C Knothe

Justus-Liebig-Universität Gießen, Gieben, Hesse, Germany

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Publications (39)85.79 Total impact

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    ABSTRACT: The exposure of blood to foreign surfaces during extracorporeal circulation (ECC) leads to an activation of the coagulation system. In arteriosclerotic patients thrombin activation is increased and plasma fibrinogen is elevated, while protein C levels are reduced. In this study we investigated the influence of different cardiac diseases on ECC-induced thrombin generation and activation of the thrombomodulin-protein C system. Twenty-four patients undergoing either elective coronary artery bypass grafting (CABG) or elective aortic valve replacement (AVR) were included in the study. Blood samples were taken at different time intervals before, during and after ECC, and in the postoperative period. Plasma concentrations of thrombin-antithrombin III-complex (TAT), modified antithrombin (ATM), prothrombin fragment F1+2, free protein S, thrombomodulin, and protein C-antigen were determined by ELISA. Fibrinogen and antithrombin III levels were detected by nephelometry. Both groups were comparable with respect to biometric and ECC-related data. TAT concentrations were elevated in both groups after induction and increased during surgery (p<0.001). As a marker of thrombin generation levels of F1+2 were higher in the CABG group during cardiopulmonary bypass (p=0.003). In CABG patients ATM peaks were higher during ECC (p=0.0024). Significantly higher plasma thrombomodulin concentrations were found in CABG patients after induction (p<0.001), while protein S concentrations were higher in the AVR group (p=0.002). Protein C levels and antithrombin III concentrations did not differ between the groups. Patients undergoing CABG were found to have lower protein S levels and increased plasma thrombomodulin concentrations as markers of endothelial damage. In these patients contact activation and as a consequence thrombin generation takes place at a higher level, indicating a hypercoagulable state. Thromboembolic events in the perioperative period may be caused by different hemostatic changes in CABG patients.
    Thrombosis Research 10/1998; 92(1):1-9. · 2.43 Impact Factor
  • C Knothe, G Hempelmann
    ains · Anästhesiologie · Intensivmedizin 08/1998; 33(7):409-10. · 0.34 Impact Factor
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    ABSTRACT: Pulmonary hypertension is responsible for a substantial part of perioperative and postoperative mortality and morbidity after cardiac transplantation. Treatment of right ventricular failure after increased pulmonary vascular resistance is difficult especially in infants and children. Therefore we started a preventive therapy of pulmonary hypertension after cardiac transplantation to avoid right ventricular failure and compared the results with a group of patients with conventional therapy. Group 1 (n = 13), with transplantation from 1988 to 1991, was treated with vasodilators when symptoms of right ventricular failure developed. Group 2 (n = 19) had preventive treatment with prostaglandin E1 (PGE1), the phosphodiesterase-III inhibitor enoximone, and alkalinazation starting during weaning from cardiopulmonary bypass. Six patients in group 1 died; four of them as the result of right ventricular failure in the immediate postoperative course despite aggressive treatment. In group 2 there were three deaths as the results of rejection (2) and infection (1). None of these patients developed right ventricular failure (p = 0.02). Cold ischemic time, extracorporeal circulation time, and waiting time before transplantation were significantly longer in group 2. Side effects of this preventive therapy were not observed. We conclude that prophylactic therapy of pulmonary hypertension with vasodilators in infants and children after heart transplantation is safe and effective in preventing right ventricular failure in the postoperative course.
    The Journal of Heart and Lung Transplantation 01/1998; 16(12):1238-47. · 5.61 Impact Factor
  • C Knothe, G Hempelmann
    ains · Anästhesiologie · Intensivmedizin 01/1998; 32(12):707. · 0.34 Impact Factor
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    ABSTRACT: Inhaled nitric oxide is a potent and selective pulmonary artery vasodilator. We studied the effects of nitric oxide inhalation in neonatal and pediatric acute respiratory distress syndrome (ARDS) patients with respect to dosage, prolonged inhalation, and weaning. Prospective, open-label study. Neonatal and pediatric intensive care units of a level three university hospital. Seventeen patients with severe ARDS (1 day to 6 yrs of age [mean 1.75]; oxygenation index of > 20 cm H2O/torr) were enrolled. To identify the optimal dosage for continuous nitric oxide inhalation, doses between 1 and 80 parts per million (ppm) of nitric oxide were tested after the patients had stabilized. Daily withdrawals of nitric oxide were made, according to predetermined criteria. Nine neonatal and eight pediatric ARDS patients (mean Pediatric Risk of Mortality score 28.4 +/- 6.1; mortality risk 54 +/- 15%) were studied. The following variables changed within 24 hrs of nitric oxide inhalation: mean oxygenation index decreased by 56% (from 34 +/- 12 to 15 +/- 7 cm H2O/torr, p = .0004); alveolar-arterial O2 gradient decreased by 31% (from 579 +/- 71 to 399 +/- 102 torr (77.2 +/- 9.5 to 53.2 +/- 13.6 kPa), p = .0004); and mean systemic arterial pressure increased by 15% (from 49 +/- 10 to 57 +/- 12 mm Hg, p = .0029). The optimal dose of nitric oxide was 20 ppm in neonates (with additional persistent pulmonary hypertension of the newborn) and 10 ppm in pediatric patients. Prolonged inhalation (4 to 21 days) was associated with continuous improvement of oxygenation. An oxygenation index of < 5 cm H2O/torr predicted successful withdrawal, with a sensitivity of 75% and a specificity of 89%. None of the patients had to be rescued with extracorporeal membrane oxygenation and 16 of the 17 patients survived. Inhaled nitric oxide enhances pulmonary gas exchange, with concomitant hemodynamic stabilization, in neonatal and pediatric ARDS. Best effective doses were 10 ppm of nitric oxide in pediatric ARDS and 20 ppm in neonates. Treatment should be continued until an oxygenation index of < or = 5 cm H2O/torr is achieved. Effects on outcome need verification in larger controlled trials.
    Critical Care Medicine 11/1996; 24(11):1913-9. · 6.15 Impact Factor
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    ABSTRACT: Different prophylactic myocardium saving strategies are often routine in open heart surgery. Even if theoretically well established, they must be critically reviewed in times of limited financial resources. Troponin-T (TnT) is a valuable tool to detect even minor myocardial damages independently from concomitant muscle injuries. We measured intra- and postoperative TnT-values and ST-wave deviations on the ECG in a control group and in patients receiving one of the following prophylactic hypothermia during cardiopulmonary bypass (CPB), nitroglycerine ([0.5 microgram/kg/min]) or nifedipine [0.1 microgram/kg/min] after aortic cross-clamping until end of operation, or perioperative Mg2+ per os. The study included 65 patients of a university hospital with preoperative good heart function scheduled for elective aorto-coronary bypass operation. TnT values increased in all groups after CPB and peaked between end of operation and first post-operative day. TnT values above the critical border of 1.0 microgram/l in the early period after CPB were less often seen in the nitroglycerine and nifedipine group. No pronounced differences could be observed after the first postoperative day. Patients of the hypothermia group had most often TnT values above 1.0 microgram/l. Maximum TnT values of the control, the hypothermia and the Mg(2+)-group correlated with the duration of aortic-crossclamping. No correlation existed between ST-deviations and TnT-values. The prophylactic measures failed to reduce myocardial damage as evidenced by the course of TnT values. They can therefore not be recommended as routine strategies in patients with good left heart function. Especially hypothermia should be considered carefully.
    The Journal of cardiovascular surgery 09/1996; 37(4):367-75. · 1.37 Impact Factor
  • Intensive Care Medicine 06/1996; 22(2). · 5.54 Impact Factor
  • C Knothe, G Hempelmann
    ains · Anästhesiologie · Intensivmedizin 06/1996; 31(4):197-9. · 0.34 Impact Factor
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    ABSTRACT: The right ventricle is more jeopardized by a cardiopulmonary bypass than the left one. Impaired right ventricular performance may profit from an afterload reduction. A selective reduction in pulmonary artery pressure (PAP) or pulmonary vascular resistance (PVR) without impairment of the systemic circulation seems to be possible by inhalation of nitric oxide (NO). Therefore in the present study we looked for influences of NO inhalation on PAP, PVR and right heart parameters immediately after weaning from the bypass. The dependence of endothelial function on age, preoperative heart function and extracorporeal circulation is well established. The relevance of such parameters on NO inhalation was also investigated. After ethical approval and informed consent were obtained, 20 patients with moderately increased PAP were included in the study. Ten patients inhaled NO at a concentration of 30 ppm; the other group served as a control group. Measurement points were 10 min after the end of extracorporeal circulation (baseline), 3, 10, and 20 min after the start, as well as 10 min after the end of NO inhalation. NO was injected near the tube into the tubing system during inspiration; dosage and monitoring of the concentration were achieved by means of a chemiluminometer. Measured parameters consisted of PAP, PVR, right ventricular ejection fraction and volumes, systemic blood pressure and resistance, central venous pressure, pulmonary capillary wedge pressure, and oxygenation parameters (paO2, pvO2, paCO2). The decrease in PAP (from 29.7 +/- 3.9 to a minimal 25.4 +/- 4.3 mm Hg, P < 0.005) and in PVR (from 169.4 +/- 51.9 to a minimal 116.3 +/- 60.9 dyn.s.cm-5, P.0.05) did not improve right heart function. A similar significant increase in SVR was observed in the NO group and in the control group. Age, haemodynamic parameters or duration of the ischaemic phase of the cardiopulmonary bypass did not influence the course of PAP or PVR. Changes in PAP (from 30.0 +/- 4.0 to a minimal 26.7 +/- 3.6 mm Hg, P < 0.05) and PVR (from 149.0 +/- 41.5 to a minimal 125.2 +/- 51.5 dyn.s.cm-5, in the control group were not statistically different from those in the NO group. Indicators of intoxication like an increase in NO2 or methaemoglobin concentrations or changes in compliance or resistance were not observed. Patients with moderate pulmonary hypertension did not profit from NO inhalation immediately after weaning from the cardiopulmonary bypass. The decreases in PAP and PVR found in the NO or control group did not improve right-heart function. When the NO and control group were compared, specific effects of NO inhalation on PAP and PVR must be questioned. This could perhaps be explained by data from animal experiments, which found high endogenous NO levels in situations with elevated cytokine levels. Cytokines are increased after extracorporeal circulation. Oxygenation was not impaired by inhalation of relatively high concentrations of NO. For all investigations with NO inhalation not preceded by steady-state conditions, a control group is recommended.
    Der Anaesthesist 03/1996; 45(3):240-8. · 0.74 Impact Factor
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    ABSTRACT: Zusammenfassung Der rechte Ventrikel ist durch extrakorporale Zirkulation (EKZ) mehr gefährdet als der linke. Eine beeinträchtigte rechtsventrikuläre Funktion kann von einer Senkung der Nachlast profitieren. Durch Inhalation von Stickstoffmonoxid (NO) kann ein pulmonaler Hypertonus ohne Auswirkungen auf den Systemkreislauf gesenkt werden. In der vorliegenden Arbeit wurde deshalb der Einfluß einer NO-Inhalation auf pulmonalarteriellen Druck (PAP), pulmonalvaskulären Widerstand (PVR) und Rechtsherzparameter unmittelbar nach EKZ untersucht. An der Studie nahmen 20 Patienten mit mäßiggradigem pulmonalen Hochdruck teil. 10 Patienten inhalierten 30 ppm NO, die anderen dienten als Kontrollgruppe. Meßzeitpunkte lagen 10 min nach EKZ (Ausgangswerte), 3, 10 und 20 min nach Start sowie 10 min nach Beendigung der NO-Inhalation. Es fand sich ein signifikanter Abfall von PAP und PVR ohne begleitende Verbesserung der Rechtsherzfunktion. In der Kontrollgruppe wurden Veränderungen von PAP und PVR in vergleichbarer Größenordnung beobachtet. Es ist somit fraglich, ob die beobachteten Effekte spezifisch für die NO-Inhalation sind. Hohe endogene NO-Konzentrationen in dieser Phase, wie im Tierexperiment gefunden, könnten dieses Verhalten erklären. Eine klinische Verbesserung der Rechtsherzfunktion nach EKZ konnte bei unseren Patienten durch NO-Inhalation nicht erreicht werden.
    Der Anaesthesist 03/1996; 45(3):240-248. · 0.74 Impact Factor
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    ABSTRACT: Some studies found endothelin-1 to be a trigger for pulmonary hypertension. Endothelin-1 is an endothelial derived substance with generally vasoconstrictive properties, but probably vasodilatory effects on pulmonary arteries. The aim of the present study was to look for influences of endothelin-1 plasma values on pulmonary artery pressure. Endothelin-1 levels during and after cardiac surgery and correlations to pulmonary artery pressure were tested in 10 control patients and 21 patients with pulmonary hypertension (mean pulmonary arterial pressure > 20 mmHg, systolic pulmonary arterial pressure > 30 mmHg). According to endothelin-1 values before anaesthesia (normal value below 4 pg/ml) patients with pulmonary hypertension could be divided into a "high endothelin-1" (10 patients, mean 8.25 +/- 2.06 pg/ml) and a "normal endothelin-1" (11 patients, mean 2.13 +/- 0.86 pg/ml) subgroup (p < 0.01). Values of the "high endothelin-1" group decreased until end of operation (from 7.58 +/- 2.35 to 2.95 +/- 1.44 pg/ml, n = 6) when pulmonary artery pressure returned to normal. Otherwise they slightly increased (from 9.43 +/- 2.24 to 11.07 +/- 1.96 pg/ml, n = 4). Levels of the "normal endothelin-1" group increased (to 2.55 pg/ml). Endothelin-1 values peaked on the intensive care unit (ICU) in all patients. Baseline endothelin-1 and systolic pulmonary artery pressure values correlated well with each other (r = 0.73, p < 0.001). Endothelin-1 decreased after extracorporeal circulation in all patients in whom pulmonary artery pressure tended to normalise, whereas no rise in pulmonary artery pressure paralleled the marked increase in endothelin-1 on the ICU. Vasodilatory effects of endothelin on pulmonary arteries can attribute to this course. Endothelin-1 seems not to trigger pulmonary hypertension but rather to vasodilate pulmonary vasculature.
    European Journal of Cardio-Thoracic Surgery 02/1996; 10(7):579-84. · 2.81 Impact Factor
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    ABSTRACT: The usefulness of body plethysmography in the assessment of thoracotomy candidates is not well documented. Reported thresholds for operability are generally expressed in absolute values, which do not take into account a patient's size, age or gender. Spirometric and plethysmographic data of 103 patients undergoing thoracotomy were examined for their ability to predict death due to cardiopulmonary insufficiency, pneumonia, and atelectasis during the first 30 postoperative days. Neither plethysmographic nor spirometric parameters could predict atelectasis. Patients who underwent lobectomy were susceptible to the development of atelectasis. A weak correlation between elevated functional residual capacity (FRC) and occurrence of postoperative pneumonia was found. Lung function testing was not able to separate survivors from non-survivors. Patients with pneumonia were at high risk of death in their postoperative course. Because of the non-linear relationship, a correlation coefficient between spirometric and plethysmographic variables was not calculated. The prevalence of cardiac risk factors was high, so the decision for invasive hemodynamic studies should rather be based upon a patient's history than restricted to patients with impaired lung function. Because of methodological differences, and probably insuitable reference values, body plethysmography cannot substitute for spirometry. For FRC and FRC to total lung capacity (FRC/ TLC) ratio, further investigations must be undertaken to establish a correct reference value.
    European Journal of Cardio-Thoracic Surgery 02/1996; 10(5):312-9. · 2.81 Impact Factor
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    ABSTRACT: Paediatric cardiac transplantation (pHTX) has gained widespread acceptance as a therapy in end-stage myocardial failure and some forms of congenital heart disease, particularly hypoplastic left heart syndrome (HLHS). The major problems to the anaesthesiologist in these patients are induction of anaesthesia in infants with HLHS and treatment of pulmonary hypertension in the early post-bypass period. PATIENTS AND METHODS. Anaesthesia for pHTX was performed in 15 children < 1 year of age (4-237 days); 12 suffered from HLHS, 2 from endocardial fibroelastosis, and 1 from dilatative cardiomyopathy. Induction of anaesthesia in patients with HLHS IS a challenge to the anaesthesiologist, as he has to maintain the delicate balance between pulmonary and systemic blood flow. Anaesthesia was induced with fentanyl (10-15 micrograms/kg) and pancuronium (0.2-0.4 mg/kg) and maintained with fentanyl (total dosage 70-100 micrograms/kg). Modification of ventilatory parameters such as FiO2, PaCO2, and airway pressure (PEEP, I:E ratio) was used to influence systemic and pulmonary blood distribution in the pre-bypass period according to changes in haemodynamics (target: O2 saturation approximately 75%-80%, PaCO2 45-50 mmHg). Treatment of pulmonary hypertension in the weaning and early post-bypass period consisted of respiratory (PaCO2 < 30 mmHg) and metabolic alkalinisation (pH 7.45-7.55, BE > +3 mmol/l), the use of prostaglandin E1 (3-6-12 micrograms/kg.h), and the phosphodiesterase inhibitor enoximone (10-15 micrograms/kg.min). Additional positive inotropic support was achieved with dobutamine (5-10 micrograms/kg.min), adrenaline (0.1-0.5 micrograms/kg.min), and/or orciprenaline (0.1-0.2 micrograms/kg.min) and calcium chloride (25-100 mg/kg). RESULTS. Two children died intraoperatively and 1 on the 1st postoperative day from overwhelming pulmonary vascular resistance and right ventricular failure. Three children died between 3 and 4 weeks postoperatively, 1 from cytomegalovirus infection, 1 from sepsis, and 1 from acute rejection. Nine patients survived and are well up to 5.5 years after transplantation. CONCLUSION. Pulmonary hypertension in the weaning and early post-bypass period is the main anaesthesiological problem of pHTX, particularly in children with HLHS. A polypragmatic approach to this problem consisting of alkalinisation, pulmonary vasodilatation, and inotropic support is presented and seems to be effective. Further improvements in concepts of pHTX are limited by the lack of donor organs. Though the experience with pHTX in neonates and infants is growing slowly, it might be a routine procedure from the anaesthesiological point of view within a few years in some selected centres.
    Der Anaesthesist 05/1995; 44(4):250-6. · 0.74 Impact Factor
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    ABSTRACT: Zusammenfassung Die orthotope Herztransplantation hat sich auch für das Neugeborenen- und Säuglingsalter zu einer akzeptierten Behandlungsmethode bei hypoplastischem Linksherzsyndrom (HLHS) oder Kardiomyopathien (CM) entwickelt. Das anästhesiologische Vorgehen bei 15 Transplantationen bei Kindern unter einem Jahr wird beschrieben. 12 Kinder litten unter HLHS, die anderen unter CM. Fentanyl wurde zur Narkoseeinleitung (10–15 μg/kg) und -führung (70–100 μg/kg) als Mononarkotikum eingesetzt. Die Stabilität der Hämodynamik in dieser Phase ist stark von Beatmungskonzepten abhängig. In der Phase der Beendigung der extrakorporalen Zirkulation wurden zur Therapie der rechtsventrikulären Nachlasterhöhung nach konsequenter respiratorischer und metabolischer Alkalisierung Prostaglandin E1 (3–6–12 μg/kg/h), Enoximon (10–15 μg/kg/min) und in zwei Fällen Tolazolin (0,025 μg/kg/min) eingesetzt. Positiv inotrope Unterstützung erfolgte in allen Fällen. Eingesetzt wurden Dobutamin (5–10 μg/kg/min), Adrenalin (0,1–0,5 μg/kg/min) und Orciprenalin (0,1–0,2 μg/kg/min). In 3 Fällen war eine passagere, in einem Fall eine permanente (A-V-)-Schrittmachertherapie erforderlich. 2 Patienten konnten aufgrund eines rechtsventrikulären Versagens nicht von der EKZ entwöhnt werden. Ein weiterer Patient starb am ersten postoperativen Tag an einem Rechtsherzversagen. Die derzeitige Überlebensrate beträgt 60% bei einem Beobachtungszeitraum bis zu 5 1 / 2 Jahren.
    Der Anaesthesist 04/1995; 44(4):250-256. · 0.74 Impact Factor
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    ABSTRACT: The endothelium appears to play an important role in the regulation of intravascular coagulation. Thrombomodulin is one of the anticoagulant substances that is expressed by endothelial cells. The influence of age and illness on the thrombomodulin-protein C system was studied prospectively in 80 cardiac surgery patients. Patients > 70 yr old (n = 20) were compared with patients < 50 yr (n = 20) (group I), and patients undergoing a simple cardiac procedure (n = 20) were compared with patients scheduled for complex surgery (n = 20) (group II). Thrombomodulin (normal < 40 ng ml-1), protein C and (free) protein S plasma concentrations were measured by enzyme-linked immunosorbent assays (ELISA) after induction of anaesthesia (baseline values), during and after cardiopulmonary bypass (CPB), at the end of surgery, 5 h after CPB and on the first day after operation. Blood loss and use of homologous blood and blood products were significantly greater in patients > 70 yr and in those undergoing complex surgery. At baseline, thrombomodulin concentration was increased in patients undergoing complex surgery (mean 52 (sd 9) ng ml-1). After bypass and after operation, thrombomodulin increased most in patients > 70 yr (from 40 (8) to 78 (10) ng ml-1) and in those patients who underwent complex cardiac operations (from 52 (8) to 79 (10 ng ml-1) (P < 0.05). Changes in protein C and protein S concentrations were similar in all groups. On the first day after operation only, protein C concentrations were reduced in patients > 70 yr and in patients who underwent complex cardiac surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
    BJA British Journal of Anaesthesia 02/1995; 74(2):174-9. · 4.35 Impact Factor
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    ABSTRACT: To describe the changes in cardiac function after administration of three different solutions infused after anesthetic induction. Thirty-six patients scheduled for elective aortocoronary bypass surgery were randomly distributed into three groups. Over a period of 25 min after anesthetic induction, 12 received 10 ml/kg of Ringer solution (low dose crystalloid group), 12 received 20 ml/kg of Ringer solution (high dose crystalloid group), and 12 received 10 ml/kg of Ringer solution with 10 ml/kg of hydroxi-ethyl-almidon solution 450,000 D, 0.7 substitution grade (group C-HEA). Minute volume, systemic and pulmonary pressures, osmolality of blood and urine, and plasma and urine sodium concentrations were measured before and after infusion of the assigned liquid. In spite of the volume infused, low dose crystalloid group showed a high incidence of oliguria, increased urinary osmolality and decreased sodium in urine. Cardiac and systolic indices and left ventricular work load remained stable after infusion of the assigned liquid in low and high dose crystalloid groups, whereas they increased significantly ion group C-HEA (+23%, +16% and +20%). Administration of restricted doses of crystalloids after anesthetic induction favors the retention of water and sodium. Higher doses of crystalloids weaken this effect. However, neither of these two regimens leads to a more effective cardiac work load. A combination of crystalloids and colloids administered immediately after anesthetic induction temporarily improves cardiac performance during surgery.
    Revista espanola de anestesiologia y reanimacion 02/1995; 42(1):9-14.
  • Anaesthesist. 01/1995; 44(4):250-256.
  • Journal of Cardiothoracic and Vascular Anesthesia 10/1994; 8(5). · 1.48 Impact Factor
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    ABSTRACT: Aprotinin has been reported to reduce bleeding in cardiac surgery patients. Its mechanisms of action on coagulation have not been fully elucidated. In a prospectively randomized study of 40 patients undergoing elective aortocoronary bypass grafting, the influence of high-dose aprotinin (2 million IU of aprotinin before CPB, 500,000 IU/h until the end of operation, 2 million IU added to the prime) (N = 20) on endothelial-related coagulation was compared to a nontreated control group (N = 20). Thrombomodulin (TM), protein C and (free) protein S as well as thrombin/antithrombin-III (TAT) plasma concentrations were measured by enzyme-linked immunosorbent assays (ELISA) before the aprotinin infusion, before cardiopulmonary bypass (CPB), during CPB and after CPB, at the end of surgery, 5 hours after CPB, and on the first postoperative day. All standard coagulation parameters (AT-III and fibrinogen plasma levels, platelet count, partial thromboplastin time) did not differ between the two groups. At baseline, TM plasma levels were within the normal range (< 40 ng/mL) and similar in both groups. During CPB, TM plasma concentrations decreased similarly in both groups (aprotinin: 18 +/- 6 ng/mL, control: 17 +/- 7 ng/mL) followed by a comparable increase in the postbypass period until the first postoperative day (aprotinin: 60 +/- 10 ng/mL, control: 53 +/- 11 ng/mL). Protein C and (free) protein S plasma levels also showed no differences between the two groups. On the first postoperative day, baseline values for protein C and protein S had not yet been reached.(ABSTRACT TRUNCATED AT 250 WORDS)
    Journal of Cardiothoracic and Vascular Anesthesia 10/1994; 8(5):527-31. · 1.48 Impact Factor
  • Journal of Cardiothoracic and Vascular Anesthesia 10/1994; 8(5). · 1.48 Impact Factor