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  • 1
    ISSN: 1432-1238
    Keywords: Weaning CPAP ; BiPAP ; Extravascular lung water ; Cardiac surgery
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective To evaluate the effects of continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) on extravascular lung water during weaning from mechanical ventilation in patients following coronary artery bypass grafting. Design Prospective, randomized clinical study. Setting Intensive care unit at a university hospital. Patients Seventy-five patients following coronary artery bypass grafting. Interventions After extubation of the trachea, patients were treated for 30 min with CPAP via face mask (n=25), with nasal BiPAP (n=25), or with oxygen administration via nasal cannula combined with routine chest physiotherapy (RCP) for 10 min (n=25). Measurements and results Extravascular lung water (EVLW), pulmonary blood volume index (PBVI) and cardiac index (CI) were obtained during mechanical ventilation (T1), T-piece breathing (T2), interventions (T3), spontaneous breathing 60 min (T4) and 90 min (T5) after extubation of the trachea using a combined dye-thermal dilution method. Changing from mechanical ventilation to T-piece breathing did not show any significant differences in EVLW between the three groups, but a significant increase in PBVI from 155±5 ml/m2 to 170±4 ml/m2 could be observed in all groups (p〈0.05). After extubation of the trachea and treatment with BiPAP, PBVI decreased significantly to 134±6 ml/m2 (p〈0.05). After treatment with CPAP or BiPAP, EVLW did not change significantly in these groups (5.5±0.3 ml/kg vs 5.0±0.4 ml/kg and 5.1±0.4 ml/kg vs 5.7±0.4 ml/kg). In the RCP-treated group, however, EVLW increased significantly from 5.8±0.3 ml/kg to 7.1±0.4 ml/kg (p〈0.05). Sixty and 90 min after extubation, EVLW stayed at a significantly higher level in the RCP-treated group (7.5±0.5 ml/kg and 7.4±0.5 ml/kg) than in the CPAP-(5.6±0.3 ml/kg and 5.9±0.4 ml/kg). No significant differences in CI could be observed within the three groups during the time period from mechanical ventilation to 90 min after extubation of the trachea. Conclusions Mask CPAP and nasal BiPAP after extubation of the trachea prevent the increase in extravascular lung water during weaning from mechanical ventilation. This effect is seen for at least 1 h after the discontinuation of CPAP or BiPAP treatment. Fuether studies have to evaluate the clinical relavance of this phenomenon.
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  • 2
    ISSN: 1432-1238
    Keywords: Key words Brain resuscitation ; Cardiac arrest ; Cerebral ischemia ; Microcirculation ; Thrombolytic therapy
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective: Successful resuscitation of the brain requires complete microcirculatory reperfusion, which, however, may be impaired by activation of blood coagulation after cardiac arrest. The study addresses the question of whether postischemic thrombolysis is effective in reducing cerebral no-reflow phenomenon. Design: 14 adult normothermic cats were submitted to 15-min cardiac arrest, followed by cardiopulmonary resuscitation (CPR) and 30 min of spontaneous recirculation. The CPR protocol included closed-chest cardiac massage, administration of epinephrine 0.2 mg/kg, bicarbonate 2 mEq/kg per 30 min, and electrical defibrillation shocks. Interventions: During CPR, animals in the treatment group (n=6) received intravenous bolus injections of 100 U/kg heparin and 1 mg/kg recombinant tissue type plasminogen activator (rt-PA), followed by an infusion of rt-PA 1 mg/kg per 30 min. Measurements and results: Microcirculatory reperfusion of the brain was visualized by labeling the circulating blood with 300 mg/kg of 15% fluorescein isothiocyanate albumin at the end of the recirculation period. Areas of cerebral no-reflow – defined as the absence of microvascular filling – were identified by fluorescence microscopy at eight standard coronal levels of forebrain, and expressed as the percentage of total sectional area. One animal in the treatment group was excluded from further analysis because of intracerebral hemorrhage due to brain injury during trepanation. Autopsy revealed the absence of intracranial, intrathoracic, or intra-abdominal bleeding in all the other animals. In untreated animals (n=8), no-reflow affected 28±13% of total forebrain sectional areas, and only 1 out of 8 animals showed homogenous reperfusion (i.e., no-reflow 〈15% of total forebrain sectional areas). Thrombolytic therapy (n=5) significantly reduced no-reflow to 7±5% of total forebrain sectional areas and all treated animals showed homogeneous reperfusion at the microcirculatory level. Conclusions: The present data demonstrate that thrombolytic therapy improves microcirculatory reperfusion of the cat brain when administered during reperfusion after cardiac arrest.
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  • 3
    ISSN: 1432-1238
    Keywords: Key words Thermodilution cardiac output ; Continuous monitoring ; Postoperative intensive care ; Extubation
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective: Commercially available semi-continuous cardiac output (SCCO) monitoring systems are based on the pulsed warm thermodilution technique. There is evidence that SCCO fails to correlate with standard intermittent bolus cardiac output (ICO) in clinical situations with thermal instability in the pulmonary artery. Furthermore, ventilation may potentially influence thermodilution measurements by enhanced respiratory variations in pulmonary artery blood temperature and by cyclic changes in venous return. Therefore, we evaluated the correlation, accuracy and precision of SCCO versus ICO measurements before and after extubation. Design: Prospective cohort study. Setting: Intensive care unit (ICU) of a university hospital. Patients and participants: 22 cardiac surgical ICU patients. Interventions: None. Measurements and results: SCCO and ICO data were obtained at nine postoperative time points while the patients were on controlled mechanical ventilation. Further sets of measurements were taken during the weaning phase 20 min before extubation, and 5 min, 20 min and 1 h after extubation. SCCO and ICO measurements yielded 286 data pairs with a range of 1.8–9.9 l/min for SCCO and 1.9–9.8 l/min for ICO. The correlation between SCCO and ICO was highly significant (r=0.92; p〈0.01), accompanied by a bias of –0.052 l/min and a precision of 0.56 l/min. Correlation, accuracy and precision were not influenced by the mode of respiration. Conclusions: Our results demonstrate excellent correlation, accuracy and precision between SCCO and ICO measurements in postoperative cardiac surgical ICU patients. We conclude that SCCO monitoring offers a reliable clinical method of cardiac output monitoring in ICU patients following cardiac surgery.
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  • 4
    ISSN: 1432-1238
    Keywords: Thermodilution cardiac output ; Continuous monitoring ; Postoperative intensive care ; Extubation
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective Commercially available semi-continuous cardiac output (SCCO) monitoring systems are based on the pulsed warm thermodilution technique. There is evidence that SCCO fails to correlate with standard intermittent bolus cardiac output (ICO) in clinical situations with thermal instability in the pulmonary artery. Furthermore, ventilation may potentially influence thermodilution measurements by enhanced respiratory variations in pulmonary artery blood temperature and by cyclic changes in venous return. Therefore, we evaluated the correlation, accuracy and precision of SCCO versus ICO measurements before and after extubation. Design Prospective cohort study. Setting Intensive care unit (ICU) of a university hospital. Patients and participants 22 cardiac surgical ICU patients. Interventions None. Measurements and results SCCO and ICO data were obtained at nine postoperative time points while the patients were on controlled mechanical ventilation. Further sets of measurements were taken during the weaning phase 20 min before extubation, and 5 min, 20 min and 1 h after extubation. SCCO and ICO measurements yielded 286 data pairs with a range of 1.8–9.9 l/min for SCCO and 1.9–9.8 l/min for ICO. The correlation between SCCO and ICO was highly significant (r=0.92;p〈0.01), accompanied by a bias of −0.052 l/min and a precision of 0.56 l/min. Correlation, accuracy and precision were not influenced by the mode of respiration. Conclusions Our results demonstrate excellent correlation, accuracy and precision between SCCO and ICO measurements in postoperative cardiac surgical ICU patients. We conclude that SCCO monitoring offers a reliable clinical method of cardiac ouput monitoring in ICU patients following cardiac surgery.
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  • 5
    ISSN: 1365-2044
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: Formation of the lignocaine metabolite monoethyl-glycine-xylidide (MEGX) by hepatic cytochrome P450 enzymes is a new method for evaluating liver function. The purpose of this study was to compare MEGX formation with other liver function parameters in surgical intensive care unit patients. The study included 29 critically ill patients who had been admitted to the unit for more than 3 days with a median APACHE III score-predicted mortality 〉 30%. On day 4, lignocaine was given intravenously at a dose of 1 mg.kg-1 over 2 min and MEGX formation was measured 15 min later. Eighty-nine percent of the patients had MEGX values below 90μg.l-1 indicating impaired liver function. Eleven patients died, 18 patients survived. The group of patients with fatal outcome had significantly lower MEGX values (median: 23μg.l-1) than the group of survivors (median: 53μg.l-1, p 〈 0.01). Bilirubin values were elevated in the non-survivor group (median: 2.8mg.dl-1) compared to the survivors (median: 0.9mg.dl-1, p 〈 0.05). There was no significant difference between the two groups in the other liver function tests. We conclude from our results that the MEGX test can be considered an indicator for hepatic dysfunction and predictor of survival in critically ill patients.
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  • 6
    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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  • 7
    ISSN: 1432-1238
    Keywords: Brain resuscitation ; Cardiac arrest ; Cerebral ischemia ; Microcirculation ; Thrombolytic therapy
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective Successful resuscitation of the brain requires complete microcirculatory reperfusion, which, however, may be impaired by activation of blood coagulation after cardiac arrest. The study addresses the question of whether postischemic thrombolysis is effective in reducing cerebral noreflow phenomenon. Design 14 adult normothermic cats were submitted to 15-min cardiac arrest, followed by cardiopulmonary resuscitation (CPR) and 30 min of spontaneous recirculation. The CPR protocol included closed-chest cardiac massage, administration of epinephrine 0.2 mg/kg, bicarbonate 2mEq/kg per 30 min, and electrical defibrillation shocks. Interventions During CPR, animals in the treatment group (n=6) received intravenous bolus injections of 100 U/kg heparin and 1 mg/kg recombinant tissue type plasminogen activator (rt-PA), followed by an infusion of rt-PA 1mg/kg per 30 min. Measurements and results Microcirculatory reperfusion of the brain was visualized by labeling the circulating blood with 300 mg/kg of 15% fluorescein isothiocyanate albumin at the end of the recirculation period. Areas of cerebral noreflow — defined as the absence of microvascular filling — were identified by fluorescence microscopy at eight standard coronal levels of forebrain, and expressed as the percentage of total sectional area. One animal in the treatment group was excluded from further analysis because of intracerebral hemorrhage due to brain injury during trepanation. Autopsy revealed the absence of intracranial, intrathoracic, or intra-abdominal bleeding in all the other animals. In untreated animals (n=8), no-reflow affected 28±13% of total forebrain sectional areas, and only 1 out of 8 animals showed homogeneous reperfusion (i.e., no-reflow 〈15% of total forebrain sectional areas). Thrombolytic therapy (n=5) significantly reduced no-reflow to 7±5% of total forebrain sectional areas and all treated animals showed homogeneous reperfusion at the microcirculatory level. Conclusions The present data demonstrate that thrombolytic therapy improves microcirculatory reperfusion of the cat brain when administered during reperfusion after cardiac arrest.
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  • 8
    ISSN: 1432-1238
    Keywords: Key words Weaning ; CPAP ; BiPAP ; Extravascular lung water ; Cardiac surgery
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective: To evaluate the effects of continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) on extravascular lung water during weaning from mechanical ventilation in patients following coronary artery bypass grafting. Design; Prospective, randomized clinical study. Setting; Intensive care unit at a university hospital. Patients; Seventy-five patients following coronary artery bypass grafting. Interventions; After extubation of the trachea, patients were treated for 30 min with CPAP via face mask (n=25), with nasal BiPAP (n=25), or with oxygen administration via nasal cannula combined with routine chest physiotherapy (RCP) for 10 min (n=25). Measurements and results: Extravascular lung water (EVLW), pulmonary blood volume index (PBVI) and cardiac index (CI) were obtained during mechanical ventilation (T1), T-piece breathing (T2), interventions (T3), spontaneous breathing 60 min (T4) and 90 min (T5) after extubation of the trachea using a combined dye-thermal dilution method. Changing from mechanical ventilation to T-piece breathing did not show any significant differences in EVLW between the three groups, but a significant increase in PBVI from 155±5 ml/m2 to 170±4 ml/m2 could be observed in all groups (p〈0.05). After extubation of the trachea and treatment with BiPAP, PBVI decreased significantly to 134±6 ml/m2 (p〈0.05). After treatment with CPAP or BiPAP, EVLW did not change significantly in these groups (5.5±0.3 ml/kg vs 5.0±0.4 ml/kg and 5.1±0.4 ml/kg vs 5.7±0.4 ml/kg). In the RCP-treated group, however, EVLW increased significantly from 5.8±0.3 ml/kg to 7.1±0.4 ml/kg (p〈0.05). Sixty and 90 min after extubation, EVLW stayed at a significantly higher level in the RCP-treated group (7.5±0.5 ml/kg and 7.4±0.5 ml/kg) than in the CPAP-(5.6±0.3 ml/kg and 5.9±0.4 ml/kg) or BiPAP-treated groups (5.2±0.4 ml/kg and 5.2±0.4 ml/kg). No significant differences in CI could be observed within the three groups during the time period from mechanical ventilation to 90 min after extubation of the trachea. Conclusions: Mask CPAP and nasal BiPAP after extubation of the trachea prevent the increase in extravascular lung water during x weaning from mechanical ventilation. This effect is seen for at least 1 h after the discontinuation of CPAP or BiPAP treatment.Further studies have to evaluate the clinical relevance of this phenomenon.
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  • 9
    ISSN: 1432-1238
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
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