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  • 1
    Electronic Resource
    Electronic Resource
    Springer
    Der Anaesthesist 49 (2000), S. 174-186 
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Koronare Herzerkrankung ; Perioperative Myokardischämie ; Operationsrisiko ; Medikamentöse Therapie ; Key words Coronary artery disease ; Perioperative myocardial ischemia ; Surgery ; Patient safety ; Drug therapy
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Perioperative cardiac morbidity and mortality are a major health care challenge with important individual as well as economic aspects. Up to 30% of all perioperative complications and up to 50% of all postoperative deaths are related to cardiac causes. Perioperative myocardial ischemia, which occurs in more than 40% of patients with or at risk for coronary artery disease and undergoing noncardiac surgery, represents a dynamic predictor of postoperative cardiac complications. Long-duration myocardial ischemia and ischemic episodes associated with myocardial cell damage are particularly of prognostic relevance. In patients suffering from this type of ischemia, the incidence of adverse cardiac outcome is increased up to 20-fold. Reducing the incidence of perioperative myocardial ischemia is associated with a decrease in adverse cardiac outcome. Important issues related to perioperative myocardial ischemia are hematocrit level, body temperature, and hemodynamic variables. In contrast, the choice of anesthetic agents and techniques appears to be less important. Perioperative administration of anti-ischemic drugs in patients at risk, however, leads to a further decrease in the incidence of myocardial ischemia and to an improvement in patient outcome. Recent studies suggest that alpha2- agonists and particularly beta-adrenoreceptor blocking agents are effective anti-ischemic drugs in the perioperative setting. Perioperative administration of beta-adrenoreceptor blocking agents in coronary risk patients undergoing noncardiac surgery is associated with a reduced rate of postoperative cardiac complications and an improvement in long-term outcome. This is particularly relevant in high risk patients with preoperative stress-induced ischemic episodes. In clinical practice, therefore, chronically administered anti-ischemic drugs should also be administered on the day of surgery and during the postoperative period. In untreated patients with or at risk for coronary artery disease and who have to undergo urgent surgical procedures without the opportunity of preoperative anti-ischemic intervention, perioperative administration of beta-adrenoreceptor blocking agents is mandatory.
    Notes: Zusammenfassung Die perioperative kardiale Morbidität und Mortalität bei Patienten mit koronarer Herzerkrankung stellt ein individuell und volkswirtschaftlich bedeutsames Gesundheitsproblem dar. Bis zu 30% aller perioperativen Komplikationen und bis zu 50% aller postoperativen Todesfälle sind auf kardiale Ursachen zurückzuführen. Perioperative Myokardischämien, die bei mehr als 40% aller koronaren Risikopatienten im Zusammenhang mit einem nichtherzchirurgischen Eingriff zu beobachten sind, gelten als dynamische Prädiktoren postoperativer kardialer Komplikationen. Dabei sind insbesondere längerdauernde bzw. mit einer myokardialen Zellschädigung einhergehende Ischämien prognostisch relevant. Treten solche Ischämien auf, so ist die Rate kardialer Komplikationen um bis zu 20fach erhöht. Eine suffiziente Prävention von perioperativen Myokardischämien reduziert die kardiale Komplikationsrate. Entscheidende perioperative Regelgrößen in diesem Zusammenhang sind der Hämatokrit, die Körpertemperatur und die Hämodynamik. Die Wahl des Anästhesieverfahrens scheint insgesamt weniger von Bedeutung zu sein. Dagegen kann der Einsatz antiischämischer Medikamente zu einer weiteren Reduktion der Ischämierate und zu einer Verbesserung des Outcomes bei koronaren Risikopatienten beitragen. Aktuelle Studien zeigen, dass Alpha2-Agonisten und v.a. Beta-Rezeptorenblocker in diesem Zusammenhang effektiv sind. Eine perioperative Applikation von Beta-Rezeptorenblockern reduziert die postoperative kardiale Komplikationsrate und verbessert das langfristige Outcome nichtherzchirurgischer koronarer Risikopatienten. Dies gilt in besonderem Maße für Hochrisikopatienten mit präoperativer Belastungsischämie. Als Leitlinie für die klinische Praxis lässt sich feststellen, dass eine chronisch applizierte antiischämische Medikation auch am Tag der Operation und postoperativ so früh als möglich weitergeführt werden sollte. Bei unbehandelten koronaren Risikopatienten, die dringlich operiert werden müssen, sollte – neben einem erweiterten perioperativen Monitoring – die prophylaktische Applikation eines Beta-Rezeptorenblockers angestrebt werden.
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  • 2
    ISSN: 1365-2044
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: In 25 cardiac surgical patients, right ventricular ejection fraction was continuously measured with a new pulmonary artery catheter and transoesophageal echocardiography, scanning the ‘fractional area change’ in a standardised transatrial cross section area. Measurements were recorded at three predefined time points (pre-, intra-, and postoperatively). Both methods were compared using the Bland-Altman analysis. Comparing right ventricular ejection fraction values obtained from the pulmonary artery catheter with those assessed by transoesophageal echocardiography, bias was −3.7%, with a precision of 30.9%. Bias and precision significantly improved when the heart rate was less than 100 beats.min−1, pulmonary artery pressures were low and cardiac performance adequate. In conclusion, the new continuous pulmonary artery catheter system appears to be a valid and useful bedside monitoring device in the haemodynamic management of critically ill patients.
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  • 3
    ISSN: 1365-2044
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Type of Medium: Electronic Resource
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  • 4
    ISSN: 1365-2044
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: We investigated the association of peri-operative myocardial ischaemia with activation of coagulation and endogenous fibrinolysis in patients undergoing vascular surgery. In 50 patients, continuous Holter monitoring was performed to assess peri-operative myocardial ischaemia and 12-lead electrocardiography was recorded preoperatively and 72 h postoperatively to assess myocardial infarction. Serial blood samples were drawn peri-operatively to determine the concentrations of fibrin monomers (for activation of coagulation), d-dimer (for endogenous fibrinolysis) and cardiac troponin T and I. Patients with myocardial ischaemia showed higher concentrations of fibrin monomers at 48 h, and higher concentrations of d-dimer preoperatively and at 24 and 48 h postoperatively. In patients with peri-operative myocardial ischaemia, strong positive correlations were observed between fibrin monomer and d-dimer concentrations at 15 min and 4 h postoperatively, and cardiac troponins at 15 min and at 4, 24, 48 and 72 h postoperatively. Early postoperative activation of coagulation and fibrinolysis is associated with peri-operative myocardial cell damage among patients who are at risk for, or have a history of, coronary artery disease plus peri-operative myocardial ischaemia.
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  • 5
    ISSN: 1365-2044
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Although several clinical studies have shown that increased serum concentrations of protein S100B predict ischaemic brain damage after cardiac surgery, S100B may also be released from the heart or other injured tissue. We therefore investigated the correlation between serum S100B levels and those of the specific cardiac marker troponin I in order to assess the cerebral vs. extracerebral origin of S100B. In 64 cardiac surgical patients, serial blood samples were drawn for the measurement of S100B and troponin I before surgery and for seven days after surgery. Neurological function was assessed before with the National Institutes of Health Stroke Scale and the Folstein Mini Mental Test. The data show that a sustained increase in serum S100B levels is associated with neurological dysfunction, as witnessed by a positive correlation between S100B values and the results of the neuropsychological tests. In contrast, the early postoperative increased levels of protein S100B derive from cardiac tissue, as shown by the positive correlation between S100B and cardiac troponin I levels.
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  • 6
    ISSN: 1365-2044
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Peri-operative myocardial ischaemia is the single most important risk factor for an adverse cardiac outcome after non-cardiac surgery. The present study examines whether intermittent 12-lead ECG recordings can be used as an early warning tool to identify patients suffering from peri-operative myocardial ischaemia and subsequent myocardial cell damage. Fifty-five vascular surgery patients at risk for or with a history of coronary artery disease were monitored for peri-operative myocardial ischaemia using intermittent 12-lead ECG recordings taken pre-operatively and at 15 min, 20 h, 48 h, 72 h and 84 h postoperatively. The effectiveness of the 12-lead ECG was gauged by examining concordance with continuous 3-channel Holter monitoring and capturing peri-operative myocardial ischaemia by serial analyses of creatine kinase myocardial band isoenzyme and cardiac troponin T and I. The incidence of peri-operative myocardial ischaemia detected by 12-lead ECG was 44% and was identifiable in most patients (88%) 15 min after surgery. The incidence of peri-operative myocardial ischaemia detected by continuous monitoring was 53%, with the most severe episodes occurring intra-operatively and during emergence from anaesthesia. The concordance of the 12-lead method with continuous monitoring was 72%. The concordance of creatine kinase myocardial band isoenzyme activity with the 12-lead method was 71% and with Holter monitoring 57%. The concordance of mass concentration of creatine kinase myocardial band with 12-lead ECG recordings was 75%, and the corresponding value for Holter monitoring was 68%. The concordance of cardiac troponin T and I levels with the 12-lead method was 85% and 87%, respectively, and concordance with Holter monitoring was 72% and 66%, respectively. The postoperative 12-lead ECG identified peri-operative myocardial ischaemia associated with subsequent myocardial cell damage in most patients undergoing vascular surgery.
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