-
[show abstract]
[hide abstract]
ABSTRACT: Das Gerinnungssystem ist ein komplexes Netzwerk aus interagierenden Proteinen und Zellen. Reguliert und kontrolliert wird
dieses System durch positive und negative Feedback-Schleifen. Eine normale Blutgerinnung ist dann vorhanden, wenn gerinnungsfördernde
und -hemmende Kräfte im Gleichgewicht stehen. Klinisch relevante Phänotypen der Hämostase, d.h. Blutungen und Thrombosen
entstehen, wenn dieses Gleichgewicht gestört wird. Für die optimale Behandlung einer perioperativ auftretenden Gerinnungsstörung
ist ein solides Grundverständnis der Hämostase erforderlich. Bei einer Blutung erlauben Anamnese und klinische Präsentation,
Laboranalysen und bettseitige Gerinnungsanalysen schnell eine spezifische Diagnose der entsprechenden Gerinnungsstörung. Ein
modernes Gerinnungsmanagement, das proaktiv, individuell und balanciert durchgeführt werden soll, orientiert sich an definierten
Algorithmen. Eine durch eine Gerinnungsstörung verursachte Blutung kann dadurch erfolgreich behandelt werden.
The coagulation system is a complex network of interacting proteins and cells with extensive sensitivity, amplification and
control pathways. The system represents a delicate balance between procoagulant and anticoagulant as well as profibrinolytic
and antifibrinolytic activities. Clinically relevant phenotypes, e.g. bleeding and thrombosis, occur immediately when this
balance is no longer in equilibrium. A correct understanding of the complex coagulation pathophysiology in the perioperative
setting is essential for an effective treatment. In a bleeding patient, patient’s history, clinical findings, routine and
advanced laboratory coagulation testing as well as point-of-care coagulation monitoring help to reliably and readily identify
the underlying coagulation disorder. Modern coagulation management is proactive, individualized, balanced and follows clearly
defined algorithms. Coagulopathic bleeding can be successfully controlled with specific interventions in the coagulation system.
SchlüsselwörterHämostase–Blutgerinnung–Gerinnungsstörung–Blutung–Thrombose
KeywordsHemostasis–Blood coagulation–Blood coagulation disorders–Bleeding–Thrombosis
Der Chirurg 05/2012; 82(7):635-644. · 0.70 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The coagulation system is a complex network of interacting proteins and cells with extensive sensitivity, amplification and control pathways. The system represents a delicate balance between procoagulant and anticoagulant as well as profibrinolytic and antifibrinolytic activities. Clinically relevant phenotypes, e.g. bleeding and thrombosis, occur immediately when this balance is no longer in equilibrium. A correct understanding of the complex coagulation pathophysiology in the perioperative setting is essential for an effective treatment. In a bleeding patient, patient's history, clinical findings, routine and advanced laboratory coagulation testing as well as point-of-care coagulation monitoring help to reliably and readily identify the underlying coagulation disorder. Modern coagulation management is proactive, individualized, balanced and follows clearly defined algorithms. Coagulopathic bleeding can be successfully controlled with specific interventions in the coagulation system.
Der Chirurg 07/2011; 82(7):635-443; quiz 644. · 0.70 Impact Factor
-
BJA British Journal of Anaesthesia 08/2010; 105(2):103-5. · 4.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Coagulopathy in surgical patients is an important factor in triggering major perioperative complications, i.e., intra- or postoperative bleeding and thrombo-embolic events associated with an increased mortality and morbidity. Different methods exist to assess the coagulation status of patients before, during and after surgery. Routine coagulation tests have long been considered to be the clinical standard. However, these tests have considerable limitations. Information regarding the kinetics of clot formation, clot strength, interaction of the coagulation components, platelet function and fibrinolysis is not available. Moreover, there is an important delay in obtaining test results. In contrast, thrombelastography and thrombelastometry, which both measure the visco-elastic properties of whole blood, allow the dynamic assessment of a developing clot, from fibrin formation to clot strengthening and clot lysis. Both techniques are increasingly being used in daily clinical practice in order to detect perioperative coagulopathy and to guide predominantly pro-coagulant therapy in different settings. This article provides an overview of both techniques, thrombelastography (TEG) and thrombelastometry (ROTEM), and their field of perioperative application considering of recently published data.
Minerva anestesiologica 02/2010; 76(2):131-7. · 2.66 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Transfusion of allogeneic blood products is associated with increased morbidity and mortality. Therefore, strategies for reducing transfusion of these products during trauma management are valuable. We report a case of severe blunt abdominal trauma, successfully treated with antifibrinolytic medication and fibrinogen concentrate. Rotational thromboelastometry (ROTEM) was used to identify hyperfibrinolysis and afibrinogenaemia. In order to achieve haemostasis, over a 3-h period, the patient received a total of 1 g of tranexamic acid, 7 U of packed red blood cells, 16 g of fibrinogen concentrate (Haemocomplettan P), 3500 ml of colloids and 5500 ml of lactated Ringer's solution. Together with surgical measures, this treatment stopped the bleeding and stabilised the patient. There was no transfusion of either fresh-frozen plasma or platelets. The limited need for allogeneic blood products is of particular interest, and clinical studies of the approach used here appear to be warranted.
Acta Anaesthesiologica Scandinavica 10/2009; 54(1):111-7. · 2.19 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Leucocyte infiltration is known to play an important role in hypoxia-induced tissue damage. However, little information is available about hypoxia and interaction of effector (neutrophils) with target cells (alveolar epithelial cells, AEC; rat pulmonary artery endothelial cells, RPAEC). The goal of this study was to elucidate hypoxia-induced changes of effector-target cell interaction. AEC and RPAEC were exposed to 5% oxygen for 2-6 h. Intercellular adhesion molecule-1 (ICAM-1) expression was determined and cell adherence as well as cytotoxicity assays were performed. Nitric oxide and heat shock protein 70 (HSP70) production was assessed in target cells. Under hypoxic conditions enhanced ICAM-1 production was found in both cell types. This resulted in an increase of adherent neutrophils to AEC and RPAEC. The death rate of hypoxia-exposed target cells decreased significantly in comparison to control cells. Nitric oxide (NO) concentration was enhanced, as was production of HSP70 in AEC. Blocking NO production in target cells resulted in increased cytotoxicity in AEC and RPAEC. This study shows for the first time that target cells are more resistant to effector cells under hypoxia, suggesting hypoxia-induced cell protection. An underlying mechanism for this phenomenon might be the protective effect of increased levels of NO in target cells.
Clinical & Experimental Immunology 12/2007; 150(2):358-67. · 3.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Hemostasis monitoring is becoming increasingly important in the management of bleeding patients in the operating room (OR)
and the intensive care unit (ICU) in order to improve outcome and reduce costs of treatment. It has been shown in cardiac
surgery that frequent reassessment of the coagulation status and transfusion according to well-structured algorithms reduced
blood loss and blood component use when compared with transfusion regimens based on clinician discretion [1, 2]. Routine laboratory based coagulation tests (e.g., prothrombin time [PT]/interna-tional normalized ratio [INR], activated
partial thromboplastin time [aPTT], fibrin-ogen) measure clotting times and factors in recalcified plasma after activation
with different coagulation activators. Platelet numbers are given to complete overall coagulation assessment. Although the
values obtained by routine coagulation testing are accurate, standardized, and have been used for a long time, their use has
been questioned in the assessment of a severely bleeding patient because values are measured in plasma, no information on
platelet function is available, and there is a time delay of 30–60 min from sampling to obtaining the results.
12/2006: pages 834-846;
-
[show abstract]
[hide abstract]
ABSTRACT: In order to improve perioperative subjective quality of care it seems desirable to shorten preoperative fasting times as much as possible within acceptable safety limits. These efforts should result in a measurable reduction of preoperative thirst and hunger as well as in improvements of patient well-being. It is unknown to what extent preoperative patient comfort is limited by thirst and hunger from a patient point of view. The purpose of this study was to determine the impact of a traditional fasting regimen on preoperative patient discomfort.
We conducted a survey on preoperative thirst and hunger in 412 adult American Society of Anesthesiologists ASA I and II patients scheduled for minor elective surgery.
Of the patients 33% complained of moderate to strong thirst, whereas 19% had moderate to strong hunger, 47% of the participants would have liked to have been able to drink and 72% would have appreciated a light breakfast before surgery. Mean preoperative fasting times were 12.8+/-3.4 h for fluids and 15.5+/-4.4 h for solids. "Thirst" was named by 3.3% and "hunger" by 0.8% of patients as the most important factor for preoperative discomfort but "long wait" (8.5%), "tenseness" (6.5%) and "anxiety" (4.8%) were the most frequently named factors. Answers were independent of the duration of preoperative fasting.
Patient comfort is compromised by traditional fasting rules and liberalization of these policies is desired by patients. However, efforts to reduce preoperative anxiety and tenseness might have an additional, important potential to improve perioperative quality of care from a patient's perspective.
Der Anaesthesist 07/2006; 55(6):643-9. · 0.99 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: HintergrundMit dem Ziel der subjektiven perioperativen Qualittsverbesserung scheint es wnschenswert, die properativen Nchternzeiten im Rahmen der als sicher geltenden Grenzen so kurz als mglich zu halten. Diese Manahmen sollten mit einer messbaren Verminderung von properativem Hunger und Durst einhergehen und v.a. in einer Verbesserung der properativen Befindlichkeit resultieren. Welchen Einfluss Durst und Hunger aus Patientensicht auf den properativen Komfort haben, ist jedoch weit gehend unbekannt. Ziel dieser Studie war es, das Ausma der Beeintrchtigung der Patienten durch eine traditionelle Nchternheitsregelung abzuschtzen.Patienten und MethodenEin Kollektiv von 412Patienten der American-Society-of-Anesthesiologists- (ASA-)RisikoklassenI und II, das sich einem kleineren chirurgischen Eingriff unterzog, wurde mithilfe eines Fragebogens zum Ausma und Stellenwert von properativem Durst und Hunger befragt.ErgebnisseEs hatten 33% der Patienten migen oder starken Durst, 19% migen bis starken Hunger. Von den Befragten mchten 47% vor der Operation noch trinken, 72% htten gern noch ein leichtes Frhstck eingenommen. Die mittlere Nchternzeit war 12,83,4h fr Flssigkeiten und 15,54,4h fr Essen. Durst wurde von 3,3% und Hunger von 0,8% der Patienten als Hauptgrund fr die Beeintrchtigung des properativen Wohlbefindens genannt. Das lange Warten (8,5%), Nervositt (6,5%) und Angst (4,8%) wurden am hufigsten genannt. Die Antworten waren unabhngig von der Zeitdauer der properativen Nchternheit.SchlussfolgerungDer Patientenkomfort ist durch eine traditionelle Nchternheitsregelung beeintrchtigt, und Minimierung der properativen Nchternzeiten wird von den Patienten gewnscht. Anstrengungen mit dem Ziel der Reduktion von properativer Angst und Nervositt bergen jedoch zustzliches groes Potenzial fr eine Steigerung der perioperativen Behandlungsqualitt aus Sicht der Patienten.BackgroundIn order to improve perioperative subjective quality of care it seems desirable to shorten preoperative fasting times as much as possible within acceptable safety limits. These efforts should result in a measurable reduction of preoperative thirst and hunger as well as in improvements of patient well-being. It is unknown to what extent preoperative patient comfort is limited by thirst and hunger from a patient point of view. The purpose of this study was to determine the impact of a traditional fasting regimen on preoperative patient discomfort.Patients and methodsWe conducted a survey on preoperative thirst and hunger in 412 adult American-Society-of-Anesthesiologists ASA I and II patients scheduled for minor elective surgery.ResultsOf the patients 33% complained of moderate to strong thirst, whereas 19% had moderate to strong hunger, 47% of the participants would have liked to have been able to drink and 72% would have appreciated a light breakfast before surgery. Mean preoperative fasting times were 12.83.4h for fluids and 15.54.4h for solids. Thirst was named by 3.3% and hunger by 0.8% of patients as the most important factor for preoperative discomfort but long wait (8.5%), tenseness (6.5%) and anxiety (4.8%) were the most frequently named factors. Answers were independent of the duration of preoperative fasting.ConclusionPatient comfort is compromised by traditional fasting rules and liberalization of these policies is desired by patients. However, efforts to reduce preoperative anxiety and tenseness might have an additional, important potential to improve perioperative quality of care from a patients perspective.
Der Anaesthesist 05/2006; 55(6):643-649. · 0.99 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The new Volumetric Ejection Fraction monitoring system (VoLEF), when combined with the Pulse Contour Cardiac Output monitoring system (PiCCO) system, allows measurement of left and right heart end-diastolic volumes by thermodilution. The aim of this study was to evaluate whether the left heart end-diastolic volume index determined by the VoLEF system (LHEDI) better reflects left ventricular end-diastolic area index (LVEDAI) measured by transoesophageal echocardiography than does global end-diastolic volume index (GEDI) measured by the PiCCO system alone. Following induction of anaesthesia, PiCCO, VoLEF and transoesophageal echocardiography measurements were performed before and after a fluid challenge in 20 patients scheduled for elective cardiac surgery. Both left ventricular end-diastolic area index and global end-diastolic volume index, but not left heart end-diastolic volume index, significantly increased after fluid administration. Mean bias +/- 2 SD for DeltaLHEDI-DeltaLVEDAI was -2.2 +/- 32.0% and for DeltaGEDI-DeltaLVEDAI -0.6 +/- 16.8%. In contrast to global end-diastolic volume index, the use of left heart end-diastolic volume index determined by the VoLEF system cannot be recommended as an estimate of left ventricular preload.
Anaesthesia 05/2006; 61(4):316-21. · 2.96 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: During cardiopulmonary bypass (CPB), measurement of kaolin-based activated clotting time (kACT) is a standard practice in monitoring heparin-induced anticoagulation. Despite the fact that the kACT test from the Sonoclot Analyzer (SkACT) has been commercially available for several years, no published data on the performance of SkACT are available. Thus, the aim of this in vitro study was to compare SkACT with an established kACT from Hemochron (HkACT).
Blood was withdrawn from 25 patients before elective cardiac surgery. SkACT and HkACT were measured in duplicate after in vitro administration of heparin (0, 1, 2 and 3 U/ml), calcium-free lactated Ringer's solution (25% and 50% haemodilution) and aprotinin (200 kIU/ml).
A total of 600 duplicate kACT measurements were obtained from 25 cardiac surgery patients. Overall, mean bias +/- SD between SkACT and HkACT was 7 +/- 70 s (1.3% +/- 14.1%). Administration of heparin, haemodilution and aprotinin induced a comparable effect on both activated clotting time (ACT) tests. Mean bias ranged from -4 +/- 39 s (-1.7% +/- 12.9%) to 4 +/- 78 s (3.2% +/- 15.6%) for heparinzed blood samples after haemodilution or aprotinin application and increased after combined aprotinin administration and haemodilution. After haemodilution and administration of aprotinin, both ACT tests were less reliable for values >480 s in heparinized blood samples.
Accuracy and performance of SkACT and HkACT were comparable after in vitro administration of heparin, aprotinin and haemodilution. Both ACT tests were considerably affected by aprotinin and haemodilution.
Acta Anaesthesiologica Scandinavica 04/2006; 50(4):461-8. · 2.19 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The animal model of inflammatory response induced by intratracheal application of lipopolysaccharide includes many typical features of acute lung injury or the acute respiratory distress syndrome. A number of experimental investigations have been performed to characterize the nature of this injury more effectively. In inflammatory conditions, hypoxia occurs frequently before and in parallel with pulmonary and non-pulmonary pathological events. This current study was designed to examine the in vivo effect of hypoxia as a potentially aggravating condition in endotoxin-induced lung injury. Lipopolysaccharide, 150 microg, was instilled intratracheally into rat lungs, and thereafter animals were exposed to either normoxia or hypoxia (10% oxygen). Lungs were collected 2, 4, 6 and 8 h later. Inflammatory response and tissue damage were evaluated by quantitative analysis of inflammatory cells and mediators, surfactant protein and vascular permeability. A significantly enhanced neutrophil recruitment was seen in lipopolysaccharide-animals exposed to hypoxia compared to lipopolysaccharide-animals under normoxia. This increased neutrophil accumulation was triggered by inflammatory mediators such as tumour necrosis factor-alpha and macrophage inflammatory protein-1beta, secreted by alveolar macrophages. Determination of vascular permeability and surfactant protein-B showed enhanced concentrations in lipopolysaccharide-lungs exposed to hypoxia, which was absent in animals previously alveolar macrophage-depleted. This study demonstrates that hypoxia aggravates lipopolysaccharide injury and therefore represents a second hit injury. The additional hypoxia-induced inflammatory reaction seems to be predominantly localized in the respiratory compartment, underlining the compartmentalized nature of the inflammatory response.
Clinical & Experimental Immunology 09/2005; 141(2):248-60. · 3.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This prospective survey aimed at elucidating the patients' expectations and needs regarding the pre-anaesthetic visit and the forthcoming anaesthesia. The same questionnaire was answered by both patients and anaesthesiologists.
A total of 200 ASA I-III patients were interviewed prior to the preoperative anaesthetic visit. The questionnaire consisted of the topics preoperative affective situation, information and self-estimation of anaesthesia knowledge, expectations regarding the pre-anaesthetic visit/anaesthesia and extent of information concerning the perioperative course including risk and possible complications. The same questionnaire was presented to 35 certified anaesthesiologists with the request to estimate the patients' answers. Answers were rated using a Likert-scale, a comparison of patients' and anaesthesiologists' replies was performed.
For all 5 topics considerable differences between patients' answers and anaesthesiologists' rating were found (e.g. for the assessment of the affective situation, the relevance of family physicians as information source, the desired anaesthetic technique or the extent of anaesthesia-related risk information). No differences were observed for the importance of an anaesthesiologist as information source and fear reduction by the pre-anaesthetic visit.
Anaesthesiologists tend to misinterpret many patients' expectations and attitudes. The results demonstrate the potential for quality improvement of the pre-anaesthetic visit.
Der Anaesthesist 12/2004; 53(11):1061-8. · 0.99 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: HintergrundIn der vorliegenden prospektiven Studie sollten die Bedrfnisse und Erwartungen der Patienten bezglich der Prmedikationsvisite und der bevorstehenden Ansthesie erfasst und mit der Einschtzung durch Ansthesisten verglichen werden.Material und MethodenVor der Prmedikationsvisite wurden 200Patienten (ASAI–III) mittels eines Fragebogens zu properativer affektiver Situation, Information und Selbsteinschtzung des Ansthesiewissens, Erwartungen an die Prmedikationsvisite/Ansthesie, Aufklrung ber Ansthesieablauf sowie ber Risiken und Komplikationen befragt. Derselbe Fragebogen wurde 35Ansthesisten zur Einschtzung der Patientenantworten vorgelegt; die Antworten wurden mit Hilfe einer Likert-Skala aufgezeichnet und gegenbergestellt.ErgebnisseIn allen 5Teilbereichen konnten Unterschiede festgestellt werden, z.B. bei der properativen affektiven Situation, der Bedeutung des Hausarztes als Informationsquelle, der Bedeutung der Wunschansthesie oder dem Umfang der Ansthesieaufklrung. Keine Unterschiede zeigten sich z.B. bei der Beurteilung des Ansthesisten als Informationsquelle oder der Angstreduktion durch die Prmedikationsvisite.SchlussfolgerungAnsthesisten erkennen die Bedrfnisse und Wnsche der Patienten in Bezug auf die Prmedikationsvisite vielfach nicht richtig. Daraus ergibt sich ein groes Potenzial fr eine Qualittsverbesserung in der perioperativen Betreuung der Patienten.BackgroundThis prospective survey aimed at elucidating the patients expectations and needs regarding the pre-anaesthetic visit and the forthcoming anaesthesia. The same questionnaire was answered by both patients and anaesthesiologists.MethodsA total of 200 ASA I–III patients were interviewed prior to the preoperative anaesthetic visit. The questionnaire consisted of the topics preoperative affective situation, information and self-estimation of anaesthesia knowledge, expectations regarding the pre-anaesthetic visit/anaesthesia and extent of information concerning the perioperative course including risk and possible complications. The same questionnaire was presented to 35 certified anaesthesiologists with the request to estimate the patients answers. Answers were rated using a Likert-scale, a comparison of patients and anaesthesiologists replies was performed.ResultsFor all 5 topics considerable differences between patients answers and anaesthesiologists rating were found (e.g. for the assessment of the affective situation, the relevance of family physicians as information source, the desired anaesthetic technique or the extent of anaesthesia-related risk information). No differences were observed for the importance of an anaesthesiologist as information source and fear reduction by the pre-anaesthetic visit.ConclusionsAnaesthesiologists tend to misinterpret many patients expectations and attitudes. The results demonstrate the potential for quality improvement of the pre-anaesthetic visit.
Der Anaesthesist 10/2004; 53(11):1061-1068. · 0.99 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVES: The aim of this study was to compare the following approaches to assess left ventricular preload by transesophageal echocardiography (TEE): left ventricular end-diastolic volume index (LVEDVI) determined by using the method of disc summation (LVEDVI(Md)) and left ventricular end-diastolic area index (LVEDAI) were compared with LVEDVI assessed by the modified Simpson formula (LVEDVI(Si)). Global end-diastolic volume index (GEDVI) and stroke volume index (SVI) measured by the PiCCO(plus) system (Pulsion Medical Systems, Munich, Germany) were used as TEE-independent reference variables. DESIGN: Prospective observational study. SETTING: Community hospital. PARTICIPANTS: Twenty-two patients undergoing elective cardiac surgery. INTERVENTIONS: After the induction of anesthesia, hemodynamic assessment by TEE and the PiCCO(plus) system was made 20 (T(1)) and 10 minutes (T(2)) before and 10 (T(3)) and 20 minutes (T(4)) after a fluid trial. At each time point, LVEDVI(Md), LVEDAI, LVEDVI(Si), GEDVI, and SVI were determined. MEASUREMENTS AND MAIN RESULTS: The fluid trial resulted in a significant increase of all preload variables measured at T(3). At T(4), all preload variables but LVEDVI(Md) showed a significant decrease. The mean bias +/- 2 SD for percent changes (Delta) of LVEDVI(Md) - DeltaLVEDVI(Si) was 1.5% +/- 59.0% and for DeltaLVEDAI - Delta LVEDVI(Si) 0.9% +/- 23.6%. The correlation between LVEDVI(Md) and LVEDVI(Si) was significantly weaker than between LVEDAI and LVEDVI(Si) (p < 0.001). Comparing TEE measurements with GEDVI and SVI, strong correlations were observed for LVEDAI and LVEDVI(Si) only. CONCLUSION: The method of disc summation cannot be recommended for preload assessment during a fluid challenge in cardiac surgery patients. By contrast, single-plane area measurements provided reliable information when compared with the application of the modified Simpson formula.
-
-
