Real-time monitoring of intravenous thrombolysis in acute ischemic stroke using rotational thromboelastometry: a feasibility pilot study.

INTRODUCTION: Rotational thromboelastometry (ROTEM) records whole blood coagulation in vitro. Data on dynamic changes of clot patterns during intravenous thrombolysis (IVT) in acute ischemic stroke is scarce. We investigated the feasibility of ROTEM as a potential point-of-care assessment tool for IVT. METHODS: In this prospective pilot study, patients with acute stroke symptoms received IVT. Whole blood coagulation was tracked on the ROTEM analyzer. Blood samples were analyzed before, and then 2, 15, 30 and 60 min after beginning IVT. In vitro clots (iCLs) were described by their maximum clot firmness (MCF), the time needed to reach MCF (MCF-t), as well as the area under the curve (AR10). National Institutes of Health Stroke Scale (NIHSS) was used as early clinical outcome parameter. RESULTS: We analyzed 288 iCLs from 12 patients undergoing IVT. In all iCLs, an early fibrinolysis (91% within the first 10 min) was detected during IVT. Three different curve progression patterns were observed: a low-responder pattern with a continuous clot increase, a high-responder pattern with a sustained clot decrease or total clotting suppression and an intermediate-responder pattern with alternating clot characteristics. There was a difference among these groups in early clinical outcome (AR10 and MCF each p = 0.01, MCF-t p = 0.02, Kruskal-Wallis Test). CONCLUSION: The fibrinolysis patterns determined using ROTEM allow for the monitoring of IVT in patients with acute ischemic stroke. This pilot study found a correlation between the in vitro fibrinolysis patterns and early clinical outcomes. These findings support a potential for individualization of IVT in the future.

Development, Implementation, Evaluation, and Long-Term Outcome of a Program to Increase Student Interest in Anesthesia and Intensive Care Training.

OBJECTIVES: The increasing need for anesthetists has been coupled with a rising number of open training positions. Thus, there is an increased need to attract future anesthetists among students and graduates from medical universities. Using results from a questionnaire, we designed an information and training program to increase interest in anesthesia and intensive care. MATERIALS AND METHODS: With the use of semistructured interviews, medical students were questioned about factors influencing their decision for a speciality. We used the results to design an information and practice program for students and young doctors. This program was held 12 times at different anesthesia departments in different hospitals. Evaluation was obtained through a feedback questionnaire at the end of each sessions and with another questionnaire 2 to 4 years after the program. RESULTS: Feedback showed positive responses concerning utility for practical work, actuality, and relevance for daily practical work. There was a 22.7% response from participants for the follow-up questionnaire. Of these, 87% stated that interest in anesthesia was increased by the program, and 74% underwent practical training in an anesthesia department. Seventeen participants started a speciality training for anesthesia and intensive care medicine. CONCLUSIONS: The design of this practice-oriented program was effective in eliciting, spreading, and increasing interest and attracting students to a medical specialty.

CobraPLUS and Cookgas air-Q versus Fastrach for blind endotracheal intubation: a randomised controlled trial.

BACKGROUND AND OBJECTIVE: CobraPLUS and Cookgas air-Q are supraglottic airways expected to allow safe ventilation as well as reliable blind intubation. In a prospective, controlled trial, we hypothesised that quality of ventilation and success rate of blind endotracheal intubation of these new devices would be superior to the Fastrach intubating laryngeal mask airway (ILMA). When blind intubation failed the quality of fibrescope-guided intubation was investigated. To allow identification of those patients in whom blind intubation would be difficult, we investigated the predictive value of currently used predictors for ease of endotracheal intubation. METHODS: One hundred and eighty adult patients with documented BMI, Mallampati score, Cormack-Lehane classification, interincisor gap and thyromental distance were randomised into three groups according to the device used. Ventilation conditions were rated as excellent, good or difficult. When blind intubation failed, fibrescope-guided intubation conditions were rated as well. Statistical analysis was performed by a χ-test. RESULTS: The quality of ventilation was excellent for all devices. Three patients in the CobraPLUS group and two patients in the ILMA and the Cookgas groups needed a slight reposition. Blind intubation through the CPLA was successful in 47%, through the Cookgas in 57%, whereas the Fastrach group had a success rate of 95%. Fibreoptic intubation was possible in all but one patient. None of the registered scores and measures allowed prediction of difficult blind intubation. CONCLUSION: All devices appeared to be safe airways. The Fastrach ILMA proved to be a reliable facilitator for blind intubation. CobraPLUS and Cookgas air-Q allowed an easy fibrescopic intubation. Failed blind intubations could not be predicted by the used parameters.

Transvenous, intracardial cardioversion for the treatment of postoperative atrial fibrillation.

Atrial fibrillation (AF) following cardiac surgery is an important factor contributing to postoperative morbidity. Transvenous, intracardial cardioversion (TIC) has been shown to be effective in the treatment of chronic AF, but is an invasive and cost-intensive procedure. However, TIC would definitely be a beneficial approach if recurrence of AF following TIC is low and pharmacological treatment could be avoided. Thus, we hypothesised that TIC would be superior to conventional treatment with amiodarone with respect to the conversion rate and recurrence of AF. We compared TIC and conventional amiodarone therapy in a prospective, randomised and controlled trial in patients who developed AF following cardiac surgery. Twenty-three patients developed AF out of a total of 76 patients who gave written informed consent. Eighteen of these AF patients could be randomised into two equally sized groups to receive either an ALERT pulmonary artery catheter and TIC, or a standard pulmonary artery catheter and treatment with amiodarone. Haemodynamic parameters were registered before intervention to exclude pulmonary hypertension or fluid overload. Rates of cardioversion were compared by a Likelyhood ratio test. Out of the nine ALERT patients, AF in five cases converted to sinus rhythm (SR) with a median of two shocks (6 J). After 24 hours however, only two patients remained in sinus rhythm. On the other hand, six of the nine patients treated with amiodarone were still in SR after 24 hours. Whereas no difference was detectable in the conversion rate, persistence of SR following TIC was low. Thus, TIC without antiarrhythmic treatment is not recommendable for the treatment of postoperative AF.

Inspiratory oscillatory flow with a portable ventilator: a bench study.

INTRODUCTION: We observed an oscillatory flow while ventilating critically ill patients with the Dräger Oxylog 3000 transport ventilator during interhospital transfer. The phenomenon occurred in paediatric patients or in adult patients with severe airway obstruction ventilated in the pressure-regulated or pressure-controlled mode. As this had not been described previously, we conducted a bench study to investigate the phenomenon. METHODS: An Oxylog 3000 intensive care unit ventilator and a Dräger Medical Evita-4 NeoFlow intensive care unit ventilator were connected to a Dräger Medical LS800 lung simulator. Data were registered by a Datex-S5 Monitor with a D-fend flow and pressure sensor, and were analysed with a laptop using S5-Collect software. Clinical conditions were simulated using various ventilatory modes, using various ventilator settings, using different filters and endotracheal tubes, and by changing the resistance and compliance. Data were recorded for 258 combinations of patient factors and respirator settings to detect thresholds for the occurrence of the phenomenon and methods to overcome it. RESULTS: Under conditions with high resistance in pressure-regulated ventilation with the Oxylog 3000, an oscillatory flow during inspiration produced rapid changes of the airway pressure. The phenomenon resulted in a jerky inspiration with high peak airway pressures, higher than those set on the ventilator. Reducing the inspiratory flow velocity was effective to terminate the phenomenon, but resulted in reduced tidal volumes. CONCLUSION: Oscillatory flow with potentially harmful effects may occur during ventilation with the Dräger Oxylog 3000, especially in conditions with high resistance such as small airways in children (endotracheal tube internal diameter <6 mm) or severe obstructive lung diseases or airway diseases in adult patients.

Money for consent--psychological consideration.

CONTEXT: Regarding the increasing gap between demand and supply of donor organs the question is increasingly discussed, if families of organ donors should receive a financial incentive for consenting to organ donation. However, little attention has been paid to the psychological consequences of such incentives. OBJECTIVE: We discuss the question of financial incentives for families of presumed organ donors in the light of relevant psychological theories. DATA SOURCES AND STUDY SELECTION: Overview of the psychological literature. Only well established theories were included. CONCLUSIONS: We summarise, that financial benefits for consent to organ donoation could affect adversely the public opinion toward organ donation and the whole process of transplantation and thus could counterproductively influence the consent rates.

Dealing with the uncertain and the unexpected: a report on the first kidney transplantations in Aden, Republic of Yemen.

First kidney transplantations were performed in Aden, Jemen in 2003. A difficult medical environment and unrehearsed decision-making process in a country of scant resources were the background of this undertaking. A brief report is given on the medical situation, training and preparedness of the Yemeni medical community for transplant procedures. Initial impressions of psychological aspects of first-ever organ transplantation in this Islamic country are presented.

Recruitment maneuvers during prone positioning in patients with acute respiratory distress syndrome.

OBJECTIVE: To evaluate the interaction of recruitment maneuvers and prone positioning on gas exchange and venous admixture in patients with early extrapulmonary acute respiratory distress syndrome ventilated with high levels of positive end-expiratory pressure. We hypothesized that a sustained inflation performed after 6 hrs of prone positioning would induce sustained improvement in oxygenation (Pao2/Fio2) and venous admixture. DESIGN: Prospective, interventional study. SETTING: Tertiary care, postoperative intensive care unit. PATIENTS: Fifteen patients with early extrapulmonary acute respiratory distress syndrome. INTERVENTIONS: After 6 hrs of prone positioning, a sustained inflation was performed with 50 cm H2O maintained for 30 secs. Data were recorded in supine position, after 6 hrs of prone positioning, at 3, 30, and 180 mins following the sustained inflation. MEASUREMENTS AND MAIN RESULTS: A response to prone positioning was observed in nine of 15 patients leading to an improvement of Pao2/Fio2 (147 +/- 37 torr vs. 225 +/- 77 torr, p = .005) and venous admixture (35.4 +/- 8.3% vs. 28.9 +/- 9.8%, p = .001). Six patients did not respond to prone positioning. Following the sustained inflation, the responders to prone positioning showed a further increase of Pao2/Fio2 and decrease of venous admixture at 3 mins (Pao2/Fio2, 225 +/- 77 torr vs. 368 +/- 90 torr, p = .018; venous admixture, 28.9 +/- 9.8% vs. 18.9 +/- 6.7%, p = .05). In all six nonresponders to prone positioning, an improvement of Pao2/Fio2 and venous admixture occurred at 3 mins following the sustained inflation (128 +/- 18 torr vs. 277 +/- 59 torr, p = .03; venous admixture, 34.2 +/- 6.0% vs. 23.8 +/- 6.3%, p = .05). The beneficial effects of the sustained inflation remained significantly elevated over 3 hrs in responders and nonresponders to prone positioning. CONCLUSION: In patients with early extrapulmonary acute respiratory distress syndrome, a sustained inflation performed after 6 hrs of prone positioning induced further and sustained improvement of oxygenation and venous admixture in both responders and nonresponders to prone positioning.

Recent Thoughts about the Ethics of Renal Transplantation.

Ethical controversies in transplantation medicine are frequent and are not only discussed in the medical societies, but also by the pubic at large. Recently, the shortage of donor organs has led to a discussion of the commonly accepted ethical principles applied in transplantation medicine. In this paper, we highlight some of the thoughts expressed in the literature and discuss them in the context of transplantation.

Aden kidney transplantation.

During the first Yemeni Congress of Uro-Nephrology in Aden, an international team performed the first kidney tranplantations in the region. We report the difficulties encountered and discuss the pros and cons for transplantations in developing countries.

The COPe concept for the training of communication in highly emotional situations.

Members of transplant teams are oft confronted with highly emotional situations. Inability to handle these situations leads to burn-out and impairs the performance of the team. We introduce and discuss first experiences with a training program--COPe--specifically concentrating on establishing and maintaining communication in such situations.

Recruitment maneuvers after a positive end-expiratory pressure trial do not induce sustained effects in early adult respiratory distress syndrome.

BACKGROUND: Recruitment maneuvers performed in early adult respiratory distress syndrome remain a matter of dispute in patients ventilated with low tidal volumes and high levels of positive end-expiratory pressure (PEEP). In this prospective, randomized controlled study the authors evaluated the impact of recruitment maneuvers after a PEEP trial on oxygenation and venous admixture (Qs/Qt) in patients with early extrapulmonary adult respiratory distress syndrome. METHODS: After a PEEP trial 30 consecutive patients ventilated with low tidal volumes and high levels of PEEP were randomly assigned to either undergo a recruitment maneuver or not. Data were recorded at baseline, 3 min after the recruitment maneuver, and 30 min after baseline. Recruitment maneuvers were performed with a sustained inflation of 50 cm H2O maintained for 30 s. RESULTS: Compared with baseline the ratio of the arterial oxygen partial pressure to the fraction of inspired oxygen (Pao2/Fio2) and Qs/Qt improved significantly at 3 min after the recruitment maneuver (Pao2/Fio2, 139 +/- 46 mm Hg versus 246 +/- 111 mm Hg, P < 0.001; Qs/Qt, 30.8 +/- 5.8% versus 21.5 +/- 9.7%, P < 0.005), but baseline values were reached again within 30 min. No significant differences in Pao2/Fio2 and Qs/Qt were detected between the recruitment maneuver group and the control group at baseline and after 30 min (recruitment maneuver group [n = 15]: Pao2/Fio2, 139 +/- 46 mm Hg versus 138 +/- 39 mm Hg; Qs/Qt, 30.8 +/- 5.8% versus 29.2 +/- 7.4%; control group: [n = 15]: Pao2/Fio2, 145 +/- 33 mm Hg versus 155 +/- 52 mm Hg; Qs/Qt, 30.2 +/- 8.5% versus 28.1 +/- 5.4%). CONCLUSION: In patients with early extrapulmonary adult respiratory distress syndrome who underwent a PEEP trial, recruitment maneuvers failed to induce a sustained improvement of oxygenation and venous admixture.

Intramural left atrial hematoma after aortocoronary artery surgery.

UNLABELLED: We report the occurrence of an intraoperative left atrial hematoma during coronary artery bypass grafting surgery. Echocardiography proved to be of great help in diagnosis and monitoring of this patient. After severe hemodynamic impairment the patient recovered and could be transferred on postoperative day eight. Follow-up examination showed no signs of atrial pathologies. Differential diagnosis and echocardiographic findings are discussed. IMPLICATIONS: The authors report the utility of transesophageal echocardiography for diagnosis and management of an intramural left atrial hematoma during coronary artery surgery.

HLA-DR as a marker for increased risk for systemic inflammation and septic complications after cardiac surgery.

OBJECTIVE: This study investigated the predictive value of a decrease in monocyte HLA-DR expression as an early marker for postoperative SIRS and septic complications. We hypothesized that decreased HLA-DR levels in the first 24 h after cardiac surgery is not related to postoperative SIRS/sepsis. We also compared HLA-DR levels of patients with postoperative complications to those with an uncomplicated course. DESIGN AND SETTING: Prospective observational study in a tertiary care postoperative intensive care unit. PATIENTS: Eighty five consecutive patients undergoing cardiac surgery. MEASUREMENTS AND RESULTS: Expression of HLA-DR on monocytes was analyzed by flow cytometry using a new quantitative and well standardized technique. Arterial blood samples were collected before induction of anesthesia, immediately after admission to the ICU, and on the first postoperative day. Postoperative HLA-DR expression was significantly decreased in all patients. There were no significant differences in HLA-DR expression during the first 24 h after surgery in patients with uncomplicated course and those developing SIRS or septic complications. CONCLUSIONS: In patients undergoing cardiac surgery the monitoring of pre- and immediate postoperative HLA-DR levels during the first 24 h does not help to predict increased risk for postoperative SIRS/sepsis or infectious complications.

Automatic tube compensation in patients after cardiac surgery: effects on oxygen consumption and breathing pattern.

OBJECTIVE: To evaluate patients without prior pulmonary disease after cardiac surgery and to determine whether resistive unloading by automatic tube compensation, pressure support ventilation, and continuous positive airway pressure has different effects on oxygen consumption, breathing pattern, gas exchange, and hemodynamics. DESIGN: Prospective, randomized, controlled study. SETTING: Tertiary care, postoperative intensive care unit. PATIENTS: Twenty-one patients scheduled for open heart coronary artery bypass graft surgery. INTERVENTIONS: Each patient was ventilated with all three modes in random order. MEASUREMENTS AND MAIN RESULTS: Patients were ventilated in three modes, each applied for 30 mins according to computer-generated randomization: pressure support ventilation with 5 cm H2O, continuous positive airway pressure, and automatic tube compensation. Oxygen consumption was calculated by means of indirect calorimetry. The hypnotic state of the patients was monitored by Bispectral Index. For hemodynamic measurements, a fiberoptic pulmonary artery catheter was inserted. The main finding of our study was that oxygen consumption and breathing pattern (tidal volume and respiratory rate) did not differ significantly during automatic tube compensation and pressure support ventilation compared with continuous positive airway pressure (oxygen consumption, 170 +/- 29 vs. 170 +/- 26 vs. 174 +/- 29 mL.min.m, respectively; tidal volume, 466 +/- 132 vs. 484 +/- 125 vs. 470 +/- 119 mL, respectively; respiratory rate, 16 +/- 4 vs. 15 +/- 4 vs. 16 +/- 4 breaths/min, respectively). Automatic tube compensation and pressure support ventilation had no clinical effects on gas exchange and hemodynamic variables compared with continuous positive airway pressure. None of the variables differed significantly during the three ventilatory settings. CONCLUSION: In postoperative tracheally intubated patients with normal ventilatory demand, automatic tube compensation and pressure support ventilation with 5 cm H2O lead to identical oxygen consumption, breathing patterns, gas exchange, and hemodynamics. We, therefore, suggest that this group of patients does not need any additional positive pressure support from the ventilator to overcome the additional work of breathing imposed by the endotracheal tube during the weaning phase from mechanical ventilation.