This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Purpose: Measurements of cerebrospinal fluid (CSF) lactate can aid in detecting infections of the... more Purpose: Measurements of cerebrospinal fluid (CSF) lactate can aid in detecting infections of the central nervous system and surrounding structures. Neurosurgical patients with temporary lumbar or ventricular CSF drainage harbor an increased risk for developing infections of the central nervous system, which require immediate therapeutic responses. Since blood gas analyzers enable rapid blood-lactate measurements, we were interested in finding out if we can reliably measure CSF-lactate by this point-ofcare technique. Methods: Neurosurgical patients on our intensive care unit (ICU) with either lumbar or external ventricular drainage due to a variety of reasons were included in this prospective observational study. Standard of care included measurements of leucocyte counts, total protein and lactate measurements in CSF by the neurochemical laboratory of our University Medical Center twice a week. With respect to this study, we additionally performed nearly daily measurements of cerebrospinal fluid by blood gas analyzers to determine the reliability of CSF-lactate measured by blood gas analyzers as compared to the standard measurements with a certified device. Results: 62 patients were included in this study. We performed 514 CSF-lactate measurements with blood gas analyzers and compared 180 of these to the in-house standard CSF-lactate measurements. Both techniques correlated highly significantly (Pearson correlation index 0.94) even though lacking full concordance in a Bland-Altman plotting. Of particular importance, regular measurements enabled immediate detection of central infection in three patients who had developed meningitis during the course of their treatment. Conclusion: Blood gas analyzers measure CSF-lactate with sufficient reliability and can help in the timely detection of a developing meningitis. In addition to and triggering established CSF diagnostics, CSF-lactate measurements by blood gas analyzers may improve surveillance of patients with CSF drainage. This study was retrospectively registered on April 20th 2020 in the German trial register. The trial registration number is DRKS00021466.
Objective: Positive end-expiratory pressure exerts its effects keeping open at end-expiration pre... more Objective: Positive end-expiratory pressure exerts its effects keeping open at end-expiration previously collapsed areas of the lung; consequently, higher positive end-expiratory pressure should be limited to patients with high recruitability. We aimed to determine which bedside method would provide positive end-expiratory pressure better related to lung recruitability. Design: Prospective study performed between 2008 and 2011. Setting: Two university hospitals (Italy and Germany). Patients: Fifty-one patients with acute respiratory distress syndrome. Interventions: Whole lung CT scans were taken in static conditions at 5 and 45 cm H2O during an end-expiratory/end-inspiratory pause to measure lung recruitability. To select individual positive end-expiratory pressure, we applied bedside methods based on lung mechanics (ExPress, stress index), esophageal pressure, and oxygenation (higher positive end-expiratory pressure table of lung open ventilation study). Measurements and Main Results: Patients were classified in mild, moderate and severe acute respiratory distress syndrome. Positive end-expiratory pressure levels selected by the ExPress, stress index, and absolute esophageal pressures methods were unrelated with lung recruitability, whereas positive end-expiratory pressure levels selected by the lung open ventilation method showed a weak relationship with lung recruitability (r 2 = 0.29; p < 0.0001). When patients were classified according to the acute respiratory distress syndrome Berlin definition, the lung open ventilation method was the only one which gave lower positive end-expiratory pressure levels in mild and moderate acute respiratory distress syndrome compared with severe acute respiratory distress syndrome (8 ± 2 and 11 ± 3 cm H 2 O vs 15 ± 3 cm H 2 O; p < 0.05), whereas ExPress, stress index, and esophageal pressure methods gave similar positive end-expiratory pressure values in mild, moderate, and severe acute respiratory distress syndrome. The positive end-expiratory pressure selected by the different methods were unrelated to each other with the exception of the two methods based on lung mechanics (ExPress and stress index). Conclusions: Bedside positive end-expiratory pressure selection methods based on lung mechanics or absolute esophageal pressures provide positive end-expiratory pressure levels unrelated to lung recruitability and similar in mild, moderate, and severe acute respiratory distress syndrome, whereas the oxygenation-based method provided positive end-expiratory pressure levels related with lung recruitability progressively increasing from mild to moderate and severe acute respiratory distress syndrome.
Journal of Neurosurgical Anesthesiology, Apr 1, 2007
Fever is common among neurologic patients and is usually treated by antipyretic drugs and externa... more Fever is common among neurologic patients and is usually treated by antipyretic drugs and external cooling. An alternative method for temperature management may be an intravascular approach. The aim of the study was to compare the effectiveness and the therapeutic costs of this new method with conventional treatment in neurologic patients. Twenty-six patients who suffered from subarachnoid hemorrhage or traumatic brain injury with febrile episodes were included the study and were randomized into 2 different groups. In the ''Conventional'' group, fever was treated with antipyretic drugs and/or surface cooling techniques to achieve a body core temperature of 36.51C. In the ''CoolGard'' group, patients were treated with an intravascular cooling catheter (Coolgard, Alsius, CA). We compared the effectiveness of these 2 approaches by calculating the mean deviation from 36.51C during a 48-hour period (fever burden). We found a significant difference in the fever burden [CoolGard: À 0.49 to 1.22 (median À 0.06) 1C vs. Conventional: 1.05-2.34 (median 1.41) 1C, P<0.05]. Costs varied significantly between the CoolGard and the Conventional groups, with markedly higher daily costs in the CoolGard group [CoolGard: 15 to 140 US dollars (USD) (median 39 USD) vs. Conventional: 1 to 9 USD (median 5 USD), P<0.05]. The effectiveness of the intravascular cooling catheter is excellent compared with conventional cooling therapies.
Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on ... more Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre-including this research content-immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
Recruitment maneuvers have been proposed as an adjunct to mechanical ventilation to re-expand col... more Recruitment maneuvers have been proposed as an adjunct to mechanical ventilation to re-expand collapsed lung regions. Although, in most patients recruitment maneuvers improve gas exchange a controversial discussion on recruitment maneuvers remains. This article reviews the physiological and patho-physiological backgrounds of recruitment maneuvers. The different recruitment maneuvers and possible monitoring are discussed as well as the influence of recruitment on other organs. Furthermore, we discuss whether recruitment maneuvers are useful if patients with acute lung injury or acute respiratory distress syndrome are ventilated with a lung-protective strategy.
The occurrence of a noninfectious interstitial lung disease is a rare but life-threatening side e... more The occurrence of a noninfectious interstitial lung disease is a rare but life-threatening side effect of infliximab, an antitumor necrosis factor alpha antibody. The following case report of a patient with Crohn disease shows an extremely dramatic progression to a severe acute respiratory distress syndrome.
Background and Objective Resistance to antibacterial substances is a huge and still emerging issu... more Background and Objective Resistance to antibacterial substances is a huge and still emerging issue, especially with regard to Gram-negative bacteria and in critically ill patients. We report a study in six patients infected with extensively drug-resistant Gram-negative bacteria in a limited outbreak who were successfully managed with a quasi-continuous infusion of cefiderocol. Methods Patients were initially treated with prolonged infusions of cefiderocol over 3 h every 8 h, and the application mode was then switched to a quasi-continuous infusion of 2 g over 8 h, i.e. 6 g in 24 h. Therapeutic drug monitoring (TDM) was established using an in-house liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. Results Determined trough plasma concentrations were a median of 50.00 mg/L [95% confidence interval (CI) 27.20, 74.60] and steady-state plasma concentrations were a median of 90.96 mg/L [95% CI 37.80, 124]. No significant differences were detected with respect to acute kidney injury/continuous renal replacement therapy. Plasma concentrations determined from different modes of storage were almost equal when frozen or cooled, but markedly reduced when stored at room temperature. Conclusions (Quasi) continuous application of cefiderocol 6 g/24 h in conjunction with TDM is a feasible mode of application; the sample for TDM should either be immediately analyzed, cooled, or frozen prior to analysis. Key Points Our results provide insight into a pharmacokinetically optimized use of cefiderocol. The continuous application of cefiderocol in combination with therapeutic drug monitoring (TDM) allows plasma levels to remain above target MICs, while preventing unnecessary high peak levels caused by bolus application. Therefore, continuous application of cefiderocol in conjunction with TDM is a feasible and pharmacologically and microbiologically beneficial mode of application; the sample for TDM should be cooled or frozen prior to analysis.
Bei Definition und Beurteilung muss genau berucksichtigt werden, worauf sich die Kostenbelastung ... more Bei Definition und Beurteilung muss genau berucksichtigt werden, worauf sich die Kostenbelastung bezieht. So sind Kosten fur das Krankenhaus solche, fur die das Krankenhaus belastet wird. Bei der Berechnung sind z. B. keine Preise (z. B. Preis eines Arzneimittels nach der Roten Liste) zu veranschlagen, da sie in der Regel nicht den realen Kosten entsprechen. Ebenfalls muss genau definiert werden, was bei einer Kostenerfassung mit einbezogen ist (etwa ubergreifende Kosten, wie anteilige Personalkosten oder Entsorgungskosten etc.).
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular disease not only causing br... more Aneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular disease not only causing brain injury but also frequently inducing a significant systemic reaction affecting multiple organ systems. In addition to hemorrhage severity, comorbidities and acute extracerebral organ dysfunction may impact the prognosis after aSAH as well. The study objective was to assess the value of illness severity scores for early outcome estimation after aSAH. A retrospective analysis of consecutive aSAH patients treated from 2012 to 2020 was performed. Comorbidities were evaluated applying the Charlson comorbidity index (CCI) and the American Society of Anesthesiologists (ASA) classification. Organ dysfunction was assessed by calculating the simplified acute physiology score (SAPS II) 24 h after admission. Modified Rankin scale (mRS) at 3 months was documented. The outcome discrimination power was evaluated. A total of 315 patients were analyzed. Significant comorbidities (CCI > 3) and physical performance impairment (ASA > 3) were found in 15% and 12% of all patients, respectively. The best outcome discrimination power showed SAPS II (AUC 0.76), whereas ASA (AUC 0.65) and CCI (AUC 0.64) exhibited lower discrimination power. A SAPS II cutoff of 40 could reliably discriminate patients with good (mRS ≤ 3) from those with poor outcome (p < 0.0001). Calculation of SAPS II allowed a comprehensive depiction of acute organ dysfunctions and facilitated a reliable early prognosis estimation in our study. In direct comparison to CCI and ASA, SAPS II demonstrated the highest discrimination power and deserves a consideration as a prognostic tool after aSAH.
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Purpose: Measurements of cerebrospinal fluid (CSF) lactate can aid in detecting infections of the... more Purpose: Measurements of cerebrospinal fluid (CSF) lactate can aid in detecting infections of the central nervous system and surrounding structures. Neurosurgical patients with temporary lumbar or ventricular CSF drainage harbor an increased risk for developing infections of the central nervous system, which require immediate therapeutic responses. Since blood gas analyzers enable rapid blood-lactate measurements, we were interested in finding out if we can reliably measure CSF-lactate by this point-ofcare technique. Methods: Neurosurgical patients on our intensive care unit (ICU) with either lumbar or external ventricular drainage due to a variety of reasons were included in this prospective observational study. Standard of care included measurements of leucocyte counts, total protein and lactate measurements in CSF by the neurochemical laboratory of our University Medical Center twice a week. With respect to this study, we additionally performed nearly daily measurements of cerebrospinal fluid by blood gas analyzers to determine the reliability of CSF-lactate measured by blood gas analyzers as compared to the standard measurements with a certified device. Results: 62 patients were included in this study. We performed 514 CSF-lactate measurements with blood gas analyzers and compared 180 of these to the in-house standard CSF-lactate measurements. Both techniques correlated highly significantly (Pearson correlation index 0.94) even though lacking full concordance in a Bland-Altman plotting. Of particular importance, regular measurements enabled immediate detection of central infection in three patients who had developed meningitis during the course of their treatment. Conclusion: Blood gas analyzers measure CSF-lactate with sufficient reliability and can help in the timely detection of a developing meningitis. In addition to and triggering established CSF diagnostics, CSF-lactate measurements by blood gas analyzers may improve surveillance of patients with CSF drainage. This study was retrospectively registered on April 20th 2020 in the German trial register. The trial registration number is DRKS00021466.
Objective: Positive end-expiratory pressure exerts its effects keeping open at end-expiration pre... more Objective: Positive end-expiratory pressure exerts its effects keeping open at end-expiration previously collapsed areas of the lung; consequently, higher positive end-expiratory pressure should be limited to patients with high recruitability. We aimed to determine which bedside method would provide positive end-expiratory pressure better related to lung recruitability. Design: Prospective study performed between 2008 and 2011. Setting: Two university hospitals (Italy and Germany). Patients: Fifty-one patients with acute respiratory distress syndrome. Interventions: Whole lung CT scans were taken in static conditions at 5 and 45 cm H2O during an end-expiratory/end-inspiratory pause to measure lung recruitability. To select individual positive end-expiratory pressure, we applied bedside methods based on lung mechanics (ExPress, stress index), esophageal pressure, and oxygenation (higher positive end-expiratory pressure table of lung open ventilation study). Measurements and Main Results: Patients were classified in mild, moderate and severe acute respiratory distress syndrome. Positive end-expiratory pressure levels selected by the ExPress, stress index, and absolute esophageal pressures methods were unrelated with lung recruitability, whereas positive end-expiratory pressure levels selected by the lung open ventilation method showed a weak relationship with lung recruitability (r 2 = 0.29; p < 0.0001). When patients were classified according to the acute respiratory distress syndrome Berlin definition, the lung open ventilation method was the only one which gave lower positive end-expiratory pressure levels in mild and moderate acute respiratory distress syndrome compared with severe acute respiratory distress syndrome (8 ± 2 and 11 ± 3 cm H 2 O vs 15 ± 3 cm H 2 O; p < 0.05), whereas ExPress, stress index, and esophageal pressure methods gave similar positive end-expiratory pressure values in mild, moderate, and severe acute respiratory distress syndrome. The positive end-expiratory pressure selected by the different methods were unrelated to each other with the exception of the two methods based on lung mechanics (ExPress and stress index). Conclusions: Bedside positive end-expiratory pressure selection methods based on lung mechanics or absolute esophageal pressures provide positive end-expiratory pressure levels unrelated to lung recruitability and similar in mild, moderate, and severe acute respiratory distress syndrome, whereas the oxygenation-based method provided positive end-expiratory pressure levels related with lung recruitability progressively increasing from mild to moderate and severe acute respiratory distress syndrome.
Journal of Neurosurgical Anesthesiology, Apr 1, 2007
Fever is common among neurologic patients and is usually treated by antipyretic drugs and externa... more Fever is common among neurologic patients and is usually treated by antipyretic drugs and external cooling. An alternative method for temperature management may be an intravascular approach. The aim of the study was to compare the effectiveness and the therapeutic costs of this new method with conventional treatment in neurologic patients. Twenty-six patients who suffered from subarachnoid hemorrhage or traumatic brain injury with febrile episodes were included the study and were randomized into 2 different groups. In the ''Conventional'' group, fever was treated with antipyretic drugs and/or surface cooling techniques to achieve a body core temperature of 36.51C. In the ''CoolGard'' group, patients were treated with an intravascular cooling catheter (Coolgard, Alsius, CA). We compared the effectiveness of these 2 approaches by calculating the mean deviation from 36.51C during a 48-hour period (fever burden). We found a significant difference in the fever burden [CoolGard: À 0.49 to 1.22 (median À 0.06) 1C vs. Conventional: 1.05-2.34 (median 1.41) 1C, P<0.05]. Costs varied significantly between the CoolGard and the Conventional groups, with markedly higher daily costs in the CoolGard group [CoolGard: 15 to 140 US dollars (USD) (median 39 USD) vs. Conventional: 1 to 9 USD (median 5 USD), P<0.05]. The effectiveness of the intravascular cooling catheter is excellent compared with conventional cooling therapies.
Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on ... more Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre-including this research content-immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
Recruitment maneuvers have been proposed as an adjunct to mechanical ventilation to re-expand col... more Recruitment maneuvers have been proposed as an adjunct to mechanical ventilation to re-expand collapsed lung regions. Although, in most patients recruitment maneuvers improve gas exchange a controversial discussion on recruitment maneuvers remains. This article reviews the physiological and patho-physiological backgrounds of recruitment maneuvers. The different recruitment maneuvers and possible monitoring are discussed as well as the influence of recruitment on other organs. Furthermore, we discuss whether recruitment maneuvers are useful if patients with acute lung injury or acute respiratory distress syndrome are ventilated with a lung-protective strategy.
The occurrence of a noninfectious interstitial lung disease is a rare but life-threatening side e... more The occurrence of a noninfectious interstitial lung disease is a rare but life-threatening side effect of infliximab, an antitumor necrosis factor alpha antibody. The following case report of a patient with Crohn disease shows an extremely dramatic progression to a severe acute respiratory distress syndrome.
Background and Objective Resistance to antibacterial substances is a huge and still emerging issu... more Background and Objective Resistance to antibacterial substances is a huge and still emerging issue, especially with regard to Gram-negative bacteria and in critically ill patients. We report a study in six patients infected with extensively drug-resistant Gram-negative bacteria in a limited outbreak who were successfully managed with a quasi-continuous infusion of cefiderocol. Methods Patients were initially treated with prolonged infusions of cefiderocol over 3 h every 8 h, and the application mode was then switched to a quasi-continuous infusion of 2 g over 8 h, i.e. 6 g in 24 h. Therapeutic drug monitoring (TDM) was established using an in-house liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. Results Determined trough plasma concentrations were a median of 50.00 mg/L [95% confidence interval (CI) 27.20, 74.60] and steady-state plasma concentrations were a median of 90.96 mg/L [95% CI 37.80, 124]. No significant differences were detected with respect to acute kidney injury/continuous renal replacement therapy. Plasma concentrations determined from different modes of storage were almost equal when frozen or cooled, but markedly reduced when stored at room temperature. Conclusions (Quasi) continuous application of cefiderocol 6 g/24 h in conjunction with TDM is a feasible mode of application; the sample for TDM should either be immediately analyzed, cooled, or frozen prior to analysis. Key Points Our results provide insight into a pharmacokinetically optimized use of cefiderocol. The continuous application of cefiderocol in combination with therapeutic drug monitoring (TDM) allows plasma levels to remain above target MICs, while preventing unnecessary high peak levels caused by bolus application. Therefore, continuous application of cefiderocol in conjunction with TDM is a feasible and pharmacologically and microbiologically beneficial mode of application; the sample for TDM should be cooled or frozen prior to analysis.
Bei Definition und Beurteilung muss genau berucksichtigt werden, worauf sich die Kostenbelastung ... more Bei Definition und Beurteilung muss genau berucksichtigt werden, worauf sich die Kostenbelastung bezieht. So sind Kosten fur das Krankenhaus solche, fur die das Krankenhaus belastet wird. Bei der Berechnung sind z. B. keine Preise (z. B. Preis eines Arzneimittels nach der Roten Liste) zu veranschlagen, da sie in der Regel nicht den realen Kosten entsprechen. Ebenfalls muss genau definiert werden, was bei einer Kostenerfassung mit einbezogen ist (etwa ubergreifende Kosten, wie anteilige Personalkosten oder Entsorgungskosten etc.).
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular disease not only causing br... more Aneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular disease not only causing brain injury but also frequently inducing a significant systemic reaction affecting multiple organ systems. In addition to hemorrhage severity, comorbidities and acute extracerebral organ dysfunction may impact the prognosis after aSAH as well. The study objective was to assess the value of illness severity scores for early outcome estimation after aSAH. A retrospective analysis of consecutive aSAH patients treated from 2012 to 2020 was performed. Comorbidities were evaluated applying the Charlson comorbidity index (CCI) and the American Society of Anesthesiologists (ASA) classification. Organ dysfunction was assessed by calculating the simplified acute physiology score (SAPS II) 24 h after admission. Modified Rankin scale (mRS) at 3 months was documented. The outcome discrimination power was evaluated. A total of 315 patients were analyzed. Significant comorbidities (CCI > 3) and physical performance impairment (ASA > 3) were found in 15% and 12% of all patients, respectively. The best outcome discrimination power showed SAPS II (AUC 0.76), whereas ASA (AUC 0.65) and CCI (AUC 0.64) exhibited lower discrimination power. A SAPS II cutoff of 40 could reliably discriminate patients with good (mRS ≤ 3) from those with poor outcome (p < 0.0001). Calculation of SAPS II allowed a comprehensive depiction of acute organ dysfunctions and facilitated a reliable early prognosis estimation in our study. In direct comparison to CCI and ASA, SAPS II demonstrated the highest discrimination power and deserves a consideration as a prognostic tool after aSAH.
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