa vs. controls: 0.8 +/- 0.5, 0.9 +/- 0.5 and 0.9 +/- 0.5 kPa). CONCLUSION: A PEEP of 10 mbar for 2 h does not compromise liver function and gastric mucosal perfusion in patients after cardiac surgery with maintained cardiac output.

Aged↗
PubMed2006

[Procalcitonin as an early marker of sepsis].

A 64-year-old male with an APC resistance (factor V mutation Leiden) and interrupted oral anticoagulation due to an erosive gastritis, was admitted to hospital for increasing dyspnoea. Transthoracic echocardiography revealed a floating thrombus via an open foramen ovale in both atria reaching both ventricles. Sonography showed multiple stage thrombosis of the left leg reaching to the V. femoralis superficialis. A few months previously, peripheral pulmonary artery embolization has been confirmed by scintigraphy. The patient was transferred to our hospital and underwent emergency surgery for closure of the atrial septum defect and thrombus removal. On the 4th postoperative day, the patient was transferred to the normal ward, however, on the 10th postoperative day, the patient developed a symptomatic transitory psychotic syndrome and became hypotensive before he was transferred to the ICU. Due to impaired oxygenation and the patient's history, a new pulmonary artery embolization was suspected. After ICU admission, the patient required increasing norepinephrine support and rapidly developed septic fever. However, serum procalcitonin was elevated and a computed tomography (skull, chest and abdomen) was performed for a focus search. Pulmonary artery embolism could be ruled out but an oval structure near to the ampulla recti (ca. 30 x 20 mm) was identified as an abscess and immediate abscess incision was performed. After surgery, the further course was characterized by a steep fall in vasopressor support and body temperature. The patient was transferred to the normal ward on the 2nd postoperative day. This case shows that procalcitonin allows early and reliable diagnosis of sepsis in patients with undefined shock.

Activated Protein C Resistance↗
PubMed2005

[Extended hemodynamic monitoring using transpulmonary thermodilution Influence of various factors on the accuracy of the estimation of intrathoracic blood volume and extravascular lung water in critically ill patients].

BACKGROUND: The transpulmonary thermal-dye dilution (TDD) is the clinical gold standard for measurement of intrathoracic blood volume (ITBV) and extravascular lung water (EVLW). Recently, experimental and clinical studies found that ITBV and EVLW can be derived reliably by single transpulmonary thermodilution (TD), however, dependency from various factors of lung function has been discussed. PATIENTS AND METHODS: We retrospectively analyzed data from 174 critically ill patients who had undergone hemodynamic monitoring by TDD. We calculated the differences of simultaneous TD and TDD determined by ITBV or EVLW measurements. Bias and standard deviations (SD) were calculated and extended Bland-Altman regression analyses were performed. Association of the differences and the potential confounders gender, age, PEEP, p(a)O(2)/F(I)O(2) ratio and the corresponding TDD measurement were analyzed by multiple linear regression and LOWESS regression. RESULTS: Overall results (bias+/-SD) were 1+/-58 ml/m(2) for ITBV and 0.0+/-1.4 ml/kg bw for EVLW, but TD overestimated TDD results in patients with higher ITBV and underestimated those for lower ITBV values. The deviations were small, and the dependence of ITBV could be explained completely by dependence on PEEP and age. However, low values of EVLW are overestimated by TD. CONCLUSION: Single transpulmonary thermodilution for estimation of ITBV or EVLW is reliable in patients with severe lung injury for normal and higher values.

Adolescent↗
PubMed2005

Increasing cardiac output by fluid loading: effects on indocyanine green plasma disappearance rate and splanchnic microcirculation.

BACKGROUND: Sufficient cardiac pre-load for maintaining adequate cardiac output is a major goal in the treatment of critically ill patients. We studied the effects of increasing cardiac output by fluid loading on the indocyanine green plasma disappearance rate (ICG-PDR) and gastric mucosal regional CO2 tension (PRco2) as an indicator of splanchnic microcirculation. METHODS: With approval by our ethics committee and written consent, we studied post-operatively 12 patients (1 female, 11 males; 66 +/- 13 years) with elective coronary artery bypass grafting (n = 10) or aortic valve replacement (n = 2). All patients had received pulmonary artery and left atrial catheterization previously for clinical indications. Cardiac output and filling pressures were measured immediately after intensive care unit (ICU) admission and 1 h after the beginning of fluid loading. RESULTS: Overall, 630 +/- 130 ml of 6% hydroxyethylstarch (130 kDa) was infused with the splanchnic perfusion pressure remaining constant. Norepinephrine and epinephrine dosages were unchanged. The cardiac index increased significantly from 2.8 +/- 0.7 to 3.5 +/- 0.6 l/min/m2 and the stroke volume index from 30 +/- 7 to 38 +/- 8 ml/m2. ICG-PDR showed no significant change, i.e. from 21.2 +/- 6.5 to 21.6 +/- 6.5%/min. Gastric mucosal PRco2 and the Pco2 gap (difference between regional and end-tidal CO2 tension) were constant, i.e. changed from 5.1 +/- 0.8 to 5.5 +/- 1.1 kPa and from 0.9 +/- 0.5 to 1.0 +/- 0.7 kPa, respectively. CONCLUSION: Increasing cardiac output to supranormal values by fluid loading is not associated with a significant change in ICG-PDR or gastric mucosal PRco2.

APACHE↗
PubMed2004

[Paraparesis of the lower extremities after acute aortic dissection and a thoracic meningioma].

HISTORY AND CLINICAL FINDINGS: A 70-year-old woman with acute chest pain was admitted to a hospital in stable cardiovascular conditions. The patient had no history of cardio-circulatory disease. INVESTIGATIONS: An acute myocardial infarction was excluded by ECG and blood tests. A computed tomography (CT) revealed an aortic dissection (Stanford type A) which extended to the left subclavian artery. TREATMENT AND COURSE: She was transferred to our institution and underwent urgent operation during which the ascending aorta and the proximal arch were replaced by a prosthesis. A few days after surgery, she developed progressive paresis of both legs. A control CT scan of the aorta revealed no evidence of a persisting aortic dissection. However, magnetic resonance tomography showed a meningioma of the thoracic spinal cord. The patient underwent surgical resection of the meningioma and her neurological symptoms diminished over the next few days. CONCLUSION: Besides spinal ischemia, paresis of both legs after acute aortic dissection may be caused by rare lesions such as a thoracic meningioma.

Aged↗
PubMed2004

[Acute respiratory failure and mediastinal mass syndrome].

A 46-year-old female with a history of a chronic obstructive lung disease was intubated by the emergency physician for acute respiratory failure. However, after intubation she developed circulatory failure and required cardio-pulmonary resuscitation. The reason for the circulatory failure following muscle relaxation and intubation was identified as a mediastinal mass syndrome. Chest X-ray and computed tomography revealed an apical right-sided large tumor of 8 x 8 cm, which displaced the V. cava superior and caused obstruction of the inferior trachea and right main stem bronchus. She underwent surgery in our institution on the following day and the tumor could be removed completely. Patho-histologic examination verified the diagnosis of a Schwann cell tumor. After stepwise reduction in airway pressures, the patient was successfully weaned from the ventilator without neurologic deficit. About 24 h later she was transferred to the normal surgical ward. A mediastinal tumor with airway and central venous obstruction may be a rare cause of acute respiratory and circulatory failure.

Acute Disease↗
PubMed2003

[Seizure as a possible symptom of septic encephalopathy following transrectal prostate needle biopsy].

A 47-year-old male patient developed a seizure and was admitted to our institution by the emergency physician after tracheal intubation due to suspected primary intracerebral lesion. A primary neurological disorder could be excluded. Urosepsis with positive blood cultures for E. coli was diagnosed and the patient received appropriate antibiotic treatment. On the following day relatives mentioned an ambulatory prostate needle puncture on the day prior to admission. After stabilisation of organ function, the patient could be weaned from the ventilator and transferred to the urological ward a few days later. In conclusion, a seizure may be a possible symptom of septic encephalopathy which by definition is a diagnosis by exclusion. In general, transrectal prostate needle biopsy may be considered as a rare cause of sepsis and septic shock.

Biopsy, Needle↗
PubMed2003

[Ischemia brain infarct and rupture of an infrarenal anortic aneurysm].

An 86-year old lady with aphasia, left sided hemiparesis, a heart rate of 110 bpm and a blood pressure of 110/60 mmHg was intubated by the emergency physician. She was given 1000 ml crystalloid fluid IV and brought to our department with suspected stroke. Clinical examination revealed a pulsatile abdominal mass, while immediate CT-scan excluded an intracranial hemorrhage. The patient developed shock and lactic acidosis, and ultrasound examination confirmed the diagnosis of a ruptured abdominal aortic aneurysm. The patient underwent emergency laparotomy, and after cross clamping of the aorta a tube prosthesis was inserted. The following day a CT-scan revealed an ischemic brain infarction in the territory of the right middle cerebral artery. On duplex examination, no relevant stenoses of the extracranial arteries could be found. Postoperatively, the patient suffered from bilateral pleural effusions and pneumonia. Finally, she was weaned successfully from the respirator and transferred to a neurologic rehabilitation clinic on day 52 after admission. Even focal neurological deficits, especially when combined with hypotension, may have systemic causes such as anemia and volume depletion, as in this patient with at first hand unnoticed bleeding.

Acidosis, Lactic↗
PubMed2003

Left ventricular regional wall motion abnormalities during pneumoperitoneum in children.

BACKGROUND: In adult patients, certain levels of PEEP (16 and 20 cm H(2)O) have been associated with left ventricular (LV) regional wall motion abnormalities. Since any increase in intra-abdominal pressure (IAP) exerted by a pneumoperitoneum is transmitted to the intrathoracic cavity, similar effects on LV regional wall motion cannot be ruled out. METHODS: To investigate the effects of pneumoperitoneum on LV regional wall motion, we performed a post hoc analysis of a transoesophageal echocardiography study in eight small children (mean age 3 yr, range 15-63 months) undergoing laparoscopic herniorrhaphy under anaesthesia with sevoflurane in nitrous oxide/oxygen and a PEEP of 5 cm H(2)O. During carbon dioxide insufflation, end-tidal carbon dioxide concentration ()was kept constant by increasing minute volume. RESULTS: An IAP of 12 mm Hg caused significant septal hypokinesia compared with baseline, while anterior and posterior wall motion was not affected. In addition, a lateral hyperkinesia occurred, though this change was not statistically significant. CONCLUSIONS: Pneumoperitoneum may affect LV regional wall motion in paediatric patients undergoing laparoscopic surgery.

Child↗
PubMed2001

Variability of splanchnic blood flow in patients with sepsis.

OBJECTIVES: Previous studies on therapeutic interventions in sepsis have assumed stability of the measure of splanchnic blood flow throughout the study. We assessed the variability of splanchnic blood flow during stable global hemodynamics in eight patients with sepsis requiring treatment with dobutamine and/or norepinephrine. DESIGN AND SETTING: Prospective clinical study in an intensive care unit of a university hospital. MEASUREMENTS AND RESULTS: Global and regional hemodynamics were measured at baseline, 2 h later, and 4 h later. Cardiac output was measured by transpulmonary thermodilution, intrathoracic blood volume as an indicator of cardiac preload, and total blood volume by the double indicator (thermo-dye) dilution technique. Total body oxygen consumption was assessed by indirect calorimetry using a metabolic cart. Splanchnic blood flow was measured by the continuous indocyanine green method, and gastric mucosal CO2 tension by gas tonometry. Neither absolute nor fractional splanchnic blood flow (as ratio of cardiac output) revealed significant global tendencies during the study period. However, variance component analysis showed that splanchnic blood flow determinations varied considerably within patients, for repeated measurements at 5-min intervals (standard error 31.1%) as well as for average values at 2-h intervals (25.6%). CONCLUSION: Stable global hemodynamics during a 4-h period in septic patients does not exclude marked changes in splanchnic blood measured by a hepatic venous catheter technique.

Adult↗
PubMed2001

Does the optimization of cardiac output by fluid loading increase splanchnic blood flow?

We studied the effects of increasing cardiac output by fluid loading on splanchnic blood flow in patients with haemodynamically stabilized septic shock. Eight patients (five female, 39-86 yr) were assessed using a transpulmonary thermo-dye-dilution technique for the measurement of cardiac index (CI) intrathoracic blood volume (ITBV) as a marker of cardiac preload and total blood volume (TBV). Splanchnic blood flow was measured by the steady state indocyanine-green technique using a hepatic venous catheter. Gastric mucosal blood flow was estimated by regional carbon dioxide tension (PRCO2). Hydroxyethyl starch was infused to increase cardiac output while mean arterial pressure was kept constant. In parallel, mean norepinephrine dosage could be reduced from 0.59 to 0.33 microg kg(-1) min(-1). Mean (SD) TBV index increased from 2549 (365) to 3125 (447) ml m(-2), as did ITBV index from 888 (167) to 1075 (266) ml m(-2) and CI from 3.6 (1.0) to 4.6 (1.0) litre min(-1) m(-2). Despite marked individual differences, splanchnic blood flow did not change significantly neither absolutely (from 1.09 (0.96) to 1.19 (0.91) litre min(-1) m(-2)) nor fractionally as part of CI (from 28.4 (19.5) to 24.9 (16.3)%). Gastric mucosal PRCO2 increased from 7.7 (2.6) to 8.3 (3.1) kPa. The PCO2-gap, the difference between regional and end-tidal PCO2, increased slightly from 3.2 (2.7) to 3.4 (3.1) kPa. Thus, an increase in cardiac output as a result of fluid loading is not necessarily associated with an increase in splanchnic blood flow in patients with stabilized septic shock.

Adult↗
PubMed2001

Therapeutic options for the treatment of impaired gut function.

Tissue hypoxia, especially in the splanchnic area, is still considered to be an important cofactor in the pathogenesis of multiple organ failure. Therefore, the specific effects of the various therapeutic interventions on splanchnic perfusion and oxygenation are of particular interest. Restoring and maintaining oxygen transport and tissue oxygenation is the most important step in the supportive treatment of patients with sepsis and impaired gut perfusion. Therefore, supportive treatment should be focused on an adequate volume resuscitation and appropriate use of vasoactive drugs. Adequate volume loading may be the most important step in the treatment of patients with septic shock. An elevated oxygen delivery may be beneficial in some patients, but the increase of oxygen delivery should be guided by the measurement of parameters assessing global and regional oxygenation. Forcing an elevation in oxygen delivery by the use of very high dosages of catecholamines can be harmful. Vasopressors should be used for achieving an adequate perfusion pressure. For norepinephrine, no negative effects on gut perfusion have been demonstrated. Epinephrine and dopamine should be avoided because they seem to redistribute blood flow away from the splanchnic region. There are no convincing data yet to support the routine use of low-dose dopamine or dopexamine to improve an impaired gut perfusion. There is even evidence that low-dose dopamine may reduce the mucosal perfusion in the gut in some patients. It has been suggested that dopexamine can improve splanchnic perfusion, but because these effects remain somewhat controversial, a general recommendation for dopexamine to improve gut perfusion is not justified.

Bacterial Infections↗
PubMed2000

Catecholamines and splanchnic perfusion.

For supportive therapy in sepsis adequate volume loading is probably the first, and possibly the most important step in the treatment of patients with septic shock. An elevated global O2-supply (DO2) may be necessary and beneficial in most of these patients, but the increase in DO2 should be guided by measurement of parameters assessing global and regional oxygenation. Routine strategies for elevating DO2 by the use of very high dosages of catecholamines cannot be recommended. Vasopressors should be used to achieve adequate perfusion pressure. With noradrenaline, no negative effects on regional perfusion have been demonstrated when the patient is adequately volume-resuscitated and the DO2 is normal or even slightly elevated. In contrast, adrenaline should be avoided because it appears to redistribute blood flow away from the splanchnic region. There is controversy as to whether dopamine should still be used as a first-line drug in patients with septic shock, since some clinical and experimental data indicate unfavourable effects on mucosal perfusion of the gut. To date there are no convincing data to support the routine use of low-dose dopamine or dopexamine in patients with sepsis. Neither low-dose dopamine nor dopexamine have been proved to prevent renal failure in septic patients. Furthermore, there is evidence that low-dose dopamine may reduce mucosal perfusion in the gut in some patients. Dopexamine has been suggested for improvement of splanchnic perfusion, but since these effects remain somewhat controversial there are no current grounds for a general recommendation in favour of dopexamine in septic patients. These recommendations are currently limited by the lack of sufficient outcome studies and studies evaluating regional perfusion. Until the various catecholamine regimes are more fully examined, recommendations for catecholamine support in sepsis must be considered "conditional".

Animals↗
PubMed2000

Comparison of invasive and noninvasive measurements of indocyanine green plasma disappearance rate in critically ill patients with mechanical ventilation and stable hemodynamics.

OBJECTIVES: We studied the correlation between invasive (aortic fiberoptic) and noninvasive (transcutaneous sensor) measurements of indocyanine green (ICG) plasma disappearance rate (PDR) in critically ill patients. DESIGN AND SETTING: Prospective clinical study in a surgical intensive care unit of a university hospital. PATIENTS: 16 critically ill patients with adult respiratory distress syndrome (n = 8), sepsis/septic shock (n = 6), subarachnoid hemorrhage (n = 1), or severe head injury (n = 1). MEASUREMENTS AND RESULTS: We analyzed 16 pairs of simultaneous ICG PDR measurements. All patients were deeply sedated and mechanically ventilated. Each patient received a 4-F aortic catheter with an integrated fiberoptic and thermistor connected to a computer system for automatic calculation of invasive ICG PDR (PDRINV). An ICG sensor was also attached to the nose wing and connected to a DDG2001 analyzer for noninvasive measurement (PDRNINV). Linear regression analysis revealed PDRNINV = 0.98 PDRINV +0.11%/min (r = 0.94, p < 0.0001) with a mean bias of 0.2 +/- 2.0%/min. CONCLUSION: Noninvasive measurements of ICG PDR are very highly correlated with values derived from an invasive fiberoptic-based reference technique.

Adolescent↗
PubMed2000

Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution.

OBJECTIVE: Transpulmonary double-indicator dilution is a useful monitoring technique for measurement of intrathoracic blood volume (ITBV) and extravascular lung water (EVLW). In this study, we compared a simpler approach using single arterial thermodilution derived measurements of ITBV and EVLW with the double-indicator dilution technique. DESIGN: Prospective observational clinical study. SETTING: Surgical intensive care units of two university hospitals. PATIENTS AND METHODS: Global end-diastolic volume (GEDV) derived from single thermodilution was used for calculation of ITBV. Structural regression analysis of the first two thermo-dye dilution measurements in a derivation population of 57 critically ill patients (38 male, 19 female, 18-79 years, 56 +/- 15 years) revealed ITBV = (1.25 x GEDV)-28.4 (ml). This equation was then applied to all first measurements in a validation population of 209 critically ill patients (139 male, 70 female, 10-88 years, mean 53 +/- 19 years), and single-thermodilution ITBV (ITBV(ST)) and EVLW (EVLW(ST)) was calculated and compared to thermo-dye dilution derived values (ITBV(TD), EVLW(TD)). For inter-individual comparison, absolute values for ITBV and EVLW were normalised as indexed by body surface area (ITBVI) and body weight (EVLWI), respectively. MEASUREMENTS AND RESULTS: Linear regression analysis yielded a correlation of ITBVI(ST) = (1.05 x ITBVI(TD))-58.0 (ml/m2), r = 0.97, P < 0.0001. Bias between ITBVI(TD) and ITBVI(ST) was 7.6 (ml/m2) with a standard deviation of 57.4 (ml/m2). Single-thermodilution EVLWI (EVLWI(ST)) was calculated using ITBVI(ST) and revealed the correlation EVLWI(ST) = (0.83 x EVLWI(TD)) + 1.6 (ml/kg), r = 0.96, P < 0.0001. Bias between EVLWI(TD) and EVLWI(ST) was -0.2 (ml/kg) with a standard deviation of 1.4 (ml/kg). In detail, EVLWI(ST) systematically overestimated EVLWI(TD) at low-normal values for EVLWI and underestimated EVLWI at higher values (above 12 ml/kg). CONCLUSION: Determinations of ITBV and EVLW by single thermodilution agreed closely with the corresponding values from the double-indicator technique. Since transpulmonary single thermodilution is simple to apply, less invasive and cheaper, all these features make it a promising technique for the bedside. Nevertheless, further validation studies are needed in the future.

Adolescent↗