Martin W Dünser

University of Toronto, Toronto, Ontario, Canada

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Publications (209)834.42 Total impact

  • Arthur Kwizera · Martin W Dünser

    No preview · Article · Dec 2015 · American Journal of Respiratory and Critical Care Medicine
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    ABSTRACT: Introduction Haemorrhagic shock is the leading cause of preventable death in trauma patients. The 2013 European trauma guidelines emphasise a comprehensive, multidisciplinary, protocol-based approach to trauma care. The aim of the present Europe-wide survey was to compare 2015 practice with the 2013 guidelines. Methods A group of members of the Trauma and Emergency Medicine section of the European Society of Intensive Care Medicine developed a 50-item questionnaire based upon the core recommendations of the 2013 guidelines, employing a multistep approach. The questionnaire covered five fields: care structure and organisation, haemodynamic resuscitation targets, fluid management, transfusion and coagulopathy, and haemorrhage control. The sampling used a two-step approach comprising initial purposive sampling of eminent trauma care providers in each European country, followed by snowball sampling of a maximum number of trauma care providers. Results A total of 296 responses were collected, 243 (81 %) from European countries. Those from outside the European Union were excluded from the analysis. Approximately three-fourths (74 %) of responders were working in a designated trauma centre. Blunt trauma predominated, accounting for more than 90 % of trauma cases. Considerable heterogeneity was observed in all five core aspects of trauma care, along with frequent deviations from the 2013 guidelines. Only 92 (38 %) of responders claimed to comply with the recommended systolic blood pressure target, and only 81 (33 %) responded that they complied with the target pressure in patients with traumatic brain injury. Crystalloid use was predominant (n = 209; 86 %), and vasopressor use was frequent (n = 171, 76 %) but remained controversial. Only 160 respondents (66 %) declared that they used tranexamic acid always or often. Conclusions This is the first European trauma survey, to our knowledge. Heterogeneity is significant across centres with regard to the clinical protocols for trauma patients and as to locally available resources. Deviations from guidelines are frequent, differ from region to region and are dependent upon specialty training. Further efforts are required to provide consensus guidelines and to improve their implementation across European countries. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1092-5) contains supplementary material, which is available to authorized users.
    Full-text · Article · Dec 2015 · Critical Care
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    ABSTRACT: In critically ill children, in-line microfilters may reduce the incidence of the systemic inflammatory response syndrome (SIRS), the overall complication and organ dysfunction rate. No data on the use of in-line microfilters exist in critically ill adults. In this prospective, randomized, controlled open-label study, we evaluated the influence of in-line microfilters on systemic immune activation in 504 critically ill adults with a central venous catheter in place and an expected length of stay in the intensive care unit >24 h. Patients were randomized to have in-line microfilters placed into all intravenous lines (intervention group) or usual care (control group). The primary endpoint was the number of intensive care unit days with SIRS. Secondary endpoints were the incidence of SIRS, SIRS criteria per day, duration of invasive mechanical ventilation, intensive care unit length of stay, the incidence of acute lung injury, maximum C-reactive protein, maximum white blood cell count, incidence of new candida and/or central-line-associated bloodstream infections, incidence of new thromboembolic complications, cumulative insulin requirements and presence of hyper- or hypoglycemia. The study groups did not differ in any baseline variable. There was no difference in the number of days in the intensive care unit with SIRS between microfilter and control patients [2 (0.8–4.7) vs. 1.8 (0.7–4.4), p = 0.62]. Except for a higher incidence of SIRS in microfilter patients (99.6 vs. 96.8 %, p = 0.04), no difference between the groups was observed in any secondary outcome parameter. Results did not change when only patients with an intensive care unit length of stay of greater than 7 days were included in the analysis. The rate of adverse events was comparable between microfilter and control patients. In two patients allocated to the microfilter group, the study intervention was discontinued for technical reasons. Use of in-line microfilters was associated with additional costs. The use of in-line microfilters failed to modulate systemic inflammation and clinical outcome parameters in critically ill adults. Trial registration: Clinical Trials NCT01534390
    Full-text · Article · Nov 2015 · Annals of Intensive Care

  • No preview · Article · Jul 2015 · Medizinische Klinik - Intensivmedizin und Notfallmedizin
  • Ilse Gradwohl-Matis · Martin W Dünser

    No preview · Article · Jul 2015 · Critical care medicine

  • No preview · Article · May 2015 · Journal of Cardiothoracic and Vascular Anesthesia
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    Arthur Kwizera · Martin Dünser · Jane Nakibuuka

    Full-text · Dataset · Apr 2015
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    ABSTRACT: The use of ECMO to stabilize critically ill patients with severely depressed cardiac function and hemodynamics increased in the last years due to broader availability, better performance and easier implantation of the devices. The present guidelines of the Austrian Society of Cardiology focus on the use of ECMO in adult non-operated patients with cardiac diseases. Not only indications and contraindications are highlighted, but also the equally important issues of monitoring, complication management, measures during implantation and operation, and weaning of the devices are treated in detail. Thereby the present guidelines aim to optimize the use of ECMO in the individual centers, and aim to help current non-ECMO centers in developing a local ECMO-program or to contact ECMO-centers for discussion of individual patients.
    No preview · Article · Mar 2015 · Wiener klinische Wochenschrift
  • Ilse Gradwohl-Matis · Sangeeta Mehta · Martin W Dünser

    No preview · Article · Feb 2015 · Intensive Care Medicine
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    ABSTRACT: To investigate current practices and timing of neurological prognostication in comatose cardiac arrest patients. An anonymous questionnaire was distributed to the 8000 members of the European Society of Intensive Care Medicine during September and October 2012. The survey had 27 questions divided into three categories; background data, clinical data, decision-making & consequences. A total of 1025 respondents (13%) answered the survey with complete forms in more than 90%. Twenty per cent of respondents practiced outside of Europe. Overall, 22% answered that they had national recommendations, with the highest percentage in the Netherlands (>80%). Eighty-nine per cent used induced hypothermia (32-34°C) for comatose cardiac arrest patients, while 11% did not. Twenty per cent had separate prognostication protocols for hypothermia patients. Seventy-nine per cent recognized that neurological examination alone is not enough to predict outcome and a similar number (76%) used additional methods. Intermittent electroencephalography (EEG), brain computed tomography (CT) scan and evoked potentials (EP) were considered most useful. Poor prognosis was defined as cerebral performance category (CPC) 3-5 (58%) or CPC 4-5 (39%) or other (3%). When prognosis was considered poor, 73% would actively withdraw intensive care while 20% would not and 7% were uncertain. National recommendations for neurological prognostication after cardiac arrest are uncommon and only one physician out of five uses a separate protocol for hypothermia treated patients. A neurological examination alone was considered insufficient to predict outcome in comatose patients and most respondents advocated a multimodal approach; EEG, brain CT and EP were considered most useful. Uncertainty regarding neurological prognostication and decisions on level of care was substantial. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    Full-text · Article · Feb 2015 · Resuscitation
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    ABSTRACT: In patients with aortic stenosis, left ventricular systolic torsion (pT) is increased to overcome excessive afterload. This study assessed left ventricular torsion before and immediately after surgical valve replacement and tested the instant effect of fluid loading. Prospective, clinical single-center study. Intensive care unit of a university hospital. 12 patients undergoing elective aortic valve replacement for aortic stenosis. Echocardiography was performed on the day before surgery, within 18 hours after surgery including a fluid challenge, and after 2.5 years. pT decreased early postoperatively by 21.2% (23.4°±5.6° to 18.4°±6.9°; p = 0.012) and reached preoperative values at 2.5 years follow-up (24±7). Peak diastolic untwisting velocity occurred later early postoperatively (13%±8% to 21%±9.4%; p = 0.019) and returned toward preoperative values at follow-up (10.2±4.7°). The fluid challenge increased central venous pressure (8±4 mmHg to 11±4 mmHg; p = 0.003) and reduced peak systolic torsion velocity (138.7±37.6/s to 121.3±32/s; p = 0.032). pT decreased in 3 and increased in 8 patients after fluid loading. Patients whose pT increased had higher early mitral inflow velocity postoperatively (p = 0.04) than those with decreasing pT. Patients with reduced pT after fluid loading received more fluids (p = 0.04) and had a higher positive fluid balance during the intensive care unit stay (p = 0.03). Torsion after fluid loading correlated with total fluid input (p = 0.001) and cumulative fluid balance (p = 0.002). pT decreased early after aortic valve replacement but remained elevated despite elimination of aortic stenosis. After 2.5 years, torsion had returned to preoperative levels. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Jan 2015 · Journal of Cardiothoracic and Vascular Anesthesia
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    ABSTRACT: Background: Miosis occurs following exposure to toxins that decrease the sympathomimetic tone, increase the cholinergic tone, or exert sedative-hypnotic effects, but has not been reported in insulin poisoning. Case report: A 64-year- old woman without co-morbidities was found unconscious next to an empty insulin pen. Her Glasgow Coma Scale was 3 with absent reflexes, bilateral reactive miosis, and injection marks across the abdominal wall. The patient was endotracheally intubated, mechanically ventilated, and transferred to this hospital. At admission, the blood glucose level was 34 mg/dL. Glasgow Coma Scale remained at 3, with persistent bilateral reactive miosis. The toxicology screening was negative for ethanol, barbiturates, tricyclic antidepressants, phenothiazines, amphetamines, cannabinoids, salicylates, acetaminophen, and cocaine. Cranial computed tomography with angiography and magnetic resonance imaging (MRI) did not show any structural brain lesions. Intravenous glucose was continued at 6-14 g/h for 3 days. On repeated neurological examinations, the patient remained deeply comatose, with partial loss of cranial nerve function. Bilateral reactive miosis persisted for 4 days. From day 5 on, the patient awoke progressively. At discharge, the patient was fully alert and orientated, without a focal neurological deficit. Conclusions: Prolonged bilateral reactive miosis can be a clinical symptom accompanying metabolic encephalopathy in severe insulin poisoning. Functional impairment of the pons due to relative hypoperfusion during hypoglycemia may serve as a reasonable pathophysiologic explanation for this phenomenon.
    Full-text · Article · Jan 2015 · American Journal of Case Reports
  • Arjen M. Dondorp · Martin W. Dünser · Marcus J. Schultz

    No preview · Chapter · Dec 2014
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    ABSTRACT: IntroductionLiberal and over-aggressive use of vasopressors during the initial period of shock resuscitation may compromise organ perfusion and worsen outcome. When transiently applying the concept of permissive hypotension it would be helpful to know at which arterial blood pressure terminal cardiovascular collapse occurs.Methods In this retrospective cohort study, we aimed to identify the arterial blood pressure associated with terminal cardiovascular collapse in 140 patients who died in the intensive care unit while being invasively monitored. Demographic data, co-morbid conditions and clinical data at admission, during 24 hours before and at the time of terminal cardiovascular collapse were collected. The systolic, mean and diastolic arterial blood pressure immediately before terminal cardiovascular collapse was documented. Terminal cardiovascular collapse was defined as an abrupt (<5 min) and exponential decrease in heart rate (>50% compared to preceding values) followed by cardiac arrest.ResultsThe mean¿±¿standard deviation (SD) of the systolic, mean and diastolic arterial blood pressure associated with terminal cardiovascular collapse was 47¿±¿12, 35¿±¿11 and 29¿±¿9 mmHg. Patients with congestive heart failure (39¿±¿13 versus 34¿±¿10 mmHg; P¿=¿0.04), left main stem stenosis (39¿±¿11 versus 34¿±¿11 mmHg; P¿=¿0.03) or acute right heart failure (39¿±¿13 versus 34¿±¿10 mmHg; P¿=¿0.03) had higher arterial blood pressures than patients without these risk factors. Patients with severe valvular aortic stenosis had the highest arterial blood pressures associated with terminal cardiovascular collapse (systolic, 60¿±¿20; mean, 46¿±¿12; diastolic, 36¿±¿10 mmHg), but this difference was not significant. Sepsis patients and patients exposed to sedatives or opioids during the terminal phase exhibited lower arterial blood pressures than patients without sepsis or administration of such drugs.Conclusions The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients was very low and varied with individual co-morbid conditions (for example congestive heart failure, left main stem stenosis, severe valvular aortic stenosis, acute right heart failure), drug exposition (for example sedatives or opioids) and the type of acute illness (for example sepsis).
    Full-text · Article · Dec 2014 · Critical care (London, England)
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    ABSTRACT: Hemodialysis is considered the renal replacement technique of choice to control life-threatening hypercalcemia. In this case series, the experience with continuous veno-venous hemodiafiltration (CVVHDF) with regional citrate anticoagulation to control five hypercalcemic crises in four patients is summarized. Overall maximum ionized and total calcium levels were ranged from 1.72-2.01 mmol/L and 3.1-4.2 mmol/L, respectively. All patients presented with impaired consciousness, cardiac arrhythmias and/or acute oliguria despite therapy. Trisodium-citrate was administered at 3 mmol/h (hourly calcium replacement 1.15-2.75 mmol). This allowed a controlled decrease of ionized calcium levels below 1.4 mmol/L within 4 hours (IQR, 2.5-10) and resolution of neurological symptoms within 15.5 hours (IQR, 12-22.8). The duration of CVVHDF was one day in those patients in whom hypercalcemia was the reason for admission. Four asymptomatic episodes of mild hypocalcemia occurred in two patients. No patient developed relevant abnormalities of serum sodium levels or pH, experienced cardiac arrhythmia or required transfusion of blood products during CVVHDF. One patient with metastatic bronchial carcinoma experienced rebound hypercalcemic crisis thirteen days following a one day session of CVVHDF with regional citrate anticoagulation.In conclusion, CVVHDF with regional citrate anticoagulation appears to be effective and potentially safe to rapidly normalize calcium levels in hypercalcemic crisis.
    No preview · Article · Dec 2014 · ASAIO journal (American Society for Artificial Internal Organs: 1992)
  • Andreas Brunauer · Daniel Dankl · Martin W Dünser
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    ABSTRACT: To the Editor,A 44-year-old man (185 cm, 80 kg) was mechanically ventilated and referred to a university hospital because of severe pneumonia-associated acute respiratory distress syndrome (ARDS; Fig. 1a). A few hours after intensive care unit admission, veno-venous extracorporeal membrane oxygenation (ECMO; outflow cannula—23 Fr: right femoral vein; inflow cannula—19 Fr: right internal jugular vein) had to be initiated because of refractory hypoxemia (PaO2, 53 mmHg) and hypercapnia (PaCO2, 144 mmHg) regardless of invasive ventilator settings (biphasic positive airway pressure with inspiratory oxygen concentration, 100 %; positive end-expiratory pressure, 15 mbar; peak pressure, 36 mbar; respiratory rate, 32 bpm). To hasten lung recruitment, the decision was made to put the patient into the prone position. However, full prone position led to compression of lines at their insertion site by the patient's weight, compromised extracorporeal blood flow and lowered the efficacy of ECMO thera ...
    No preview · Article · Dec 2014 · Wiener klinische Wochenschrift
  • M M Berger · I Gradwohl-Matis · A Brunauer · H Ulmer · M W Dünser
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    ABSTRACT: Perioperative fluid management plays a fundamental role in maintaining organ perfusion, and is considered to affect morbidity and mortality. Targets according to which fluid therapy should be administered are poorly defined. This systematic review aimed to identify specific targets for perioperative fluid therapy. The PubMed database (January 1993-December 2013) and reference lists were searched to identify clinical trials which evaluated specific targets of perioperative fluid therapy and reported clinically relevant perioperative endpoints in adult patients. Only studies in which targeted fluid therapy was the sole intervention were included into the main data analysis. A pooled data analysis was used to compare mortality between goal-directed fluid therapy and control interventions. Thirty-six clinical studies were selected. Sixteen studies including 1224 patients specifically evaluated targeted fluid therapy and were included into the main data analysis. Three specific targets for perioperative fluid therapy were identified: a systolic or pulse pressure variation <10-12%, an increase in stroke volume <10%, and a corrected flow time of 0.35-0.4 s in combination with an increase in stroke volume <10%. Targeting any one of these goals resulted in less postoperative complications (pooled data analysis: OR 0.53; CI95, 0.34-0.83; P=0.005) and a shorter length of intensive care unit/hospital stay, but no difference in postoperative mortality (pooled data analysis: OR 0.61; CI95, 0.33-1.11; P=0.12). This systematic review identified three goals for perioperative fluid administration, targeting of which appeared to be associated with less postoperative complications and shorter intensive care unit/hospital lengths of stay. Perioperative mortality remained unaffected.
    No preview · Article · Sep 2014 · Minerva anestesiologica
  • I Gradwohl-Matis · A Brunauer · D Dankl · M Dünser
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    ABSTRACT: Restoration of adequate tissue perfusion is the goal of resuscitation in septic shock. A growing understanding of microcirculatory dysfunction in sepsis led to a change in resuscitation practice away from targeting arterial and central venous pressures and towards tissue perfusion-guided protocols. This change in the approach to resuscitation was accompanied by a change in the role of vasoconstrictors. This review summarizes the pathophysiological and therapeutic mainstays of septic shock resuscitation and attempts to critically evaluate the scientific evidence on the use of vasopressin as a non-adrenergic vasoconstrictor in septic shock. Based on the published study results vasopressin appears to be of potential benefit in adult patients with moderate septic shock (norepinephrine requirements < 15 μg/min) and lacking signs of systemic hypoperfusion (e.g. normal arterial lactate levels). A vasopressin infusion with the sole target to increase arterial blood pressure despite the presence of systemic hypoperfusion is dangerous and can result in a critical deterioration of tissue perfusion.
    No preview · Article · May 2014 · Der Anaesthesist

  • No preview · Article · May 2014 · Chest
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    ABSTRACT: Dermatomyositis is a chronic inflammatory disorder characterized by muscular and dermatologic symptoms with variable internal organ involvement. This is the first report on a patient with acute dermatomyositis and fulminant systemic capillary leak syndrome. A 69-year-old Caucasian woman with chronic dermatomyositis presented with clinical signs of severe hypovolemic shock and pronounced hemoconcentration (hematocrit, 69%). Her colloid osmotic pressure was 4.6mmHg. Following a bolus dose of prednisolone (500mg), fluid resuscitation was initiated. During volume loading, anasarca and acute respiratory distress rapidly developed. Echocardiography revealed an underfilled, hypokinetic, diastolic dysfunctional left ventricle with pericardial effusion but no signs of tamponade. Despite continued fluid resuscitation and high-dosed catecholamine therapy, the patient died from refractory shock 12 hours after intensive care unit admission. A laboratory analysis of her complement system suggested the presence of C1 inhibitor deficiency as the cause for systemic capillary leakage. The post-mortem examination revealed bilateral pleural, pericardial and peritoneal effusions as well as left ventricular hypertrophy with patchy myocardial fibrosis. Different patterns of endomysial/perimysial lymphocytic infiltrations adjacent to degenerated cardiomyocytes in her myocardium and necrotic muscle fibers in her right psoas major muscle were found in the histological examination. This case report indicates that acute exacerbation of chronic dermatomyositis can result in a fulminant systemic capillary leak syndrome with intense hemoconcentration, hypovolemic shock and acute heart failure. In the presented patient, the cause for diffuse capillary leakage was most probably acquired angioedema, a condition that has been associated with both lymphoproliferative and autoimmunologic disorders.
    Full-text · Article · Jan 2014 · Journal of Medical Case Reports

Publication Stats

4k Citations
834.42 Total Impact Points

Institutions

  • 2015
    • University of Toronto
      Toronto, Ontario, Canada
  • 2011-2015
    • Paracelsus Medical University Salzburg
      • University Clinic of Anaesthesiology, Perioperative Medicine and General Intensive Care
      Salzburg, Salzburg, Austria
  • 2008-2015
    • Universität Bern
      Berna, Bern, Switzerland
  • 2006-2013
    • Inselspital, Universitätsspital Bern
      • Department of Intensive Medicine
      Berna, Bern, Switzerland
  • 2010
    • Karolinska Institutet
      Solna, Stockholm, Sweden
  • 1990-2010
    • University of Innsbruck
      • • Institute of Biochemistry
      • • Institut für Psychologie
      Innsbruck, Tyrol, Austria
  • 2009
    • Medizinische Universität Innsbruck
      • Department of Anaesthesiology and Critical Care Medicine
      Innsbruck, Tyrol, Austria