Max Ragaller

Publications (9)84.35 Total impact

• Article: Variability of structures in German intensive care units--a representative, nationwide analysis.

  Jürgen Graf, Andrea Reinhold, Frank M Brunkhorst, Max Ragaller, Konrad Reinhart, Markus Loeffler, Christoph Engel
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  ABSTRACT: Structures in intensive care medicine comprise human as well as material resources, organization, and management and may be related to processes thereby affecting patients' outcomes. Utilizing a unique data base we evaluated structures of German intensive care units (ICUs). The study was carried out by the German Competence Network Sepsis (SepNet). Data were prospectively collected on a cross-sectional basis in a representative random sample of German hospitals utilizing a questionnaire. Structures were related to ICU outcome of patients with severe sepsis or septic shock. The sample was subdivided in 5 strata according to hospital size. A total of 454 ICUs cared for 3877 patients including 415 patients (11%) with severe sepsis or septic shock. The mean number of beds per ICU was 10.4, the ratio of ICU to hospital beds 1:27, both with significant differences depending on hospital size. 81% of the ICUs provided around the clock physician presence (range: 66-98% across hospital strata, p < 0.001). Shift-wise, one nurse was responsible for a mean number of 2.7 patients (morning 1:2.3, afternoon 1:2.6, night 1:3.3 patients) with significant variation according to hospital size (smaller hospitals 1:2.9, university hospitals 1:2.1, p < 0.001). More than half of all German ICUs are lead by anesthesiologists. Neither physician nor nurse staffing was associated with mortality in the subset of patients with sepsis. In a representative, nationwide sample of German ICUs key elements of structures varied considerably with respect to hospital size. This has to be considered when proposing standards, reimbursement strategies, or quality assessment.
  Wiener klinische Wochenschrift 10/2010; 122(19-20):572-8. · 0.81 Impact Factor
• Article: What's new in Emergencies, Trauma and Shock? Coagulation is in the focus!

  Max Ragaller
  Journal of Emergencies Trauma and Shock 01/2010; 3(1):1-3.
• Source

  Available from: Onnen Moerer

  Article: Practice and perception--a nationwide survey of therapy habits in sepsis.

  Frank M Brunkhorst, Christoph Engel, Max Ragaller, Tobias Welte, Rolf Rossaint, Herwig Gerlach, Konstantin Mayer, Stefan John, Frank Stuber, Norbert Weiler, Michael Oppert, Onnen Moerer, Holger Bogatsch, Konrad Reinhart, Markus Loeffler, Christiane Hartog
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  ABSTRACT: To simultaneously determine perceived vs. practiced adherence to recommended interventions for the treatment of severe sepsis or septic shock. One-day cross-sectional survey. Representative sample of German intensive care units stratified by hospital size. Adult patients with severe sepsis or septic shock. None. Practice recommendations were selected by German Sepsis Competence Network (SepNet) investigators. External intensivists visited intensive care units randomly chosen and asked the responsible intensive care unit director how often these recommendations were used. Responses "always" and "frequently" were combined to depict perceived adherence. Thereafter patient files were audited. Three hundred sixty-six patients on 214 intensive care units fulfilled the criteria and received full support. One hundred fifty-two patients had acute lung injury or acute respiratory distress syndrome. Low-tidal volume ventilation < or = 6 mL/kg/predicted body weight was documented in 2.6% of these patients. A total of 17.1% patients had tidal volume between 6 and 8 mL/kg predicted body weight and 80.3% > 8 mL/kg predicted body weight. Mean tidal volume was 10.0 +/- 2.4 mL/kg predicted body weight. Perceived adherence to low-tidal volume ventilation was 79.9%. Euglycemia (4.4-6.1 mmol/L) was documented in 6.2% of 355 patients. A total of 33.8% of patients had blood glucose levels < or = 8.3 mmol/L and 66.2% were hyperglycemic (blood glucose > 8.3 mmol/L). Among 207 patients receiving insulin therapy, 1.9% were euglycemic, 20.8% had blood glucose levels < or = 8.3 mmol/L, and 1.0% were hypoglycemic. Overall, mean maximal glucose level was 10.0 +/- 3.6 mmol/L. Perceived adherence to strict glycemic control was 65.9%. Although perceived adherence to recommendations was higher in academic and larger hospitals, actual practice was not significantly influenced by hospital size or university affiliation. This representative survey shows that current therapy of severe sepsis in German intensive care units complies poorly with practice recommendations. Intensive care unit directors perceive adherence to be higher than it actually is. Implementation strategies involving all intensive care unit staff are needed to overcome this gap between current evidence-based knowledge, practice, and perception.
  Critical care medicine 08/2008; 36(10):2719-25. · 6.37 Impact Factor
• Article: [Microcirculation in sepsis and septic shock - therapeutic options?].

  Max Ragaller
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  ABSTRACT: In severe sepsis and septic shock the severe impairment of the microcirculation is one of the main reasons for tissue hypoxia, multiple organ failure and death. Fast resuscitation of the microvascular blood flow to improve the reduced functional capillary density is necessary. Based scientific evidence, an early haemodynamic stabilisation directed by predefined haemodynamic and metabolic goals and the application of activated protein C (rhAPC) according to the guidelines could be recommended. The specific effects of dobutamine and rhAPC on the microcirculation as well as the effects selective inhibitors of iNOS or vasodilators may be therapeutic options in the future.
  ains · Anästhesiologie · Intensivmedizin 02/2008; 43(1):48-53; quiz 54. · 0.41 Impact Factor
• Source

  Available from: Onnen Moerer

  Article: Intensive insulin therapy and pentastarch resuscitation in severe sepsis.

  Frank M Brunkhorst, Christoph Engel, Frank Bloos, Andreas Meier-Hellmann, Max Ragaller, Norbert Weiler, Onnen Moerer, Matthias Gruendling, Michael Oppert, Stefan Grond, [......], Rolf Rossaint, Tobias Welte, Martin Schaefer, Peter Kern, Evelyn Kuhnt, Michael Kiehntopf, Christiane Hartog, Charles Natanson, Markus Loeffler, Konrad Reinhart
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  ABSTRACT: The role of intensive insulin therapy in patients with severe sepsis is uncertain. Fluid resuscitation improves survival among patients with septic shock, but evidence is lacking to support the choice of either crystalloids or colloids. In a multicenter, two-by-two factorial trial, we randomly assigned patients with severe sepsis to receive either intensive insulin therapy to maintain euglycemia or conventional insulin therapy and either 10% pentastarch, a low-molecular-weight hydroxyethyl starch (HES 200/0.5), or modified Ringer's lactate for fluid resuscitation. The rate of death at 28 days and the mean score for organ failure were coprimary end points. The trial was stopped early for safety reasons. Among 537 patients who could be evaluated, the mean morning blood glucose level was lower in the intensive-therapy group (112 mg per deciliter [6.2 mmol per liter]) than in the conventional-therapy group (151 mg per deciliter [8.4 mmol per liter], P<0.001). However, at 28 days, there was no significant difference between the two groups in the rate of death or the mean score for organ failure. The rate of severe hypoglycemia (glucose level, < or = 40 mg per deciliter [2.2 mmol per liter]) was higher in the intensive-therapy group than in the conventional-therapy group (17.0% vs. 4.1%, P<0.001), as was the rate of serious adverse events (10.9% vs. 5.2%, P=0.01). HES therapy was associated with higher rates of acute renal failure and renal-replacement therapy than was Ringer's lactate. The use of intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events related to hypoglycemia. As used in this study, HES was harmful, and its toxicity increased with accumulating doses. (ClinicalTrials.gov number, NCT00135473.)
  New England Journal of Medicine 01/2008; 358(2):125-39. · 53.30 Impact Factor
• Source

  Available from: Reinhard Richard Brunkhorst

  Article: Epidemiology of sepsis in Germany: results from a national prospective multicenter study.

  Christoph Engel, Frank M Brunkhorst, Hans-Georg Bone, Reinhard Brunkhorst, Herwig Gerlach, Stefan Grond, Matthias Gruendling, Guenter Huhle, Ulrich Jaschinski, Stefan John, [......], Michael Quintel, Max Ragaller, Rolf Rossaint, Frank Stuber, Norbert Weiler, Tobias Welte, Holger Bogatsch, Christiane Hartog, Markus Loeffler, Konrad Reinhart
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  ABSTRACT: To determine the prevalence and mortality of ICU patients with severe sepsis in Germany, with consideration of hospital size. Prospective, observational, cross-sectional 1-day point-prevalence study. 454 ICUs from a representative nationwide sample of 310 hospitals stratified by size. Data were collected via 1-day on-site audits by trained external study physicians. Visits were randomly distributed over 1 year (2003). Inflammatory response of all ICU patients was assessed using the ACCP/SCCM consensus conference criteria. Patients with severe sepsis were followed up after 3 months for hospital mortality and length of ICU stay. Main outcome measures were prevalence and mortality. A total of 3,877 patients were screened. Prevalence was 12.4% (95% CI, 10.9-13.8%) for sepsis and 11.0% (95% CI, 9.7-12.2%) for severe sepsis including septic shock. The ICU and hospital mortality of patients with severe sepsis was 48.4 and 55.2%, respectively, without significant differences between hospital size. Prevalence and mean length of ICU stay of patients with severe sepsis were significantly higher in larger hospitals and universities (</= 200 beds: 6% and 11.5 days, universities: 19% and 19.2 days, respectively). The expected number of newly diagnosed cases with severe sepsis in Germany amounts to 76-110 per 100,000 adult inhabitants. To allow better comparison between countries, future epidemiological studies should use standardized study methodologies with respect to sepsis definitions, hospital size, and daily and monthly variability.
  Intensive Care Medicine 04/2007; 33(4):606-18. · 5.40 Impact Factor
• Article: Evaluation of a new device for noninvasive measurement of nonshunted pulmonary capillary blood flow in patients with acute lung injury.

  Marcelo Gama de Abreu, Stefan Geiger, Tilo Winkler, Max Ragaller, Thomas Pfeiffer, Dirk Leutheuser, Detlev Michael Albrecht
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  ABSTRACT: To evaluate the performance of a new device for noninvasive measurement of nonshunted pulmonary capillary blood flow (PCBF) by partial CO2 rebreathing. Prospective clinical trial in an intensive care unit of a university hospital. Twenty mechanically ventilated patients with acute lung injury. Variations in PEEP of +/-3 cmH2O. Initially PCBF was measured invasively as cardiac output minus venous admixture (Q(VA)/Q(t)) flow, and by partial CO2 rebreathing at baseline PEEP (PEEP(b)). The PEEP was then reduced by 3 cmH2O (to PEEP(b-3)) and measurements were repeated after 30 min. PEEP was then increased by 6 cmH2O (to PEEP(b+3)), and measurements were repeated after 10, 20, and 30 min. The overall correlation coefficient between noninvasive and invasive PCBF measurements at PEEP(b) was high ( r=0.97), with close agreement between methods being observed (0.1+/-0.6 l/min, bias and precision, respectively). Accordingly, both the correlation coefficient and agreement between methods for changes in PCBF from PEEP(b-3) to PEEP(b+3) levels were satisfactory ( r=0.71; 0.2+/-0.5 l/min, bias and precision). The new device was able to detect the correct PCBF trend in 17 of 20 patients investigated and in all patients who showed invasive PCBF changes equal to or greater than 0.3 l/min ( n=12). Noninvasive PCBF changes were stable as early as 10 min after variation in PEEP, as compared to 30 min values. The new device appears to be clinically useful for the monitoring of PCBF in patients suffering from acute lung injury. Our results suggest that titration of PEEP aimed at improving PCBF can be performed with the new device.
  Intensive Care Medicine 04/2002; 28(3):318-23. · 5.40 Impact Factor
• Article: Is the Partial Co2 Rebreathing Technique A Useful Tool for Trending Pulmonary Capillary Blood Flow During Adjustments of Peep?

  Marcelo Gama de Abreu, Stefan Geiger, Max Ragaller, Tilo Winkler, Stefan Rasche, Anna von Waldenfels, Detlev Michael Albrecht
  Critical Care Medicine 12/1997; 26(1):106A. · 6.33 Impact Factor
• Article: Measurement of Pulmonary Capillary Blood Flow for Trending Mixed Venous Blood Oxygen Saturation and Oxygen Delivery

  Marcelo Gama de Abreu, Stefan Geiger, Max Ragaller, Tilo Winkler, Stefan Rasche, Anna von Waldenfels, Detlev Michael Albrecht
  Critical Care Medicine 12/1997; 26(1):106A. · 6.33 Impact Factor