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  • 1
    ISSN: 1432-055X
    Keywords: Schlüsselwörter ALV ; Rückgekoppelte Beatmung ; Beatmungsform ; Atmungsmechanik ; Künstliche Beatmung ; Beatmungsarbeit ; Nephrektomie ; Seitenlagerung ; Key words Adaptive lung ventilation ; Closed-loop control of ventilation ; Model of ventilation ; Pulmonary mechanics ; Artificial ventilation ; Work of breathing ; Nephrectomy ; Lateral decubitus position
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract The lateral decubitus position is the standard position for nephrectomies. There is a lack of data about the effects of this extreme position upon respiratory mechanics and gas exchange. In 20 patients undergoing surgery in the nephrectomy position, we compared a new closed-loop-controlled ventilation algorithm, adaptive lung ventilation (ALV), which adapts the breathing pattern automatically, to the respiratory mechanics with conventionally controlled mandatory ventilation (CMV). The aims of our study were (1) to describe positioning effects on respiratory mechanics and gas exchange, (2) to compary ventilatory parameters selected by the ALV controller with traditional settings of CMV, and (3) to assess the individual adaptation of the ventilatory parameters by the ALV controller. The respirator used was a modified Amadeus ventilator, which is controlled by an external computer and possesses an integrated lung function analyzer. In a first set of measurements, we compared parameters of respiratory mechanics and gas exchange in the horizontal supine position and 20 min after changing to the nephrectomy position. In a second set of measurements, patients were ventilated with ALV and CMV using a randomized crossover design. The CMV settings were a tidal volume of 10 ml/kg body weight, a respiratory rate of 10 breaths/min, an I:E ratio of 1:1.5, and an end-inspiratory pause of 30% of inspiratory time. With both ventilation modes FiO2 was set to 0.5 and PEEP to 3 cm H2O. During ALV a desired alveolar ventilation of 70 ml/kg KG·min was preset. All other ventilatory parameters were determined by the ALV controller according to the instantaneously measured respiratory parameters. Positioning induced a reduction of compliance from 61.6 to 47.9 ml/cm H2O; the respiratory time constant shortened from 1.2 to 1.08 s, whereas physiological dead space increased from 158.9 to 207.5 ml. On average, the ventilatory parameters selected by the ALV controller resembled very closely those used with CMV. However, an adaptation to individual respiratory mechanics was clearly evident with ALV. In conclusion, we found that the effects of positioning for nephrectomy are minor and may give rise to problems only in patients with restrictive lung disease. The novel ALV controller automatically selects ventilatory parameters that are clinically sound and are better adapted to the respiratory mechanics of ventilated patients than the standardized settings of CMV are.
    Notes: Zusammenfassung ALV stellt ein neues automatisches Beatmungsverfahren dar. Wir verglichen an 20 Patienten in Nephrektomielagerung ALV mit der konventionellen CMV-Beatmung. Ziele der Studie waren 1) Auswirkungen der Lagerung auf Atmungsmechanik und Gasaustausch festzustellen, 2) die vom ALV-Regler gewählten Beatmungsparameter mit den traditionell unter CMV eingestellten zu vergleichen und 3) die individuelle Anpassung der Beatmungsparameter unter ALV zu beurteilen. Zunächst wurden Atmungsmechanik- und Gasaustauschwerte in Rückenlage und 20 min nach Umlagerung verglichen. Danach wurden die Patienten nach einem randomisierten Crossover-Design sowohl ALV als auch CMV beatmet. Unter CMV wurde ein Atemzugvolumen von 10 ml/kg KG, eine Atmungsfrequenz von 10 AZ/min, ein I:E-Verhältnis von 1:1,5 und eine endinspiratorische Pause von 30% der Inspirationszeit eingestellt. Unter ALV wurde eine gewünschte alveoläre Ventilation von 70 ml/kg Körpergewicht und Minute vorgegeben. Nach Umlagerung nahm die Compliance von 61,6 auf 47,9 ml/cm H2O ab, die respiratorische Zeitkonstante verkürzte sich von 1,2 auf 1,08 s und der physiologische Totraum nahm von 158,9 auf 207,5 ml zu. Der ALV-Regler beatmete die Patienten mit Beatmungsparametern, die zwar im Mittel weitgehend identisch mit den unter CMV vorgegebenen waren, die aber eine individuelle Anpassung an die unterschiedliche Atmungsmechanik beobachten ließen.
    Type of Medium: Electronic Resource
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  • 2
    Electronic Resource
    Electronic Resource
    Springer
    Der Anaesthesist 45 (1996), S. 900-902 
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Pharmakodynamik: Rocuronium ; Medikamentöse Wechselwirkung: Cimetidin ; Key words Pharmacodynamics: rocuronium ; Drug interactions: rocuronium ; cimetidine
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Cimetidine is a commonly used H2-receptor antagonist that has been recommended for the prevention of acid aspiration syndrome and has been shown to potentiate vecuronium-induced neuromuscular block. The present study was designed to investigate the influence of a single IV dose of cimetidine on the neuromuscular effects of rocuronium, an analogue of vecuronium with a short onset time. Methods. Twenty adults aged 18–65 years were included in the study with their informed consent and approval of the Ethics Committee. Following oxazepam premedication, 10 patients were randomly allocated to receive cimetidine 400 mg IV 30 min before anaesthesia. After fentanyl and thiopentone induction, single-twitch stimulation of the ulnar nerve was performed every 10 s. Following stabilisation of control responses, patients received rocuronium 0.6 mg/kg for intubation. Anaesthesia was maintained with enflurane ≤0.8 vol.% (end-tidal) and 65% nitrous oxide. Onset time and recovery times to 25% and 75% of the twitch control values were recorded. Results. Onset and recovery times did not differ between groups. Conclusions. The results of the present study demonstrate that cimetidine does not increase the duration of rocuronium neuromuscular blockade. Inhibition of the cytochrome P450 system or a direct effect at the neuromuscular junction have been suggested as the mechanisms of drug interaction associated with cimetidine. Impairment of hepatic microsomal drug metabolism results in a prolonged duration of action of vecuronium, which appears to be eliminated primarily via the liver. Data on the elimination pathway of rocuronium in humans are not available. The fact that cimetidine does not alter the recovery from rocuronium-induced neuromuscular block confirms a previous suggestion that rocuronium may not be eliminated principally by the liver. A direct effect of cimetidine on the neuromuscular junction could not be confirmed by this study. Therefore, cimetidine can be given as premedication without a risk of prolonged rocuronium block.
    Notes: Zusammenfassung Nach Gabe von Cimetidin kann die Wirkungszeit nichtdepolarisierender Muskelrelaxanzien verlängert sein. Wir untersuchten diesen Zusammenhang für Rocuronium nach einer Einzeldosis von 400 mg Cimetidin intravenös im Vergleich mit einer Kontrollgruppe. Die Antwort des M. adductor pollicis nach Stimulation des N. ulnaris wurde elektromyographisch registriert. Die Anschlags- und Erholungszeiten sind in beiden Gruppen vergleichbar. Der fehlende Einfluß von Cimetidin auf die neuromuskuläre Blockade von Rocuronium könnte darauf hindeuten, daß die Elimination von Rocuronium nicht nur in der Leber stattfindet. Eine mögliche direkte Beeinflussung der neuromuskulären Endplatte durch Cimetidin, wie sie für Vecuronium postuliert worden ist, trifft nach unseren Ergebnissen nicht für Rocuronium zu. Die Anwendung von Cimetidin in der Prämedikation verlängert nicht die Dauer der neuromuskulären Blockade durch Rocuronium.
    Type of Medium: Electronic Resource
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  • 3
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Hyperglykämie ; Hypoglykämie ; regionale Organdurchblutung ; Microspheres ; kardiopulmonale Reanimation (CPR) ; Key words Hyperglycaemia ; Hypoglycaemia ; Regional organ blood flow ; Microspheres ; Cardiopulmonary resuscitation (CPR)
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Blood glucose alterations prior to cerebral ischaemia are associated with poor neurologic outcome, possibly due to extensive lactic acidosis or energy failure. Cerebral effects of hyper- or hypoglycaemia during cardiopulmonary resuscitation (CPR) are less well known. In addition, little information is available concerning cardiac effects of blood glucose alterations. The aim of this study was to evaluate the effects of pre-cardiac-arrest hypo- or hyperglycaemia compared to normoglycaemia upon haemodynamics, cerebral blood flow (CBF) and metabolism (CMRO2), and regional cardiac blood flow during CPR subsequent to 3 min of cardiac and respiratory arrest and after restoration of spontaneous circulation. Methods. After approval by the State Animal Investigation Committee, 29 mechanically ventilated, anaesthetised pigs were instrumented for haemodynamic monitoring and blood flow determination by the radiolabeled microsphere technique. The animals were randomly assigned to one of three groups: in group I (n=9) blood glucose was not manipulated; in group II (n=10) blood glucose was increased by slow infusion of 40% glucose to 319±13 mg/dl; in group III (n=10) blood glucose was lowered by careful titration with insulin to 34±2 mg/dl. After 3 min of untreated ventricular fibrillation and respiratory arrest, CPR (chest compressor/ventilator (Thumper®) and epinephrine infusion) was commenced and continued for 8 min. Thereafter, defibrillation was attempted, and if successful, the animals were observed for another 240 min. Cerebral perfusion pressure (CPP), CBF, CMRO2, coronary perfusion pressure (CorPP), and regional cardiac blood flow were determined at control, after 3 min of CPR, and at 10, 30, and 240 min post-CPR. Results. In group I, 4/9 animals (44%) could be successfully resuscitated; in group II 4/10 (40%); and in group III 0/10 (0%). Prior to cardiac arrest, mean arterial pressure, CPP, and CorPP in group III were significantly lower compared to groups I and II. In group I, CPP during CPR was 26±6 mmHg; CBF 31±9 ml/min/100 g CMRO2 3.8±1.2 ml/min/100 g; CorPP 18±5 mmHg; and left ventricular (LV) flow 35±15 ml/min/100 g. In group II: CPP=21±5; CBF 21±7; CMRO2 1.8±0.8; CorPP 16±6; and LV flow 22±9; and in group III: CPP 15±3; CBF 11±8; CMRO2 1.5±1.1; CorPP 4±2; and LV flow 19±10. During the 240-min post-resuscitation period, there were no differences in CBF, CMRO2, or LV flow between groups I and II. Conclusion. Hypoglycaemia prior to cardiac arrest appears to be predictive for a poor cardiac outcome, whereas hyperglycaemia does not impair resuscitability compared to normoglycaemia. In addition, hyperglycaemia did not affect LV flow, CBF, or CMRO2. However, it has to be kept in mind that haemodynamics and organ blood flow do not permit conclusions with respect to functional neurologic recovery or histopathologic damage to the brain, which is very likely to be associated with hyperglycaemia.
    Notes: Zusammenfassung Gegenstand der vorliegenden Untersuchung im Schweinemodell ist der Einfluß einer prä-ischämischen Normo-, Hyper- oder Hypoglykämie auf Hämodynamik, regionale Organdurchblutung und Reanimierbarkeit nach 3minüti-gem unbehandelten Herz-Kreislauf-Stillstand und anschließender kardiopulmonalen Reanimation (CPR). Hypoglykämie (Blutzuckerkonzentration von 34±2 mg/dl) war bereits vor der Reanimation mit einer deutlichen Beeinträchtigung hämodynamischer Parameter assoziiert. Keines der hypoglykämischen Tiere konnte erfolgreich reanimiert werden, im Gegensatz zu den hyper- (Blutzucker 319±13 mg/dl) bzw. normoglykämischen Tieren, die keinen Unterschied hinsichtlich der Erfolgsrate der Reanimation aufwiesen. Weder vor noch während oder nach Reanimation unterschieden sich hyper- und normoglykämische Tiere in bezug auf Hämodynamik oder regionale kardiale oder zerebrale Durchblutung. Somit bleibt festzuhalten, daß Hypoglykämie bei CPR mit einer schlechten kardialen Prognose assoziiert ist, während Hyperglykämie die kardiale Reanimation offenbar nicht beeinträchtigt.
    Type of Medium: Electronic Resource
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  • 4
    Electronic Resource
    Electronic Resource
    Springer
    Der Anaesthesist 49 (2000), S. S16 
    ISSN: 1432-055X
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Type of Medium: Electronic Resource
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  • 5
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Pharmakodynamik: Atracurium ; Rocuronium ; Vecuronium ; Relaxation: Anschlagszeit ; Erholung ; Altersfaktoren ; Key words Pharmacodynamics: atracurium ; rocuronium ; vecuronium ; Neuromuscular block: onset ; recovery ; Age factors
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Elderly patients may show an age-related decline in physiologic functions, which may be responsible for the prolonged duration of some neuromuscular blocking agents. Previous studies have yielded conflicting results as to the effects of these drugs in the elderly. Methods. After obtaining informed consent and approval of the Ethics Committee, we compared onset and recovery times of single IV doses of atracurium, rocuronium, and vecuronium given to 108 patients divided into three groups according to age (18–50, 51–64, ≥65 years). Following oxazepam premedication and fentanyl and thiopentone induction, patients were randomly allocated to receive atracurium, rocuronium or vecuronium (0.5, 0.6, or 0.1 mg/kg, respectively) in ≤0.8 vol.% enflurane (end-tidal)-nitrous oxide anaesthesia. Muscular relaxation was assessed by electromyographic (EMG) recording of the adductor pollicis muscle after supramaximal single-twitch stimulation of the ulnar nerve every 10 s. Onset time and recovery to 25%, 75% and 90% of twitch control values (DUR25, 75, 90) were recorded. Creatinine clearance predicted from serum creatinine (Ccr) was correlated with recovery from neuromuscular block. Results. Onset time was not different among groups or relaxants. The results showed a prolonged duration of action for atracurium (DUR75, DUR90), rocuronium (DUR25, DUR75), and vecuronium (DUR25) in the elderly. A number of patients did not reach DUR75 or DUR90. There was a significant relationship between age and failure to return to control values during recovery from neuromuscular block, especially after atracurium and rocuronium. Ccr showed a negative correlation with age for all relaxants, but a negative significant correlation between Ccr and recovery was found only for rocuronium. Conclusions. This study suggests that onset time for atracurium, rocuronium and vecuronium is not age-dependent. Recovery was prolonged in the elderly for all three relaxants. This effect appears to be secondary to changes in body composition and function accompanying the aging process. Neither atracurium nor vecuronium depends significantly on the kidney for elimination, but the negative correlation between Ccr and rocuronium suggests an appreciable role for the kidney in the elimination of this relaxant. The long recovery times observed in this study could also be related to enflurane anaesthesia. We suggest that failure of EMG responses to return to baseline values during recovery from neuromuscular block may be related to age, especially for atracurium and rocuronium.
    Notes: Zusammenfassung Bei alten Patienten kann die Wirkung von Muskelrelaxanzien verändert sein. Wir untersuchten diesen Zusammenhang an 108 Patienten dreier Altersgruppen, die randomisiert klinisch übliche Intubationsdosen von Atracurium, Rocuronium und Vecuronium erhielten. Anschlagszeit und Erholung von der neuromuskulären Blockade wurden mit dem evozierten EMG des M. adductor pollicis nach Stimulation des N. ulnaris (Einzelreizung, 0,1 Hz) ermittelt. Die Anschlagszeiten sind in allen drei Altersgruppen vergleichbar, die Erholungszeiten bei den alten Patienten nach allen drei Relaxanzien verlängert. Die verlängerte Erholungszeit für Rocuronium korreliert mit erhöhten Werten der berechneten Kreatinin-Clearance, was für eine im Vergleich mit Atracurium und Vecuronium vermehrte renale Elimination spricht. Die nicht vollständige Erholung von der neuromuskulären Blockade bei einigen Patienten, auch nach längerer Zeit, korreliert mit dem Alter. Eine Erklärung hierfür kann nicht gegeben werden.
    Type of Medium: Electronic Resource
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  • 6
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Pharmakodynamik ; Muskelrelaxanzien ; Rocuronium ; Medikamentöse Wechselwirkung ; Rauchen ; Nikotin ; Key words Pharmacodynamics ; Neuromuscular blocking agents ; Rocuronium ; Drug interactions ; Smoking ; Nicotine
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Recent studies have shown different results concerning the effects of smoking on neuromuscular blocking agents. Some reports indicate that smokers need higher doses of vecuronium, but are more sensitive to atracurium. The aim of this study was to evaluate the effects of smoking on onset and recovery time after a single 0.6 mg/kg intubating dose of rocuronium an analog of vecuronium. Methods: Following institutional approval and informed consent, 20 smokers (〉10 cigarettes/day) and 20 nonsmokers were included in the study. Following oxazepam premedication and induction with fentanyl and thiopental, single-twitch stimulation of the ulnar nerve was performed every 10 s. Following stabilisation of control responses, patients received rocuronium 0.6 mg/kg for intubation. Anaesthesia was maintained with enflurane ≤0.8 vol.% (end-tidal) and 65% nitrous oxide in oxygen. Onset time and recovery to 25% and 75% of the twitch control values were recorded. Results: Onset and recovery times were not different between smokers and nonsmokers. Conclusions: The results of the present study suggest that chronic nicotine exposure does not change onset time or duration of rocuronium neuromuscular blockade. A previous study found a greater need for vecuronium in smokers and discussed stimulation of the neuromuscular junction and enhanced biotransformation due to the enzyme-inducing properties of nicotine. The differences in our results could be partly due to a longer period of refraining from smoking in our patients, leading to very low nicotine blood concentrations without the proposed receptor-stimulating effect. Another cause for different behaviour of the two analogs could be different elimination pathways. Recent investigations suggest that rocuronium may not be eliminated principally by the liver. Therefore, enhanced nicotine-induced biotransformation, as suggested for vecuronium, would not occur with rocuronium.
    Notes: Zusammenfassung Nach bisherigen Untersuchungen beeinflußt das Rauchen die Pharmakodynamik von Muskelrelaxanzien in unterschiedlicher Weise. Einerseits wurden bei Rauchern höhere Dosen von Vecuronium benötigt, andererseits reagierten Raucher sensibler auf Atracurium. Methoden: Wir untersuchten diesen Zusammenhang für eine Einzeldosis von Rocuronium 0,6 mg/kg an jeweils 20 Rauchern und 20 Nichtrauchern. Die Antwort des M. adductor pollicis nach Stimulation des N. ulnaris wurde elektromyographisch registriert. Ergebnis: Nikotin beeinflußte die klinische Wirkung von Rocuronium nicht, die Anschlags- und Erholungszeiten waren in beiden Gruppen vergleichbar. Diskussion: Der fehlende Einfluß des Nikotins auf die neuromuskuläre Blockade von Rocuronium könnte auf die lange Nikotinkarenz von 8–10 h zurückgeführt werden ebenso wie auf die Tatsache, daß die Metabolisierung von Rocuronium nach neuesten Erkenntnissen nicht der seines Analogons Vecuronium entspricht. Eine durch Nikotin verursachte hepatische Enzyminduktion mit rascherer Metabolisierung, wie dies für Vecuronium diskutiert worden ist, würde daher nicht in dem entsprechenden Umfang für das Rocuronium zu erwarten sein. Aus unseren Ergebnissen schließen wir, daß nach einer Karenzzeit von 8–10 h keine Beeinflussung der Pharmakodynamik von Rocuronium bei Rauchern stattfindet.
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  • 7
    ISSN: 1432-1238
    Keywords: Key words Shoshin beriberi ; Thiamine deficiency ; Hyperdynamic shock ; Metabolic acidosis
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract A 39-year-old man, with no history of alcohol intake, who had had an esophago-ileo-colo-gastroplasty with ileotransversostomy, developed diplopia, seizures, metabolic acidosis, and cardiac failure and finally refractory hyperdynamic shock. He died 20 h after admission to our intensive care unit from cardiocirculatory collapse. Postmortem results revealed low erythrocyte transketolase activity, which was increased by 22 % by in vitro addition of thiamine diphosphate (TDP effect). Cerebral pathology showed the alterations of Wernicke's encephalopathy. We discuss the possible mechanisms of fatal cardiovascular collapse and the unusual presentation of a case without a history of alcoholic intake or clinical malnutrition.
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  • 8
    ISSN: 1432-1084
    Keywords: Key words: Pleura – Pleural – diseases – Pleural fluid – Pleural neoplasms – CT
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract. Computed tomography studies are usually used to assess patients with pleural effusions, and radiologists should be aware of the significance of different CT findings for the diagnosis of the effusion. The purpose of this study was to evaluate CT findings for etiological diagnosis of pleural effusions. Contrast-enhanced CT of the chest of 211 patients with pleural effusion of definite diagnosis were evaluated. The CT images were evaluated for the presence and extent of pleural effusion, thickening or nodules, extrapleural fat and other changes in the mediastinum or lung. The CT scans were read by two independent observers and correlation between them was evaluated. Comparison of CT findings between benign and malignant effusions, between exudates and transudates, and between empyemas and the other parapneumonic effusions were carried out. Kappa values for most CT findings were 〉 0.85. Loculation, pleural thickening, pleural nodules, and extrapleural fat of increased density were only present in exudative effusions. Multiple pleural nodules and nodular pleural thickening were the only pleural findings limited to malignant pleural effusions. The signs were also more frequently seen in empyemas than in other parapneumonic effusions. Computed tomography findings can help to distinguish between transudates and exudates. Although there is some overlap between benign and malignant pleural effusions, pleural nodules and nodular pleural thickening were present almost exclusively in the latter. Although differences between CT findings of empyemas and the other parapneumonic effusions exist, there is no finding which can definitely differentiate between them.
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  • 9
    Electronic Resource
    Electronic Resource
    Oxford, UK : Blackwell Publishing Ltd
    Pediatric anesthesia 14 (2004), S. 0 
    ISSN: 1460-9592
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Background : The objective of the present study was to evaluate the prelaryngeal position of the laryngeal mask airway (LMATM) in children, and to determine the influence of mask positioning on gastric insufflation and oropharyngeal air leakage.Methods : A total of 100 children, 3–11 years old, scheduled for surgical procedures in the supine position under general anaesthesia were studied. After clinically satisfactory LMA placement, tidal volumes were increased stepwise until air entered the stomach, airway pressure exceeded 30 cmH2O, or air leakage from the mask seal prevented further increases in tidal volume. LMA position in relation to the laryngeal entrance was verified using a flexible bronchoscope.Results : The insertion of the LMA with a clinically satisfactory position was achieved in all patients at the first attempt. Gastric air insufflation occurred in five of 49 patients with malpositioned LMA. No incident of gastric air insufflation was observed in 51 patients with correctly positioned LMA. The minimum inspiratory pressure leading to mask leakage was 17 cmH2O for incorrectly positioned LMA, and 25 cmH2O for correctly positioned LMA. Clinically unrecognized LMA malposition was associated with a significantly increased incidence of either oropharyngeal leakage (r = 0.59; P = 0.0001) or gastric insufflation (r = 0.25; P = 0.01).Conclusions : Clinically undetected LMA malpositioning is a significant risk factor for gastric air insufflation in children between 3 and 11 years, undergoing positive pressure ventilation, especially at inspiratory airway pressures above 17 cmH2O.
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  • 10
    Electronic Resource
    Electronic Resource
    Springer
    Intensive care medicine 24 (1998), S. 837-838 
    ISSN: 1432-1238
    Keywords: Key words Nitric oxide ; Platelets ; Bleeding time
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Some studies have suggested that nitric oxide (NO) may cause platelet dysfunction. We present an ARDS patient who need this treatment, with a transient alteration of platelet function and a significant prolongation of bleeding time.
    Type of Medium: Electronic Resource
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