Showing papers by "Jürgen Peters published in 2007"
TL;DR: Assessment of supraglottic airway diameter and volume by respiratory-gated magnetic resonance imaging, upper airway dilator muscle function (genioglossus force and EMG), and changes in lung volume, respiratory timing, and peripheral muscle function before, during, and after partial neuromuscular blockade in healthy, awake volunteers concluded that impaired neuromUScular transmission markedly impairs upperAirway dimensions and function.
Abstract: Rationale: Partial neuromuscular transmission failure by acetylcholine receptor blockade (neuromuscular blockade) or antibody-mediated functional loss (myasthenia gravis), even with a magnitude of muscle weakness that does not evoke respiratory symptoms, can evoke dysphagia and decreased inspiratory airflow, and increases the risk of susceptible patients to develop severe pulmonary complications.Objectives: To assess whether impaired neuromuscular transmission predisposes individuals to inspiratory upper airway collapse, we assessed supraglottic airway diameter and volume by respiratory-gated magnetic resonance imaging, upper airway dilator muscle function (genioglossus force and EMG), and changes in lung volume, respiratory timing, and peripheral muscle function before, during, and after partial neuromuscular blockade in healthy, awake volunteers.Measurements and Main Results: Partial neuromuscular blockade (train-of-four [TOF] ratio: 0.5 and 0.8) was associated with the following: (1) a decrease of insp...
195 citations
TL;DR: In critically ill patients with MODS, argatroban 2 μg/kg/min, as recommended by the manufacturer, resulted in extensive anticoagulation, and a tenfold lower starting dose is sufficient and safe for effective antICOagulation in this specific patient population.
Abstract: Background:Despite long-term use of argatroban in clinical practice, no dosing recommendations exist for critically ill patients with multiple organ dysfunction (MODS) and suspected or proven heparin-induced thrombocytopenia (HIT).Objective:To determine the suitability of argatroban use in critically ill patients with MODS and HIT.Methods:We conducted prospective observation of 24 consecutive patients with suspected HIT who were being anticoagulated with argatroban (target activated partial thromboplastin time [aPTT] 1.5–2 times normal or 50–60 sec) using 2 μg/kg/min in the first 5 patients and 0.2 μg/kg/min in the subsequent 19 patients.Results:Infusion of argatroban 2 μg/kg/min over 4 hours caused bleeding complications in 3 patients as aPTT increased from 51 ± 18 to 86 ± 34 seconds (p = 0.02), prothrombin time (PT) decreased from 76 ± 27% to 33 ± 12% of normal reference values, and international normalized ratio (INR) increased from 1.4 ± 0.4 to 2.5 ± 0.9 (p = 0.007). Infusion of argatroban 0.2 μg/kg/m...
107 citations
TL;DR: Argatroban is a feasible and effective anticoagulant for patients with suspected HIT undergoing ECMO, however, a dose 10-fold lower than that recommended by the manufacturer is sufficient to achieve appropriate antICOagulation in critically ill patients undergoingECMO.
Abstract: The objective of this study was to assess the required dose and anticoagulatory effect of argatroban (Mitsubishi, Pharma Deutschland GmbH, Dusseldorf, Germany), a direct thrombin inhibitor approved for anticoagulation in patients with heparin-induced thrombocytopenia (HIT) undergoing extracorporeal membrane oxygenation (ECMO). Nine consecutive patients undergoing ECMO for severe acute respiratory distress syndrome (ARDS) and presenting with suspected HIT were treated with a continuous argatroban infusion. Coagulation variables were measured and dose adjustments of argatroban were performed to target for an activated partial thromboplastin time (aPTT) of 50 to 60 s. The first patient received argatroban 2 microg/kg/min as recommended by the manufacturer. This resulted in excessive anticoagulation and severe bleeding. The consecutive eight patients received a 10-fold lower dose (0.2 microg/kg/min). This dose sufficiently increased aPTT time from 46 +/- 6 s to 65 +/- 14 s (P < 0.001) and thrombin time from 18 +/- 8 s to 45 +/- 11 s (P = 0.001). The maintenance dose averaged 0.15 microg/kg/min. Duration of argatroban infusion for ECMO averaged 4 +/- 1 days and no oxygenator or extracorporeal system clotting was observed. In three of nine patients (33%), HIT was confirmed. Argatroban is a feasible and effective anticoagulant for patients with suspected HIT undergoing ECMO. However, a dose 10-fold lower than that recommended by the manufacturer is sufficient to achieve appropriate anticoagulation in critically ill patients undergoing ECMO.
106 citations
TL;DR: It is identified for the first time extracellular, biologically active, ATP- and ubiquitin-independent 20S proteasome in the human alveolar space, with a high albumin cleavage rate.
Abstract: We hypothesized that 20S proteasome is present and functional in the extracellular alveolar space in humans. Proteasomal activity was measured in bronchoalveolar lavage (BAL) supernatant from eight...
51 citations
TL;DR: Genotypes of the NFKB1 promoter polymorphism were associated neither with 30-day survival nor with duration of ICU stay, suggesting the severity but not the mortality of ARDS.
Abstract: This study investigated whether the insertion/deletion polymorphism in the promoter of NFKB1 is associated with severity and/or mortality in ARDS. Prospective study in a mixed anesthesiological ICU of the University Hospital Essen. 103 adult patients with ARDS (white Germans). Patients with ARDS were genotyped for the insertion/deletion polymorphism in the promoter of NFKB1 (−94ins/delATTG). In ARDS patients genotypes differed significantly between those with severe ARDS [Lung Injury Score (LIS) ≥ 3; 23 homozygote deletion (DD), heterozygote (ID) 31, and homozygote insertion wildtype (II) 23], and those with LIS below 3 (1 DD, 9 ID, 16 II). Likewise, the frequency of the D allele was significantly less in patients with higher LIS (50% D) than lower LIS (21% D). Using these values produces a significantly higher OR of 16.0 (95% CI 1.96–130.9) for DD than for II, while the OR for ID vs. II was 2.4 (95% CI 0.9–6.4). Genotypes of the NFKB1 promoter polymorphism were associated neither with 30-day survival nor with duration of ICU stay. The insertion/deletion polymorphism in the promoter of NFKB1 influences the severity but not the mortality of ARDS.
37 citations
TL;DR: Balancing the risks of stent occlusion and epidural bleeding, bedside impedance aggregometry helped to identify the optimum time window for epidural catheter removal with the lowest bleeding risk in this patient.
25 citations
TL;DR: The case of a five year old girl with homozygote, severe factor XI deficiency presenting for surgery on two occasions is presented and prophylactic use of tranexamic acid is decided on.
Abstract: Factor XI deficiency is a rare, hereditary bleeding disorder associated with a trauma-related bleeding tendency, caused by insufficient generation of the thrombin activatable fibrinolysis inhibitor (TAFI) evoking increased fibrinolysis. We present the case of a five year old girl with homozygote, severe factor XI deficiency presenting for surgery on two occasions. Modified thrombelastography (ROTEM) was used to assess effects of factor XI deficiency on coagulation, endogenous fibrinolysis, and potential effects of tranexamic acid, aprotinin and recombinant, activated Factor VII in an in vitro model of hyperfibrinolysis. According to our data and in consideration of the mechanisms of factor XI deficiency we decided on prophylactic use of tranexamic acid.
24 citations
TL;DR: Minimally invasive endoscopic intracardiac surgery consumes many more anaesthesia resources than conventional surgery and can result in hypoxaemia, but overall can be considered feasible provided that extensive continuous monitoring is employed.
Abstract: Minimally invasive endoscopic intracardiac surgery including one lung ventilation has been proposed to decrease surgical trauma but its impact on oxygenation and resource consumption has not been reported. We compared effects on gas exchange, induction, total anaesthesia time, staffing costs, and complications in 42 consecutive patients to a matched group undergoing similar surgery conventionally. Use of endoscopic compared to conventional surgery evoked a decrease in the P(a)o(2)/F(I)o(2) ratio (mean (SD) 24.1 (14.9) vs 48.9 (14) kPa, p < 0.05) following termination of bypass with one lung ventilation (10 patients showed a P(a)o(2)/F(i)o(2) below 13.3 kPa (100 mmHg)). There was also an increase of anaesthesia induction time (47 (13) vs 31 (9) min, p < 0.05), and an increase by 156 min of total anaesthesia time (474 (89) vs 321 (69) min, p < 0.05). Anaesthetist staffing costs increased by 300%. Thus, minimally invasive endoscopic intracardiac surgery consumes many more anaesthesia resources than conventional surgery and can result in hypoxaemia, but overall can be considered feasible provided that extensive continuous monitoring is employed.
19 citations
TL;DR: Lidocaine inhalation attenuated the bronchial response of direct smooth muscle stimulation with methacholine, as well as bronchoconstriction elicited by mechanical irritation, which could be mediated by direct effects on smooth muscle or by reflex attenuation.
Abstract: Background: Lidocaine inhalation attenuates histamine-induced bronchoconstriction, as well as bronchoconstriction elicited by mechanical irritation. This effect could be mediated by direct effects on smooth muscle or by reflex attenuation. Therefore, we evaluated whether lidocaine attenuated the bronchial response of direct smooth muscle stimulation with methacholine.
Methods: In 15 volunteers with bronchial hyperreactivity, a methacholine challenge was performed following the inhalation of lidocaine, dyclonine (which does not attenuate bronchial reactivity) or saline on three different days in a randomized, double-blind fashion. Lung function, response to methacholine, and lidocaine and dyclonine plasma concentrations were measured.
Results: The inhaled methacholine concentration (PC20) necessary for a 20% decrease in the forced expiratory volume in 1 s (FEV1) was 8.8 ± 6.1 mg/ml at the screening evaluation. The sensitivity to methacholine challenge (PC20) remained unchanged regardless of which solution was inhaled (9.1 ± 7.5 mg/ml for lidocaine, 10.2 ± 9.0 mg/ml for dyclonine and 9.8 ± 8.3 mg/ml for saline; P= 0.58, means ± standard deviation). Furthermore, the inhalation of all three solutions caused a significant decrease in FEV1 from baseline (P= 0.0007), with a significantly larger effect for dyclonine than lidocaine (P= 0.0153).
Conclusions: Although both inhaled and intravenous lidocaine attenuates histamine-evoked bronchoconstriction, it does not alter the response to methacholine. Therefore, the attenuation of bronchial reactivity by lidocaine appears to be related solely to neurally mediated reflex attenuation, rather than to the attenuation of direct constriction of airway smooth muscle.
18 citations
TL;DR: Aneresting complication of right ventricular cannulation and he related anesthetic management are described, often as a bridge to transplantation.
6 citations
TL;DR: The effects of a pre‐anaesthetic treatment course with candesartan on cerebral arterial‐jugular bulb oxygen content difference, middle cerebral artery blood velocity, and vasopressor requirements in hypertensive patients undergoing elective on‐pump coronary artery bypass graft surgery are assessed.
Abstract: BACKGROUND: The angiotensin II receptor type 1 antagonist candesartan has been hypothesized to alter vasopressor requirements and brain-blood flow by changing cerebrovascular autoregulation. Therefore, we assessed the effects of a pre-anaesthetic treatment course with candesartan on cerebral arterial-jugular bulb oxygen content difference, middle cerebral artery blood velocity, and vasopressor requirements in hypertensive patients undergoing elective on-pump coronary artery bypass graft surgery. METHODS: In a randomized, double-blind, placebo-controlled study, we evaluated the effects of candesartan (8 mg po/d, given for 6-8 days before surgery) in 35 hypertensive patients. The mean arterial pressure was maintained above 60 mmHg by bolus administration of phenylephrine, if required, and dosages were recorded. RESULTS: Candesartan did not significantly alter oxygen content difference across the cerebral circulation, mean middle cerebral artery blood velocity during cardiopulmonary bypass, or phenylephrine requirements either before (0.0067 microg/kg/min+/-0.0042 vs. 0.0056 microg/kg/min+/-0.0049, P=0.48) or during cardiopulmonary bypass (0.0240 microg/kg/min+/-0.0240 vs. 0.0250 microg/kg/min+/-0.0190, P=0.97) compared with placebo. CONCLUSION: Thus, a 6-8-day treatment course with candesartan does not alter global cerebral perfusion and oxygen supply/demand ratio during cardiopulmonary bypass, or vasopressor requirements in hypertensive patients undergoing on-pump coronary artery bypass graft surgery, and no deleterious consequences of AT1-receptor blockade were detected.
TL;DR: The accidental perforation of a pulmonary artery branch during right heart catheterization in an 84-year-old woman undergoing aortic valvuloplasty was reported and the management of the crisis resulting in full recovery of the patient was management.
Abstract: Wir berichten uber die iatrogene Perforation eines Pulmonalarterienastes bei einer 84-jahrigen Patientin nach Aortenklappenvalvuloplastie und das nachfolgende Krisenmanagement mit Restitutio ad integrum. Die Perforation verursachte eine intrapulmonale Hamorrhagie mit drohender Asphyxie. Die Ursache wurde rasch erkannt und die Blutung durch Repositionierung des Swan-Ganz-Katheters mit Balloninsufflation proximal der Perforationsstelle gestoppt, wahrend gleichzeitig eine Narkose mit Intubation und Bronchiallavage eingeleitet wurde. Die Perforationsstelle wurde definitiv durch die Injektion von Thrombin (5000 IE) uber den Swan-Ganz-Katheter verschlossen und dessen Ballon in insuffliertem Zustand fur sechs Stunden belassen. Die Patientin wurde nach 12 h extubiert und nach 48 h auf die Normalstation verlegt. Es traten keine neurologischen Defizite auf. Im Verlauf bildete sich kein Pseudoaneurysma aus.