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Paredes S, Harb A, Rössler J, Nikoo MZ, Ruetzler K, Turan A, Pu X, Sessler DI. Metformin Use in Type 2 Diabetics and Delirium After Noncardiac Surgery: A Retrospective Cohort Analysis. Anesth Analg 2024; 138:1304-1312. [PMID: 38517762 DOI: 10.1213/ane.0000000000006863] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The cause of postoperative delirium is unknown, but it is thought to result at least in part from inflammation. Metformin, besides its hypoglycemic properties, demonstrates anti-inflammatory effects systemically and in the brain. We tested the primary hypothesis that chronic metformin use in adults with type 2 diabetes is associated with less delirium during the first 5 days after major noncardiac surgery. Secondary outcomes were a composite of serious complications (myocardial infarction, cardiac arrest, stage 2-3 acute kidney injury [AKI], and mortality) and time to discharge alive. METHODS We considered adults with type 2 diabetes who did or did not routinely use metformin daily and had noncardiac surgery. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit (CAM-ICU) or brief Confusion Assessment Method (bCAM) for 5 postoperative days. Postoperative AKI was defined by Kidney Disease Improving Global Guidelines. Logistic regression and generalized estimating equation models accounted for within-patient correlation across multiple surgeries and explored the association between metformin use and postoperative delirium and complications. Inverse propensity score weighting and propensity score calibration (PSC) adjusted for confounding variables. RESULTS No significant difference was observed in the incidence of postoperative delirium between the 2 groups, with 260 of 4744 cases (5.5%) among metformin users and 502 of 5918 cases (8.5%) cases in nonmetformin users, for an odds ratio of 0.88 (95% confidence interval [CI], 0.73-1.05; P = .155), number-needed-to-expose = 118 patients. Similarly, there were fewer composite complications in metformin users (3.3%) than in nonusers (11.7%); However, the common-effect odds ratio of 0.67 was not statistically significant (97.5% CI, 0.39-1.17; P = .106). Discharge from the hospital was significantly faster in patients who took metformin (3 [interquartile range, IQR, 1-5] days for metformin users and 3 [IQR, 2-6] days for nonmetformin users), with a hazard ratio of 1.07 for early discharge, and tight CIs (1.01-1.13). CONCLUSIONS Chronic metformin use was associated with slightly and nonsignificantly less delirium. However, patients who used metformin had clinically meaningfully fewer major complications, mostly stage 2 to 3 kidney injury. While not statistically significant, the reduction was substantial and warrants further investigation because there is currently no effective preventive measure for perioperative renal injury. Benefit would be especially meaningful if it could be produced by acute perioperative treatment. Finally, metformin was associated with faster hospital discharge, although not by a clinically meaningful amount.
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Affiliation(s)
- Stephania Paredes
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Ayoub Harb
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, Ohio
| | - Julian Rössler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Kurt Ruetzler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Xuan Pu
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- From the Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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Rössler J, Shah K, Medellin S, Turan A, Ruetzler K, Singh M, Sessler DI, Maheshwari K. Development and validation of delirium prediction models for noncardiac surgery patients. J Clin Anesth 2024; 93:111319. [PMID: 37984177 DOI: 10.1016/j.jclinane.2023.111319] [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] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023]
Abstract
STUDY OBJECTIVE Postoperative delirium is associated with morbidity and mortality, and its incidence varies widely. Using known predisposing and precipitating factors, we sought to develop postoperative delirium prediction models for noncardiac surgical patients. DESIGN Retrospective prediction model study. SETTING Major quaternary medical center. PATIENTS Our January 2016 to June 2020 training dataset included 51,677 patients of whom 2795 patients had delirium. Our July 2020 to January 2022 validation dataset included 14,438 patients of whom 912 patients had delirium. INTERVENTIONS None. MEASUREMENTS We trained and validated two static prediction models and one dynamic delirium prediction model. For the static models, we used random survival forests and traditional Cox proportional hazard models to predict postoperative delirium from preoperative variables, or from a combination of preoperative and intraoperative variables. We also used landmark modeling to dynamically predict postoperative delirium using preoperative, intraoperative, and postoperative variables before onset of delirium. MAIN RESULTS In the validation analyses, the static random forest model had a c-statistic of 0.81 (95% CI: 0.79, 0.82) and a Brier score of 0.04 with preoperative variables only, and a c-statistic of 0.86 (95% CI: 0.84, 0.87) and a Brier score of 0.04 when preoperative and intraoperative variables were combined. The corresponding Cox models had similar discrimination metrics with slightly better calibration. The dynamic model - using all available data, i.e., preoperative, intraoperative and postoperative data - had an overall c-index of 0.84 (95% CI: 0.83, 0.85). CONCLUSIONS Using preoperative and intraoperative variables, simple static models performed as well as a dynamic delirium prediction model that also included postoperative variables. Baseline predisposing factors thus appear to contribute far more to delirium after noncardiac surgery than intraoperative or postoperative variables. Improved postoperative data capture may help improve delirium prediction and should be evaluated in future studies.
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Affiliation(s)
- Julian Rössler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Karan Shah
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, OH, USA
| | - Sara Medellin
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Mriganka Singh
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, USA; Center on Innovation-Long Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Rössler J, Abramczyk E, Paredes S, Anusic N, Pu X, Maheshwari K, Turan A, Ruetzler K. Association of Intravenous Neostigmine and Anticholinergics or Sugammadex with Postoperative Delirium: A Retrospective Cohort Study. Anesth Analg 2024:00000539-990000000-00778. [PMID: 38446705 DOI: 10.1213/ane.0000000000006939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND Administration of cholinesterase inhibitors in combination with anticholinergic drugs for reversal of neuromuscular blocks may precipitate delirium through impairment of central cholinergic transmission, which could be avoided by using sugammadex. Therefore, we tested the primary hypothesis that postoperative delirium is less common when neuromuscular block is reversed with sugammadex than with neostigmine combined with glycopyrrolate or atropine. METHODS We conducted a single-center retrospective cohort study, analyzing all adult patients having general anesthesia for noncardiac surgery who received neostigmine or sugammadex from January 2016 to March 2022. Inverse propensity score weighting and propensity score calibration were used to adjust for appropriate confounders. Our primary outcome was presence of delirium within the first 4 days after surgery, defined as at least 1 positive brief Confusion Assessment Method (bCAM) screening. The secondary outcome was the presence of early delirium within 24 hours of surgery. RESULTS Among 49,468 cases in our analysis, 6881 received sugammadex and 42,587 received neostigmine. After propensity weighting, the incidence of delirium was 1.09% in the sugammadex group and 0.82% in the neostigmine group. The odds of postoperative delirium did not differ between the sugammadex and neostigmine groups, with an estimated odds ratio (95% confidence interval) of 1.33 (0.91-1.95), P = .147. A sensitivity analysis restricted to only include cases with at least 6 bCAM measurements over postoperative day (POD) 1 to 4 had consistent results, as sugammadex compared with neostigmine was associated with an estimated odds ratio for postoperative delirium of 1.20 (0.82-1.77), P = .346. Sugammadex was significantly associated with an increased incidence of early postoperative delirium, with an estimated odds ratio of 1.71 (1.07-2.72), P = .025. Further analysis showed no treatment-by-age interaction for either postoperative delirium (P = .637) or postoperative early delirium (P = .904). CONCLUSIONS Compared to neostigmine, use of sugammadex for reversal of neuromuscular block was not associated with an increased risk of postoperative delirium in this retrospective single-center study. Though sugammadex was associated with a statistically significant increased risk of postoperative early delirium, the difference was small and not clinically relevant, and may reflect the presence of unknown confounders.
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Affiliation(s)
| | | | - Stephania Paredes
- From the Department of Outcomes Research
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Xuan Pu
- From the Department of Outcomes Research
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Kamal Maheshwari
- From the Department of Outcomes Research
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- From the Department of Outcomes Research
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kurt Ruetzler
- From the Department of Outcomes Research
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Rössler J, Cywinski JB, Argalious M, Ruetzler K, Khanna S. Anesthetic management in patients having catheter-based thrombectomy for acute pulmonary embolism: A narrative review. J Clin Anesth 2024; 92:111281. [PMID: 37813080 DOI: 10.1016/j.jclinane.2023.111281] [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] [Received: 07/25/2023] [Revised: 08/25/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
Pulmonary embolism is the third leading cause of cardiovascular death. Novel percutaneous catheter-based thrombectomy techniques are rapidly becoming popular in high-risk pulmonary embolism - especially in the presence of contraindications to thrombolysis. The interventional nature of these procedures and the risk of sudden cardiorespiratory compromise requires the presence of an anesthesiologist. Facilitating catheter-based thrombectomy can be challenging since qualifying patients are often critically ill. The purpose of this narrative review is to provide guidance to anesthesiologists for the assessment and management of patients having catheter-based thrombectomy for acute pulmonary embolism. First, available techniques for catheter-based thrombectomy are reviewed. Then, we discuss definitions and application of common risk stratification tools for pulmonary embolism, and how to assess patients prior to the procedure. An adjudication of risks and benefits of anesthetic strategies for catheter-based thrombectomy follows. Specifically, we give guidance and rationale for use monitored anesthesia care and general anesthesia for these procedures. For both, we review strategies for assessing and mitigating hemodynamic perturbations and right ventricular dysfunction, ranging from basic monitoring to advanced inodilator therapy. Finally, considerations for management of right ventricular failure with mechanical circulatory support are discussed.
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Affiliation(s)
- Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jacek B Cywinski
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Maged Argalious
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Sandeep Khanna
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Cardiothoracic and Vascular Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
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Ruetzler K, Montalvo M, Rotem OM, Ekrami E, Rössler J, Duran JAA, Dahan A, Gozal Y, Richebe P, Farhang B, Turan A, Sessler DI. Generalizability of nociception level as a measure of intraoperative nociceptive stimulation: A retrospective analysis. Acta Anaesthesiol Scand 2023; 67:1187-1193. [PMID: 37317549 DOI: 10.1111/aas.14286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Nociception-guided intraoperative opioid administration might help reduce postoperative pain. A commonly used and validated nociception monitor system is nociception level (NOL), which provides the nociception index, ranging from 0 to 100, with 0 representing no nociception and 100 representing extreme nociception. We tested the hypothesis that NOL responses are similar in men and women given remifentanil and fentanyl, across various types of anesthesia, as a function of American Society of Anesthesiologists physical status designations, and over a range of ages and body morphologies. METHODS We conducted a retrospective cohort analysis of trial data from eight prospective NOL validation studies. Among 522 noncardiac surgical patients enrolled in these studies, 447 were included in our analysis. We assessed NOL responses to various noxious and non-noxious stimuli. RESULTS The average NOL in response to 315 noxious stimuli was 47 ± 15 (95% CI = 45-49). The average NOL in response to 361 non-noxious stimuli was 10 ± 12 (95% CI = 9-11). NOL responses were similar in men and women, in patients given remifentanil and fentanyl, across various types of anesthesia, as a function of American Society of Anesthesiologists physical status designations, and over a range of ages and body morphologies. CONCLUSION Nociception level appears to provide accurate estimates of intraoperative nociception over a broad range of patients and anesthetic conditions.
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Affiliation(s)
- Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mateo Montalvo
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Elyad Ekrami
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yaacov Gozal
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Medical Center, Jerusalem, Israel
| | - Philippe Richebe
- Département d'Anesthésiologie et Médecine de la Douleur, Université de Montréal, Montréal, Canada
| | - Borzoo Farhang
- University of Vermont Medical Center, Larner College of Medicine, Department of Anesthesiology, Burlington, Vermont, USA
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Müller-Wirtz LM, Ruetzler K, Rössler J. Intraoperative hypotension and delirium. J Clin Anesth 2023; 89:111153. [PMID: 37245475 DOI: 10.1016/j.jclinane.2023.111153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/17/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Lukas M Müller-Wirtz
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Schmidt M, Rössler J, Brooker J, Lara-Erazo V, Ekrami E, Pu X, Turan A, Sessler DI, Ruetzler K. Postoperative oxygenation assessed by SpO 2/FiO 2 ratio and respiratory complications after reversal of neuromuscular block with Sugammadex or neostigmine: A retrospective cohort study. J Clin Anesth 2023; 88:111138. [PMID: 37148836 DOI: 10.1016/j.jclinane.2023.111138] [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: 01/24/2023] [Revised: 03/31/2023] [Accepted: 04/26/2023] [Indexed: 05/08/2023]
Abstract
STUDY OBJECTIVE Residual neuromuscular block may lead to postoperative muscle weakness, inadequate oxygenation, and other pulmonary complications. Sugammadex may provide more rapid and effective restoration of neuromuscular function than neostigmine. We therefore tested the primary hypothesis that noncardiac surgical patients given sugammadex oxygenate better during initial recovery than those given neostigmine. Secondarily, we tested the hypothesis that patients given sugammadex have fewer pulmonary complications during hospitalization. DESIGN Retrospective cohort analysis. SETTING Postoperative recovery area of a tertiary care hospital. PATIENTS Adults who had non-cardiothoracic surgery and were given either neostigmine or sugammadex. INTERVENTIONS None. MEASUREMENTS The primary outcome was the lowest SpO2/FiO2 ratio in the post-anesthesia care unit. The secondary outcome was a composite of pulmonary complications. MAIN RESULTS Among 71,457 cases, 10,708 (15%) were given sugammadex and 60,749 (85%) received neostigmine. After propensity weighting, the mean minimum SpO2/FiO2 ratio was 301 ± 77 (SD) in patients given sugammadex and 303 ± 71 in those given neostigmine, yielding an estimated difference in means of -3.5 (95% confidence interval: -5.3, -1.7; P = 0.0002). 4.4% of patients given sugammadex and 3.6% of patients given neostigmine had postoperative pulmonary complications (P = 0.0005, number-needed-to-be-exposed =136; 95% CI: 83, 330), with the main contributing components being new bronchospasm or exacerbation of obstructive pulmonary disease. CONCLUSIONS Postoperative minimum SpO2/FiO2 ratio during PACU admission was similar after reversal of neuromuscular block by sugammadex and neostigmine. Reversal with sugammadex was associated with more pulmonary complications, but most were minor and of little consequence.
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Affiliation(s)
- Marc Schmidt
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Jack Brooker
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Valentina Lara-Erazo
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Elyad Ekrami
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Xuan Pu
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, OH, United States of America
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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Stuby J, Kaserer A, Ott S, Ruetzler K, Rössler J. [Perioperative hyperoxia-More harmful than beneficial?]. Anaesthesiologie 2023; 72:342-347. [PMID: 37084143 DOI: 10.1007/s00101-023-01274-4] [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] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND The ideal perioperative oxygen concentration is controversial and study results are inconsistent. OBJECTIVE Current knowledge on the beneficial and adverse effects of perioperative hyperoxia. MATERIAL AND METHODS Narrative review RESULTS: Perioperative hyperoxia is unlikely to increase the incidence of atelectasis, pulmonary or cardiovascular complications or mortality. Few and small potential beneficial effects, such as reduction of surgical wound infections or postoperative nausea and vomiting have been demonstrated. According to the current state of evidence, it is recommended to avoid perioperative hyperoxia and to aim for normoxia instead.
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Affiliation(s)
- Johann Stuby
- Institut für Anästhesiologie, Universitätsspital Zürich, 8091, Zürich, Schweiz.
| | - Alexander Kaserer
- Institut für Anästhesiologie, Universitätsspital Zürich, 8091, Zürich, Schweiz
| | - Sascha Ott
- Klinik für Kardioanästhesiologie und Intensivmedizin, Deutsches Herzzentrum Berlin, 13353, Berlin, Deutschland
- Klinik für Kardioanästhesiologie und Intensivmedizin, Charité Universitätsmedizin Berlin, 13353, Berlin, Deutschland
- DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Berlin, Berlin, Deutschland
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, USA
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, USA
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, USA
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Ruetzler K, Montalvo M, Bakal O, Essber H, Rössler J, Mascha EJ, Han Y, Ramachandran M, Keebler A, Turan A, Sessler DI. Nociception Level Index-Guided Intraoperative Analgesia for Improved Postoperative Recovery: A Randomized Trial. Anesth Analg 2023; 136:761-771. [PMID: 36727855 DOI: 10.1213/ane.0000000000006351] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Nociception is the physiological response to nociceptive stimuli, normally experienced as pain. During general anesthesia, patients experience and respond to nociceptive stimuli by increasing blood pressure and heart rate if not controlled by preemptive analgesia. The PMD-200 system from Medasense (Ramat Gan, Israel) evaluates the balance between nociceptive stimuli and analgesia during general anesthesia and generates the nociception level (NOL) index from a single finger probe. NOL is a unitless index ranging from 0 to 100, with values exceeding 25 indicating that nociception exceeds analgesia. We aimed to demonstrate that titrating intraoperative opioid administration to keep NOL <25 optimizes intraoperative opioid dosing. Specifically, we tested the hypothesis that pain scores during the initial 60 minutes of recovery are lower in patients managed with NOL-guided fentanyl than in patients given fentanyl per clinical routine. METHODS We conducted a randomized, single-center trial of patients having major abdominal open and laparoscopic surgeries. Patients were randomly assigned 1:1 to intraoperative NOL-guided fentanyl administration or fentanyl given per clinical routine. The primary outcome was pain score (0-10 verbal response scale) at 10-minute intervals during the initial 60 minutes of recovery. Our secondary outcome was a measure of adequate analgesia, defined as a pain score <5, assessed separately at each interval. RESULTS With a planned maximum sample size of 144, the study was stopped for futility after enrolling 72 patients from November 2020 to October 2021. Thirty-five patients were assigned to NOL-guided analgesic dosing and 37 to routine care. Patients in the NOL group spent significantly less time with a NOL index >25 (median reduction [95% confidence interval {CI}] of 14 [4-25] minutes) were given nearly twice as much intraoperative fentanyl (median [quartiles] 500 [330, 780] vs 300 [200, 330] µg), and required about half as much morphine in the recovery period (3.3 [0, 8] vs 7.7 [0, 13] mg). However, in the primary outcome analysis, NOL did not reduce pain scores in the first 60 minutes after awakening, assessed in a linear mixed effects model with mean (standard error [SE]) of 4.12 (0.59) for NOL and 4.04 (0.58) for routine care, and estimated difference in means of 0.08 (-1.43, 1.58), P = .895. CONCLUSIONS More intraoperative fentanyl was given in NOL-guided patients, but NOL guidance did not reduce initial postoperative pain scores.
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Affiliation(s)
- Kurt Ruetzler
- From the Departments of Outcomes Research
- General Anesthesiology
| | | | - Omer Bakal
- From the Departments of Outcomes Research
| | | | | | - Edward J Mascha
- From the Departments of Outcomes Research
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Yanyan Han
- From the Departments of Outcomes Research
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Alparslan Turan
- From the Departments of Outcomes Research
- General Anesthesiology
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Schmidt MT, Paredes S, Rössler J, Mukhia R, Pu X, Mao G, Turan A, Ruetzler K. Postoperative Risk of Transfusion After Reversal of Residual Neuromuscular Block With Sugammadex Versus Neostigmine: A Retrospective Cohort Study. Anesth Analg 2023; 136:745-752. [PMID: 36651854 DOI: 10.1213/ane.0000000000006275] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sugammadex and neostigmine are routinely used to reverse residual neuromuscular blocks at the end of surgery. Sugammadex has been linked with prolongation of laboratory coagulation markers, but clinical relevance on postoperative blood loss and transfusions remains unclear. METHODS In this retrospective, single-center, cohort study, we analyzed medical records of adult patients having noncardiac surgery who were given sugammadex or neostigmine from May 2016 to December 2020. Our primary outcome was the incidence of any postoperative transfusion of red blood cells, and/or fresh-frozen plasma, and/or platelets. Secondary outcomes were duration of hospitalization, need for resurgery, and postoperative intensive care unit (ICU) admission. After propensity score weighting, the odds ratio (OR) for postoperative transfusion was assessed in both groups (sugammadex versus neostigmine) using a generalized estimation equation to count within-subject correlation weighted by the inverse propensity score. RESULTS Out of 39,325 eligible surgeries, 33,903 surgeries in 29,062 patients were included in the analysis; with 4581 patients receiving sugammadex and 29,322 patients receiving neostigmine. The raw incidence of postoperative transfusion was 7.40% in sugammadex and 7.45% in the neostigmine group. After weighting by propensity score, the incidence of postoperative transfusion was 8.01% in the sugammadex and 7.38% in the neostigmine group (OR, 1.11 [95% confidence interval [CI], 0.97-1.26; P = .118]). There was no difference in duration of hospitalization and need for resurgery, but odds of postoperative ICU admission were significantly higher for patients receiving sugammadex than those receiving neostigmine (OR, 1.33 [98.33% CI, 1.17-1.52; P < .0001]). Our a priori planned analysis of coagulation laboratory parameters could not be completed because of a high amount of missing laboratory data. CONCLUSIONS There is no statistically significant nor clinically important difference in the risk of postoperative transfusion in patients receiving sugammadex or neostigmine.
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Affiliation(s)
- Marc T Schmidt
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Julian Rössler
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rupashi Mukhia
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Xuan Pu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Guangmei Mao
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kurt Ruetzler
- From the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Bello C, Rössler J, Shehata P, Smilowitz NR, Ruetzler K. Perioperative strategies to reduce risk of myocardial injury after non-cardiac surgery (MINS): A narrative review. J Clin Anesth 2023; 87:111106. [PMID: 36931053 DOI: 10.1016/j.jclinane.2023.111106] [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: 01/03/2023] [Revised: 02/06/2023] [Accepted: 03/03/2023] [Indexed: 03/17/2023]
Abstract
Myocardial injury is a frequent complication of surgical patients after having non-cardiac surgery that is strongly associated with perioperative mortality. While intraoperative anesthesia-related deaths are exceedingly rare, about 1% of patients undergoing non-cardiac surgery die within the first 30 postoperative days. Given the number of surgeries performed annually, death following surgery is the second leading cause of death in the United States. Myocardial injury after non-cardiac surgery (MINS) is defined as an elevation in troponin concentrations within 30 days postoperatively. Although typically asymptomatic, patients with MINS suffer myocardial damage and have a 10% risk of death within 30 days after surgery and excess risks of mortality that persist during the first postoperative year. Many factors for the development of MINS are non-modifiable, such as preexistent coronary artery disease. Preventive measures, systematic approaches to surveillance and treatment standards are still lacking, however many factors are modifiable and should be considered in clinical practice: the importance of hemodynamic control, adequate oxygen supply, metabolic homeostasis, the use of perioperative medications such as statins, anti-thrombotic agents, beta-blockers, or anti-inflammatory agents, as well as some evidence regarding the choice of sedative and analgesic for anesthesia are discussed. Also, as age and complexity in comorbidities of the surgical patient population increase, there is an urgent need to identify patients at risk for MINS and develop prevention and treatment strategies. In this review, we provide an overview of current screening standards and promising preventive options in the perioperative setting and address knowledge gaps requiring further investigation.
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Affiliation(s)
- Corina Bello
- Department of Anaesthesiology and Pain Medicine, Inselspital Bern, University Hospital, University of Bern, Switzerland
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Peter Shehata
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, United States of America; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, New York, NY, United States of America
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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Sahli SD, Castellucci C, Roche TR, Rössler J, Spahn DR, Kaserer A. The impact of direct oral anticoagulants on viscoelastic testing - A systematic review. Front Cardiovasc Med 2022; 9:991675. [PMID: 36419490 PMCID: PMC9676657 DOI: 10.3389/fcvm.2022.991675] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 07/26/2022] [Accepted: 10/03/2022] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND In case of bleeding patients and in acute care, the assessment of residual direct oral anticoagulant (DOAC) activity is essential for evaluating the potential impact on hemostasis, especially when a timely decision on urgent surgery or intervention is required. Viscoelastic tests are crucial in a modern goal-directed coagulation management to assess patients' coagulation status. However, the role of viscoelastic test to detect and quantify residual DOAC plasma levels is controversially discussed. The aim of this review was to systematically summarize the evidence of viscoelastic tests for the assessment of residual DOAC activity. METHOD PubMed, Embase, Scopus, and the Cochrane Library were searched for original articles investigating the effect of rivaroxaban, apixaban, edoxaban, or dabigatran plasma levels on different viscoelastic tests of the adult population from database inception to December 31, 2021. RESULTS We included 53 studies from which 31 assessed rivaroxaban, 22 apixaban, six edoxaban, and 29 dabigatran. The performance of viscoelastic tests varied across DOACs and assays. DOAC specific assays are more sensitive than unspecific assays. The plasma concentration of rivaroxaban and dabigatran correlates strongly with the ROTEM EXTEM, ClotPro RVV-test or ECA-test clotting time (CT) and TEG 6s anti-factor Xa (AFXa) or direct thrombin inhibitor (DTI) channel reaction time (R). Results of clotting time (CT) and reaction time (R) within the normal range do not reliable exclude relevant residual DOAC plasma levels limiting the clinical utility of viscoelastic assays in this context. CONCLUSION Viscoelastic test assays can provide fast and essential point-of-care information regarding DOAC activity, especially DOAC specific assays. The identification and quantification of residual DOAC plasma concentration with DOAC unspecific viscoelastic assays are not sensitive enough, compared to recommended anti-Xa activity laboratory measurements. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=320629], identifier [CRD42022320629].
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Affiliation(s)
- Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Clara Castellucci
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Tadzio R. Roche
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
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13
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Smigielski L, Wotruba D, Treyer V, Rössler J, Papiol S, Falkai P, Grünblatt E, Walitza S, Rössler W. The Interplay Between Postsynaptic Striatal D2/3 Receptor Availability, Adversity Exposure and Odd Beliefs: A [11C]-Raclopride PET Study. Schizophr Bull 2021; 47:1495-1508. [PMID: 33876249 PMCID: PMC8379534 DOI: 10.1093/schbul/sbab034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 12/30/2022]
Abstract
BACKGROUND Between unaffected mental health and diagnosable psychiatric disorders, there is a vast continuum of functioning. The hypothesized link between striatal dopamine signaling and psychosis has guided a prolific body of research. However, it has been understudied in the context of multiple interacting factors, subclinical phenotypes, and pre-postsynaptic dynamics. METHOD This work investigated psychotic-like experiences and D2/3 dopamine postsynaptic receptor availability in the dorsal striatum, quantified by in vivo [11C]-raclopride positron emission tomography, in a sample of 24 healthy male individuals. Additional mediation and moderation effects with childhood trauma and key dopamine-regulating genes were examined. RESULTS An inverse relationship between nondisplaceable binding potential and subclinical symptoms was identified. D2/3 receptor availability in the left putamen fully mediated the association between traumatic childhood experiences and odd beliefs, that is, inclinations to see meaning in randomness and unfounded interpretations. Moreover, the effect of early adversity was moderated by a DRD2 functional variant (rs1076560). The results link environmental and neurobiological influences in the striatum to the origination of psychosis spectrum symptomology, consistent with the social defeat and diathesis-stress models. CONCLUSIONS Adversity exposure may affect the dopamine system as in association with biases in probabilistic reasoning, attributional style, and salience processing. The inverse relationship between D2/3 availability and symptomology may be explained by endogenous dopamine occupying the receptor, postsynaptic compensatory mechanisms, and/or altered receptor sensitivity. This may also reflect a cognitively stabilizing mechanism in non-help-seeking individuals. Future research should comprehensively characterize molecular parameters of dopamine neurotransmission along the psychosis spectrum and according to subtype profiling.
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Affiliation(s)
- Lukasz Smigielski
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich Program for Sustainable Development of Mental Health Services (ZInEP), University of Zurich, Zurich, Switzerland,Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric University Hospital Zurich, University of Zurich, Zurich, Switzerland,To whom correspondence should be addressed; Psychiatric University Hospital Zurich, Militärstrasse 8, 8004 Zurich, Switzerland; tel: +044-296-73-94, fax: +044-296-74-69, e-mail:
| | - Diana Wotruba
- Collegium Helveticum, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland,Institute for Regenerative Medicine, University of Zurich, Schlieren, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Sergi Papiol
- Institute of Psychiatric Phenomics and Genomics, University Hospital, Ludwig Maximilian University, Munich, Germany,Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Edna Grünblatt
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric University Hospital Zurich, University of Zurich, Zurich, Switzerland,Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland,Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric University Hospital Zurich, University of Zurich, Zurich, Switzerland,Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland,Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Wulf Rössler
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich Program for Sustainable Development of Mental Health Services (ZInEP), University of Zurich, Zurich, Switzerland,Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin, Campus Charité Mitte, Berlin, Germany,Laboratory of Neuroscience (LIM 27), Institute of Psychiatry, University of São Paulo, São Paulo, Brazil
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14
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Sahli SD, Kaserer A, Braun J, Halbe M, Dahlem Y, Spahn MA, Rössler J, Krüger B, Maisano F, Spahn DR, Wilhelm MJ. Predictors associated with mortality of extracorporeal life support therapy for acute heart failure: single-center experience with 679 patients. J Thorac Dis 2021; 14:1960-1971. [PMID: 35813709 PMCID: PMC9264083 DOI: 10.21037/jtd-21-1770] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 11/08/2021] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
Abstract
Background Extracorporeal life support (ECLS) therapy is increasingly used for cardiac and respiratory support postcardiotomy, refractory cardiogenic shock and cardiopulmonary resuscitation. This study aims to describe in-hospital mortality of patients requiring ECLS, identify independent predictors associated with mortality and analyze changes of mortality over time. Methods This retrospective study includes all adult ECLS cases at the University Hospital Zurich, a designated ECLS center in Switzerland, in the period 2007 to 2019. Results ECLS therapy was required in 679 patients (median age 60 years, 27.5% female). In-hospital mortality was 55.5%. Cubic spline interpolation did not detect evidence for a change in mortality over the whole period of 13 years. In-hospital mortality significantly varied between ECLS indications: 70.7% (152/215) for postcardiotomy, 67.9% (108/159) for cardiopulmonary resuscitation, 47.0% (110/234) for refractory cardiogenic shock, and 9.9% (7/71) for lung transplantation and expansive thoracic surgery (P<0.001). Logistic regression modelling showed excellent discrimination in the receiver operating characteristic (ROC) area under the curve (AUC) of 0.89 [95% confidence interval (CI): 0.87–0.92] and identified significant mortality predictors: age, simplified acute physiology score (SAPS) II, as well as new liver failure and each allogenic blood transfusion unit given per day. ECLS after cardiopulmonary resuscitation was associated with significantly higher mortality compared to ECLS for refractory cardiogenic shock. Conclusions In-hospital mortality of patients treated with ECLS therapy is high. Outcomes have not changed significantly in the observed period. We identified age, SAPS II, new liver failure and each allogenic blood transfusion unit given per day as independent mortality predictors. Knowledge of predictors strongly associated with in-hospital mortality may affect future decisions about ECLS indications and the respective management to use this elaborate therapy more effectively.
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Affiliation(s)
- Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Julia Braun
- Departments of Biostatistics and Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Maximilian Halbe
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, Zurich, Switzerland
| | - Yuliya Dahlem
- Medical Controlling, Medical Directorate University Hospital Zurich, Zurich, Switzerland
| | - Muriel A. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Bernard Krüger
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Markus J. Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, Zurich, Switzerland
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15
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Roche TR, Said S, Rössler J, Gozdzik M, Meybohm P, Zacharowski K, Spahn DR, Nöthiger CB, Tscholl DW. Physicians' Perceptions of a Situation Awareness-Oriented Visualization Technology for Viscoelastic Blood Coagulation Management (Visual Clot): Mixed Methods Study. JMIR Serious Games 2020; 8:e19036. [PMID: 33172834 PMCID: PMC7748952 DOI: 10.2196/19036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/16/2020] [Accepted: 11/10/2020] [Indexed: 01/17/2023] Open
Abstract
Background Viscoelastic tests enable a time-efficient analysis of coagulation properties. An important limitation of viscoelastic tests is the complicated presentation of their results in the form of abstract graphs with a multitude of numbers. We developed Visual Clot to simplify the interpretation of presented clotting information. This visualization technology applies user-centered design principles to create an animated model of a blood clot during the hemostatic cascade. In a previous simulation study, we found Visual Clot to double diagnostic accuracy, reduce time to decision making and perceived workload, and improve care providers’ confidence. Objective This study aimed to investigate the opinions of physicians on Visual Clot technology. It further aimed to assess its strengths, limitations, and clinical applicability as a support tool for coagulation management. Methods This was a researcher-initiated, international, double-center, mixed qualitative-quantitative study that included the anesthesiologists and intensive care physicians who participated in the previous Visual Clot study. After the participants solved six coagulation scenarios using Visual Clot, we questioned them about the perceived pros and cons of this new tool. Employing qualitative research methods, we identified recurring answer patterns, and derived major topics and subthemes through inductive coding. Based on them, we defined six statements. The study participants later rated their agreement to these statements on five-point Likert scales in an online survey, which represented the quantitative part of this study. Results A total of 60 physicians participated in the primary Visual Clot study. Among these, 36 gave an interview and 42 completed the online survey. In total, eight different major topics were derived from the interview field note responses. The three most common topics were “positive design features” (29/36, 81%), “facilitates decision making” (17/36, 47%), and “quantification not made” (17/36, 47%). In the online survey, 93% (39/42) agreed to the statement that Visual Clot is intuitive and easy to learn. Moreover, 90% (38/42) of the participants agreed that they would like the standard result and Visual Clot displayed on the screen side by side. Furthermore, 86% (36/42) indicated that Visual Clot allows them to deal with complex coagulation situations more quickly. Conclusions A group of anesthesia and intensive care physicians from two university hospitals in central Europe considered Visual Clot technology to be intuitive, easy to learn, and useful for decision making in situations of active bleeding. From the responses of these possible future users, Visual Clot appears to constitute an efficient and well-accepted way to streamline the decision-making process in viscoelastic test–based coagulation management.
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Affiliation(s)
- Tadzio Raoul Roche
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Sadiq Said
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Malgorzata Gozdzik
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Patrick Meybohm
- Department of Anesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Donat R Spahn
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Christoph B Nöthiger
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - David W Tscholl
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
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Kataife ED, Said S, Braun J, Roche TR, Rössler J, Kaserer A, Spahn DR, Mileo FG, Tscholl DW. The Haemostasis Traffic Light, a user-centred coagulation management tool for acute bleeding situations: a simulation-based randomised dual-centre trial. Anaesthesia 2020; 76:902-910. [PMID: 33210309 DOI: 10.1111/anae.15314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 12/14/2022]
Abstract
The Haemostasis Traffic Light is a cognitive aid with a user-centred design to enhance and simplify situation awareness and decision-making during peri-operative bleeding. Its structure helps to prioritise therapeutic interventions according to the pathophysiology and the severity of the bleeding. This investigator-initiated, randomised, prospective, international, dual-centre study aimed to validate the Haemostasis Traffic Light by adapting it to the local coagulation protocols of two university hospitals. Between 9 January and 12 May 2020, we recruited 84 participants at the University Hospital Zurich, Switzerland, and the Italian Hospital of Buenos Aires, Argentina. Each centre included 21 resident and 21 staff anaesthetists. Participants were randomly allocated to either the text-based algorithm or the Haemostasis Traffic Light. All participants managed six bleeding scenarios using the same algorithm. In simulated bleeding scenarios, the design of the Haemostasis Traffic Light algorithm enabled more correctly solved cases, OR (95%CI) 7.23 (3.82-13.68), p < 0.001, and faster therapeutic decisions, HR (95%CI) 1.97 (1.18-3.29, p = 0.010). In addition, the tool improved therapeutic confidence, OR (95%CI) 4.31 (1.67-11.11, p = 0.003), and reduced perceived work-load coefficient (95%CI) -6.1 (-10.98 to -1.22), p = 0.020). This study provides empirical evidence for the importance of user-centred design in the development of haemostatic management protocols.
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Affiliation(s)
- E D Kataife
- Department of Anaesthesiology, Hospital Italiano de Buenos Aires, Argentina
| | - S Said
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Switzerland
| | - J Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - T R Roche
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Switzerland
| | - J Rössler
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Switzerland
| | - A Kaserer
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Switzerland
| | - D R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Switzerland
| | - F G Mileo
- Department of Anaesthesiology, Hospital Italiano de Buenos Aires, Argentina
| | - D W Tscholl
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Switzerland
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Rössler J, Kaserer A, Albiez B, Braun J, Breckwoldt J, Spahn DR, Nöthiger C, Tscholl DW. Correction: Comparing Classroom Instruction to Individual Instruction as an Approach to Teach Avatar-Based Patient Monitoring With Visual Patient: Simulation Study. JMIR Med Educ 2020; 6:e24459. [PMID: 33001840 PMCID: PMC7563624 DOI: 10.2196/24459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 06/11/2023]
Abstract
[This corrects the article DOI: 10.2196/17922.].
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Affiliation(s)
| | | | | | - Julia Braun
- Biostatistics and Prevention InstituteDepartments of Epidemiology and BiostatisticsUniversity of ZurichZurichSwitzerland
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18
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Said S, Gozdzik M, Roche TR, Braun J, Rössler J, Kaserer A, Spahn DR, Nöthiger CB, Tscholl DW. Validation of the Raw National Aeronautics and Space Administration Task Load Index (NASA-TLX) Questionnaire to Assess Perceived Workload in Patient Monitoring Tasks: Pooled Analysis Study Using Mixed Models. J Med Internet Res 2020; 22:e19472. [PMID: 32780712 PMCID: PMC7506540 DOI: 10.2196/19472] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/29/2020] [Accepted: 08/11/2020] [Indexed: 01/18/2023] Open
Abstract
Background Patient monitoring is indispensable in any operating room to follow the patient’s current health state based on measured physiological parameters. Reducing workload helps to free cognitive resources and thus influences human performance, which ultimately improves the quality of care. Among the many methods available to assess perceived workload, the National Aeronautics and Space Administration Task Load Index (NASA-TLX) provides the most widely accepted tool. However, only few studies have investigated the validity of the NASA-TLX in the health care sector. Objective This study aimed to validate a modified version of the raw NASA-TLX in patient monitoring tasks by investigating its correspondence with expected lower and higher workload situations and its robustness against nonworkload-related covariates. This defines criterion validity. Methods In this pooled analysis, we evaluated raw NASA-TLX scores collected after performing patient monitoring tasks in four different investigator-initiated, computer-based, prospective, multicenter studies. All of them were conducted in three hospitals with a high standard of care in central Europe. In these already published studies, we compared conventional patient monitoring with two newly developed situation awareness–oriented monitoring technologies called Visual Patient and Visual Clot. The participants were resident and staff anesthesia and intensive care physicians, and nurse anesthetists with completed specialization qualification. We analyzed the raw NASA-TLX scores by fitting mixed linear regression models and univariate models with different covariates. Results We assessed a total of 1160 raw NASA-TLX questionnaires after performing specific patient monitoring tasks. Good test performance and higher self-rated diagnostic confidence correlated significantly with lower raw NASA-TLX scores and the subscores (all P<.001). Staff physicians rated significantly lower workload scores than residents (P=.001), whereas nurse anesthetists did not show any difference in the same comparison (P=.83). Standardized distraction resulted in higher rated total raw NASA-TLX scores (P<.001) and subscores. There was no gender difference regarding perceived workload (P=.26). The new visualization technologies Visual Patient and Visual Clot resulted in significantly lower total raw NASA-TLX scores and all subscores, including high self-rated performance, when compared with conventional monitoring (all P<.001). Conclusions This study validated a modified raw NASA-TLX questionnaire for patient monitoring tasks. The scores obtained correctly represented the assumed influences of the examined covariates on the perceived workload. We reported high criterion validity. The NASA-TLX questionnaire appears to be a reliable tool for measuring subjective workload. Further research should focus on its applicability in a clinical setting.
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Affiliation(s)
- Sadiq Said
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Malgorzata Gozdzik
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Tadzio Raoul Roche
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Julia Braun
- Department of Epidemiology and Biostatistics, University of Zurich, Zurich, Switzerland
| | - Julian Rössler
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
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Kaserer A, Rössler J, Slankamenac K, Arvanitakis M, Spahn DR, Giovanoli P, Steiger P, Plock JA. Impact of allogeneic blood transfusions on clinical outcomes in severely burned patients. Burns 2020; 46:1083-1090. [DOI: 10.1016/j.burns.2019.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/11/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022]
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20
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Sahli SD, Rössler J, Tscholl DW, Studt JD, Spahn DR, Kaserer A. Point-of-Care Diagnostics in Coagulation Management. Sensors (Basel) 2020; 20:E4254. [PMID: 32751629 PMCID: PMC7435714 DOI: 10.3390/s20154254] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022]
Abstract
This review provides a comprehensive and up-to-date overview of point-of-care (POC) devices most commonly used for coagulation analyses in the acute settings. Fast and reliable assessment of hemostasis is essential for the management of trauma and other bleeding patients. Routine coagulation assays are not designed to visualize the process of clot formation, and their results are obtained only after 30-90 m due to the requirements of sample preparation and the analytical process. POC devices such as viscoelastic coagulation tests, platelet function tests, blood gas analysis and other coagulometers provide new options for the assessment of hemostasis, and are important tools for an individualized, goal-directed, and factor-based substitution therapy. We give a detailed overview of the related tests, their characteristics and clinical implications. This review emphasizes the evident advantages of the speed and predictive power of POC clot measurement in the context of a goal-directed and algorithm-based therapy to improve the patient's outcome. Interpretation of viscoelastic tests is facilitated by a new visualization technology.
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Affiliation(s)
- Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - David W. Tscholl
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Jan-Dirk Studt
- Division of Hematology, University and University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
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21
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Rössler J, Hegemann I, Schoenrath F, Seifert B, Kaserer A, Spahn GH, Falk V, Spahn DR. Efficacy of quadruple treatment on different types of pre-operative anaemia: secondary analysis of a randomised controlled trial. Anaesthesia 2020; 75:1039-1049. [PMID: 32342498 DOI: 10.1111/anae.15062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2020] [Indexed: 12/16/2022]
Abstract
In patients with pre-operative anaemia undergoing cardiac surgery, combination treatment with intravenous iron, subcutaneous erythropoietin alpha, vitamin B12 and oral folic acid reduces allogeneic blood product transfusions. It is unclear if certain types of anaemia particularly benefit from this treatment. We performed a post-hoc analysis of anaemic patients from a randomised trial on the 'Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery'. We used linear regression analyses to examine the efficacy of a combination anaemia treatment compared with placebo on the following deficiencies, each representing a part of the combination treatment: ferritin and transferrin saturation; endogenous erythropoietin; holotranscobalamine; and folic acid in erythrocytes. Efficacy was defined as change in reticulocyte count from baseline to the first, third and fifth postoperative days and represented erythropoietic activity in the immediate peri-operative recovery phase. In all 253 anaemic patients, iron deficiency was the most common cause of anaemia. Treatment significantly increased reticulocyte count in all regression analyses on postoperative days 1, 3 and 5 (all p < 0.001). Baseline ferritin and endogenous erythropoietin were negatively associated with change in reticulocyte count on postoperative day 5, with an unstandardised regression coefficient B of -0.08 (95%CI -0.14 to -0.02) and -0.14 (95%CI -0.23 to -0.06), respectively. Quadruple anaemia treatment was effective regardless of the cause of anaemia and its effect manifested early in the peri-operative recovery phase. The more pronounced a deficiency was, the stronger the subsequent boost to erythropoiesis may have been.
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Affiliation(s)
- J Rössler
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - I Hegemann
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - F Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, German Centre for Cardiovascular Research, Berlin, Germany
| | - B Seifert
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - A Kaserer
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - G H Spahn
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - V Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, German Centre for Cardiovascular Research, Berlin, Germany.,Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin, Germany.,Department of Health Science and Technology, Swiss Federal Institute of Technology, Zürich, Switzerland
| | - D R Spahn
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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22
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Rössler J, Kaserer A, Albiez B, Braun J, Breckwoldt J, Spahn DR, Nöthiger C, Tscholl DW. Comparing Classroom Instruction to Individual Instruction as an Approach to Teach Avatar-Based Patient Monitoring With Visual Patient: Simulation Study. JMIR Med Educ 2020; 6:e17922. [PMID: 32205304 PMCID: PMC7206517 DOI: 10.2196/17922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/26/2020] [Accepted: 03/23/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Visual Patient is an avatar-based alternative to standard patient monitor displays that significantly improves the perception of vital signs. Implementation of this technology in larger organizations would require it to be teachable by brief class instruction to large groups of professionals. Therefore, our study aimed to investigate the efficacy of such a large-scale introduction to Visual Patient. OBJECTIVE In this study, we aimed to compare 2 different educational methods, one-on-one instruction and class instruction, for training anesthesia providers in avatar-based patient monitoring. METHODS We presented 42 anesthesia providers with 30 minutes of class instruction on Visual Patient (class instruction group). We further selected a historical sample of 16 participants from a previous study who each received individual instruction (individual instruction group). After the instruction, the participants were shown monitors with either conventional displays or Visual Patient displays and were asked to interpret vital signs. In the class instruction group, the participants were shown scenarios for either 3 or 10 seconds, and the numbers of correct perceptions with each technology were compared. Then, the teaching efficacy of the class instruction was compared with that of the individual instruction in the historical sample by 2-way mixed analysis of variance and mixed regression. RESULTS In the class instruction group, when participants were presented with the 3-second scenario, there was a statistically significant median increase in the number of perceived vital signs when the participants were shown the Visual Patient compared to when they were shown the conventional display (3 vital signs, P<.001; effect size -0.55). No significant difference was found for the 10-second scenarios. There was a statistically significant interaction between the teaching intervention and display technology in the number of perceived vital signs (P=.04; partial η2=.076). The mixed logistic regression model for correct vital sign perception yielded an odds ratio (OR) of 1.88 (95% CI 1.41-2.52; P<.001) for individual instruction compared to class instruction as well as an OR of 3.03 (95% CI 2.50-3.70; P<.001) for the Visual Patient compared to conventional monitoring. CONCLUSIONS Although individual instruction on Visual Patient is slightly more effective, class instruction is a viable teaching method; thus, large-scale introduction of health care providers to this novel technology is feasible.
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Affiliation(s)
| | | | | | - Julia Braun
- Biostatistics and Prevention Institute, Departments of Epidemiology and Biostatistics, University of Zurich, Zurich, Switzerland
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23
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Rössler J, Kaserer A, Spahn GH, Spahn DR. Not all anemia is solely due to iron deficiency. J Thorac Dis 2020; 12:1130-1132. [PMID: 32274185 PMCID: PMC7138976 DOI: 10.21037/jtd.2019.12.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Julian Rössler
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Gabriela H Spahn
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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24
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Tscholl DW, Rössler J, Said S, Kaserer A, Spahn DR, Nöthiger CB. Situation Awareness-Oriented Patient Monitoring with Visual Patient Technology: A Qualitative Review of the Primary Research. Sensors (Basel) 2020; 20:E2112. [PMID: 32283625 PMCID: PMC7180744 DOI: 10.3390/s20072112] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/01/2020] [Accepted: 04/04/2020] [Indexed: 12/15/2022]
Abstract
Visual Patient technology is a situation awareness-oriented visualization technology that translates numerical and waveform patient monitoring data into a new user-centered visual language. Vital sign values are converted into colors, shapes, and rhythmic movements-a language humans can easily perceive and interpret-on a patient avatar model in real time. In this review, we summarize the current state of the research on the Visual Patient, including the technology, its history, and its scientific context. We also provide a summary of our primary research and a brief overview of research work on similar user-centered visualizations in medicine. In several computer-based studies under various experimental conditions, Visual Patient transferred more information per unit time, increased perceived diagnostic certainty, and lowered perceived workload. Eye tracking showed the technology worked because of the way it synthesizes and transforms vital sign information into new and logical forms corresponding to the real phenomena. The technology could be particularly useful for improving situation awareness in settings with high cognitive demand or when users must make quick decisions. This comprehensive review of Visual Patient research is the foundation for an evaluation of the technology in clinical applications, starting with a high-fidelity simulation study in early 2020.
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Affiliation(s)
- David Werner Tscholl
- Institute of Anesthesiology, University and University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland; (J.R.); (S.S.); (A.K.); (D.R.S.); (C.B.N.)
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25
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Rössler J, Rössler W, Seifritz E, Unterrassner L, Wyss T, Haker H, Wotruba D. Dopamine-Induced Dysconnectivity Between Salience Network and Auditory Cortex in Subjects With Psychotic-like Experiences: A Randomized Double-Blind Placebo-Controlled Study. Schizophr Bull 2020; 46:732-740. [PMID: 31751466 PMCID: PMC7147573 DOI: 10.1093/schbul/sbz110] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Indexed: 02/06/2023]
Abstract
Dopamine is involved in the pathophysiology of schizophrenia. Disrupted salience processing by the salience network (SN) may be a central link between dysregulated dopamine function and psychotic symptoms. However, dopaminergic influence on the SN and its presumed influence on psychotic and subpsychotic symptoms or psychotic-like experiences in healthy individuals remain unclear. Therefore, we investigated dopamine-induced changes in functional connectivity of the right anterior insula (rAI), a central SN hub, and their association with psychotic-like experiences. We enrolled 54 healthy, right-handed male subjects in a randomized, double-blind, cross-sectional placebo-controlled experiment. Psychotic-like experiences were assessed using the revised Exceptional Experiences Questionnaire (PAGE-R). They then received either placebo (n = 32) or 200 mg L-DOPA (n = 33), a dopamine precursor, orally and underwent resting-state functional magnetic resonance imaging. In a seed-to-voxel approach, we analyzed dopamine-induced changes in functional connectivity of the rAI and assessed the relationship between functional connectivity changes and PAGE-R score. L-DOPA reduced functional connectivity between the rAI and the left auditory cortex planum polare. In the placebo group, we found a strong negative correlation between PAGE-R score and rAI to planum polare functional connectivity; in the L-DOPA group, there was a strong positive correlation between PAGE-R score and functional connectivity between rAI and planum polare. The PAGE-R score explained about 30% of the functional connectivity variation between rAI and planum polare in the two groups. Our findings suggest that psychotic-like experiences are associated with dopamine-induced disruption of auditory input to the SN, which may lead to aberrant attribution of salience.
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Affiliation(s)
- Julian Rössler
- Collegium Helveticum, University of Zurich and ETH Zurich, Zurich, Switzerland,Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland,To whom correspondence should be addressed; tel: +41442538202, fax: +41 (0)44 255 44 09, e-mail:
| | - Wulf Rössler
- Collegium Helveticum, University of Zurich and ETH Zurich, Zurich, Switzerland,Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Zurich, Switzerland,Laboratory of Neuroscience (LIM 27), Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil,Department of Psychiatry and Psychotherapy, Charité Mitte, Charité, Berlin, Germany
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Zurich, Switzerland
| | - Lui Unterrassner
- Collegium Helveticum, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Thomas Wyss
- Collegium Helveticum, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Helene Haker
- Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Zurich, Switzerland,Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Diana Wotruba
- Collegium Helveticum, University of Zurich and ETH Zurich, Zurich, Switzerland,The Zurich Program for Sustainable Development of Mental Health Services (ZInEP), University Hospital of Psychiatry Zurich, Zurich, Switzerland
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26
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Tscholl DW, Rössler J, Handschin L, Seifert B, Spahn DR, Nöthiger CB. The Mechanisms Responsible for Improved Information Transfer in Avatar-Based Patient Monitoring: Multicenter Comparative Eye-Tracking Study. J Med Internet Res 2020; 22:e15070. [PMID: 32175913 PMCID: PMC7105929 DOI: 10.2196/15070] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 11/14/2019] [Accepted: 12/16/2019] [Indexed: 01/06/2023] Open
Abstract
Background Patient monitoring is central to perioperative and intensive care patient safety. Current state-of-the-art monitors display vital signs as numbers and waveforms. Visual Patient technology creates an easy-to-interpret virtual patient avatar model that displays vital sign information as it would look in a real-life patient (eg, avatar changes skin color from healthy to cyanotic depending on oxygen saturation). In previous studies, anesthesia providers using Visual Patient perceived more vital signs during short glances than with conventional monitoring. Objective We aimed to study the deeper mechanisms underlying information perception in conventional and avatar-based monitoring. Methods In this prospective, multicenter study with a within-subject design, we showed 32 anesthesia providers four 3- and 10-second monitoring scenarios alternatingly as either routine conventional or avatar-based in random sequence. All participants observed the same scenarios with both technologies and reported the vital sign status after each scenario. Using eye-tracking, we evaluated which vital signs the participants had visually fixated (ie, could have potentially read and perceived) during a scenario. We compared the frequencies and durations of participants’ visual fixations of vital signs between the two technologies. Results Participants visually fixated more vital signs per scenario in avatar-based monitoring (median 10, IQR 9-11 versus median 6, IQR 4-8, P<.001; median of differences=3, 95% CI 3-4). In multivariable linear regression, monitoring technology (conventional versus avatar-based monitoring, difference=−3.3, P<.001) was an independent predictor of the number of visually fixated vital signs. The difference was less prominent in the longer (10-second) scenarios (difference=−1.5, P=.04). Study center, profession, gender, and scenario order did not influence the differences between methods. In all four scenarios, the participants visually fixated 9 of 11 vital signs statistically significantly longer using the avatar (all P<.001). Four critical vital signs (pulse rate, blood pressure, oxygen saturation, and respiratory rate) were visible almost the entire time of a scenario with the avatar; these were only visible for fractions of the observations with conventional monitoring. Visual fixation of a certain vital sign was associated with the correct perception of that vital sign in both technologies (avatar: phi coefficient=0.358; conventional monitoring: phi coefficient=0.515, both P<.001). Conclusions This eye-tracking study uncovered that the way the avatar-based technology integrates the vital sign information into a virtual patient model enabled parallel perception of multiple vital signs and was responsible for the improved information transfer. For example, a single look at the avatar’s body can provide information about: pulse rate (pulsation frequency), blood pressure (pulsation intensity), oxygen saturation (skin color), neuromuscular relaxation (extremities limp or stiff), and body temperature (heatwaves or ice crystals). This study adds a new and higher level of empirical evidence about why avatar-based monitoring improves vital sign perception compared with conventional monitoring.
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Affiliation(s)
| | - Julian Rössler
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Lucas Handschin
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Burkhardt Seifert
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
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27
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Garot O, Rössler J, Pfarr J, Ganter MT, Spahn DR, Nöthiger CB, Tscholl DW. Avatar-based versus conventional vital sign display in a central monitor for monitoring multiple patients: a multicenter computer-based laboratory study. BMC Med Inform Decis Mak 2020; 20:26. [PMID: 32041584 PMCID: PMC7011453 DOI: 10.1186/s12911-020-1032-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maintaining adequate situation awareness is crucial for patient safety. Previous studies found that the use of avatar-based monitoring (Visual Patient Technology) improved the perception of vital signs compared to conventional monitoring showing numerical and waveform data; and was further associated with a reduction of perceived workload. In this study, we aimed to evaluate the effectiveness of Visual Patient Technology on perceptive performance and perceived workload when monitoring multiple patients at the same time, such as in central station monitors in intensive care units or operating rooms. METHODS A prospective, within-subject, computer-based laboratory study was performed in two tertiary care hospitals in Switzerland in 2018. Thirty-eight physician and nurse anesthetists volunteered for the study. The participants were shown four different central monitor scenarios in sequence, where each scenario displayed two critical and four healthy patients simultaneously for 10 or 30 s. After each scenario, participants had to recall the vital signs of the critical patients. Perceived workload was assessed with the National Aeronautics and Space Administration Task-Load-Index (NASA TLX) questionnaire. RESULTS In the 10-s scenarios, the median number of remembered vital signs significantly improved from 7 to 11 using avatar-based versus conventional monitoring with a mean of differences of 4 vital signs, 95% confidence interval (CI) 2 to 6, p < 0.001. At the same time, the median NASA TLX scores were significantly lower for avatar-based monitoring (67 vs. 77) with a mean of differences of 6 points, 95% CI 0.5 to 11, p = 0.034. In the 30-s scenarios, vital sign perception and workload did not differ significantly. CONCLUSIONS In central monitor multiple patient monitoring, we found a significant improvement of vital sign perception and reduction of perceived workload using Visual Patient Technology, compared to conventional monitoring. The technology enabled improved assessment of patient status and may, thereby, help to increase situation awareness and enhance patient safety.
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Affiliation(s)
- Olivier Garot
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Juliane Pfarr
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anesthesiology and Pain Therapy, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christoph B Nöthiger
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - David W Tscholl
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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28
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Rössler J, Meybohm P, Spahn DR, Zacharowski K, Braun J, Nöthiger CB, Tscholl DW. Improving decision making through presentation of viscoelastic tests as a 3D animated blood clot: the Visual Clot. Anaesthesia 2020; 75:1059-1069. [DOI: 10.1111/anae.14985] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2019] [Indexed: 12/28/2022]
Affiliation(s)
- J. Rössler
- Institute of Anesthesiology University of Zurich and University Hospital Zurich Zurich Switzerland
| | - P. Meybohm
- Department of Anaesthesiology Intensive Care Medicine and Pain Therapy University Hospital Frankfurt Frankfurt/Main Germany
| | - D. R. Spahn
- Institute of Anesthesiology University of Zurich and University Hospital Zurich Zurich Switzerland
| | - K. Zacharowski
- Department of Anaesthesiology Intensive Care Medicine and Pain Therapy University Hospital Frankfurt Frankfurt/Main Germany
| | - J. Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute University of Zurich Switzerland
| | - C. B. Nöthiger
- Institute of Anesthesiology University of Zurich and University Hospital Zurich Zurich Switzerland
| | - D. W. Tscholl
- Institute of Anesthesiology University of Zurich and University Hospital Zurich Zurich Switzerland
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Stein AL, Rössler J, Braun J, Sprengel K, Beeler PE, Spahn DR, Kaserer A, Stein P. Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma. Scand J Trauma Resusc Emerg Med 2019; 27:117. [PMID: 31888722 PMCID: PMC6937999 DOI: 10.1186/s13049-019-0697-0] [Citation(s) in RCA: 6] [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: 11/27/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A factor-based coagulation management following major trauma is recommended as standard of care by the European Trauma Treatment Guidelines. However, concerns about the thromboembolic risk of this approach are still prevalent. Our study therefore aims to assess if such a haemostatic management is associated with an increased risk for thromboembolic events. METHODS In this retrospective observational study carried out at the University Hospital Zurich we compared two three-year periods before (period 1: 2005-2007) and after (period 2: 2012-2014) implementation of a factor-based coagulation algorithm. We included all adult patients following major trauma primarily admitted to the University Hospital Zurich. Thromboembolic events were defined as a new in-hospital appearance of any peripheral thrombosis, arterial embolism, pulmonary embolism, stroke or myocardial infarction. A logistic regression was performed to investigate the association of thromboembolic events with possible confounders such as age, sex, specific Abbreviated Injury Scale (AIS) subgroups, allogeneic blood products, and the coagulation management. RESULTS Out of 1138 patients, 772 met the inclusion criteria: 344 patients in period 1 and 428 patients in period 2. Thromboembolic events were present in 25 patients (7.3%) of period 1 and in 42 patients (9.8%) of period 2 (raw OR 1.39, 95% CI 0.83 to 2.33, p = 0.21). Only AIS extremities (adjusted OR 1.26, 95% CI 1.05 to 1.52, p = 0.015) and exposure to allogeneic blood products (adjusted OR 2.39, 95% CI 1.33 to 4.30, p = 0.004) were independently associated with thromboembolic events in the logistic regression, but the factor-based coagulation management was not (adjusted OR 1.60, 95% CI 0.90-2.86, p = 0.11). CONCLUSION There is no evidence that a goal-directed, factor-based coagulation management is associated with an increased risk for thromboembolic events following major trauma.
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Affiliation(s)
- Anais L Stein
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, 8057, Zurich, Switzerland
| | - Julian Rössler
- Institute of Anaesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Julia Braun
- Departments of Biostatistics and Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Kai Sprengel
- Department of Trauma, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Patrick E Beeler
- Department of Internal Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anaesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anaesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anaesthesiology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400, Winterthur, Switzerland.
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Kiavialaitis GE, Müller S, Braun J, Rössler J, Spahn DR, Stein P, Kaserer A. Clinical practice of pre-hospital analgesia: An observational study of 20,978 missions in Switzerland. Am J Emerg Med 2019; 38:2318-2323. [PMID: 31785972 DOI: 10.1016/j.ajem.2019.10.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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] [Received: 07/25/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pain is a frequent problem faced by emergency medical services (EMS) in pre-hospital settings. This large observational study aims to assess the prevalence of sufficiently provided analgesia and to analyze the efficacy of different analgesics. Moreover, we evaluated if quality of analgesia changed with an emergency physician on scene or depended on paramedics' gender. METHODS This is a retrospective analysis of all pre-hospital medical charts from adults and adolescents treated by the municipal EMS Schutz & Rettung Zürich over a period of 4 years from 2013 to 2016. Inclusion criteria were age ≥16 years, initial GCS > 13, NACA score ≥I and ≤V, an initial numeric rating scale (NRS) ≥ I and a documented NRS at hospital admission. 20,978 out of 142,484 missions fulfilled the inclusion criteria and therefore underwent further investigation. Descriptive, univariate and multivariate analyses were applied. RESULTS Initial NRS on scene was on average 5.2 ± 3.0. Mean NRS reduction after treatment was 2.2 ± 2.5 leading to a NRS at hospital admission of 3.0 ± 1.9. This resulted in sufficient analgesia for 77% of included patients. Among analgesics, the highest odds ratio for sufficient analgesia was observed for ketamine (OR 4.7, 95%CI 2.2-10.4, p < 0.001) followed by fentanyl (OR 1.4, 95%CI 1.1-1.7, p = 0.004). Female paramedics provided better analgesia (OR 1.2, 95%CI 1.1-1.2; p < 0.001). Patient's sex had no influence on analgesia. In patients with a NACA score > 2, the presence of an emergency physician on scene improved the quality of analgesia significantly. CONCLUSIONS Pre-hospital analgesia is mostly adequate, especially when done with ketamine or fentanyl. Female paramedics provided better analgesia and in selected patients, an emergency physician on scene improved quality of analgesia in critical patients.
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Affiliation(s)
| | - Stefan Müller
- Schutz & Rettung Zürich, Zurich, Switzerland; Institute of Anesthesiology and Intensive Care Medicine, Stadtspital Triemli, Zurich, Switzerland
| | - Julia Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland; Institute of Anesthesiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
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Kaserer A, Kiavialaitis GE, Braun J, Schedler A, Stein P, Rössler J, Spahn DR, Studt JD. Impact of rivaroxaban plasma concentration on perioperative red blood cell loss. Transfusion 2019; 60:197-205. [PMID: 31682296 DOI: 10.1111/trf.15560] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/26/2019] [Accepted: 09/26/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND This study investigates the impact of preoperative calculated rivaroxaban (RXA) plasma concentration on perioperative red blood cell (RBC) loss. STUDY DESIGN AND METHODS In this retrospective single-center study, we identified patients with RXA intake according to a preoperative determination of RXA levels within 96 hours before surgery. RXA plasma concentration at the beginning of surgery was then calculated from the last RXA intake using a single-compartment pharmacokinetic model with four categories of RXA concentration (≤20, 21-50, 51-100, and >100 μg/L). Patients were classified into surgery with high (≥500 mL) or low (<500 mL) expected blood loss. Perioperative bleeding was determined by calculating RBC loss. RESULTS We analyzed 308 surgical interventions in 298 patients during the period from January 2012 to July 2018. Among patients undergoing surgery with low expected blood loss, RBC loss varied from 164 mL (standard deviation [SD], 189) to 302 mL (SD, 397) (p = 0.66), and no association of calculated RXA concentration with RBC loss was observed. In patients undergoing surgery with high expected blood loss, we found a significant correlation of calculated RXA concentration with RBC loss (Pearson's correlation coefficient, 0.29; p = 0.002). RBC loss increased with rising RXA concentration from 575 mL (SD, 365) at RXA concentration of 20 μg/L or less up to 1400 mL (SD, 1300) at RXA concentration greater than 100 μg/L. RXA concentration greater than 100 μg/L was associated with a significant increase of in RBC loss of 840 mL (95% confidence interval, 360-1300; p < 0.001). Transfusion of RBC and fresh frozen plasma units tended to increase in patients with RXA concentrations greater than 100 μg/L. The proportion of patients treated with prothrombin complex concentrate and coagulation factor XIII concentrate increased significantly with higher RXA concentrations. CONCLUSION Only in surgery with high expected blood loss, a calculated RXA concentration of greater than 100 μg/L was associated with a significant increase of perioperative RBC loss.
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Affiliation(s)
- Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Julia Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Andreas Schedler
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Jan-Dirk Studt
- Division of Hematology, University and University Hospital Zurich, Zurich, Switzerland
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Rössler J, Schoenrath F, Seifert B, Kaserer A, Spahn GH, Falk V, Spahn DR. Iron deficiency is associated with higher mortality in patients undergoing cardiac surgery: a prospective study. Br J Anaesth 2019; 124:25-34. [PMID: 31668348 DOI: 10.1016/j.bja.2019.09.016] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [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: 05/30/2019] [Revised: 08/13/2019] [Accepted: 09/04/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Iron deficiency is frequent in patients undergoing cardiac surgery. The relevance of iron deficiency, however, is ill defined. Therefore, our study aimed to investigate the impact of iron deficiency (ferritin <100 μg L-1) with or without concomitant anaemia on clinical outcome after cardiac surgery. METHODS In this prospective observational study, 730 patients undergoing elective cardiac surgery were assigned into four groups according to their iron status and anaemia. Mortality, serious adverse events (SAEs), major cardiac and cerebrovascular events (MACCEs), allogenic blood transfusion requirements, and length of hospital stay were assessed during a 90-day follow-up period. The effect of iron deficiency on these outcomes was first calculated in models adjusting for anaemia only, followed by two multivariate models adjusting for anaemia and either the EuroSCORE II or any possible confounders. RESULTS The presence of iron deficiency (ferritin <100 μg L-1) was associated with an increase in 90-day mortality from 2% to 5% in patients without anaemia, and from 4% to 14% in patients with anaemia. Logistic regression resulted in an odds ratio of 3.5 (95% confidence interval: 1.5-8.4); P=0.004. The effect persisted in both multivariate models. Moreover, iron deficiency was associated with an increased incidence of SAEs, MACCEs, transfusion, and prolonged hospital stay. CONCLUSIONS Preoperative iron deficiency (ferritin <100 μg L-1) was independently associated with increased mortality, more SAEs, and prolonged hospital stay after cardiac surgery. These findings underline the importance of preoperative iron deficiency screening in the context of a comprehensive patient blood management programme, and highlight its importance as a research topic in cardiac surgery. CLINICAL TRIAL REGISTRATION NCT02031289.
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Affiliation(s)
- Julian Rössler
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Burkhardt Seifert
- Department of Biostatistics at the Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Gabriela H Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.
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Kaserer A, Rössler J, Braun J, Farokhzad F, Pape H, Dutkowski P, Plass A, Horisberger T, Volbracht J, Manz MG, Spahn DR. Impact of a Patient Blood Management monitoring and feedback programme on allogeneic blood transfusions and related costs. Anaesthesia 2019; 74:1534-1541. [DOI: 10.1111/anae.14816] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2019] [Indexed: 11/27/2022]
Affiliation(s)
- A. Kaserer
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
| | - J. Rössler
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
| | - J. Braun
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute University of Zurich Switzerland
| | - F. Farokhzad
- Medical Directorate University of Zurich and University Hospital Zurich Switzerland
| | - H.‐C. Pape
- Department of Surgery University of Zurich and University Hospital Zurich Switzerland
| | - P. Dutkowski
- Department of Surgery University of Zurich and University Hospital Zurich Switzerland
| | - A. Plass
- Department of Surgery University of Zurich and University Hospital Zurich Switzerland
| | - T. Horisberger
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
| | - J. Volbracht
- Medical Directorate University of Zurich and University Hospital Zurich Switzerland
| | - M. G. Manz
- Department of Medical Oncology and Haematology University of Zurich and University Hospital Zurich Switzerland
| | - D. R. Spahn
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
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Tscholl DW, Handschin L, Rössler J, Weiss M, Spahn DR, Nöthiger CB. It's not you, it's the design - common problems with patient monitoring reported by anesthesiologists: a mixed qualitative and quantitative study. BMC Anesthesiol 2019; 19:87. [PMID: 31138143 PMCID: PMC6540409 DOI: 10.1186/s12871-019-0757-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 01/03/2019] [Accepted: 05/14/2019] [Indexed: 12/31/2022] Open
Abstract
Background Patient monitoring is critical for perioperative patient safety as anesthesiologists routinely make crucial therapeutic decisions from the information displayed on patient monitors. Previous research has shown that today’s patient monitoring has room for improvement in areas such as information overload and alarm fatigue. The rationale of this study was to learn more about the problems anesthesiologists face in patient monitoring and to derive improvement suggestions for next-generation patient monitors. Methods We conducted a two-center qualitative/quantitative study. Initially, we interviewed 120 anesthesiologists (physicians and nurses) about the topic: common problems with patient monitoring in your daily work. Through deductive and inductive coding, we identified major topics and sub themes from the interviews. In a second step, a field survey, a separate group of 25 anesthesiologists rated their agree- or disagreement with central statements created for all identified major topics. Results We identified the following six main topics: 1. “Alarms,” 2. “Artifacts,” 3. “Software,” 4. “Hardware,” 5. “Human Factors,” 6. “System Factors,” and 17 sub themes. The central statements rated for the major topics were: 1. “problems with alarm settings complicate patient monitoring.” (56% agreed) 2. “artifacts complicate the assessment of the situation.” (64% agreed) 3. “information overload makes it difficult to get an overview quickly.” (56% agreed) 4. “problems with cables complicate working with patient monitors.” (92% agreed) 5. “factors related to human performance lead to critical information not being perceived.” (88% agreed) 6. “Switching between monitors from different manufacturers is difficult.” (88% agreed). The ratings of all statements differed significantly from neutral (all p < 0.03). Conclusion This study provides an overview of the problems anesthesiologists face in patient monitoring. Some of the issues, to our knowledge, were not previously identified as common problems in patient monitoring, e.g., hardware problems (e.g., cable entanglement and worn connectors), human factor aspects (e.g., fatigue and distractions), and systemic factor aspects (e.g., insufficient standardization between manufacturers). An ideal monitor should transfer the relevant patient monitoring information as efficiently as possible, prevent false positive alarms, and use technologies designed to improve the problems in patient monitoring. Electronic supplementary material The online version of this article (10.1186/s12871-019-0757-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David W Tscholl
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Lucas Handschin
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Mona Weiss
- Department of Management, School of Business and Economics, Free University of Berlin, Garystrasse 21, 14195, Berlin, Germany
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christoph B Nöthiger
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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Rössler J, Unterassner L, Wyss T, Haker H, Brugger P, Rössler W, Wotruba D. Schizotypal Traits are Linked to Dopamine-Induced Striato-Cortical Decoupling: A Randomized Double-Blind Placebo-Controlled Study. Schizophr Bull 2019; 45:680-688. [PMID: 29878280 PMCID: PMC6483584 DOI: 10.1093/schbul/sby079] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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] [Indexed: 12/17/2022]
Abstract
The dopamine hypothesis of schizophrenia implies that alterations in the dopamine system cause functional abnormalities in the brain that may converge to aberrant salience attribution and eventually lead to psychosis. Indeed, widespread brain disconnectivity across the psychotic spectrum has been revealed by resting-state functional magnetic resonance imaging (rs-fMRI). However, the dopaminergic involvement in intrinsic functional connectivity (iFC) and its putative relationship to the development of psychotic spectrum disorders remains partly unclear-in particular at the low-end of the psychosis continuum. Therefore, we investigated dopamine-induced changes in striatal iFC and their modulation by psychometrically assessed schizotypy. Our randomized, double-blind placebo-controlled study design included 54 healthy, right-handed male participants. Each participant was assessed with the Schizotypal Personality Questionnaire (SPQ) and underwent 10 minutes of rs-fMRI scanning. Participants then received either a placebo or 200 mg of L-DOPA, a dopamine precursor. We analyzed iFC of 6 striatal seeds that are known to evoke modulation of dopamine-related networks. The main effect of L-DOPA was a significant functional decoupling from the right ventral caudate to both occipital fusiform gyri. This dopamine-induced decoupling emerged primarily in participants with low SPQ scores, while participants with high positive SPQ scores showed decoupling indifferently of the L-DOPA challenge. Taken together, these findings demonstrate that schizotypal traits may be the result of dopamine-induced striato-occipital decoupling.
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Affiliation(s)
- Julian Rössler
- Collegium Helveticum, University of Zurich; and ETH Zurich, Zurich, Switzerland,To whom correspondence should be addressed; Julian Rössler, Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, Zurich 8091, Switzerland; tel: +41 442551111; fax: +41 442554409; e-mail:
| | - Lui Unterassner
- Collegium Helveticum, University of Zurich; and ETH Zurich, Zurich, Switzerland
| | - Thomas Wyss
- Collegium Helveticum, University of Zurich; and ETH Zurich, Zurich, Switzerland
| | - Helene Haker
- Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Peter Brugger
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Wulf Rössler
- Collegium Helveticum, University of Zurich; and ETH Zurich, Zurich, Switzerland,Psychiatric University Hospital, Zürich University, Zürich, Switzerland,Laboratory of Neuroscience (LIM 27), Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil,Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany
| | - Diana Wotruba
- Collegium Helveticum, University of Zurich; and ETH Zurich, Zurich, Switzerland
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Weiss A, Sommer G, Schindera C, Wengenroth L, Karow A, Diezi M, Michel G, Kuehni CE, Ammann R, Scheinemann K, Ansari M, Beck Popovic M, Brazzola P, Greiner J, Grotzer M, Hengartner H, Kuehne T, Rössler J, Niggli F, Schilling F, von der Weid N. Hearing loss and quality of life in survivors of paediatric CNS tumours and other cancers. Qual Life Res 2018; 28:515-521. [DOI: 10.1007/s11136-018-2021-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2018] [Indexed: 12/20/2022]
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Rössler J, Unterrassner L, Wyss T, Haker H, Brugger P, Rössler W, Wotruba D. L-dopa Modulates Striatal Functional Connectivity in Adults with Psychotic-like Experiences: A Randomized Double-blind Placebo-controlled Study. Eur Psychiatry 2017. [DOI: 10.1016/j.eurpsy.2017.01.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IntroductionAccording to the dopamine hypothesis functional brain abnormalities and neurochemical alterations may converge to cause psychosis through aberrant salience attribution. Indeed, resting-state functional magnetic resonance imaging (rs-fMRI) has revealed widespread brain disconnectivity across the psychotic spectrum.ObjectivesTo advance the understanding of the dopaminergic involvement in intrinsic functional connectivity (iFC) and its putative relationship to the development of psychotic disorders we aimed to investigate the link between L-Dopa, a dopamine precursor, and its modulation of striatal iFC in subthreshold psychosis, i.e. non-clinical psychosis.MethodsWe used a randomized, double-blind placebo controlled study design including in our sample 56 healthy, male, right-handed, subjects with no familiar risk factors for psychosis who were assessed with the Schizotypal Personality Questionnaire (SPQ) and underwent 10 minutes of rs-fMRI scanning. All subjects received either 250 mg of Madopar DR®(200 mg L-Dopa plus 50 mg benserazid, dual release form) or a placebo. We analysed resting-state iFC of 6 striatal seeds, known to evoke dopamine related networks.ResultsThe main effect of L-Dopa presented itself (FWE-corrected) as a significant decrease in iFC from the right ventral striatum to the cerebellum and the precuneus cortex, and an increase in iFC to the occipital cortex. Subjects with high SPQ positive symptom sub-scores showed a significant increase of L-Dopa induced connectivity.ConclusionWe identified striatal functional connectivity being modulated by augmented dopamine availability, and in support of the dopamine hypothesis, we found that those iFC patterns are associated to high scores of psychotic like experiences.Disclosure of interestThe authors have not supplied their declaration of competing interest.
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Notaro S, Reimer D, Fiegl H, Schmid G, Wiedemair A, Rössler J, Marth C, Zeimet AG. Bewertung der Folat-Rezeptor 1 (FOLR1) mRNA-Expression, seine promotorspezifische DNA-Methylierung und die globale DNA-Hypomethylierung im Typ I und Typ II Ovarialkarzinom. Geburtshilfe Frauenheilkd 2016. [DOI: 10.1055/s-0036-1579604] [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: 10/22/2022] Open
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Notaro S, Fiegl H, Reimer D, Duggan-Peer M, Wiedemair A, Rössler J, Altevogt P, Zeimet AG, Marth C. Evaluierung der L1CAM-Expression beim Endometriumkarzinom mittels quantitativer Real-time PCR. Geburtshilfe Frauenheilkd 2016. [DOI: 10.1055/s-0036-1579602] [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: 10/22/2022] Open
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Notaro S, Reimer D, Fiegl H, Wiedermair A, Rössler J, Zeimet AG. Die Rolle der mir-34 Familie beim Typ I und Typ II Ovarialkarzinom. Geburtshilfe Frauenheilkd 2016. [DOI: 10.1055/s-0036-1579601] [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: 10/22/2022] Open
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Notaro S, Duggan-Peer M, Fiegl H, Reimer D, Wiedemair A, Rössler J, Marth C, Zeimet AG. JARID1 Familie Transkript Evaluierung bei Ovarialkarzinom und deren Korrelationen mit BRCA-Gen-Mutation und Expression. Geburtshilfe Frauenheilkd 2016. [DOI: 10.1055/s-0036-1579603] [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: 10/22/2022] Open
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Harttrampf AC, Schupp W, Timme S, Niemeyer CM, Otten JE, Rössler J. Surgical management of extranasal nasal glioma. J Eur Acad Dermatol Venereol 2015; 30:1209-11. [PMID: 25820156 DOI: 10.1111/jdv.13129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A C Harttrampf
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, University Medical Center, Freiburg, Germany
| | - W Schupp
- Department of Oral and Maxillofacial Surgery, University Medical Center, Freiburg, Germany
| | - S Timme
- Department of Pathology, University Medical Center, Freiburg, Germany
| | - C M Niemeyer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, University Medical Center, Freiburg, Germany
| | - J E Otten
- Department of Oral and Maxillofacial Surgery, University Medical Center, Freiburg, Germany
| | - J Rössler
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, University Medical Center, Freiburg, Germany
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Abstract
The therapy of vascular tumors and malformations should be interdisciplinary and performed according to available guidelines. Infantile hemangiomas (IH) are the most frequent vascular tumors of childhood and do not require treatment in most cases. If the IH is complicated by its location (e.g. facial or genital) or if the lesion threatens to cause loss of function, small localized IH should be treated by laser- or cryotherapy. If the IH is diffuse or rapidly growing it can be successfully treated using the β blocker propranolol. The mechanism underlying the efficacy of this medication-based therapy is not completely understood and this still represents an experimental therapy. The results of molecular studies on vascular malformations have indicated new strategies for medical therapies. However, lymphatic malformations (LM) are still treated by surgery where possible, or sclerotherapy. Further investigations are necessary to determine whether new drugs such as the mTOR inhibitor rapamycin may be effective for treatment of diffuse LM. First case reports seem to be promising.
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Affiliation(s)
- J Rössler
- Interdisziplinäre Spezialsprechstunde für Hämangiome und vaskuläre Malformationen, Universitätsklinikum Freiburg, Freiburg, Deutschland,
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Affiliation(s)
- A Puzik
- Department of Pediatric Hematology and Oncology, Albert-Ludwigs-University of Freiburg , Mathildenstrasse 1, Freiburg , Germany
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Hatina J, Reimer D, Sopper S, Boesch M, Martowicz A, Rössler J, Wiedemair A, Wolf D, Zeimet AG. Tumorstammzellen und die Biologie der Chemoresistenz beim Ovarialkarzinom. Geburtshilfe Frauenheilkd 2012. [DOI: 10.1055/s-0032-1309223] [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: 10/28/2022] Open
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Rössler J, Schill T, Bähr A, Truckenmüller W, Noellke P, Niemeyer CM. Propranolol for proliferating infantile haemangioma is superior to corticosteroid therapy--a retrospective, single centre study. J Eur Acad Dermatol Venereol 2011; 26:1173-5. [PMID: 22035186 DOI: 10.1111/j.1468-3083.2011.04314.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Moske-Eick O, Taschner CA, Krauss S, Kirschner J, van Velthoven V, Rottenburger C, Rössler J, Prinz M. Freiburg neuropathology case conference: an intramedullary mass lesion in a child. Clin Neuroradiol 2010; 20:135-9. [PMID: 20549169 DOI: 10.1007/s00062-010-0008-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- O Moske-Eick
- Department of Neuroradiology, University Hospital Freiburg, Freiburg, Germany
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André N, Pasquier E, Verschuur A, Sterba J, Gentet JC, Rössler J. [Metronomic chemotherapy in pediatric oncology: hype or hope?]. Arch Pediatr 2009; 16:1158-65. [PMID: 19446445 DOI: 10.1016/j.arcped.2009.03.019] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Revised: 11/11/2008] [Accepted: 03/29/2009] [Indexed: 10/20/2022]
Abstract
Angiogenesis is crucial for the growth of cancer. As such, it has become an established target in fighting cancer. Metronomic chemotherapy-the chronic administration of chemotherapy at relatively low, minimally toxic doses on a frequent schedule of administration at close regular intervals, with no prolonged drug-free breaks-is a potential novel approach to controlling advanced cancer disease. It is thought to work primarily through antiangiogenic mechanisms and has the property of killing resistant cancer cells while significantly reducing undesirable toxic side effects. We review the data regarding the use of metronomic chemotherapy in children with cancer and discuss its potential uses and limits.
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Affiliation(s)
- N André
- Service d'oncologie pédiatrique, hôpital pour enfants de La-Timone, boulevard Jean-Moulin, 13005 Marseille, France.
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Zardo I, Yu L, Conesa-Boj S, Estradé S, Alet PJ, Rössler J, Frimmer M, Roca I Cabarrocas P, Peiró F, Arbiol J, Morante JR, Fontcuberta I Morral A. Gallium assisted plasma enhanced chemical vapor deposition of silicon nanowires. Nanotechnology 2009; 20:155602. [PMID: 19420550 DOI: 10.1088/0957-4484/20/15/155602] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Silicon nanowires have been grown with gallium as catalyst by plasma enhanced chemical vapor deposition. The morphology and crystalline structure has been studied by electron microscopy and Raman spectroscopy as a function of growth temperature and catalyst thickness. We observe that the crystalline quality of the wires increases with the temperature at which they have been synthesized. The crystalline growth direction has been found to vary between <111> and <112>, depending on both the growth temperature and catalyst thickness. Gallium has been found at the end of the nanowires, as expected from the vapor-liquid-solid growth mechanism. These results represent good progress towards finding alternative catalysts to gold for the synthesis of nanowires.
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Affiliation(s)
- I Zardo
- Walter Schottky Institut, Technische Universität München, Am Coulombwall, D-85748 Garching, Germany
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Taylor M, Geoerger B, Lagodny J, Farace F, Vassal G, Rössler J. [Potential role of antiangiogenic treatment in neuroblastoma]. Arch Pediatr 2009; 16:457-67. [PMID: 19299115 DOI: 10.1016/j.arcped.2009.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Revised: 09/17/2008] [Accepted: 02/01/2009] [Indexed: 10/21/2022]
Abstract
Focus on new drug development over the last few years has yielded new agents that differ from unspecific classical chemotherapeutics and ionizing radiation, while still targeting the cancer cell itself. Antiangiogenesis is a totally distinct approach targeting the tumor's blood vessels. This concept has now found its eligibility for the treatment of several adult solid tumors: the human antivascular endothelial growth factor (VEGF) antibody bevacizumab, as well as the VEGF receptor tyrosine kinase inhibitors, sunitinib and sorafinib, have recently been licensed by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMEA) for the treatment of colorectal, renal, and lung cancer. Other antiangiogenic drugs are under preclinical and early clinical evaluation. However, what do we know of the use of these drugs in pediatric solid tumors, such as sarcomas and embryonal and neuronal tumors? For some time now, neuroblastoma has been shown to be dependent on angiogenesis. However, the first preclinical data on antiangiogenic drugs in neuroblastoma have not been published until recently, and clinical trials with antiangiogenic agents in neuroblastoma treatment protocols are scarce. This review adresses current knowledge on the important role and mechanisms of angiogenesis in neuroblastoma and summarizes available preclinical and clinical results of antiangiogenic agents used to treat neuroblastoma. Our review clearly demonstrates that clinical trials are urgently needed to bring forward promising antiangiogenesis concepts in neuroblastoma therapy.
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Affiliation(s)
- M Taylor
- Institut Gustave-Roussy, UPRES EA3535 Pharmacologie et nouveaux traitements dans le cancer, université Paris-Sud, 63, rue Gabriel-Péri, 94276 Le Kremlin-Bicêtre, France
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