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  • 1
    Electronic Resource
    Electronic Resource
    Kontinuierliche intravasale Blutgasanalyse (1994)
    Springer
    Der Anaesthesist 43 (1994), S. 642-647 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter: Blutgasanalyse, fiberoptisch – Sauerstoffpartialdruck – Kohlendioxidpartialdruck – Wasserstoffionenkonzentration ; Key words: Blood gas analysis – Fiber-optics – Partial pressure – Oxygen – Carbon dioxide – Hydrogen-ion concentration
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract. Continuous monitoring of blood gases and pH could add substantially to patient safety. During the last decade, efforts have been made to develop continuous optochemical blood gas sensors. The initial evaluation of such fibreoptic-based systems showed major patient-interface problems [11]. We evaluated a new intra-arterial blood gas monitoring system (PB3300, Puritan-Bennett, Carlsbad CA) under routine clinical conditions. Methods. After institutional review board approval and with written informed consent, 38 sensors were tested in 25 patients with acute respiratory failure (e.g., the acute respiratory distress syndrome, complications after lung transplantation). Two conventional bench-top blood gas analysers (ABL 520 and ABL 300, Radiometer, Copenhagen) served as criterion standards. The mean differences (bias) and standard deviations (SD) of the differences (precision) were calculated according to the method of Bland and Altman [2]. In addition, linear regression analysis and correlation coefficients were calculated. The quality of blood pressure tracings was assessed using a grading system. Results. The median sensor lifetime was 81.3 h; 869 blood samples (median 14 per sensor) were analysed for the comparison of continuous and conventional blood gas analysis. The ranges for measured parameters were: pH: 6.92 to 7.55; PCO2: 20 to 83 torr; PO2: 31 to 518 torr. The mean differences (SD) were: pH: −0.03 (0.03) or −0.4 (0.4)%; PCO2: −2.6 (4.1) torr or −6.9 (10.9)%; PO2: −3.4 (10.5) torr or −2.9 (7.0)%. The results of linear regression analysis and the correlation coefficients are depicted in Table 2. The mean grade of blood pressure tracings was satisfactory for the clinical setting. Conclusions. The continuous blood gas monitor is sufficiently accurate and precise for clinical use. Bias and precision are better than those known from former studies evaluating fibreoptic blood gas monitors under experimental conditions [7]. Cost-effectiveness was not an issue of this study.
    Notes: Zusammenfassung. Ein neuer kontinuierlicher intravasaler Blutgasmonitor auf optochemischer Basis (PB3300, Puritan-Bennett) wurde im klinischen Routineeinsatz auf der Intensivstation bei Patienten mit respiratorischer Insuffizienz getestet. 38 Sensoren wurden bei 25 Patienten implantiert. Als Standard dienten Blutproben, gemessen in zwei konventionellen Blutgasanalysatoren (ABL 520 und ABL 300, beide Radiometer). Die mittleren Differenzen (Standardabweichung der Differenzen) als Maß für die Übereinstimmung beider Methoden betrugen für den pH −0,03 (0,03) oder −0,4% (0,4), für den PCO2−2,6 mm Hg (4,1) oder −6,9% (10,9) und für den PO2−3,4 mm Hg (10,5) oder −2,9% (7,0). Für den klinisch relevanten Bereich (PO2〈150 mm Hg) betrug die mittlere Differenz −2,0 mm Hg (5,8) oder −2,6% (6,8). Die Korrelationskoeffizienten zwischen konventioneller und kontinuierlicher Blutgasanalyse betrugen zwischen 0,90 (pH) und 0,99 (PO2). Die Steigerungen der Regressionsgeraden lagen zwischen 0,97 und 1,09. Die kontinuierliche Blutgasmessung auf optochemischer Basis scheint das Stadium der klinischen Anwendbarkeit erreicht zu haben.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050104
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  • 2
    Electronic Resource
    Electronic Resource
    Die kontinuierliche Messung des Herzzeitvolumens mit der Pulskonturanalyse (1995)
    Springer
    Der Anaesthesist 44 (1995), S. 493-500 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Kontinuierliche Herzzeitvolumenmessung ; Pulskonturmethode ; kritisch Kranke ; hämodynamisches Monitoring ; Key words Continuous cardiac output ; Haemodynamic monitoring ; Intensive care patients ; Pulse contour analysis ; Vasoactive agents
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Pulse contour cardiac output (PCCO) is an easily applicable method for continuous measurement of cardiac output in critically ill patients. Calculation of stroke volume is possible by analysing the area under the systolic part of the arterial pulse pressure waveform together with an individual calibration factor (Zao) to account for the individually variable vascular impedance. Since vascular impedance is potentially affected by altered vascular tone, it was the aim of the present study to examine the validity of PCCO in ICU patients receiving various dosages of a variety of vasoactive drugs. Patients and methods. Continuous cardiac output was measured in 20 ICU patients for a total of 110 h using the pulse contour method. The precision of PCCO was determined in comparison with its calibration reference, the thermodilution method (TDCO): (1) during administration of vasoactive drugs at a constant rate and (2) during conditions with altered vascular tone and haemodynamics elicited by changes in vasoactive drug dosage. For this purpose, the patients received varying dosages of vasoactive drugs (dopamine, dobutamine, epinephrine, norepinephrine, nitroglycerin, prostacycline and urapidil). Results. A total of 165 data sets was obtained, each consisting of the average of four capnometrically triggered TDCO measurements and the corresponding PCCO values. The relative difference between methods (±2 SD) was ±23.9% (SD 0.85 l ·min−1; r=0.93) if a single calibration at the beginning of measurement series was performed (Fig. 2). The bias of the mean cardiac output values of both methods was −0.09 l·min−1. The precision of PCCO improved to ±15.7% by additional calibrations (SD 0.56 ·min−1; r=0.96; bias 0.003 l·min−1). Data of two patients showed that recalibration may be necessary after extreme haemodynamic changes due to septic shock or cooling. Alteration of vascular tone by clinically used dosage of vasoactive drugs, however, had no destabilizing effect on the pulse contour method. Conclusions. It could be demonstrated that PCCO provides a valuable method for continuous cardiac output measurement in the intensive care setting with a precision comparable to that of thermodilution.
    Notes: Zusammenfassung Die Pulskonturanalyse ist ein einfach anzuwendendes Verfahren zur kontinuierlichen Bestimmung des Herzzeitvolumens (PCCO) bei kritisch kranken Patienten. Die Berechnung des Schlagvolumens erfolgt über die Analyse der arteriellen Pulsdruckkurve zusammen mit einem für jeden Patienten mittels Referenzverfahren individuell zu bestimmenden Kalibrationsfaktor. PCCO wurde an 20 Intensivpatienten über eine Gesamtzeit von 110 h gemessen und mit Thermodilutionswerten (TDCO) verglichen. Die relative Abweichung (±2 SD) von PCCO gegenüber TDCO wurde ermittelt: (1) unter hämodynamisch stabilen Bedingungen, und (2) unter Bedingungen von verändertem Vasotonus und Hämodynamik bei Dosisänderungen vasoaktiver Substanzen. Insgesamt wurden an 165 Meßzeitpunkten TDCO-Messungen durchgeführt und die korrespondierenden PCCO-Werte registriert. Die relative Abweichung von PCCO gegenüber TDCO betrug ±23,9% (SD=0,85 l·min −1 ), wenn die PCCO-Methode einmalig bei jedem Patienten vor Beginn der Meßserien kalibriert wurde. Die Differenz der Mittelwerte der Herzzeitvolumina (CO) beider Methoden (Bias) war dabei −0,09 l·min −1 . Durch zusätzliche Kalibrationen konnte die relative Abweichung (±2 SD) auf ±15,7% verbessert werden (SD= 0,56 l·min −1 ; Bias 0,003 l·min −1 ). Änderungen in der Dosierung vasoaktiver Substanzen in klinisch üblichen Größenordnungen hatten keinen Einfluß auf die Meßgenauigkeit von PCCO. Es konnte gezeigt werden, daß die Pulskonturanalyse ein leicht anzuwendendes und klinisch ausreichend genaues Verfahren zur kontinuierlichen Messung des CO darstellt.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050182
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  • 3
    Electronic Resource
    Electronic Resource
    Maximierung des O2-Transports beim kritisch Kranken Ein rationales Therapiekonzept? (1997)
    Springer
    Der Anaesthesist 46 (1997), S. 46-52 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Sauerstofftransport ; Sauerstoffaufnahme ; kritisch kranke Patienten ; Überlebensrate ; Übersicht ; Key words Oxygen transport ; Oxygen uptake ; Critically ill patients ; Mortality rate ; Review
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Critically ill patients frequently exhibit indirect signs of tissue hypoxia such as metabolic acidosis or elevated blood lactate levels. According to the concept of supply dependence of oxygen uptake (V·O2), improvement of tissue oxygenation and secondary reduced mortality rates may be achieved in critically ill patients by an increase in systemic oxygen transport (D·O2). However, a critical review of available clinical data and studies suggests that a positive correlation between calculated V·O2 and oxygen delivery does not necessarily imply ”pathological” oxygen-supply dependence. Possible pitfalls in the interpretation of data are mathematical coupling of data, alterations of oxygen demand, and calorigenic effects of catecholamines. Due to cellular dysfunction in specific tissues, increases in blood lactate concentration in patients with severe sepsis are not proof of tissue hypoxia. Retrospective analyses of data from survivors of critical illnesses form the basis of the therapeutic concept of maximising D·O2 to supranormal values. Volume expansion, erythrocytes, catecholamines, and vasoactive agents were used to reach this aim. The results of two studies suggest that beginning the optimisation of D·O2 preoperatively may be beneficial in high-risk surgical patients. There is evidence, however, that therapeutic interventions designed to achieve supranormal values of cardiac output, D·O2, or V·O2 in a heterogeneous population of critically ill patients do not result in reduced morbidity or mortality.
    Notes: Zusammenfassung Kritisch kranke Patienten bieten oft indirekte Zeichen der Gewebshypoxie, wie metabolische Azidose und erhöhte Laktatspiegel im Blut. Das Konzept der Abhängigkeit der O2-Aufnahme (V·O2) vom systemischen O2-Transport (D·O2) besagt, daß bei diesen Patienten durch eine Steigerung von D·O2 auch die Gewebeoxygenierung und damit die Überlebensrate verbessert werden kann. Eine kritische Bewertung klinischer Befunde und Studien ergibt, daß eine positive Korrelation zwischen D·O2 und V·O2nicht immer einer „pathologischen” Abhängigkeit beider Größen entspricht. Fehlermöglichkeiten bei der Interpretation der Daten sind die mathematische Kopplung der Meßwerte, Änderungen des O2-Bedarfs und die kalorigenen Effekte von Katecholaminen. Bei Sepsis und Organdysfunktion ist eine Laktatämie aufgrund des Hypermetabolismus dieser Patienten nicht beweisend für eine Gewebshypoxie. Ausgangspunkt des Therapiekonzepts zur Maximierung des O2-Transports waren retrospektive Analysen der Daten kritisch kranker Patienten, wonach die Überlebenden über die Norm erhöhte („supranormale”) Werte von Herzzeitvolumen, D·O2 und V·O2 geboten hatten. Volumenzufuhr, Ersatz von Erythrozyten, Katecholamine und vasoaktive Substanzen wurden zur Maximierung von D·O2 eingesetzt. Eine bereits präoperativ begonnene Steigerung von D·O2 hat sich bei Hochrisikopatienten in zwei Untersuchungen als benefiziell erwiesen. Die Ergebnisse mehrerer kontrollierter Studien zeigen jedoch, daß der undifferenzierte Einsatz dieser Einzelmaßnahmen zur Maximierung von D·O2, aber auch die Kombination von Therapiemodalitäten, bei einem heterogenen Kollektiv kritisch kranker Patienten keinen positiven Effekt auf Morbidität und Überlebensrate hat.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050371
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  • 4
    Electronic Resource
    Electronic Resource
    Veno-venöse extrakorporale Membranoxygenierung (ECMO) mit heparinbeschichtetem Bypass-System Eine effektive Erweiterung bei der Behandlung des akuten Lungenversagens (ARDS) (1996)
    Springer
    Der Anaesthesist 45 (1996), S. 437-448 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Akutes Lungenversagen ; Maschinelle Beatmung ; Extrakorporale Membranoxygenierung ; Barotrauma ; Volutrauma ; Key words Respiratory distress syndrome ; adult ; Ventilation ; mechanical ; Extracorporeal membrane oxygenation ; Barotrauma ; Volutrauma
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Mortality of severe acute respiratory distress syndrome (ARDS) in Germany is about 60%. Respiratory therapy can make the lung injury worse by high positive airway pressures, high tidal volumes and high inspiratory oxygen concentrations. Extracorporeal membrane oxygenation (ECMO) was employed to reduce aggressive mechanical ventilation, but it has not been proved to be superior to conventional ventilation. However, encouraged by recently developed improvements in the technique and concept of ECMO, we introduced this therapy into our program for the treatment of ARDS. Patients and methods. All patients with severe ARDS (lung injury score 〉2.5) admitted to our multidisciplinary intensive care unit from March 1992 to March 1995 were evaluated prospectively. After admission, the patients first underwent a conventional therapeutic approach, including pressure-controlled inverse-ratio ventilation, permissive hypercapnia, changes in body position (in particular, the prone position), negative fluid balance, antibiotics, and low-dose hydrocortisone infusion. ECMO via a covalently heparin-coated, venovenous bypass-system with a vortex pump and two membrane lungs was performed if ARDS did not improve after 24–96 h of conventional therapy and if two of three of the slow-entry criteria for ECMO were fulfilled: (1) PaO2/FiO2 〈150 mmHg at PEEP 〉5 mbar; (2) semistatic compliance 〈30 ml/mbar; (3) right-left shunt 〉30%. Only in cases of life-threatening hypoxemia (PaO2 〈50 mmHg at FiO2 1.0 and PEEP 〉5 mbar for 〉2 h (fast-entry criteria) was ECMO instituted immediately. Results. Sixty patients fulfilled the entry criteria for our study. Thirty-nine patients were treated with a conventional protocol, 37 after improvement of ARDS and 2 who had not improved but in whom there were contraindications to the use of ECMO. ECMO was performed in 10 patients who had not improved, but who fulfilled the slow-entry criteria and in 11 primarily hypoxemic patients who fulfilled the fast-entry criteria. The survival rate was 30/39 (77%) for the conventional therapy group, 6/10 (60%) for the slow-entry group, and 11/11 (100%) for the fast-entry group. The onset of ECMO allowed a significant decrease in peak and mean airway pressures, tidal volume, ventilatory rate, minute volume and inspiratory oxygen concentration. Sufficient gas exchange was provided, and pulmonary artery pressures significantly decreased on bypass. The most frequent complications on bypass were pneumothorax (15/21 patients) and bleeding (7/21 patients). Conclusion. In comparison with the historical results at our own institution, the present study demonstrates an improvement in the survival rate from 56% to 78% since ECMO has become available. We conclude that venovenous ECMO with a heparin-bonded bypass circuit is an effective additional option for the treatment of patients with severe ARDS.
    Notes: Zusammenfassung Die Letalität des ARDS ist nach wie vor hoch. Um den Stellenwert der ECMO als zusätzliche Behandlungsoption zur konventionellen Beatmungstherapie zu untersuchen, wurden 60 Patienten mit schwerem ARDS prospektiv evaluiert. 39 Patienten wurden konventionell behandelt, weil sich ihr pulmonaler Gasaustausch besserte (n=37) oder Kontraindikationen gegen ECMO bestanden (n=2). Zehn konventionell nicht besserbare Patienten wurden nach 24 bis 96 h an ein heparinbeschichtetes, veno-venöses Bypass-System mit mikroporösen Membranlungen angeschlossen (slow entry-Gruppe). Sofort mit ECMO begonnen wurde bei 11 Patienten, die eine lebensbedrohliche Hypoxämie aufwiesen (fast entry-Gruppe). In der konventionellen Behandlungsgruppe überlebten 77%, in der slow entry-Gruppe 60% und in der fast entry-Gruppe 100% der Patienten. Nach ECMO-Beginn konnten Atemwegsdrücke, Beatmungsvolumina und inspiratorische Sauerstoffkonzentration signifikant reduziert werden. Unter ECMO wurden bei allen Patienten tolerable Blutgaswerte und ein Abfall der pulmonalarteriellen Drücke gemessen. Häufigste Komplikationen am Bypass waren Pneumothoraces und Blutungen. Im Vergleich zu früheren Jahren ergab sich im eigenen Krankengut seit Einführung der ECMO eine Steigerung der Überlebensrate des ARDS von 56% auf derzeit 78%. Die Ergebnisse zeigen, daß die veno-venöse ECMO mit heparinbeschichtetem Bypass-System eine effektive Erweiterung bei der Behandlung des schweren ARDS ist.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050278
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  • 5
    Electronic Resource
    Electronic Resource
    Begleitmedikation Notwendigkeit, Nebenwirkungen und Interaktionen in der perioperativen Phase (1999)
    Springer
    Der Anaesthesist 48 (1999), S. 267-283 
    Details
    ISSN: 1432-055X
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Arzneimittelinteraktionen sind aufgrund der Polymedikation vor allem der älteren Bevölkerung bei hospitalisierten Patienten häufig und oft mit unerwünschten Nebenwirkungen behaftet. Im Rahmen einer Allgemeinanästhesie kommen eine Reihe sehr potenter Wirkstoffe mit zum Teil geringer therapeutischer Breite zur Anwendung. Um unerwünschte Arzneimittelinteraktionen zu vermeiden, muß eine gezielte Medikamentenanamnese erhoben werden und das Spektrum der Interaktionen mit den in der perioperativen Phase verwendeten Substanzen bekannt sein. Nur wenige der dauerhaft von den Patienten eingenommenen Medikamente müssen vor einer Narkose abgesetzt werden. Dazu zählen MAO-Hemmer der 1. Generation, lang wirkende ACE-Hemmer, wenn mit erheblichen Volumenverlusten gerechnet wird, Thrombozytenaggregationshemmer bei geplanter rückenmarknaher Regionalanästhesie, lang wirkende Sulfonylharnstoff-Antidiabetika und das orale Antidiabetikum Metformin. Meist kann durch Modifikation der Narkoseführung die Vormedikation berücksichtigt und dadurch entweder kritische Kombinationen von Substanzen oder unerwünschte Wirkungen vermieden werden. Dies gelingt um so leichter, da die meisten in der Anästhesie eingesetzten Medikamente ohnehin nach ihrer Wirkung dosiert werden. Oft birgt gerade das präoperative Absetzen der Dauertherapie die eigentlichen Gefahren: dies gilt insbesondere für die Behandlung mit β-Blockern, Antihypertensiva, Nitraten, Antiarrhythmika, bestimmten Psychopharmaka und die medikamentöse Behandlung des Morbus Parkinson. Bei perioperativ eingeschränkten Organfunktionen kann der Serumspiegel von Substanzen mit geringer therapeutischerBreite (Digitalis, Theophyllin, Antiepileptika, Lithium, Aminoglykoside) bestimmt werden. Etwa 10% der mitteleuropäischen Bevölkerung weisen genetisch determinierte Enzymdefekte des Cytochrom P450-Systems auf, die eine verlangsamte Metabolisierung auch perioperativ eingesetzter Arzneimittel zur Folge haben. Nur wenig bekannt ist über Medikamenteninteraktionen bei Therapie mit zahlreichen hochpotenten Medikamenten im Bereich der Intensivmedizin und gleichzeitiger Multiorgandysfunktion.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050701
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  • 6
    Electronic Resource
    Electronic Resource
    Rechtsherzversagen Ein Thema für den Anästhesisten? (2000)
    Springer
    Der Anaesthesist 49 (2000), S. 785-787 
    Details
    ISSN: 1432-055X
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010070051
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  • 7
    Electronic Resource
    Electronic Resource
    Epiduraler Abszeß nach lumbalem Epiduralkatheter zur Mobilisation des Kniegelenks (1999)
    Springer
    Der Anaesthesist 48 (1999), S. 169-172 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Epiduraler Abszeß ; kontinuierliche Epiduralanästhesie ; katheterassoziierte Infektion ; Key words Epidural abscess ; Continuous epidural anaesthesia ; Catheter-associated-infection
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract We report on a case of a lumbar epidural abscess with staphylococcus aureus following a catheter epidural anaesthesia in a previously healthy and not immunesuppressed 34-year-old female. The indication for the epidural anaesthesia was mobilization of the right knee following arthrotomy due to chronic synovitis. On postoperative day 7 the patient experienced lumbar pain, headache and meningism. Magnetic resonance imaging revealed an epidural abscess at the height of the 3rd and 4th lumbar vertebrae. A rightsided intralaminar fenestration with debridement and drainage of the abscess was carried out immediately after confirmation of the diagnosis. The patient was discharged from hospital on postoperative day 21 without any neurological sequelae. This is another addition to the published cases of epidural abscess following a epidural technique. It underlines the need for a proper aseptic technique, to abandon frequent changes of bacterial filters, daily examination of the entry site of the catheter and strategies for close and continuous monitoring of patients following epidural anaesthesia.
    Notes: Zusammenfassung In einer Kasuistik wird über das Auftreten eines lumbalen epiduralen Abszesses (Nachweis von Staphylococcus aureus) nach Anlage eines Epiduralkatheters bei einer 34jährigen gesunden Frau berichtet. Insbesondere lagen bei der Patientin keinerlei Hinweise auf eine immunsupprimierende Erkrankung vor. Die kontinuierliche Epiduralanalgesie erfolgte zur Mobilisation des rechten Kniegelenks nach Arthrotomie wegen chronisch rezidivierender Synovitis. Der operative Eingriff wurde stationär in einem auswärtigen Krankenhaus durchgeführt. Nach Auftreten von Lumbalgie, Zephalgie und Meningismus am 7. postoperativen Tag wurde durch Kernspintomographie der LWS die Verdachtsdiagnose eines epiduralen Abszesses in Höhe LWK 3/4 bestätigt. Noch am selben Tage erfolgte die rechtsseitige interlaminäre Fensterung, Abszeßdrainage, Wunddebridement und Spülung in unserer Klinik. Bei komplikationslosem Verlauf wurde die Patientin am 12. postoperativen Tag (21. Tag nach Anlage des Epiduralkatheters) ohne neurologische Residuen in die hausärztliche Betreuung entlassen. Die Kasuistik hebt erneut die Bedeutung steriler Vorgehensweisen bei der Anlage eines Epiduralkatheters und der Vermeidung häufiger Wechsel des Bakterienfilters hervor. Betont wird darüber hinaus eine tägliche Kontrolle der Punktionsstelle und Strategien zur Überwachung von Patientenmit rückenmarknahen Anästhesieverfahren.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050684
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  • 8
    Electronic Resource
    Electronic Resource
    Low-dose hydrocortisone infusion attenuates the systemic inflammatory response syndrome (1994)
    Springer
    Journal of molecular medicine 72 (1994), S. 782-787 
    Details
    ISSN: 1432-1440
    Keywords: Sepsis ; Shock ; septic ; Glucocorticoids ; Hydrocortisone ; Fever ; Phospholipase A2 ; C-reactive protein ; Elastase
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract There is increasing evidence that the hypercortisolemia in inflammatory diseases suppresses the elaboration of proinflammatory cytokines, thus protecting the host from its own defence reactions. In severe sepsis and septic shock cortisol levels are usually elevated, but some patients may have relative adrenal insufficiency. This may contribute to the overwhelming systemic inflammatory response syndrome. We evaluated the impact of low-dose hydrocortisone infusion (10 mg/h) on the course of the systemic inflammatory response syndrome. This dose corresponds to a maximum secretory rate of cortisol achieved in corticotropin-stimulated healthy humans. In a prospective observational study 57 surgical patients with severe sepsis or septic shock were studied, of which in addition to the conventional treatment 12 patients were infused with low-dose hydrocortisone, and 45 were treated without any corticosteroid. In the longitudinal analysis the systemic inflammatory response — as judged by body temperature, cardiovascular response, and kinetics of inflammatory mediators such as phospholipase A2, C-reactive protein, and neutrophil elastase — started to differ in favor of the hydrocortisone-treated patients after 2 days of treatment (P 〈 0.05, Mann-Whitney U test). The difference disappeared after withdrawal of exogenous cortisol. Shock reversal was achieved in all patients treated with low-dose hydrocortisone. The data provide evidence that low-dose hydrocortisone infusion attenuates the systemic inflammatory response in human septic shock. From an immunological point of view a relative cortisol deficiency may contribute to the amplified immune response in systemic inflammatory diseases. A randomized clinical trial must clarify the impact of low-dose hydrocortisone infusion on the clinical course and outcome of septic shock patients.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF00180547
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  • 9
    Electronic Resource
    Electronic Resource
    The predictive value of four scoring systems in liver transplant recipients (1995)
    Springer
    Intensive care medicine 21 (1995), S. 32-37 
    Details
    ISSN: 1432-1238
    Keywords: Scoring systems ; Orthotopic liver transplantation ; Intensive care medicine ; Prognosis of outcome ; Apache II score ; MPM score ; SAPS score ; Hospital mortality
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective To compare 4 general severity classification scoring systems concerning prognosis of outcome in 123 liver transplant recipients. The compared scoring systems were: the mortality prediction model (admission model and 24 h model); the simplified acute physiology score; the acute physiology and chronic health evaluation (Apache II) and the acute organ systems failre score. Design Retrospective, consecutive sample. Setting Adult intensive care unit in a university hospital. Patients 123 adult liver allograft recipients after admission to the intensive care unit. Measurements and main results The scoring systems were calculated as described by the authors to classify the severity of illness after admission of the allograft recipients to the intensive care unit. The mean and median values of survivors and the group of patients, that died during hospital stay were compared. Receiver-operating characteristics were plotted for all scoring systems and the areas under the curves of receiver-operating characteristics were calculated. The predictive value of the 4 scoring systems was tested using a variety of sensitivity analyses. The mortality prediction model (24 h model) was found to have a high significance (p〈0.001) in predicting mortality and showed the greatest area under the curve (0.829). Simplified acute physiology score (p〈0.001) and acute physiology and chronic health evaluation (Apache II) (p〈0.01) had a high significance as well, but did not hit the level of prognosis of mortality prediction model, as shown in the area under the curves. Accordingly, sensitivity was highest in MPM-24 h (83%), followed by SAPS (72%) and Apache II (71%). MPM-24h had a total misclassification rate of 22% (SAPS=32%, Apache II=33%). MPM-admission failed in predicting mortality (sensitivity=52%). Organ systems failure score seemed not to be useful in liver transplant recipients. Conclusion General disease classification systems, such as the mortality prediction model, simplified acute physiology score or acute physiology and chronic health evaluation are good mortality prediction models in patients after liver transplantation. We suggest that there is no need for improvement of a special scoring system.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF02425151
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  • 10
    Electronic Resource
    Electronic Resource
    A comparison of the adrenocortical response during septic shock and after complete recovery (1996)
    Springer
    Intensive care medicine 22 (1996), S. 894-899 
    Details
    ISSN: 1432-1238
    Keywords: Septic shock ; Cortisol ; ACTH ; Adrenocortical insufficiency ; Hemodynamics
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract 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 μg/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 μg/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.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF02044113
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