1
|
Voicu V, Diehm N, Moarof I, Parejo S, Badiqué F, Burden A, Niedrig D, Béchir M, Russmann S. Antiplatelet therapy guided by CYP2C19 point-of-care pharmacogenetics plus multidimensional treatment decisions. Pharmacogenomics 2024; 25:5-19. [PMID: 38230622 DOI: 10.2217/pgs-2023-0200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
Aim: Implementation of CYP2C19 point-of-care (POC) pharmacogenetic (PGx) testing with personalized treatment recommendations. Methods: POC CYP2C19 genotyping plus expert evaluation of risk factors for ischemic and bleeding events. Results: 167 patients underwent PGx testing, 54 (32.3%) were CYP2C19 loss of function carriers, and POC versus standard PGx analysis results for *2 and *3 variants matched in 100%. Antiplatelet therapy was adjusted in 44 patients (26.3%), but always required consideration of patient-specific factors. Conclusion: CYP2C19 POC-PGx is reliable and offers clinically relevant advantages for immediate evidence-based adaptations of antiplatelet therapy, whereas in less acute cases conventional PGx testing can also have advantages. Antiplatelet therapy has become more complex, and implementation of PGx-based personalized antiplatelet therapy requires complementary expert knowledge.
Collapse
Affiliation(s)
- Victor Voicu
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
| | - Nicolas Diehm
- Center for Vascular Medicine, 5000, Aarau, Switzerland
| | - Igal Moarof
- Cardiology Center Mittelland, 5001, Aarau, Switzerland
| | - Sarah Parejo
- Medical Genetics Laboratory, Labor Risch, 3097, Berne-Liebefeld, Switzerland
| | - Florent Badiqué
- Medical Genetics Laboratory, Labor Risch, 3097, Berne-Liebefeld, Switzerland
| | - Andrea Burden
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
| | - David Niedrig
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
- Hospital Pharmacy, Clinic Hirslanden Zurich, 8032, Zurich, Switzerland
| | - Markus Béchir
- Center for Internal Medicine, Hirslanden Clinic Aarau, 5001 Aarau, Switzerland
| | - Stefan Russmann
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
- Center for Internal Medicine, Hirslanden Clinic Aarau, 5001 Aarau, Switzerland
- University of Nicosia Medical School, 2408, Nicosia-Egkomi, Cyprus
| |
Collapse
|
2
|
Russmann S, Martinelli F, Jakobs F, Pannu M, Niedrig DF, Burden AM, Kleber M, Béchir M. Identification of Medication Prescription Errors and Factors of Clinical Relevance in 314 Hospitalized Patients for Improved Multidimensional Clinical Decision Support Algorithms. J Clin Med 2023; 12:4920. [PMID: 37568322 PMCID: PMC10419486 DOI: 10.3390/jcm12154920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Potential medication errors and related adverse drug events (ADE) pose major challenges in clinical medicine. Clinical decision support systems (CDSSs) help identify preventable prescription errors leading to ADEs but are typically characterized by high sensitivity and low specificity, resulting in poor acceptance and alert-overriding. With this cross-sectional study we aimed to analyze CDSS performance, and to identify factors that may increase CDSS specificity. Clinical pharmacology services evaluated current pharmacotherapy of 314 patients during hospitalization across three units of two Swiss tertiary care hospitals. We used two CDSSs (pharmaVISTA and MediQ), primarily for the evaluation of drug-drug interactions (DDI). Additionally, we evaluated potential drug-disease, drug-age, drug-food, and drug-gene interactions. Recommendations for change of therapy were forwarded without delay to treating physicians. Among 314 patients, automated analyses by both CDSSs produced an average of 15.5 alerts per patient. In contrast, additional expert evaluation resulted in only 0.8 recommendations per patient to change pharmacotherapy. For clinical pharmacology experts, co-factors such as comorbidities and laboratory results were decisive for the classification of CDSS alerts as clinically relevant in individual patients in about 70% of all decisions. Such co-factors should therefore be used for the development of multidimensional CDSS alert algorithms with improved specificity. In combination with local expert services, this poses a promising approach to improve drug safety in clinical practice.
Collapse
Affiliation(s)
- Stefan Russmann
- Swiss Federal Institute of Technology Zurich (ETHZ), 8093 Zurich, Switzerland; (F.M.); (F.J.); (A.M.B.)
- Faculty of Medicine, University of Nicosia, 2408 Egkomi, Cyprus; (M.P.); (M.B.)
- Drugsafety.ch, Seestrasse 221, 8703 Küsnacht, Switzerland;
- Department of Internal Medicine, Clinic Hirslanden Zurich, 8032 Zurich, Switzerland;
- Center for Internal Medicine, Clinic Hirslanden Aarau, 5001 Aarau, Switzerland
| | - Fabiana Martinelli
- Swiss Federal Institute of Technology Zurich (ETHZ), 8093 Zurich, Switzerland; (F.M.); (F.J.); (A.M.B.)
| | - Franziska Jakobs
- Swiss Federal Institute of Technology Zurich (ETHZ), 8093 Zurich, Switzerland; (F.M.); (F.J.); (A.M.B.)
| | - Manjinder Pannu
- Faculty of Medicine, University of Nicosia, 2408 Egkomi, Cyprus; (M.P.); (M.B.)
| | - David F. Niedrig
- Drugsafety.ch, Seestrasse 221, 8703 Küsnacht, Switzerland;
- Hospital Pharmacy, Clinic Hirslanden Zurich, 8032 Zurich, Switzerland
| | - Andrea Michelle Burden
- Swiss Federal Institute of Technology Zurich (ETHZ), 8093 Zurich, Switzerland; (F.M.); (F.J.); (A.M.B.)
| | - Martina Kleber
- Department of Internal Medicine, Clinic Hirslanden Zurich, 8032 Zurich, Switzerland;
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - Markus Béchir
- Faculty of Medicine, University of Nicosia, 2408 Egkomi, Cyprus; (M.P.); (M.B.)
- Center for Internal Medicine, Clinic Hirslanden Aarau, 5001 Aarau, Switzerland
| |
Collapse
|
3
|
Niedrig DF, Rahmany A, Heib K, Hatz KD, Ludin K, Burden AM, Béchir M, Serra A, Russmann S. Clinical Relevance of a 16-Gene Pharmacogenetic Panel Test for Medication Management in a Cohort of 135 Patients. J Clin Med 2021; 10:jcm10153200. [PMID: 34361984 PMCID: PMC8347064 DOI: 10.3390/jcm10153200] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/11/2021] [Accepted: 07/19/2021] [Indexed: 12/17/2022] Open
Abstract
There is a growing number of evidence-based indications for pharmacogenetic (PGx) testing. We aimed to evaluate clinical relevance of a 16-gene panel test for PGx-guided pharmacotherapy. In an observational cohort study, we included subjects tested with a PGx panel for variants of ABCB1, COMT, CYP1A2, CYP2B6, CYP3A4, CYP3A5, CYP2C9, CYP2C19, CYP2D6, CYP4F2, DPYD, OPRM1, POR, SLCO1B1, TPMT and VKORC1. PGx-guided pharmacotherapy management was supported by the PGx expert system SONOGEN XP. The primary study outcome was PGx-based changes and recommendations regarding current and potential future medication. PGx-testing was triggered by specific drug-gene pairs in 102 subjects, and by screening in 33. Based on PharmGKB expert guidelines we identified at least one "actionable" variant in all 135 (100%) tested patients. Drugs that triggered PGx-testing were clopidogrel in 60, tamoxifen in 15, polypsychopharmacotherapy in 9, opioids in 7, and other in 11 patients. Among those, PGx variants resulted in clinical recommendations to change PGx-triggering drugs in 33 (32.4%), and other current pharmacotherapy in 23 (22.5%). Additional costs of panel vs. single gene tests are moderate, and the efficiency of PGx panel testing challenges traditional cost-benefit calculations for single drug-gene pairs. However, PGx-guided pharmacotherapy requires specialized expert consultations with interdisciplinary collaborations.
Collapse
Affiliation(s)
- David F. Niedrig
- Drugsafety.ch, 8703 Kusnacht, Switzerland; (D.F.N.); (A.R.)
- Hospital Pharmacy, Clinic Hirslanden Zurich, 8032 Zurich, Switzerland
| | - Ali Rahmany
- Drugsafety.ch, 8703 Kusnacht, Switzerland; (D.F.N.); (A.R.)
- Swiss Federal Institute of Technology Zurich (ETHZ), 8093 Zurich, Switzerland;
| | - Kai Heib
- INTLAB AG, 8707 Uetikon am See, Switzerland; (K.H.); (K.-D.H.)
| | | | - Katja Ludin
- Labor Risch, Molecular Genetics, 3097 Berne, Switzerland;
| | - Andrea M. Burden
- Swiss Federal Institute of Technology Zurich (ETHZ), 8093 Zurich, Switzerland;
| | - Markus Béchir
- Center for Internal Medicine, Clinic Hirslanden Aarau, 5001 Aarau, Switzerland;
| | - Andreas Serra
- Institute of Internal Medicine and Nephrology, Clinic Hirslanden Zurich, 8032 Zurich, Switzerland;
| | - Stefan Russmann
- Drugsafety.ch, 8703 Kusnacht, Switzerland; (D.F.N.); (A.R.)
- Swiss Federal Institute of Technology Zurich (ETHZ), 8093 Zurich, Switzerland;
- Institute of Internal Medicine and Nephrology, Clinic Hirslanden Zurich, 8032 Zurich, Switzerland;
- Correspondence: ; Tel.: +41-(0)44-221-1003
| |
Collapse
|
4
|
Weiss J, Elmer A, Béchir M, Brunner C, Eckert P, Endermann S, Lenherr R, Nebiker M, Tisljar K, Haberthür C, Immer FF. Deceased organ donation activity and efficiency in Switzerland between 2008 and 2017: achievements and future challenges. BMC Health Serv Res 2018; 18:876. [PMID: 30458762 PMCID: PMC6247533 DOI: 10.1186/s12913-018-3691-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 11/05/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Various actions have been taken during the last decade to increase the number of organs from deceased donors available for transplantation in Switzerland. This study provides an overview on key figures of the Swiss deceased organ donation and transplant activity between 2008 and 2017. In addition, it puts the evolution of the Swiss donation program's efficiency in relation to the situation in the neighboring countries. METHODS This study is an analysis of prospective registry data, covering the period from 1 January 2008 to 31 December 2017. It includes all actual deceased organ donors (ADD) in Switzerland. Donor data were extracted from the Swiss Organ Allocation System. The "donor conversion index" (DCI) methodology and data was used for the comparison of donation program efficiency in Switzerland, Germany, Austria, Italy and France. RESULTS During the study period there were 1116 ADD in Switzerland. The number of ADD per year increased from 91 in 2008 to 145 in 2017 (+ 59%). The reintroduction of the donation after cardiocirculatory death (DCD) program in 2011 resulted in the growth of annual percentages of DCD donors, reaching a maximum of 27% in 2017. The total number of organs transplanted from ADD was 3763 (3.4 ± 1.5 transplants per donor on average). Of these, 48% were kidneys (n = 1814), 24% livers (n = 903), 12% lungs (n = 445), 9% hearts (n = 352) and 7% pancreata or pancreatic islets (n = 249). The donation program efficiency assessment showed an increase of the Swiss DCI from 1.6% in 2008 to 2.7% in 2017 (+ 69%). The most prominent efficiency growth was observed between 2012 and 2017. Even though Swiss donation efficiency increased during the study period, it remained below the DCI of the French and Austrian donation programs. CONCLUSION Swiss donation activity and efficiency grew during the last decade. The increased donation efficiency suggests that measures implemented so far were effective. The lower efficiency of the Swiss donation program, compared to the French and Austrian programs, may likely be explained by the lower consent rate in Switzerland. This issue should be addressed in order to achieve the goal of more organs available for transplantation.
Collapse
Affiliation(s)
- Julius Weiss
- Swisstransplant, the Swiss National Foundation for Organ Donation and Transplantation, Bern, Switzerland
| | - Andreas Elmer
- Swisstransplant, the Swiss National Foundation for Organ Donation and Transplantation, Bern, Switzerland
| | - Markus Béchir
- Zentrum für Innere Medizin, Hirslanden Klinik Aarau, Aarau, Switzerland
| | - Christian Brunner
- Zentrum für Intensivmedizin, Luzerner Kantonsspital, Luzern, Switzerland
| | - Philippe Eckert
- Service de Médecine Intensive Adulte et Centre des Brûlés, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Susann Endermann
- Klinik für Anästhesiologie, Intensiv-, Rettungs- und Schmerzmedizin, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Renato Lenherr
- Chirurgische Intensivmedizin USZ, Universitätsspital Zürich, Zürich, Switzerland
| | - Mathias Nebiker
- Transplantationszentrum, Direktion Medizin und Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Kai Tisljar
- Medizinische Intensivstation, Universitätsspital Basel, Basel, Switzerland
| | - Christoph Haberthür
- Klinik Hirslanden, Institut für Anästhesiologie und Intensivmedizin, Zürich, Switzerland
| | - Franz F Immer
- Swisstransplant, the Swiss National Foundation for Organ Donation and Transplantation, Bern, Switzerland.
| | | |
Collapse
|
5
|
Cottini SR, Brandi G, Pagnamenta A, Weder W, Schuepbach RA, Béchir M, Huber LC, Benden C. Pulmonary hypertension is not a risk factor for grade 3 primary graft dysfunction after lung transplantation. Clin Transplant 2018; 32:e13251. [DOI: 10.1111/ctr.13251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 01/21/2023]
Affiliation(s)
- Silvia R. Cottini
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
| | - Giovanna Brandi
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
| | - Alberto Pagnamenta
- Department of Intensive Care Medicine of the Ente Ospedaliero Cantonale (EOC): Intensive Care Unit of Regional Hospital of Mendrisio; Mendrisio Switzerland
- Unit of Clinical Epidemiology; Ente Ospedaliero Cantonale; Bellinzona Switzerland
| | - Walter Weder
- Division of Thoracic Surgery; University Hospital Zurich; Zurich Switzerland
| | - Reto A. Schuepbach
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
- Swiss Paraplegic Center; Nottwil Switzerland
| | - Lars C. Huber
- Division of Pulmonology; University Hospital Zurich; Zurich Switzerland
- Clinic for Internal Medicine; City Hospital Triemli; Zurich Switzerland
| | - Christian Benden
- Division of Pulmonology; University Hospital Zurich; Zurich Switzerland
| |
Collapse
|
6
|
Müller R, Landmann G, Béchir M, Hinrichs T, Arnet U, Jordan X, Brinkhof MWG. Chronic pain, depression and quality of life in individuals with spinal cord injury: Mediating role of participation. J Rehabil Med 2018; 49:489-496. [PMID: 28597908 DOI: 10.2340/16501977-2241] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To test the hypotheses that: (i) pain is associated with depressive symptoms and quality of life; and (ii) participation restriction, satisfaction, and frequency mediate these relationships. DESIGN Population-based, cross-sectional study. SUBJECTS/PATIENTS Community-dwelling individuals with spinal cord injury (n = 1,549). METHODS Hypotheses were tested in individuals with at least moderate chronic pain on the spinal cord injury - Secondary Conditions Scale (n = 834), applying structural equation modelling to data for spinal cord injury subgroups related to lesion severity (paraplegia, tetraplegia, complete, incomplete) and time since injury (≤ 10 vs ≥ 10 years). Model parameters included pain intensity (numerical rating scale), participation frequency, restriction, satisfaction (Utrecht Scale of Evaluation of Rehabilitation-Participation; USER-Participation), depressive symptoms (5-item Mental Health Index of the Short Form Health Survey; MHI-5), and 5 selected quality of life items (World Health Organization Quality of Life Scale; WHOQoL-BREF). RESULTS Structural equation models confirmed associations of pain with depressive symptoms and quality of life, as well as the mediating role of participation restriction and low satisfaction with participation. These findings were apparent in individuals with tetraplegia or complete lesion and in those ≤ 10 years since paraplegia or incomplete injury. CONCLUSION Unrestricted or satisfactory participation was found to be a crucial resource for individuals living less than 10 years with a more severe spinal cord injury, since it represents buffering potential for the negative effects of chronic pain on mental health and quality of life.
Collapse
Affiliation(s)
- Rachel Müller
- Empowerment, Participation and Social Integration Unit, Swiss Paraplegic Research (SPF), 6207 Nottwil, Switzerland.
| | | | | | | | | | | | | |
Collapse
|
7
|
Abakar MF, Schelling E, Béchir M, Ngandolo BN, Pfister K, Alfaroukh IO, Hassane HM, Zinsstag J. Trends in health surveillance and joint service delivery for pastoralists in West and Central Africa. REV SCI TECH OIE 2017; 35:683-691. [PMID: 27917961 DOI: 10.20506/rst.35.2.2549] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In most sub-Saharan African countries, pastoralism represents an important economic resource and contributes significantly to national growth; however, challenges remain, particularly in providing social services to pastoralists (especially health and education) and in avoiding conflict with local sedentary communities and local authorities. All of this takes place while pastoralists try to maintain their mobile lifestyle within a rapidly changing ecosystem. Transdisciplinary approaches, such as 'One Health', which covers both human and animal health, have proven effective in delivering services and reaching mobile pastoralists in remote areas. The pastoralist way of life could be described as being linked to both their livestock and their environment, which makes social science an important element when researching the delivery and adaptation of social services to pastoralists. Early or pre-diagnostic detection of emerging and endemic infectious disease remains a vital aspect of health surveillance targeted at preventing further transmission and spread. Community-based syndromic surveillance, coupled with visual mobile phone technology, adapted to the high levels of illiteracy among nomads, could offer an alternative to existing health surveillance systems. Such an approach could contribute to accelerated reporting, which could in turn lead to targeted intervention among mobile pastoralists in sub-Saharan Africa. Although considerable efforts have been made towards integrating mobile pastoralists into social services, obstacles remain to the adoption of a clear, specific and sustainable policy on pastoralism in sub-Saharan Africa.
Collapse
|
8
|
Schelling E, Greter H, Kessely H, Abakar MF, Ngandolo BN, Crump L, Bold B, Kasymbekov J, Baljinnyam Z, Fokou G, Zinsstag J, Bonfoh B, Hattendorf J, Béchir M. Human and animal health surveys among pastoralists. REV SCI TECH OIE 2017; 35:659-671. [PMID: 27917962 DOI: 10.20506/rst.35.2.2547] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Valid human and livestock health surveys, including longitudinal follow-up, are feasible among mobile pastoralists and provide fundamental information to agencies for interventions that are responsive to realities and effective in addressing the needs of pastoralists. However, pastoralists are often excluded from studies, surveillance systems and health programmes. The occurrence of preventable and treatable diseases such as perinatal tetanus, measles and tuberculosis are indicative of limited access to health providers and information. It is difficult for health services to include effective outreach with their available financial and human resources. One consequence is that maternal mortality rates among pastoralists are unacceptably high. Environmental determinants such as the quality of water and the pasture ecosystems further influence the morbidity of pastoralists. In the Sahel, the nutritional status of pastoralist children is seasonally better than that of settled children; but pastoralist women tend to have higher acute malnutrition rates. Pastoralist women are more vulnerable than men to exclusion from health services for different context-specific reasons. Evidence-based control measures can be assessed in cluster surveys with simultaneous assessments of health among people and livestock, where data on costs of disease and interventions are also collected. These provide important arguments for governmental and non-governmental agencies for intervention development. New, integrated One Health surveillance systems making use of mobile technology and taking into account local concepts and the experiences and priorities of pastoralist communities, combined with sound field data, are essential to develop and provide adapted human and animal health services that are inclusive for mobile pastoralist communities and allow them to maintain their mobile way of life.
Collapse
|
9
|
Reck T, Chang EC, Béchir M, Kallenbach U. Applying a Part of the Daily Dose as Boli May Improve Intrathecal Opioid Therapy in Patients With Chronic Pain. Neuromodulation 2016; 19:533-40. [DOI: 10.1111/ner.12391] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 05/11/2015] [Accepted: 11/24/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Tim Reck
- Centre for Pain Medicine, Swiss Paraplegic Centre; Nottwil Switzerland
| | - En-Chul Chang
- Centre for Pain Medicine, Swiss Paraplegic Centre; Nottwil Switzerland
| | - Markus Béchir
- Centre for Pain Medicine, Swiss Paraplegic Centre; Nottwil Switzerland
| | - Ulrich Kallenbach
- Centre for Pain Medicine, Swiss Paraplegic Centre; Nottwil Switzerland
| |
Collapse
|
10
|
Cottini SR, Ehlers UE, Pagnamenta A, Brandi G, Weder W, Schuepbach RA, Béchir M, Benden C. Pretransplant dyslipidaemia influences primary graft dysfunction after lung transplantation. Interact Cardiovasc Thorac Surg 2015; 22:402-5. [DOI: 10.1093/icvts/ivv295] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/22/2015] [Indexed: 01/01/2023] Open
|
11
|
Klinzing S, Brandi G, Stehberger PA, Raptis DA, Béchir M. The combination of MELD score and ICG liver testing predicts length of stay in the ICU and hospital mortality in liver transplant recipients. BMC Anesthesiol 2014; 14:103. [PMID: 25844060 PMCID: PMC4384315 DOI: 10.1186/1471-2253-14-103] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 10/27/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Early prediction of outcome would be useful for an optimal intensive care management of liver transplant recipients. Indocyanine green clearance can be measured non-invasively by pulse spectrophometry and is closely related to liver function. METHODS This study was undertaken to assess the predictive value of a combination of the model of end stage liver disease (MELD) score and early indocyanine plasma disappearance rates (ICG-PDR) for length of stay in the intensive care unit (ICU), length of stay in the hospital and hospital mortality in liver transplant recipients. RESULTS Fifty consecutive liver transplant recipients were included in this post Hoc single-center study. ICG-PDR was determined within 6 hours after ICU admission. Endpoints were length of stay in the ICU, length of hospital stay and hospital mortality. The combination of a high MELD score (MELD >25) and a low ICG-PDR clearance (ICG-PDR < 20%/minute) predicts a significant longer stay in the ICU (p = 0.004), a significant longer stay in the hospital (p < 0.001) and a hospital mortality of 40% vs. 0% (p = 0.003). CONCLUSION The combination of MELD scores and a singular ICG-PDR measurement in the early postoperative phase is an accurate predictor for outcome in liver transplant recipients. This easy-to-assess tool might be valuable for an optimal intensive care management of those patients.
Collapse
Affiliation(s)
- Stephanie Klinzing
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Giovanna Brandi
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Paul A Stehberger
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Visceral- and Transplantation Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| |
Collapse
|
12
|
Zoller B, Spanaus K, Gerster R, Fasshauer M, Stehberger PA, Klinzing S, Vergopoulos A, von Eckardstein A, Béchir M. ICG-liver test versus new biomarkers as prognostic markers for prolonged length of stay in critically ill patients - a prospective study of accuracy for prediction of length of stay in the ICU. Ann Intensive Care 2014; 4:19. [PMID: 25045579 PMCID: PMC4100565 DOI: 10.1186/s13613-014-0019-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 05/22/2014] [Indexed: 12/05/2022] Open
Abstract
Background Prognostic abilities of medical parameters, which are scoring systems, measurements and biomarkers, are important for stratifying critically ill patients. Indocyanine green plasma disappearance (ICG-PDR) is an established clinical tool for the assessment of liver perfusion and function. Copeptin, MR-proANP and pro-ADM are biomarkers whose prognostic value is still unclear. The goal of this prospective study was to evaluate ICG-PDR, copeptin, MR-proANP and pro-ADM to predict prolonged length of stay (pLOS) in the ICU. Methods This study was conducted as a prospective single center study including 110 consecutively admitted ICU patients. Primary endpoint was prolonged length of stay (pLOS) in the ICU, defined as more than three days of stay there. Results ROC analysis showed an AUC of 0.73 for ICG-PDR, 0.70 for SAPS II, 0.65 for MR-proANP, 0.64 for pro-ADM and 0.54 for copeptin for pLOS in the ICU. Conclusions The prediction of pLOS in the ICU might be better by means of ICG-PDR than with the new biomarkers copeptin, MR-proANP or pro-ADM. Nevertheless, there is more need for research to evaluate whether ICG-PDR is an overall prognostic marker for pLOS. Trial registration (ClinicalTrials.gov number, NCT01126554).
Collapse
Affiliation(s)
- Bernhard Zoller
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Katharina Spanaus
- Institute of Clinical Chemistry, University and University Hospital Zurich, Zurich, Switzerland
| | - Rahel Gerster
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Mario Fasshauer
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Paul A Stehberger
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Stephanie Klinzing
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Athanasios Vergopoulos
- Institute of Clinical Chemistry, University and University Hospital Zurich, Zurich, Switzerland
| | - Arnold von Eckardstein
- Institute of Clinical Chemistry, University and University Hospital Zurich, Zurich, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland ; Swiss Paraplegic Center, Nottwil, Switzerland
| |
Collapse
|
13
|
Landmann G, Stockinger L, Béchir M, Chang EC. P999: Sensitivity of infrared thermography imaging in the evaluation of the accuracy of nerve root and sympathetic nerve blocks. Clin Neurophysiol 2014. [DOI: 10.1016/s1388-2457(14)51035-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
14
|
Landmann G, Lustenberger C, Stockinger L, Béchir M, Ljutow A. P143: What do laser-evoked potentials (LEP) show in patients with functional non organic sensory disturbances: a report of 2 cases. Clin Neurophysiol 2014. [DOI: 10.1016/s1388-2457(14)50283-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
15
|
Klinzing S, Brandi G, Raptis DA, Wenger U, Weber D, Stehberger PA, Inci I, Béchir M. Influence on ICU course, outcome and costs for lung transplantation after implementation of the new Swiss transplantation law. Transplant Res 2014; 3:9. [PMID: 24690254 PMCID: PMC3975267 DOI: 10.1186/2047-1440-3-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 03/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Swiss organ allocation system for donor lungs was implemented on 1 July 2007. The effects of this implementation on patient selection, intensive care unit course, outcomes and intensive care costs are unknown. METHODS The first 37 consecutive lung transplant recipients following the implementation of the new act were compared with the previous 42 lung transplant recipients. RESULTS Following implementation of the new law, baseline characteristics and cumulative one-year patient survival were comparable in both groups (88.1% vs 83.8%, P = 0.58). The costs for each case increased by 35,000 euros after adoption of the new law. Stratifying patients after implementation of the law according to urgency status shows that urgent patients required longer mechanical ventilation (P = 0.04), a longer ICU stay (P = 0.045) and a longer hospital stay (P = 0.04) and ICU costs (median 64,050 euros) were higher compared to regular patients. CONCLUSION The new transplantation law has increased ICU costs with the implementation of the Swiss organ allocation system. Patients listed as 'urgent' contribute significantly to the increase in ICU costs.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland.
| |
Collapse
|
16
|
Fisher OM, Oberkofler CE, Raptis DA, Soll C, Béchir M, Schiesser M, Graf R. Pancreatic stone protein (PSP) and pancreatitis-associated protein (PAP): a protocol of a cohort study on the diagnostic efficacy and prognostic value of PSP and PAP as postoperative markers of septic complications in patients undergoing abdominal surgery (PSP study). BMJ Open 2014; 4:e004914. [PMID: 24604486 PMCID: PMC3948573 DOI: 10.1136/bmjopen-2014-004914] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Major abdominal surgery leads to a postoperative systemic inflammatory response, making it difficult to discriminate patients with systemic inflammatory response syndrome from those with a beginning postoperative infectious complication. At present, physicians have to rely on their clinical experience to differentiate between the two. Pancreatic stone protein (PSP) and pancreatitis-associated protein (PAP), both secretory proteins produced by the pancreas, are dramatically increased during pancreatic disease and have been shown to act as acute-phase proteins. Increased levels of PSP have been detected in polytrauma patients developing sepsis and PSP has shown a high diagnostic accuracy in discriminating the severity of peritonitis and in predicting death in intensive care unit patients. However, the prognostic value of PSP/PAP for infectious complications among patients undergoing major abdominal surgery is unknown. METHODS AND ANALYSIS 160 patients undergoing major abdominal surgery will be recruited preoperatively. On the day before surgery, baseline blood values are attained. Following surgery, daily blood samples for measuring regular inflammatory markers (c-reactive protein, procalcitonin, interleukin-6, tumour necrosis factor-α and leucocyte counts) and PSP/PAP will be acquired. PSP/PAP will be measured using a validated ELISA developed in our research laboratory. Patient's discharge marks the end of his/her trial participation. Complication grade including mortality and occurrence of infectious postoperative complications according to validated diagnostic criteria will be correlated with PSP/PAP values. Total intensive care unit days and total length of stay will be recorded as further outcome parameters. ETHICS AND DISSEMINATION The PSP trial is a prospective monocentric cohort study evaluating the prognostic value of PSP and PAP for postoperative infectious complications. In addition, a comparison with established inflammatory markers in patients undergoing major abdominal surgery will be performed to help evaluate the role of these proteins in predicting and diagnosing infectious and other postoperative complications. INSTITUTION ETHICS BOARD APPROVAL ID KEKZH-Nr. STV 11-2009. TRIAL REGISTRATION ClinicalTrials.gov: NCT01258179.
Collapse
Affiliation(s)
| | | | | | - Christopher Soll
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Unit, University Hospital Zurich, Zurich, Switzerland
| | - Marc Schiesser
- Department of Surgery, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Rolf Graf
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
17
|
Béchir M, Puhan MA, Fasshauer M, Schuepbach RA, Stocker R, Neff TA. Early fluid resuscitation with hydroxyethyl starch 130/0.4 (6%) in severe burn injury: a randomized, controlled, double-blind clinical trial. Crit Care 2013; 17:R299. [PMID: 24365167 PMCID: PMC4057504 DOI: 10.1186/cc13168] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 12/02/2013] [Indexed: 01/28/2023]
Abstract
Introduction There are limited data on the efficacy of early fluid resuscitation with third-generation hydroxyethyl starch (HES 130) in burn injury. Adverse effects of HES on survival and organ function have been reported. Methods In this randomized, controlled, double-blind trial, 48 patients with severe burn injury were assigned to receive either lactated Ringer’s solution plus 6% HES 130/0.4 in a ratio of 2:1 or lactated Ringer’s solution with no colloid supplement for the first 72 hours. Primary outcome parameter was the group difference of administered total fluid from intensive care unit (ICU) admission up to day 3. Secondary outcomes included kidney and lung injury and failure, length of stay, and mortality. Results Three-day totals of administered resuscitation fluid (medians) were 21,190 mL in the lactated Ringer’s group and 19,535 mL in the HES group (HES: −1,213 mL; P = 0.39). Creatinine levels from day 1 to 3 (HES: +0.4 μmol/L; 95% confidence interval (CI) −18.7 to 19.5; P = 0.97) and urinary outputs from day 1 to 3 (HES: −58 mL; 95% CI −400 to 283; P = 0.90) were not different. Six patients in each group developed acute respiratory distress syndrome (ARDS) (risk ratio 0.96; 95% CI 0.35 to 2.64; P = 0.95). Length of ICU stay (HES vs. lactated Ringer’s: 28 vs. 24 days; P = 0.80) and length of hospital stay (31 vs. 29 days; P = 0.57) were similar. Twenty-eight-day mortality was 4 patients in each group (risk ratio 0.96; 95% CI 0.27 to 4.45; P = 0.95), and in-hospital mortality was 8 in the HES group vs. 5 patients in the lactated Ringer’s group (hazard ratio 1.86; 95% CI 0.56 to 6.19; P = 0.31). Conclusions There was no evidence that early fluid resuscitation with balanced HES 130/0.4 (6%) in addition to lactated Ringer’s solution would lead to a volume-sparing effect in severe burn injury. Together with the findings that early renal function, incidence of ARDS, length of stay, and mortality were not negatively influenced by HES in this setting, balanced HES 130/0.4 (6%) plus lactated Ringer’s solution could not be considered superior to lactated Ringer’s solution alone. Trial registration ClinicalTrials.gov NCT01012648
Collapse
|
18
|
Zuercher AJ, Inci I, Benden C, Fretz G, Béchir M, Boehler A, Weder W. Intra-operative extracorporeal membrane oxygenation use in pediatric lung transplantation--the Zurich experience. Pediatr Transplant 2013; 17:800-5. [PMID: 24164829 DOI: 10.1111/petr.12155] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2013] [Indexed: 11/29/2022]
Abstract
There is a lack of data regarding use of ECMO in children undergoing lung transplantation. We evaluated our experience of ECMO in pediatric lung transplant recipients. All patients (<18 yr) who underwent lung transplants between 1997 and 2011 were included (17 children; nine males; median age 16 yr), and the use of intra-operative ECMO evaluated. Transplant procedures were carried out with intra-operative ECMO in seven children (all bilateral lung transplants). Demographics of ECMO and non-ECMO patients were comparable. One child was already on ECMO pre-operative. Lung graft size reduction was undertaken in five ECMO and four non-ECMO cases, respectively. Five patients were taken off ECMO intra-operatively; the other patients were weaned off ECMO within 48 h post-operatively. Three-months survival was 100%. By 12 months post-transplantation, one patient each died in the ECMO and in the non-ECMO group. At the end of the study, six of seven ECMO cases were still alive (median survival 48.5 months); one patient required a retransplant at 53 months. Our small case series suggests that lung transplant procedures can be safely carried out in selected children on intra-operative ECMO support; however, our pediatric experience regarding this scenario is very limited but probably almost unique.
Collapse
Affiliation(s)
- Alice J Zuercher
- Division of Pulmonary Medicine, University Hospital Zurich, Zurich, Switzerland
| | | | | | | | | | | | | |
Collapse
|
19
|
Weber D, Cottini SR, Locher P, Wenger U, Stehberger PA, Fasshauer M, Schuepbach RA, Béchir M. Association of intraoperative transfusion of blood products with mortality in lung transplant recipients. Perioper Med (Lond) 2013; 2:20. [PMID: 24472535 PMCID: PMC3964322 DOI: 10.1186/2047-0525-2-20] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 09/19/2013] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The impact of intraoperative transfusion on postoperative mortality in lung transplant recipients is still elusive. METHODS Univariate and multivariate analysis were performed to investigate the influence of red blood cells (RBCs) and fresh frozen plasma (FFP) on mortality in 134 consecutive lung transplants recipients from September 2003 until December 2008. RESULTS Intraoperative transfusion of RBCs and FFP was associated with a significant increase in mortality with odds ratios (ORs) of 1.10 (1.03 to 1.16, P = 0.02) and 1.09 (1.02 to 1.15, P = 0.03), respectively. For more than four intraoperatively transfused RBCs multivariate analysis showed a hazard ratio for mortality of 3.8 (1.40 to 10.31, P = 0.003). Furthermore, non-survivors showed a significant increase in renal replacement therapy (RRT) (36.6% versus 6.9%, P <0.0001), primary graft dysfunction (PGD) (39.3% versus 5.9%, P <0.0001), postoperative need of extracorporeal membrane oxygenation (ECMO) (26.9% versus 3.1%, P = 0.0019), sepsis (24.2% versus 4.0%, P = 0.0004), multiple organ dysfunction syndrome (MODS) (26.9% versus 3.1%, P <0.0001), infections (18.1% versus 0.9%, P = 0.0004), retransplantation (12.1% versus 6.9%, P = 0.039) and readmission to the ICU (33.3% versus 12.8%, P = 0.024). CONCLUSIONS Intraoperative transfusion is associated with a strong negative influence on outcome in lung transplant recipients.
Collapse
Affiliation(s)
- Denise Weber
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Silvia R Cottini
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Pascal Locher
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Urs Wenger
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Paul A Stehberger
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Mario Fasshauer
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Reto A Schuepbach
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH-8091, Switzerland
| |
Collapse
|
20
|
Corti N, Rudiger A, Chiesa A, Marti I, Jetter A, Rentsch K, Müller D, Béchir M, Maggiorini M. Pharmacokinetics of daily daptomycin in critically ill patients undergoing continuous renal replacement therapy. Chemotherapy 2013; 59:143-51. [PMID: 24051895 DOI: 10.1159/000353400] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 05/28/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND The optimal daptomycin dosing regimen for critically ill patients undergoing continuous renal replacement therapy (CRRT) has still to be established. METHODS Daptomycin pharmacokinetics was determined in 9 patients after administration of 6 mg/kg/day over 5 days. RESULTS At steady state, which was reached by day 3, the area under the curve over 24 h (AUC24h) was 667.4 ± 356.6 mg·h/l, and the maximum concentration (Cmax) was 66.9 ±25.3 mg/l. Mean CRRT clearance accounted for 48% (range 32-67%) of total clearance (mean 10.2 ml/min, range 6.1-18 ml/min). Significant correlations were observed between Cmax, minimum concentration (Cmin) and AUC24h (R(2) = 0.91, p < 0.001, and R(2) = 0.94, p < 0.001) and between albumin plasma concentration and free daptomycin (R(2) = 0.7, p = 0.009). CONCLUSION No significant accumulation occurred with a daily daptomycin dose of 6 mg/kg in patients undergoing CRRT with an effluent flow rate of >30 ml/kg/h. The quantification of trough concentrations (Cmin) appears to be a good surrogate to estimate AUC24h and to monitor daptomycin treatment in patients undergoing CRRT.
Collapse
Affiliation(s)
- Natascia Corti
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Cottini SR, Wenger U, Sailer S, Stehberger PA, Schuepbach RA, Hasenclever P, Wilhelm M, Béchir M. Extracorporeal membrane oxygenation: beneficial strategy for lung transplant recipients. J Extra Corpor Technol 2013; 45:16-20. [PMID: 23691779 PMCID: PMC4557458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 02/05/2013] [Indexed: 06/02/2023]
Abstract
The role of extracorporeal membrane oxygenation (ECMO) as a therapeutic strategy has been very well documented for over a decade now with consistently positive remarks. The aim of the present study was analyzing the outcome of ECMO application in our lung transplant program, especially the feasibility and safety of our ECMO approach. Therefore, we retrospectively analyzed the data of 15 patients recipients requiring ECMO support. We analyzed clinical data, complications, and survival of the lung-transplanted population that needed ECMO support at our institution from 2006-2009. During that period, 19 applications of ECMO were done on 15 adult patients with the following indications: primary graft dysfunction (10 patients), "bridge to transplantation" (five), pulmonary hypertension (three), and severe acute respiratory distress syndrome (one). At 28 days, the overall survival was 93% (14 of 15 patients) and 12 of these patients (80%) survived at least 6 months. Complications included acute renal insufficiency with temporary need of renal replacement therapy (53%), bleeding (33%), critical illness polyneuropathy (66%), and reversible thrombocytopenia (73%). Based on the evaluation of the patients in this analysis, ECMO seems to be a safe therapeutic approach in lung transplant recipients with severe respiratory failure directly after transplantation.
Collapse
Affiliation(s)
- Silvia R. Cottini
- Surgical Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Urs Wenger
- Surgical Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Susanne Sailer
- Surgical Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Paul A. Stehberger
- Surgical Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Reto A. Schuepbach
- Surgical Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Peter Hasenclever
- Division of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Markus Wilhelm
- Division of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| |
Collapse
|
22
|
Wenger U, Neff TA, Oberkofler CE, Zimmermann M, Stehberger PA, Scherrer M, Schuepbach RA, Cottini SR, Steiger P, Béchir M. The relationship between preoperative creatinine clearance and outcomes for patients undergoing liver transplantation: a retrospective observational study. BMC Nephrol 2013; 14:37. [PMID: 23409777 PMCID: PMC3582487 DOI: 10.1186/1471-2369-14-37] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 02/13/2013] [Indexed: 12/24/2022] Open
Abstract
Background Renal failure with following continuous renal replacement therapy is a major clinical problem in liver transplant recipients, with reported incidences of 3% to 20%. Little is known about the significance of postoperative acute renal failure or acute-on-chronic renal failure to postoperative outcome in liver transplant recipients. Methods In this post hoc analysis we compared the mortality rates of 135 consecutive liver transplant recipients over 6 years in our center subject to their renal baseline conditions and postoperative RRT. We classified the patients into 4 groups, according to their preoperative calculated Cockcroft formula and the incidence of postoperative renal replacement therapy. Data then were analyzed in regard to mortality rates and in addition to pre- and peritransplant risk factors. Results There was a significant difference in ICU mortality (p=.008), hospital mortality (p=.002) and cumulative survival (p<.0001) between the groups. The highest mortality rate occurred in the group with RRT and normal baseline kidney function (20% ICU mortality, 26.6% hospital mortality and 50% cumulative 1-year mortality, respectively). The hazard ratio in this group was 9.6 (CI 3.2-28.6, p=.0001). Conclusion This study shows that in liver transplant recipient’s acute renal failure with postoperative RRT is associated with mortality and the mortality rate is higher than in patients with acute-on-chronic renal failure and postoperative renal replacement therapy.
Collapse
Affiliation(s)
- Urs Wenger
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH 8091, Switzerland
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Meierhans R, Brandi G, Fasshauer M, Sommerfeld J, Schüpbach R, Béchir M, Stover JF. Arterial lactate above 2 mM is associated with increased brain lactate and decreased brain glucose in patients with severe traumatic brain injury. Minerva Anestesiol 2012; 78:185-193. [PMID: 21971438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Lactate fuels cerebral energy-consuming processes and it is neuroprotective. The impact of arterial lactate on brain metabolism determined by microdialysis was investigated retrospectively in patients with severe traumatic brain injury (TBI). METHODS Cerebral microdialysis (glucose, lactate), neuromonitoring (ICP, CPP, ptiO2, SjvO2) and blood gas data collected in 20 patients during pharmacologic coma were grouped within predefined arterial lactate clusters (<1, 1-2, >2 mM). Microdialysis samples were only taken from time points characterized by normoventilation (paCO2 34.5-42 mmHg), sufficient oxygenation (paO2 >75 mmHg) and hematocrit (≥24%) to exclude confounding influences. RESULTS Elevated arterial lactate ≥2 mM was associated with significantly increased brain lactate which coincided with markedly decreased brain glucose despite significantly increased arterial glucose levels and sufficient cerebral perfusion indirectly determined by normal SjvO2 and ptiO2 values. At elevated arterial lactate levels signs of significantly increased cerebral lactate uptake coincided with markedly decreased cerebral glucose uptake. Infused lactate above 50 mM per 24 hours was associated with significantly decreased cerebral glucose. CONCLUSION Increased arterial lactate levels were associated with increased cerebral lactate uptake and elevated brain lactate. At the same time brain glucose uptake and brain glucose were significantly reduced. It remains unclear whether arterial lactate is the driving force for the increased cerebral lactate levels or if the reduced glucose uptake also contributed to the increased cerebral lactate levels. Further studies are required to assess the impact of lactate infusion under clinical conditions.
Collapse
Affiliation(s)
- R Meierhans
- Surgical Intensive Care, University Hospital Zürich, Zürich, Switzerland
| | | | | | | | | | | | | |
Collapse
|
24
|
Dutkowski P, Oberkofler CE, Béchir M, Müllhaupt B, Geier A, Raptis DA, Clavien PA. The model for end-stage liver disease allocation system for liver transplantation saves lives, but increases morbidity and cost: a prospective outcome analysis. Liver Transpl 2011; 17:674-84. [PMID: 21618688 DOI: 10.1002/lt.22228] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We analyzed the first 100 patients who underwent liver transplantation by Model for End-Stage Liver Disease (MELD) allocation, and compared the outcome of patients on the waiting list and after orthotopic liver transplantation with the last 100 patients who underwent transplantation prior to the introduction of the MELD system in July 2007. MELD allocation resulted in decreased waiting list mortality (386 versus 242 deaths per 1000 patient-years, P < 0.0001) and the transplantation of sicker recipients (uncorrected median MELD score 13.5 versus 20, P = 0.003). Recipient posttransplant morbidity was significantly higher, mainly caused by increased percentage of renal failure requiring renal replacement therapy (13 versus 46%, P < 0.0001). However, kidney function recovered in most cases within 6 months after OLT. Hospital mortality remained similar in both groups (6% versus 9%). Patient 1-year survival was 91% versus 83% (pre-MELD versus MELD era, P = 0.2154), graft 1-year survival was 88% versus 78% (P = 0.1013), respectively. Costs accumulated were significantly higher after introduction of the MELD policy (US $81,967 versus US $127,453, a 55% increase, P = 0.02) with a strong correlation with the individual MELD score (P < 0.0001). The MELD system addresses the goal of fairness well. However, the postoperative course appears more difficult in the MELD era with increased financial burden, but reasonable patient and graft survival. This is the inevitable price to balance justice and utility in liver graft allocation.
Collapse
Affiliation(s)
- Philipp Dutkowski
- Swiss Hepato-Pancreatico-Biliary and Transplant Center, Department of Surgery, Zürich, Switzerland
| | | | | | | | | | | | | |
Collapse
|
25
|
Schuepbach RA, Bestmann L, Béchir M, Fehr J, Bachli EB. High Prevalence of Iron Deficiency among Educated Hospital Employees in Switzerland. Int J Biomed Sci 2011; 7:150-7. [PMID: 23675232 PMCID: PMC3614822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 04/08/2011] [Indexed: 11/04/2022]
Abstract
Iron deficiency is known to cause symptoms such as fatigue, depression and restless legs syndrome resulting in impaired quality of life and working capacity. We sought to examine the iron status of reportedly healthy individuals by a framed study design in 58 highly educated Swiss hospital employees and to compare the use of non invasive tests for assessing iron deficiency (ID). A structured interview was used to assess health status, nutritional intake and potential blood loss, blood counts as well as parameters proposed to diagnose iron deficiency were determined. All subjects felt well and were working at their maximum capacity. The male subjects were neither anaemic nor had decreased iron parameters however 50% (23/46) of the women had a serum ferritin of below 22 μg/L, still 33% (15/46) of the women had a ferritin value below the more stringent cut off value of 15 μg/L. In 15% (7/46) of the women we diagnosed iron deficient anaemia. Red meat consumption correlated with ferritin values as did the menstrual blood loss which was estimated by asking the amount of tampons used. Of the additionally analysed iron parameters only the percentage of hypochromic erythrocytes, soluble transferrin receptor and transferrin values were significantly correlated with ferritin and reached an AUCROC of ≥0.7 indicating good predictive tests. Nevertheless neither soluble transferrin receptor nor transferrin showed diagnostic advantages for the diagnosis of ID compared to ferritin alone or together with erythrocyte parameters. Working in a hospital environment and having access to health education does not seem to correlate with prevention of ID or ID anaemia in female hospital employees.
Collapse
Affiliation(s)
- Reto A. Schuepbach
- Medical Clinic, Department of Medicine, University Hospital Zurich, Zurich, Switzerland;,Division of Surgical Intensive Care, University Hospital Zurich, Zurich, Switzerland;
| | - Lukas Bestmann
- Institute of Clinical Chemistry, University Hospital Zurich, Zurich, Switzerland;
| | - Markus Béchir
- Division of Surgical Intensive Care, University Hospital Zurich, Zurich, Switzerland;
| | - Jörg Fehr
- Division of Haematology, Department of Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Esther B. Bachli
- Medical Clinic, Department of Medicine, University Hospital Zurich, Zurich, Switzerland;
| |
Collapse
|
26
|
Bachli EB, Bösiger J, Béchir M, Stover JF, Stocker R, Maggiorini M, Renner EL, Müllhaupt B, Schuepbach RA. Thromboelastography to monitor clotting/bleeding complications in patients treated with the molecular adsorbent recirculating system. Crit Care Res Pract 2011; 2011:313854. [PMID: 21527982 PMCID: PMC3064997 DOI: 10.1155/2011/313854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 01/13/2011] [Indexed: 11/17/2022] Open
Abstract
Background. The Molecular Adsorbent Recirculating System (MARS) has been shown to clear albumin-bound toxins from patients with liver failure but might cause bleeding complications potentially obscuring survival benefits. We hypothesized that monitoring clotting parameters and bed-side thromboelastography allows to reduce bleeding complications. Methods. Retrospective analysis of 25 MARS sessions during which clotting parameters were monitored by a standardized protocol. Results. During MARS therapy median INR increased significantly from 1.7 to 1.9 platelet count and fibrinogen content decreased significantly from 57 fL(-1) to 42 fL(-1) and 2.1 g/L to 1.5 g/L. Nine relevant complications occurred: the MARS system clotted 6 times 3 times we observed hemorrhages. Absent thrombocytopenia and elevated plasma fibrinogen predicted clotting of the MARS system (ROC 0.94 and 0.82). Fibrinolysis, detected by thromboelastography, uniquely predicted bleeding events. Conclusion. Bed-side thromboelastography and close monitoring of coagulation parameters can predict and, therefore, help prevent bleeding complications during MARS therapy.
Collapse
Affiliation(s)
- Esther B. Bachli
- Medical Intensive Care Unit, University Hospital Zurich, 8091 Zurich, Switzerland
- Clinic of Internal Medicine, Hospital Uster, 8610 Uster, Switzerland
| | - Jörg Bösiger
- Division of Haematology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Unit, University Hospital Zurich, HOF-B-110, Raemistraße 100, 8091 Zurich, Switzerland
| | - John F. Stover
- Surgical Intensive Care Unit, University Hospital Zurich, HOF-B-110, Raemistraße 100, 8091 Zurich, Switzerland
| | - Reto Stocker
- Surgical Intensive Care Unit, University Hospital Zurich, HOF-B-110, Raemistraße 100, 8091 Zurich, Switzerland
| | - Marco Maggiorini
- Medical Intensive Care Unit, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Eberhard L. Renner
- Division of Gastroenterology and Hepatology, University Hospital Zurich, 8091 Zurich, Switzerland
- Multiorgan Transplant Program, University Health Network, University of Toronto, Toronto, Canada ON M5G 2N2
| | - Beat Müllhaupt
- Division of Gastroenterology and Hepatology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Reto A. Schuepbach
- Medical Intensive Care Unit, University Hospital Zurich, 8091 Zurich, Switzerland
- Surgical Intensive Care Unit, University Hospital Zurich, HOF-B-110, Raemistraße 100, 8091 Zurich, Switzerland
| |
Collapse
|
27
|
Oberkofler CE, Stocker R, Raptis DA, Stover JF, Schuepbach RA, Müllhaupt B, Dutkowski P, Clavien PA, Béchir M. Same quality - higher price? The paradox of allocation: the first national single center analysis after the implementation of the new Swiss transplantation law: the ICU view. Clin Transplant 2010; 25:921-8. [DOI: 10.1111/j.1399-0012.2010.01364.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
28
|
Béchir M, Meierhans R, Brandi G, Sommerfeld J, Fasshauer M, Cottini SR, Stocker R, Stover JF. Insulin differentially influences brain glucose and lactate in traumatic brain injured patients. Minerva Anestesiol 2010; 76:896-904. [PMID: 20634790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Hypo- and hyperglycemia must be avoided to prevent additional brain damage following traumatic brain injury (TBI). However, the optimal blood glucose range requiring insulin remains unknown. Cerebral microdialysis is helpful in unmasking signs of metabolic impairment, thereby identifying deleterious blood glucose levels. METHODS A retrospective analysis of prospectively collected cerebral microdialysis samples obtained from 20 non-diabetic patients with severe TBI treated at the trauma surgical intensive care unit at the University Hospital Zürich, Switzerland. RESULTS The impact of different arterial blood glucose values and concomitant insulin administration on cerebral interstitial glucose and lactate levels was investigated. In addition, energetic impairment was determined by calculating lactate-to-glucose ratios. Insulin administration was associated with significantly reduced cerebral glucose concentrations and significantly increased lactate-to-glucose ratios with arterial blood glucose levels <5 mM. At arterial blood glucose levels >7 mM, insulin administration was associated with significantly increased interstitial glucose values, significantly decreased lactate concentrations, and markedly diminished lactate-to-glucose ratios. CONCLUSION Insulin exerts differential effects that depend strongly on the underlying arterial blood glucose concentrations. To avoid energetic impairment, insulin should not be administered at arterial blood glucose levels <5 mM. However, at arterial blood glucose levels >7-8 mM, insulin administration appears to be encouraged to increase extracellular glucose concentrations and decrease energetic impairment reflected by reduced interstitial brain lactate and decreased lactate-to-glucose ratios. Nevertheless, frequent analysis is required to minimize the risk of inducing impaired brain metabolism.
Collapse
Affiliation(s)
- M Béchir
- Surgical Intensive Care, University Hospital Zürich, Zürich, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Chenevard R, Hürlimann D, Spieker L, Béchir M, Enseleit F, Hermann M, Flammer AJ, Sudano I, Corti R, Lüscher TF, Noll G, Ruschitzka F. Reconstituted HDL in acute coronary syndromes. Cardiovasc Ther 2010; 30:e51-7. [PMID: 20840194 DOI: 10.1111/j.1755-5922.2010.00221.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES The strong inverse relationship between plasma high-density lipoprotein (HDL)-cholesterol and atherosclerotic cardiovascular disease provides the epidemiological basis that HDL is atheroprotective. Since HDL enhances cholesterol efflux and exhibits potent antiinflammatory properties, the aim of the present study was to investigate whether infusion of reconstituted HDL (rHDL) impacts on vascular function, a well-established surrogate of atherosclerotic vascular disease, as well as markers of inflammation and oxidative stress in patients with acute coronary syndromes (ACS). METHODS Twenty-nine patients with ACS were randomized to double-blind treatment with rHDL or albumin. Endothelium-dependent and independent vasodilatation to intraarterial acetylcholine and sodium nitroprusside were measured by forearm venous occlusion plethysmography. In addition, oxidized LDL and high-sensitivity C-reactive protein were determined as markers of oxidative stress and vascular inflammation. RESULTS rHDL infusion increased plasma HDL (P < 0.0001) and decreased LDL (P < 0.0001). Oxidized LDL (P= 0.11), high-sensitivity C-reactive protein (P= 0.12) and the response to endothelium-dependent and -independent vasodilatators remained unchanged after rHDL compared to albumin infusion (14.9 ± 9.2 versus 14.5 ± 12.4, P= 0.93 and 12.8 ± 7.1 versus 13.2 ± 9.6, P= 0.27, respectively). CONCLUSIONS An increase of HDL and a reduction of LDL notwithstanding, human rHDL did not improve vascular function in patients with ACS thus further challenging the clinical benefit of interventions, which rapidly raise HDL in ACS, particularly with the infusion of reconstituted HDL.
Collapse
Affiliation(s)
- Rémy Chenevard
- Cardiovascular Center, Cardiology, University Hospital, Zurich, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Béchir M, Puhan MA, Neff SB, Guggenheim M, Wedler V, Stover JF, Stocker R, Neff TA. Early fluid resuscitation with hyperoncotic hydroxyethyl starch 200/0.5 (10%) in severe burn injury. Crit Care 2010; 14:R123. [PMID: 20584291 PMCID: PMC2911771 DOI: 10.1186/cc9086] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 01/02/2010] [Accepted: 06/28/2010] [Indexed: 11/22/2022]
Abstract
Introduction Despite large experience in the management of severe burn injury, there are still controversies regarding the best type of fluid resuscitation, especially during the first 24 hours after the trauma. Therefore, our study addressed the question whether hyperoncotic hydroxyethyl starch (HES) 200/0.5 (10%) administered in combination with crystalloids within the first 24 hours after injury is as effective as 'crystalloids only' in severe burn injury patients. Methods 30 consecutive patients were enrolled to this prospective interventional open label study and assigned either to a traditional 'crystalloids only' or to a 'HES 200/0.5 (10%)' volume resuscitation protocol. Total amount of fluid administration, complications such as pulmonary failure, abdominal compartment syndrome, sepsis, renal failure and overall mortality were assessed. Cox proportional hazard regression analysis was performed for binary outcomes and adjustment for potential confounders was done in the multivariate regression models. For continuous outcome parameters multiple linear regression analysis was used. Results Group differences between patients receiving crystalloids only or HES 200/0.5 (10%) were not statistically significant. However, a large effect towards increased overall mortality (adjusted hazard ratio 7.12; P = 0.16) in the HES 200/0.5 (10%) group as compared to the crystalloids only group (43.8% versus 14.3%) was present. Similarly, the incidence of renal failure was 25.0% in the HES 200/0.5 (10%) group versus 7.1% in the crystalloid only group (adjusted hazard ratio 6.16; P = 0.42). Conclusions This small study indicates that the application of hyperoncotic HES 200/0.5 (10%) within the first 24 hours after severe burn injury may be associated with fatal outcome and should therefore be used with caution. Trial registration NCT01120730.
Collapse
Affiliation(s)
- Markus Béchir
- Division of Surgical Intensive Care, University Hospital of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Oberkofler CE, Dutkowski P, Stocker R, Schuepbach RA, Stover JF, Clavien PA, Béchir M. Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients. Crit Care 2010; 14:R117. [PMID: 20550662 PMCID: PMC2911764 DOI: 10.1186/cc9068] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 04/30/2010] [Accepted: 06/15/2010] [Indexed: 02/06/2023]
Abstract
Introduction The impact of model of end stage liver disease (MELD) score on postoperative morbidity and mortality is still elusive, especially for high MELD. There are reports of poorer patient outcome in transplant candidates with high MELD score, others though report no influence of MELD score on outcome and survival. Methods We retrospectively analyzed data of 144 consecutive liver transplant recipients over a 72-month period in our transplant unit, from January 2003 until December 2008 and performed uni- and multivariate analysis for morbidity and mortality, in particular to define the influence of MELD to these parameters. Results This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by intensive care unit (ICU) stay longer than 10 days (odds ratio 7.0) but in contrast had no negative impact on mortality. Furthermore, we identified transfusion of more than 7 units of red blood cells as independent risk factor for mortality (hazard ratio 7.6) and for prolonged ICU stay (odds ratio [OR] 7.8) together with transfusion of more than 10 units of fresh frozen plasma (OR 11.6). Postoperative renal failure is a strong predictor of morbidity (OR 7.9) and postoperative renal replacement therapy was highly associated with increased mortality (hazard ratio 6.8), as was hepato renal syndrome prior to transplantation (hazard ratio 13.2). Conclusions This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by ICU stay longer than 10 days but in contrast had no negative impact on mortality. This finding supports the transplantation of patients with high MELD score but only with knowledge of increased morbidity.
Collapse
Affiliation(s)
- Christian E Oberkofler
- Department of Visceral- and Transplantation Surgery, University Hospital of Zurich, Raemistrasse 100, Zürich 8091, Switzerland.
| | | | | | | | | | | | | |
Collapse
|
32
|
Brandi G, Béchir M, Sailer S, Haberthür C, Stocker R, Stover JF. Transcranial color-coded duplex sonography allows to assess cerebral perfusion pressure noninvasively following severe traumatic brain injury. Acta Neurochir (Wien) 2010; 152:965-72. [PMID: 20379747 DOI: 10.1007/s00701-010-0643-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 03/17/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Assess optimal equation to noninvasively estimate intracranial pressure (eICP) and cerebral perfusion pressure (eCPP) following severe traumatic brain injury (TBI) using transcranial color-coded duplex sonography (TCCDS). DESIGN AND SETTING This is an observational clinical study in a university hospital. PATIENTS A total of 45 continuously sedated (BIS < 50), normoventilated (paCO(2) > 35 mmHg), and non-febrile TBI patients. METHODS eICP and eCPP based on TCCDS-derived flow velocities and arterial blood pressure values using three different equations were compared to actually measured ICP and CPP in severe TBI patients subjected to standard treatment. Optimal equation was assessed by Bland-Altman analysis. RESULTS The equations: ICP = 10:927 x PI(pulsatility index) - 1:284 and CPP = 89:646 - 8:258 PI resulted in eICP and eCPP similar to actually measured ICP and CPP with eICP 10.6 +/- 4.8 vs. ICP 10.3 +/- 2.8 and eCPP 81.1 +/- 7.9 vs. CPP 80.9 +/- 2.1 mmHg, respectively. The other two equations, eCPP = (MABP x EDV)/mFV + 14 and eCPP = mFV / (mFV - EDV)] x (MABP - RRdiast), resulted in significantly decreased eCPP values: 72.9 +/- 10.1 and 67 +/- 19.5 mmHg, respectively. Superiority of the first equation was confirmed by Bland-Altman revealing a smallest standard deviations for eCPP and eICP. CONCLUSIONS TCCDS-based equation (ICP = 10.927 x PI - 1.284) allows to screen patients at risk of increased ICP and decreased CPP. However, adequate therapeutic interventions need to be based on continuously determined ICP and CPP values.
Collapse
Affiliation(s)
- Giovanna Brandi
- Surgical Intensive Care, University Hospital Zuerich, Zurich, Switzerland
| | | | | | | | | | | |
Collapse
|
33
|
Flückiger C, Béchir M, Brenni M, Ludwig S, Sommerfeld J, Cottini SR, Keel M, Stocker R, Stover JF. Increasing hematocrit above 28% during early resuscitative phase is not associated with decreased mortality following severe traumatic brain injury. Acta Neurochir (Wien) 2010; 152:627-36. [PMID: 20033233 DOI: 10.1007/s00701-009-0579-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 12/04/2009] [Indexed: 01/10/2023]
Abstract
BACKGROUND To prevent iatrogenic damage, transfusions of red blood cells should be avoided. For this, specific and reliable transfusion triggers must be defined. To date, the optimal hematocrit during the initial operating room (OR) phase is still unclear in patients with severe traumatic brain injury (TBI). We hypothesized that hematocrit values exceeding 28%, the local hematocrit target reached by the end of the initial OR phase, resulted in more complications, increased mortality, and impaired recovery compared to patients in whom hematocrit levels did not exceed 28%. METHODS Impact of hematocrit (independent variable) reached by the end of the OR phase on mortality and morbidity determined by the extended Glasgow outcome scale (eGOS; dependent variables) was investigated retrospectively in 139 TBI patients. In addition, multiple logistic regression analysis was performed to identify additional important variables. FINDINGS Following severe TBI, mortality and morbidity were neither aggravated by hematocrit above 28% reached by the end of the OR phase nor worsened by the required transfusions. Upon multiple logistic regression analysis, eGOS was significantly influenced by the highest intracranial pressure and the lowest cerebral perfusion pressure values during the initial OR phase. CONCLUSIONS Based on this retrospective observational analysis, increasing hematocrit above 28% during the initial OR phase following severe TBI was not associated with improved or worsened outcome. This questions the need for aggressive transfusion management. Prospective analysis is required to determine the lowest acceptable hematocrit value during the OR phase which neither increases mortality nor impairs recovery. For this, a larger caseload and early monitoring of cerebral metabolism and oxygenation are indispensable.
Collapse
Affiliation(s)
- Carole Flückiger
- Surgical Intensive Care Medicine, University Hospital Zürich, 8091 Zürich, Switzerland
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Bosshart M, Stover JF, Stocker R, Asmis LM, Feige J, Neff TA, Schuepbach RA, Cottini SR, Béchir M. Two different hematocrit detection methods: different methods, different results? BMC Res Notes 2010; 3:65. [PMID: 20214819 PMCID: PMC2845149 DOI: 10.1186/1756-0500-3-65] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 03/09/2010] [Indexed: 11/18/2022] Open
Abstract
Background Less is known about the influence of hematocrit detection methodology on transfusion triggers. Therefore, the aim of the present study was to compare two different hematocrit-assessing methods. In a total of 50 critically ill patients hematocrit was analyzed using (1) blood gas analyzer (ABLflex 800) and (2) the central laboratory method (ADVIA® 2120) and compared. Findings Bland-Altman analysis for repeated measurements showed a good correlation with a bias of +1.39% and 2 SD of ± 3.12%. The 24%-hematocrit-group showed a correlation of r2 = 0.87. With a kappa of 0.56, 22.7% of the cases would have been transfused differently. In the-28%-hematocrit group with a similar correlation (r2 = 0.8) and a kappa of 0.58, 21% of the cases would have been transfused differently. Conclusions Despite a good agreement between the two methods used to determine hematocrit in clinical routine, the calculated difference of 1.4% might substantially influence transfusion triggers depending on the employed method.
Collapse
Affiliation(s)
- Marco Bosshart
- Surgical Intensive Care Medicine, University Hospital of Zurich, CH 8091 Zurich, Switzerland
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Meierhans R, Béchir M, Ludwig S, Sommerfeld J, Brandi G, Haberthür C, Stocker R, Stover JF. Brain metabolism is significantly impaired at blood glucose below 6 mM and brain glucose below 1 mM in patients with severe traumatic brain injury. Crit Care 2010; 14:R13. [PMID: 20141631 PMCID: PMC2875528 DOI: 10.1186/cc8869] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 12/20/2009] [Accepted: 02/08/2010] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The optimal blood glucose target following severe traumatic brain injury (TBI) must be defined. Cerebral microdialysis was used to investigate the influence of arterial blood and brain glucose on cerebral glucose, lactate, pyruvate, glutamate, and calculated indices of downstream metabolism. METHODS In twenty TBI patients, microdialysis catheters inserted in the edematous frontal lobe were dialyzed at 1 microl/min, collecting samples at 60 minute intervals. Occult metabolic alterations were determined by calculating the lactate- pyruvate (L/P), lactate- glucose (L/Glc), and lactate- glutamate (L/Glu) ratios. RESULTS Brain glucose was influenced by arterial blood glucose. Elevated L/P and L/Glc were significantly reduced at brain glucose above 1 mM, reaching lowest values at blood and brain glucose levels between 6-9 mM (P < 0.001). Lowest cerebral glutamate was measured at brain glucose 3-5 mM with a significant increase at brain glucose below 3 mM and above 6 mM. While L/Glu was significantly increased at low brain glucose levels, it was significantly decreased at brain glucose above 5 mM (P < 0.001). Insulin administration increased brain glutamate at low brain glucose, but prevented increase in L/Glu. CONCLUSIONS Arterial blood glucose levels appear to be optimal at 6-9 mM. While low brain glucose levels below 1 mM are detrimental, elevated brain glucose are to be targeted despite increased brain glutamate at brain glucose >5 mM. Pathogenity of elevated glutamate appears to be relativized by L/Glu and suggests to exclude insulin- induced brain injury.
Collapse
Affiliation(s)
- Roman Meierhans
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Markus Béchir
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Silke Ludwig
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Jutta Sommerfeld
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Giovanna Brandi
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
- Ospedale Maggiore Policlinico Milano, Via Francesco Sforza, 28, I-20122 Milano, Italy
| | - Christoph Haberthür
- Surgical Intensive Care, Luzerner Kantonsspital, 6000 Luzern 16, Switzerland
| | - Reto Stocker
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - John F Stover
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| |
Collapse
|
36
|
Stover JF, Stocker R, Lenherr R, Neff TA, Cottini SR, Zoller B, Béchir M. Noninvasive cardiac output and blood pressure monitoring cannot replace an invasive monitoring system in critically ill patients. BMC Anesthesiol 2009; 9:6. [PMID: 19821993 PMCID: PMC2766368 DOI: 10.1186/1471-2253-9-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 10/12/2009] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Monitoring of cardiac output and blood pressure are standard procedures in critical care medicine. Traditionally, invasive techniques like pulmonary artery catheter (PAC) and arterial catheters are widely used. Invasiveness bears many risks of deleterious complications. Therefore, a noninvasive reliable cardiac output (CO) and blood pressure monitoring system could improve the safety of cardiac monitoring. The aim of the present study was to compare a noninvasive versus a standard invasive cardiovascular monitoring system. METHODS Nexfin HD is a continuous noninvasive blood pressure and cardiac output monitor system and is based on the development of the pulsatile unloading of the finger arterial walls using an inflatable finger cuff. During continuous BP measurement CO is calculated. We included 10 patients with standard invasive cardiac monitoring system (pulmonary artery catheter and arterial catheter) comparing invasively obtained data to the data collected noninvasively using the Nexfin HD. RESULTS Correlation between mean arterial pressure measured with the standard arterial monitoring system and the Nexfin HD was r2 = 0.67 with a bias of -2 mmHg and two standard deviations of +/- 16 mmHg. Correlation between CO derived from PAC and the Nexfin HD was r2 = 0.83 with a bias of 0.23 l/min and two standard deviations of +/- 2.1 l/min; the percentage error was 29%. CONCLUSION Although the noninvasive CO measurement appears promising, the noninvasive blood pressure assessment is clearly less reliable than the invasively measured blood pressure. Therefore, according to the present data application of the Nexfin HD monitoring system in the ICU cannot be recommended generally. Whether such a tool might be reliable in certain critically ill patients remains to be determined.
Collapse
Affiliation(s)
- John F Stover
- Surgical Intensive Care Unit, University Hospital of Zurich, CH 8091 Zurich, Switzerland.
| | | | | | | | | | | | | |
Collapse
|
37
|
Holbein M, Béchir M, Ludwig S, Sommerfeld J, Cottini SR, Keel M, Stocker R, Stover JF. Differential influence of arterial blood glucose on cerebral metabolism following severe traumatic brain injury. Crit Care 2009; 13:R13. [PMID: 19196488 PMCID: PMC2688130 DOI: 10.1186/cc7711] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 12/01/2008] [Accepted: 02/06/2009] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Maintaining arterial blood glucose within tight limits is beneficial in critically ill patients. Upper and lower limits of detrimental blood glucose levels must be determined. METHODS In 69 patients with severe traumatic brain injury (TBI), cerebral metabolism was monitored by assessing changes in arterial and jugular venous blood at normocarbia (partial arterial pressure of carbon dioxide (paCO2) 4.4 to 5.6 kPa), normoxia (partial arterial pressure of oxygen (paO2) 9 to 20 kPa), stable haematocrit (27 to 36%), brain temperature 35 to 38 degrees C, and cerebral perfusion pressure (CPP) 70 to 90 mmHg. This resulted in a total of 43,896 values for glucose uptake, lactate release, oxygen extraction ratio (OER), carbon dioxide (CO2) and bicarbonate (HCO3) production, jugular venous oxygen saturation (SjvO2), oxygen-glucose index (OGI), lactate-glucose index (LGI) and lactate-oxygen index (LOI). Arterial blood glucose concentration-dependent influence was determined retrospectively by assessing changes in these parameters within pre-defined blood glucose clusters, ranging from less than 4 to more than 9 mmol/l. RESULTS Arterial blood glucose significantly influenced signs of cerebral metabolism reflected by increased cerebral glucose uptake, decreased cerebral lactate production, reduced oxygen consumption, negative LGI and decreased cerebral CO2/HCO3 production at arterial blood glucose levels above 6 to 7 mmol/l compared with lower arterial blood glucose concentrations. At blood glucose levels more than 8 mmol/l signs of increased anaerobic glycolysis (OGI less than 6) supervened. CONCLUSIONS Maintaining arterial blood glucose levels between 6 and 8 mmol/l appears superior compared with lower and higher blood glucose concentrations in terms of stabilised cerebral metabolism. It appears that arterial blood glucose values below 6 and above 8 mmol/l should be avoided. Prospective analysis is required to determine the optimal arterial blood glucose target in patients suffering from severe TBI.
Collapse
Affiliation(s)
- Monika Holbein
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Silke Ludwig
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Jutta Sommerfeld
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Silvia R Cottini
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Marius Keel
- Department of Surgery, Division of Trauma Surgery, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Reto Stocker
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - John F Stover
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| |
Collapse
|
38
|
Béchir M, Stover JF, Bosshart M, Stocker R. Influence of hematocrit detection methodology on transfusion practice. Crit Care 2009. [PMCID: PMC4084301 DOI: 10.1186/cc7579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
39
|
Meierhans R, Stover JF, Béchir M, Keel M, Stocker R. Reduced midazolam clearance must be considered in prolonged coma. Anaesth Intensive Care 2008; 36:915-916. [PMID: 19115666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
|
40
|
Meier R, Béchir M, Ludwig S, Sommerfeld J, Keel M, Steiger P, Stocker R, Stover JF. Differential temporal profile of lowered blood glucose levels (3.5 to 6.5 mmol/l versus 5 to 8 mmol/l) in patients with severe traumatic brain injury. Crit Care 2008; 12:R98. [PMID: 18680584 PMCID: PMC2575586 DOI: 10.1186/cc6974] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 07/14/2008] [Accepted: 08/04/2008] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Hyperglycaemia is detrimental, but maintaining low blood glucose levels within tight limits is controversial in patients with severe traumatic brain injury, because decreased blood glucose levels can induce and aggravate underlying brain injury. METHODS In 228 propensity matched patients (age, sex and injury severity) treated in our intensive care unit (ICU) from 2000 to 2004, we retrospectively evaluated the influence of different predefined blood glucose targets (3.5 to 6.5 versus 5 to 8 mmol/l) on frequency of hypoglycaemic and hyperglycaemic episodes, insulin and norepinephrine requirement, changes in intracranial pressure and cerebral perfusion pressure, mortality and length of stay on the ICU. RESULTS Mortality and length of ICU stay were similar in both blood glucose target groups. Blood glucose values below and above the predefined levels were significantly increased in the 3.5 to 6.5 mmol/l group, predominantly during the first week. Insulin and norepinephrine requirements were markedly increased in this group. During the second week, the incidences of intracranial pressure exceeding 20 mmHg and infectious complications were significantly decreased in the 3.5 to 6.5 mmol/l group. CONCLUSION Maintaining blood glucose within 5 to 8 mmol/l appears to yield greater benefit during the first week. During the second week, 3.5 to 6.5 mmol/l is associated with beneficial effects in terms of reduced intracranial hypertension and decreased rate of pneumonia, bacteraemia and urinary tract infections. It remains to be determined whether patients might profit from temporally adapted blood glucose limits, inducing lower values during the second week, and whether concomitant glucose infusion to prevent hypoglycaemia is safe in patients with post-traumatic oedema.
Collapse
Affiliation(s)
- Regula Meier
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, CH 8091 Zuerich, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, CH 8091 Zuerich, Switzerland
| | - Silke Ludwig
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, CH 8091 Zuerich, Switzerland
| | - Jutta Sommerfeld
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, CH 8091 Zuerich, Switzerland
| | - Marius Keel
- Department of Surgery, Division of Trauma Surgery, University Hospital Zuerich, Raemistrasse 100, CH 8091 Zuerich, Switzerland
| | - Peter Steiger
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, CH 8091 Zuerich, Switzerland
| | - Reto Stocker
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, CH 8091 Zuerich, Switzerland
| | - John F Stover
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, CH 8091 Zuerich, Switzerland
| |
Collapse
|
41
|
Béchir M, Schwegler K, Chenevard R, Binggeli C, Caduff C, Büchi S, Buddeberg C, Lüscher TF, Noll G. Anxiolytic therapy with alprazolam increases muscle sympathetic activity in patients with panic disorders. Auton Neurosci 2007; 134:69-73. [PMID: 17363337 DOI: 10.1016/j.autneu.2007.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Revised: 01/16/2007] [Accepted: 01/23/2007] [Indexed: 10/23/2022]
Abstract
Anxiolytic therapy with the benzodiazepine alprazolam is an established therapy in patients with panic disorder. Normally, panic-like anxiety and its concomitant physical symptoms quickly disappear under such treatment. Therefore we investigated whether there is a difference in sympathetic nervous system in patients with panic disorder compared to healthy controls. Three groups of subjects were included: ten patients with panic disorder, who received alprazolam and 20 healthy control subjects who were given either alprazolam (n=10) or matching placebo (n=10). Muscle sympathetic nerve activity (MSNA) and heart rate did not differ at baseline but significantly increased both in patients and healthy controls after intake of alprazolam (1 mg). However, in both groups both MSNA and heart rate were significantly elevated when compared to both baseline and the placebo control group. This study demonstrates (1) that anxiolytic therapy with alprazolam increases muscle sympathetic nerve activity and heart rate not only in patients with panic disorder but also in healthy controls and (2) that a significant difference in sympathetic nervous system activity between patients and controls, at baseline and during the therapy with alprazolam could not be demonstrated.
Collapse
Affiliation(s)
- Markus Béchir
- Cardiovascular Center, Cardiology, University Hospital, Rämistrasse 100, 8091 Zürich, Switzerland.
| | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Abstract
In hypertension baroreceptor-mediated modulation of heart rate is impaired, resulting in a decreased vagal control. Reactive oxygen species produced locally in the vasculature decrease baroreceptor sensitivity. Folic acid has antioxidant properties. Therefore, the aim of this study was to test whether folic acid improves baroreceptor function in hypertension. Twenty-one male patients with hypertension not taking any drugs for 2 weeks participated in the study and were randomized to folic acid 5 mg or matching placebo. Cardiac and vascular sympathetic baroreceptor functions were tested before and after a single dose of folic acid or placebo with two different methods: the alpha-coefficient method and the phenylephrine (PE) and sodium nitroprusside (SNP) bolus method. In the folic acid group both methods showed significantly improved cardiac and vascular sympathetic baroreceptor sensitivity compared with placebo. This study provides evidence that folic acid improves cardiac and vascular sympathetic baroreceptor sensitivity in hypertensive patients, which suggests an improved vagal control and an enhanced baroreceptor modulation of sympathetic vasomotor tone. Thus, folic acid may represent a novel treatment for prevention of orthostatic dysregulation and/or arrhythmic complications resulting from baroreceptor dysfunction.
Collapse
Affiliation(s)
- Markus Béchir
- Cardiovascular Center, Cardiology, University Hospital, Zürich, Switzerland.
| | | | | | | | | | | |
Collapse
|
43
|
Hürlimann D, Chenevard R, Ruschitzka F, Flepp M, Enseleit F, Béchir M, Kobza R, Muntwyler J, Ledergerber B, Lüscher TF, Noll G, Weber R. Effects of statins on endothelial function and lipid profile in HIV infected persons receiving protease inhibitor-containing anti-retroviral combination therapy: a randomised double blind crossover trial. Heart 2005; 92:110-2. [PMID: 15797933 PMCID: PMC1860959 DOI: 10.1136/hrt.2004.056523] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
44
|
Béchir M, Enseleit F, Chenevard R, Lüscher TF, Noll G. Effect of losartan on muscle sympathetic activity and baroreceptor function in systemic hypertension. Am J Cardiol 2005; 95:129-31. [PMID: 15619411 DOI: 10.1016/j.amjcard.2004.08.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2004] [Revised: 08/24/2004] [Accepted: 08/24/2004] [Indexed: 10/26/2022]
Abstract
Angiotensin II directly stimulates muscle sympathetic nerve activity and facilitates adrenergic sympathetic transmission. The hypotheses that the chronic blockade of angiotensin II receptors (AT(1) type) reduces muscle sympathetic activity and that there is an interaction with baroreceptor function in patients with mild to moderate hypertension were investigated. Muscle sympathetic nerve activity decreased from 51.7 +/- 3.5 to 45.9 +/- 4.2 bursts/min (p = 0.022), and cardiac baroreceptor sensitivity increased from 3.2 +/- 1.3 to 4.9 +/- 1.8 ms/mm Hg (p = 0.007). This study for the first time demonstrates that in hypertensive patients, chronic AT(1) receptor antagonism inhibits muscle sympathetic nerve activity and that baroreceptor function is improved under these conditions.
Collapse
|
45
|
Béchir M, Binggeli C, Corti R, Chenevard R, Spieker L, Ruschitzka F, Lüscher TF, Noll G. Dysfunctional baroreflex regulation of sympathetic nerve activity in patients with vasovagal syncope. Circulation 2003; 107:1620-5. [PMID: 12668496 DOI: 10.1161/01.cir.0000056105.87040.2b] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The interplay of resting muscle sympathetic nerve activity (MSA) and the baroreceptor reflex in patients with vasovagal syncope remains elusive. Hence, the aim of the present study was to investigate MSA, baroreceptor sensitivity, heart rate, and blood pressure under resting conditions and during orthostatic stress in patients with a history of vasovagal syncope. METHODS AND RESULTS MSA was measured using microneurography at rest and during lower body negative pressure (LBNP) to mimic orthostatic stress in patients with a history of vasovagal syncope (n=10) and in age-matched healthy controls (n=8). Heart rate and blood pressure were simultaneously recorded. Cardiac baroreceptor sensitivity was calculated with the spectral technique (alpha coefficient). Resting MSA in the patients with syncope was significantly increased as compared with controls (42.4+/-2.3 versus 26.5+/-3.6 bursts/min, P=0.001), whereas activation of MSA during orthostatic stress in the patient group was significantly blunted (5.1+/-1.6 versus 15.2+/-2.1 bursts/min at LBNP -50 mm Hg, P=0.002). In the patients with syncope, cardiac baroreceptor sensitivity was significantly reduced under supine resting conditions (8.5+/-0.7 versus 13.0+/-1.1 ms/mm Hg, P=0.001), as well as under orthostatic stress (7.3+/-0.7 versus 13.4+/-1.5 ms/mm Hg, P=0.003). CONCLUSIONS This study shows that in patients with vasovagal syncope, resting MSA is increased and baroreflex regulation during orthostatic stress is blunted, thus leading to impaired MSA adaptation. These results provide new insights into mechanisms of vasovagal syncope and suggest that pharmacological modulation of baroreceptor sensitivity may represent a promising treatment of neuromediated syncope.
Collapse
Affiliation(s)
- Markus Béchir
- Cardiovascular Center, Cardiology, University Hospital, Rämistrasse 100, 8091 Zürich, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Chenevard R, Hürlimann D, Béchir M, Enseleit F, Spieker L, Hermann M, Riesen W, Gay S, Gay RE, Neidhart M, Michel B, Lüscher TF, Noll G, Ruschitzka F. Selective COX-2 inhibition improves endothelial function in coronary artery disease. Circulation 2003; 107:405-9. [PMID: 12551863 DOI: 10.1161/01.cir.0000051361.69808.3a] [Citation(s) in RCA: 277] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is an ongoing debate as to whether the gastrointestinal safety of COX-2 inhibition compared with nonsteroidal antiinflammatory drugs (NSAIDs) may come at the cost of increased cardiovascular events. In view of the large number of patients at cardiovascular risk requiring chronic analgesic therapy with COX-2 inhibitors for arthritic and other inflammatory conditions, the effects of selective COX-2 inhibition on clinically useful surrogates for cardiovascular disease, particularly endothelial function, need to be determined. METHODS AND RESULTS Fourteen male patients (mean age, 66+/-3 years) with severe coronary artery disease (average of 2.6 vessels with stenosis >75%) undergoing stable background therapy with aspirin and statins were included. The patients received celecoxib (200 mg BID) or placebo for a duration of 2 weeks in a double-blind, placebo-controlled, crossover fashion. After each treatment period, flow-mediated dilation of the brachial artery, high-sensitivity C-reactive protein, oxidized LDL, and prostaglandins were measured. Celecoxib significantly improved endothelium-dependent vasodilation compared with placebo (3.3+/-0.4% versus 2.0+/-0.5%, P=0.026), whereas endothelium-independent vasodilation, as assessed by nitroglycerin, remained unchanged (9.0+/-1.6% versus 9.5+/-1.3%, P=0.75). High-sensitivity C-reactive protein was significantly lower after celecoxib (1.3+/-0.4 mg/L) than after placebo (1.8+/-0.5 mg/L, P=0.019), as was oxidized LDL (43.6+/-2.4 versus 47.6+/-2.6 U/L, P=0.028), whereas prostaglandins did not change. CONCLUSIONS This is the first study to demonstrate that selective COX-2 inhibition improves endothelium-dependent vasodilation and reduces low-grade chronic inflammation and oxidative stress in coronary artery disease. Thus, selective COX-2 inhibition holds the potential to beneficially impact outcome in patients with cardiovascular disease.
Collapse
Affiliation(s)
- Rémy Chenevard
- Cardiovascular Center, Cardiology and Department of Rheumatology, University Hospital Zürich, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Hürlimann D, Forster A, Noll G, Enseleit F, Chenevard R, Distler O, Béchir M, Spieker LE, Neidhart M, Michel BA, Gay RE, Lüscher TF, Gay S, Ruschitzka F. Anti-tumor necrosis factor-alpha treatment improves endothelial function in patients with rheumatoid arthritis. Circulation 2002; 106:2184-7. [PMID: 12390945 DOI: 10.1161/01.cir.0000037521.71373.44] [Citation(s) in RCA: 425] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is associated with accelerated atherosclerosis and increased cardiovascular morbidity and mortality. Striking similarities exist in the inflammatory and immunologic response in RA and atherosclerosis. Indeed, adhesion molecules and cytokines, tumor necrosis factor (TNF)-alpha in particular, are key mediators of joint inflammation and of vascular dysfunction and progression of atherosclerotic vascular disease. Hence, the aim of the present study was to assess the effect of chronic antiinflammatory treatment with the anti-TNF-alpha antibody infliximab on disease activity and endothelial function in patients with active RA. METHODS AND RESULTS Eleven RA patients (mean age 46+/-5 years; disease duration 9+/-2 years) with high disease activity despite treatment with stable doses of methotrexate (<or=25 mg/wk) and prednisone (<or=10 mg/d) were investigated. Clinical status and endothelium-dependent and -independent vasodilation of the brachial artery as assessed by high-resolution ultrasound were measured before and after 12 weeks of infliximab therapy. Flow-mediated vasodilation improved from 3.2+/-0.4% to 4.1+/-0.5% (P=0.018), whereas endothelium-independent vasodilation with nitroglycerin and baseline diameter remained unchanged (13.6+/-1.2% versus 12.8+/-1.4%, P=0.98, and 3.74+/-0.15 versus 3.66+/-0.11 mm, P=0.54, respectively). Disease activity score (DAS28) was significantly reduced, from 5.6+/-0.3 to 3.5+/-0.6 (P=0.002). Erythrocyte sedimentation rate and C-reactive protein were lowered from 34+/-7 to 19+/-5 mm/h (P=0.04) and from 38+/-11 to 15+/-10 mg/L (P=0.08), respectively. CONCLUSIONS This is the first study to show that anti-TNF-alpha treatment improves endothelial function in RA. The data suggest that in RA, endothelial dysfunction is part of the disease process and is mediated by TNF-alpha.
Collapse
Affiliation(s)
- David Hürlimann
- Cardiology Department, University Hospital, Zürich, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|