Benjamin A Kohl

Publications (15)54.62 Total impact

• Article: Clinical Risk Factors for Primary Graft Dysfunction after Lung Transplantation.

  Joshua M Diamond, James C Lee, Steven M Kawut, Rupal J Shah, A Russell Localio, Scarlett Bellamy, David J Lederer, Edward Cantu, Benjamin A Kohl, Vibha N Lama, [......], Keith Wille, Jonathan Orens, Ashish S Shah, Ann Weinacker, Selim Arcasoy, Pali D Shah, David S Wilkes, Lorraine B Ware, Scott M Palmer, Jason D Christie
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  ABSTRACT: RATIONALE: Primary graft dysfunction (PGD) is the main cause of early morbidity and mortality after lung transplantation. Previous studies have yielded conflicting results for PGD risk factors. OBJECTIVE: We sought to identify donor, recipient, and peri-operative risk factors for PGD. METHODS: We performed a 10 center prospective cohort study enrolled between March 2002 and December 2010 (the Lung Transplant Outcomes Group). The primary outcome was ISHLT grade 3 PGD at 48 or 72 hours post transplant. The association of potential risk factors with PGD was analyzed using multivariable conditional logistic regression. MEASUREMENTS AND MAIN RESULTS: 1255 patients from 10 centers were enrolled, 211 subjects (16.8%) developed grade 3 PGD. In multivariable models, independent risk factors for PGD were any history of donor smoking (OR=1.8, 95%CI 1.2, 2.6, p=0.002), FiO2 during allograft reperfusion (OR=1.1 per 10% increase in FiO2, 95%CI 1.0, 1.2; p=0.01), single lung transplant (OR=2.0, 95%CI 1.2, 3.3; p=0.008), use of cardiopulmonary bypass (OR=3.4, 95%CI 2.2, 5.3; p<0.001), overweight (OR=1.8, 95%CI 1.2, 2.7; p=0.01) and obese (OR=2.3, 95%CI 1.3, 3.9; p=0.004) recipient BMI, pre-operative sarcoidosis (OR=2.5, 95%CI 1.1, 5.6; p=0.03) or pulmonary arterial hypertension (OR=3.5, 95%CI 1.6, 7.7; p=0.002), and mean pulmonary artery pressure (OR=1.3 per 10mmHg increase, 95%CI 1.1, 1.5; p<0.001). PGD was significantly associated with 90 day (relative risk (RR)=4.8, absolute risk increase (ARI)=18%, p<0.001) and 1 year (RR=3.0, ARI=23%, p<0.001) mortality. Interpretation: We identified grade 3 PGD risk factors, several of which are potentially modifiable and should be prioritized for future research aimed at preventative strategies.
  American Journal of Respiratory and Critical Care Medicine 01/2013; · 11.08 Impact Factor
• Article: Elevated pulmonary artery pressure is a risk factor for primary graft dysfunction following lung transplantation for idiopathic pulmonary fibrosis.

  Adam Fang, Sean Studer, Steven M Kawut, Vivek N Ahya, James Lee, Keith Wille, Vibha Lama, Lorraine Ware, Jonathan Orens, Ann Weinacker, Scott M Palmer, Maria Crespo, David J Lederer, Clifford S Deutschman, Benjamin A Kohl, Scarlett Bellamy, Ejigayehu Demissie, Jason D Christie
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  ABSTRACT: Idiopathic pulmonary fibrosis (IPF) is often associated with elevations in pulmonary artery pressures. Although primary pulmonary arterial hypertension (PAH) has been associated with primary graft dysfunction (PGD), the role of secondary PAH in mediating PGD risk in patients with IPF is incompletely understood. The purpose of this study was to evaluate the relationship between mean pulmonary artery pressure (mPAP) and PGD among patients with IPF. We performed a multicenter prospective cohort study of 126 lung transplant procedures performed for IPF between March 2002 and August 2007. The primary outcome was grade 3 PGD at 72 h after lung transplant. The mPAP was measured as the initial reading following insertion of the right-sided heart catheter during lung transplant. Multivariable logistic regression was used to adjust for confounding variables. The mPAP for patients with PGD was 38.5 ± 16.3 mm Hg vs 29.6 ± 11.5 mm Hg for patients without PGD (mean difference, 8.9 mm Hg [95% CI, 3.6-14.2]; P = .001). The increase in odds of PGD associated with each 10-mm Hg increase in mPAP was 1.64 (95% CI, 1.18-2.26; P = .003). In multivariable models, this relationship was independent of confounding by other clinical variables, although the use of cardiopulmonary bypass partially attenuated the relationship. Higher mPAP in patients with IPF is associated with the development of PGD.
  Chest 04/2011; 139(4):782-7. · 5.25 Impact Factor
• Article: Glycemic control and weight reduction without causing hypoglycemia: the case for continued safe aggressive care of patients with type 2 diabetes mellitus and avoidance of therapeutic inertia.

  Stanley S Schwartz, Benjamin A Kohl
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  ABSTRACT: Diabetes mellitus (DM) is a major and growing concern in the United States, in large part because of an epidemic of obesity in America and its relation to type 2 DM. In affected patients, postprandial glucose may be an early indicator of glucose intolerance or a prediabetes condition, which may be a better predictor of cardiovascular risk than impaired fasting glucose level. Treating patients who have early signs of hyperglycemia, including elevated postprandial glucose level, with intensive glucose control that does not lead to weight gain, and ideally may be associated with weight reduction, may be vital to preventing or reducing later cardiovascular morbidity and mortality. Because hypoglycemia is an important complication of current DM treatments and may cause acute secondary adverse cardiovascular outcomes, not causing hypoglycemia is mandatory. Given that weight loss can significantly lower cardiovascular risk and improve other cardiovascular risk factors in patients with type 2 DM and that medications are available that can result in weight reduction without leading to hypoglycemia, the successful treatment of patients with type 2 DM should be individualized and should address the complete pathophysiologic process. This review is a hypothesis article that presents arguments against general approaches to the treatment of type 2 DM. An algorithm is presented in which the goal for managing patients with type 2 DM is to lower the blood glucose level as much as possible for as long as possible without causing hypoglycemia. In addition, body weight should ideally be improved, reducing cardiovascular risk factors and avoiding therapeutic inertia.
  Mayo Clinic Proceedings 12/2010; 85(12 Suppl):S15-26. · 5.70 Impact Factor
• Article: How to manage perioperative endocrine insufficiency.

  Benjamin A Kohl, Stanley Schwartz
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  ABSTRACT: Patients with endocrinopathies frequently present to the operating room. Although many of these disorders are managed on a chronic basis, patients may have acute changes in the perioperative period that, if left unrecognized, can have a negative effect on perioperative morbidity and mortality. It is imperative that anesthesiologists understand the implications of the surgical stress response on hormonal flux. This article focuses on the 4 most commonly encountered endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Specific challenges pertaining to patients with pheochromocytoma are also discussed.
  Anesthesiology Clinics 03/2010; 28(1):139-55.
• Source

  Available from: PubMed Central

  Article: Type 2 diabetes mellitus and the cardiometabolic syndrome: impact of incretin-based therapies.

  Stanley Schwartz, Benjamin A Kohl
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  ABSTRACT: The rates of type 2 diabetes mellitus, obesity, and cardiovascular disease (CVD) continue to increase at epidemic proportions. It has become clear that these disease states are not independent but are frequently interrelated. By addressing conditions such as obesity, insulin resistance, stress hyperglycemia, impaired glucose tolerance, and diabetes mellitus, with its micro- and macrovascular complications, a specific treatment strategy can be developed. These conditions can be addressed by early identification of patients at high risk for type 2 diabetes, prompt and aggressive treatment of their hyperglycemia, recognition of the pleiotropic and synergistic benefits of certain antidiabetes agents on CVD, and thus, avoiding potential complications including hypoglycemia and weight gain. Incretin-based therapies, which include glucagon-like peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase-IV (DPP-IV) inhibitors, have the potential to alter the course of type 2 diabetes and associated CVD complications. Advantages of these therapies include glucose-dependent enhancement of insulin secretion, infrequent instances of hypoglycemia, weight loss with GLP-1 receptor agonists, weight maintenance with DPP-IV inhibitors, decreased blood pressure, improvements in dyslipidemia, and potential beneficial effects on CV function.
  Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 01/2010; 3:227-42.
• Source

  Available from: unjbg.edu.pe

  Article: Surgery in the patient with endocrine dysfunction.

  Benjamin A Kohl, Stanley Schwartz
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  ABSTRACT: Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.
  Anesthesiology Clinics 12/2009; 27(4):687-703.
• Article: Plasma levels of receptor for advanced glycation end products, blood transfusion, and risk of primary graft dysfunction.

  Jason D Christie, Chirag V Shah, Steven M Kawut, Nilam Mangalmurti, David J Lederer, Joshua R Sonett, Vivek N Ahya, Scott M Palmer, Keith Wille, Vibha Lama, Pali D Shah, Ashish Shah, Ann Weinacker, Clifford S Deutschman, Benjamin A Kohl, Ejigayehu Demissie, Scarlett Bellamy, Lorraine B Ware
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  ABSTRACT: The receptor for advanced glycation end products (RAGE) is an important marker of lung epithelial injury and may be associated with impaired alveolar fluid clearance. We hypothesized that patients with primary graft dysfunction (PGD) after lung transplantation would have higher RAGE levels in plasma than patients without PGD. To test the association of soluble RAGE (sRAGE) levels with PGD in a prospective, multicenter cohort study. We measured plasma levels of sRAGE at 6 and 24 hours after allograft reperfusion in 317 lung transplant recipients at seven centers. The primary outcome was grade 3 PGD (Pa(O(2))/Fi(O(2)) < 200 with alveolar infiltrates) within the first 72 hours after transplantation. Patients who developed PGD had higher levels of sRAGE than patients without PGD at both 6 hours (median 9.3 ng/ml vs. 7.5 ng/ml, respectively; P = 0.028) and at 24 hours post-transplantation (median 4.3 ng/ml vs. 1.9 ng/ml, respectively; P < 0.001). Multivariable logistic regression analyses indicated that the relationship between levels of sRAGE and PGD was attenuated by elevated right heart pressures and by the use of cardiopulmonary bypass. Median sRAGE levels were higher in subjects with cardiopulmonary bypass at both 6 hours (P = 0.003) and 24 hours (P < 0.001). sRAGE levels at 6 hours were significantly associated with intraoperative red cell transfusion (Spearman's rho = 0.39, P = 0.002 in those with PGD), and in multivariable linear regression analyses this association was independent of confounding variables (P = 0.02). Elevated plasma levels of sRAGE are associated with PGD after lung transplantation. Furthermore, plasma sRAGE levels are associated with blood product transfusion and use of cardiopulmonary bypass.
  American Journal of Respiratory and Critical Care Medicine 08/2009; 180(10):1010-5. · 11.08 Impact Factor
• Article: Transesophageal echocardiography diagnosis of coronary sinus thrombosis.

  Jonathan K Frogel, Stuart J Weiss, Benjamin A Kohl
  Anesthesia and analgesia 03/2009; 108(2):441-2. · 3.08 Impact Factor
• Source

  Available from: Craig A Umscheid

  Article: Antifibrinolytic use in adult cardiac surgery.

  Craig A Umscheid, Benjamin A Kohl, Kendal Williams
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  ABSTRACT: Antifibrinolytics are used to attenuate the coagulopathy associated with cardiopulmonary bypass. However, recent studies suggest that the antifibrinolytic aprotinin is associated with increased renal and vascular events and death compared to its alternatives. To develop a recommendation for antifibrinolytic use in adult cardiac surgery, we performed a systematic review and meta-analysis to determine the association of the antifibrinolytics with efficacy, safety and cost outcomes. Aprotinin, when compared to placebo, significantly decreased blood transfusions and reoperations for bleeding, strokes and cognitive dysfunction, and significantly increased renal dysfunction but not renal failure. Tranexamic acid significantly decreased blood transfusions, but was not statistically associated with other outcomes. Aminocaproic acid was not statistically associated with any measured outcome. Although aprotinin costs more than its alternatives, its costs may approximate those of its alternatives when longer time horizons are considered. We support the targeted use of aprotinin in adult cardiac surgery patients at high risk for bleeding or stroke, and discourage the use of aprotinin in those at high risk for renal failure. Although fewer data are available for tranexamic and aminocaproic acid, we support their use as alternatives to aprotinin in those at high risk for bleeding.
  Current Opinion in Hematology 10/2007; 14(5):455-67. · 4.52 Impact Factor
• Article: Color-flow Doppler recognition of intraoperative brachiocephalic malperfusion during operative repair of acute type a aortic dissection: utility of transcutaneous carotid artery ultrasound scanning.

  John G T Augoustides, Benjamin A Kohl, Hilary Harris, Alberto Pochettino
  Journal of Cardiothoracic and Vascular Anesthesia 03/2007; 21(1):81-4. · 1.64 Impact Factor
• Article: Who should care for intensive care unit patients?

  Jacob T Gutsche, Benjamin A Kohl
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  ABSTRACT: The question of who should direct the care of critically ill patients is both multifaceted and timely. Currently, only about 30% of critical care units in the United States are staffed by dedicated intensivists. This number is likely to increase as groups such as Leapfrog financially reward hospitals that have dedicated intensivists around the clock. The problem, however, is that the supply of intensivists by training is not projected to increase, whereas the demand for health care, by all accounts, will significantly increase in the near future. There is an increasing body of literature suggesting not only morbidity and mortality benefits but decreased length of stay and profound cost savings when a team directed by critical care physicians cares for patients in the intensive care unit. Despite this, many have argued that a consultant-based unit (so called open unit) is less alienating to a patient's primary care physician or surgeon and promotes continuity of care. In addition, although much of the literature has suggested purported benefit derived from a dedicated intensivist staffing model, little has been published regarding optimal intensivist/patient ratios. If dedicated critical care teams decrease complications in the intensive care unit, one may logically reason that as the intensivist/patient ratio decreases, morbidity or mortality, or both, might increase. This, however, has not yet been shown. This article will address many of these issues, discuss the history of critical care medicine in the United States, and review the pertinent literature. With the projected shortage of critical care-trained physicians and an increasingly aging population, it is imperative that health professionals evaluate this issue sooner rather than later.
  Critical Care Medicine 03/2007; 35(2 Suppl):S18-23. · 6.33 Impact Factor
• Article: The inflammatory response to surgery and trauma.

  Benjamin A Kohl, Clifford S Deutschman
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  ABSTRACT: The inflammatory or stress response to injury has evolved to ensure survival. This review will examine this response in otherwise healthy patients. Additionally, the impact of several common comorbid conditions on the inflammatory response will be considered. What will become evident is that the stress response may be exaggerated in some conditions and suppressed in others. Rapid identification of both an abnormal response and its cause will allow clinicians to maximize a patient's healing potential. Recent work has shown that an altered inflammatory response has marked effects on both immune competence and the endocrine system. Investigations are ongoing to delineate the mechanism of lymphocyte dysfunction. With regard to critical care endocrinopathies, the effects of insulin and hyperglycemia on inflammation and wound healing are being investigated. An understanding of the stress response will aid the clinician in preparing for expected responses, recognizing and perhaps correcting deviations from the norm and accounting for potential complications that arise in the face of preexisting disease. Deviations from the normal time course may represent the effects of preexisting medical illness, treatment or postoperative/injury complications.
  Current Opinion in Critical Care 09/2006; 12(4):325-32. · 2.51 Impact Factor
• Article: Con: Should aspirin be continued after cardiac surgery in the setting of thrombocytopenia?

  Benjamin A Kohl
  Journal of Cardiothoracic and Vascular Anesthesia 03/2006; 20(1):114-6. · 1.64 Impact Factor
• Article: Anesthesia and neurocerebral monitoring for aortic dissection.

  Benjamin A Kohl, Michael L McGarvey
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  ABSTRACT: Patients presenting to the operating room for repair of aortic dissection are challenging in all aspects of their care. Without exception, they require a multidisciplinary team approach. This article will review some of the specific challenges faced by anesthesiologists and neurologists when confronted with such a diagnosis. Specifically, we will discuss the myriad anesthetic issues that present in the preoperative stage and continue into the postoperative period. Neurologic complications during dissection repair result in increased morbidity and mortality. A variety of neurophysiologic monitoring techniques exist that may reduce this risk and will be discussed in detail. Finally, we will present some "controversies in care," emphasizing that our respective fields continue to grow, learn, and improve what information we have on the morbidity and mortality of aortic dissection.
  Seminars in Thoracic and Cardiovascular Surgery 02/2005; 17(3):236-46.
• Article: I.v. heparin for acute coronary syndrome?

  Benjamin A Kohl, Laura M Kosseim
  Postgraduate Medicine 07/2002; 111(6):113-4. · 1.78 Impact Factor