J Klein

Erasmus MC, Rotterdam, South Holland, Netherlands

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Publications (38)86.28 Total impact

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    ABSTRACT: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. We studied 570 patients (mean age 69 ±9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p = 0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24,95% CI: 0.10-0.70; p = 0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.
    Preview · Article · Sep 2011 · European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery
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    ABSTRACT: Nearly 60% of the Dutch population undergoing surgery is aged 65 years and over. Older patients are at increased risk of developing perioperative complications (e.g., myocardial infarction, pneumonia, or delirium), which may lead to a prolonged hospital stay or death. Preoperative risk stratification calculates a patient's risk by evaluating the presence and extent of frailty, pathophysiological risk factors, type of surgery, and the results of (additional) testing. Type of anesthesia, fluid management, and pain management affect outcome of surgery. Recent developments focus on multimodal perioperative care of the older patient, using minimally invasive surgery, postoperative anesthesiology rounds, and early geriatric consultation.
    Full-text · Article · Jun 2011 · Zeitschrift für Gerontologie + Geriatrie
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    ABSTRACT: Early recovery of patients following sedation/analgesia and anesthesia is important in ambulatory practice. The aim of this study was to assess whether modafinil, used for the treatment of narcolepsy, improves recovery following sedation/analgesia. Patients scheduled for extracorporeal shock wave lithotripsy were randomly assigned to one of four groups. Two groups received a combination of fentanyl/midazolam with either modafinil or placebo. The remaining groups received remifentanil/propofol with either modafinil or placebo. Modafinil 200 mg was administered to the treatment group patients 1 h before sedation/analgesia. Groups were compared using the digital symbol substitution test (DSST), trail making test (TMT), observer scale of sedation and analgesia (OAA/S) and Aldrete score. Verbal rating scale (VRS) scores for secondary outcome variables e.g. energy, tiredness and dizziness were also recorded before and after treatment. Sixty-seven patients successfully completed the study. Groups received similar doses of sedation and analgesic drugs. No statistically significant difference was found for DSST between groups. No significant adverse effects occurred in relation to modafinil. No statistically significant difference between groups was identified for TMT, OAA/S and Aldrete scores. The mean VRS score for tiredness was lesser in the modafinil/fentanyl/midazolam group [1.3 (2.0)] compared with the placebo group [3.8 (2.5)], P=0.02. Such a difference was not found between the remifentanil/propofol groups [placebo 2.6 (2.2) vs. modafinil 3.1(2.7)], p>0.05. Dizziness was greater in the modafinil/remifentanil/propofol group 1.7 (2.0) vs. placebo 0.0 (0.5), p<0.05. Modafinil reduces patient-reported tiredness after sedation/analgesia but does not improve recovery in terms of objective measures of patient psychomotor skills.
    No preview · Article · Aug 2009 · Acta Anaesthesiologica Scandinavica
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    ABSTRACT: To assess the predictive value of walking distance after an exercise test on long-term outcome in patients with normal and impaired ankle-brachial index (ABI). A total of 2191 patients with known or suspected peripheral arterial disease (PAD), who were referred for a single-stage treadmill exercise test to diagnose or evaluate their PAD, were enrolled in an observational study between 1993 and 2006. They were divided into two groups: normal ABI (>or=0.90) and impaired ABI (<0.90). Walking distance was divided into quartiles (no (reference), mild, moderate or severe impairment). In patients with normal ABI, severe walking distance was, after adjustment, associated with higher mortality risk (hazard ratio (HR): 2.60 (range: 1.16-5.78)). In patients with impaired ABI, all walking distance impairment quartiles were associated with higher mortality (mild HR: 1.26 (range: 0.95-1.67), moderate HR: 1.52 (range: 1.13-2.05) and severe HR: 1.69 (range: 1.26-2.27)). Furthermore, comparable associations were observed between all walking distance quartiles, cardiac death or major adverse cerebrovascular and cardiac events. Our study illustrated that walking impairment is a strong prognostic indicator of long-term outcome in patients with impaired and normal ABI, which should be a warning sign to physicians to monitor these patients carefully and to provide them optimal treatment.
    No preview · Article · Aug 2009 · European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery
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    E Blommers · M Klimek · J Klein · P G Noordzij
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    ABSTRACT: Nearly 60% of the Dutch population undergoing surgery is over the age of 65. The elderly are at higher risk of developing perioperative complications (e.g. myocardial infarction, pneumonia or delirium), that lead to a prolonged hospital stay or death. Preoperative risk stratification calculates the patient's risk by evaluating the presence and extent of frailty, and pathophysiological risk factors, type of surgery and the results of additional testing. The type of anaesthesia, fluid management and pain management strongly influences the outcome of surgery and the way this is experienced by the patient. Recent developments focus on multimodal perioperative care of the older patient to shorten hospital stay, using minimal invasive surgery, postoperative anaesthesiology rounds and early geriatric consultation.
    Full-text · Article · Aug 2008 · Nederlands tijdschrift voor geneeskunde
  • E.M. Galvin · H. Boesjes · J. Whool · J. Klein
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    ABSTRACT: We conducted a survey on anaesthesia practise for ambulatory surgery in The Netherlands with the purpose of identifying patterns and comparing them to published recommendations. Overall response rate was 69%. 97% of Dutch hospitals have ambulatory wards and 25% have dedicated operating rooms. Preoperative anxiolytic use is relatively high, approximately 40%. Prophylactic anti-emetic use is low, 33% for laparoscopic cholecystectomy, but a further 33% of patients require rescue treatment. Combination analgesic use is infrequent, with just one analgesic being used in more than 50% of patients. There is a strong preference for both locoregional, 85% for upper limb surgery, and neuroaxial techniques, 65% for lower limb surgery. However, use of continuous peripheral nerve block catheters for pain control following discharge is limited. We conclude that closer adherence to guidelines on PONV prophylaxis and greater use of multimodal approaches to pain management would be beneficial.
    No preview · Article · Apr 2008
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    ABSTRACT: Sugammadex is the first selective relaxant binding agent and reverses rocuronium-induced neuromuscular block. A case is reported in which a patient accidentally received a high dose of sugammadex (40 mg kg−1) to reverse a rocuronium-induced (1.2 mg kg−1) profound neuromuscular block. A fast and efficient recovery from profound neuromuscular block was achieved and no adverse events or other safety concerns were reported.
    Preview · Article · Jun 2007 · BJA British Journal of Anaesthesia

  • No preview · Article · Dec 2006 · Nederlands Tijdschrift voor Anesthesiologie
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    ABSTRACT: To study whether beta-blockers reduce in-hospital and long-term mortality in patients with severe left ventricular dysfunction (LVD) undergoing major vascular surgery. Observational cohort study. Five hundred and eleven patients with severe LVD (ejection fraction<30%) undergoing major non-cardiac vascular surgery. In all patients, cardiac risk factors, medication (including beta-blockers), and dobutamine stress echocardiography (DSE) results were noted prior to surgery. DSE was evaluated for rest and stress-induced new wall motion abnormalities. Endpoint was in-hospital and long-term mortality. Propensity scores for beta-blockers were calculated and regression models were used to analyse the relation between beta-blockers and mortality. Mean age was 64+/-11 years and 383 patients (75%) were male. 139 patients (27%) used beta-blockers. Stress-induced ischemia occurred in 82 patients (16%). Median follow-up was 7 years (interquartile range: 3-10). In-hospital and long-term mortality was observed in 64 (13%) and 171 (33%) patients, respectively. After adjusting for clinical variables, DSE results and propensity scores, beta-blockers were significantly associated with reduced in-hospital and long-term mortality (OR: 0.18, 95% CI: 0.04-0.74 and HR: 0.38, 95% CI: 0.22-0.65, respectively). In patients with severe LVD undergoing major vascular surgery, the use of beta-blockers is associated with a reduced incidence of in-hospital and long-term postoperative mortality.
    Full-text · Article · Apr 2006 · European Journal of Vascular and Endovascular Surgery
  • H C Rettig · M J M Gielen · E Boersma · J Klein
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    ABSTRACT: This prospective, randomized study compared the efficacy of the vertical infraclavicular and axillary approaches using a single injection blockade of the brachial plexus. The primary endpoint was complete blockade in dermatomes C5-Th1, while secondary endpoints included onset time, motor block, block performance time, surgical success rate, patient satisfaction, and side-effects/complications. Sixty patients, American Society of Anesthesiologists physical status I or II, scheduled for surgery of the forearm or hand received either a vertical infraclavicular (n = 30) or an axillary block (n = 30). A single injection of 0.5 ml/kg ropivacaine 7.5 mg/ml was made after electrolocalization of nerve fibres corresponding to the median nerve at maximum 0.5 mA (2 Hz, 0.1 ms). Onset and distribution of analgesia and motor block were assessed at 5, 10, 15, 20, 30 and 60 min after the local anaesthetic injection. A complete block was defined as analgesia in all dermatomes (C5-Th1) at 60 min post-injection. The vertical infraclavicular approach provided complete blockade in 29 patients (97%) and the axillary approach in 23 patients (77%). Analgesia in C5-C6 dermatomes and corresponding motor block occurred significantly more frequently in the vertical infraclavicular approach, which also had the shortest onset time. Block procedure was quicker in the axillary approach. Side-effects were similar in both groups, and there were no permanent sequelae. Patient satisfaction was equally high in both groups. The vertical infraclavicular approach provides a more complete block than the axillary approach when using a single injection technique and equal volumes/doses of local anaesthetic.
    No preview · Article · Dec 2005 · Acta Anaesthesiologica Scandinavica

  • No preview · Article · Aug 2005 · ACC Current Journal Review

  • No preview · Article · May 2005 · European Journal of Anaesthesiology

  • No preview · Article · May 2005 · European Journal of Anaesthesiology

  • No preview · Article · May 2005 · European Journal of Anaesthesiology
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    D Poldermans · J Klein

    Preview · Article · Jan 2005 · European Heart Journal – Cardiovascular Imaging
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    M.D. Kertai · E. Moersma · J. Klein

    Full-text · Article · Nov 2004 · Journal of Vascular Surgery
  • Source
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    ABSTRACT: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. We studied 570 patients (mean age 69+/-9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p=0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24, 95% CI: 0.10-0.70; p=0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.
    Full-text · Article · Oct 2004 · European Journal of Vascular and Endovascular Surgery
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    ABSTRACT: The open lung concept (OLC) is a method of ventilation intended to maintain end-expiratory lung volume by increased airway pressure. Since this could increase right ventricular afterload, we studied the effect of this method on right ventricular afterload in patients after cardiac surgery. We studied 24 stable patients after coronary artery surgery and/or valve surgery with cardiopulmonary bypass. Patients were randomly assigned to OLC or conventional mechanical ventilation (CMV). In the OLC group, recruitment manoeuvres were applied until Pa(o(2))/FI(O(2)) was greater than 50 kPa (reflecting an open lung). This value was maintained by sufficient positive airway pressure. In the CMV group, volume-controlled ventilation was used with a PEEP of 5 cm H(2)O. Cardiac index, right ventricular preload, contractility and afterload were measured with a pulmonary artery thermodilution catheter during the 3-h observation period. Blood gases were monitored continuously. To achieve Pa(O(2))/Fl(O(2)) > 50 kPa, 5.3 (3) (mean, SD) recruitment attempts were performed with a peak pressure of 45.5 (2) cm H(2)O. To keep the lung open, PEEP of 17.0 (3) cm H(2)O was required. Compared with baseline, pulmonary vascular resistance and right ventricular ejection fraction did not change significantly during the observation period in either group. No evidence was found that ventilation according to the OLC affects right ventricular afterload.
    Full-text · Article · Oct 2004 · BJA British Journal of Anaesthesia
  • P. Palanchon · A. Bouakaz · J Klein · N de Jong
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    ABSTRACT: The classification of circulating microemboli as gaseous or particulate matter is essential to establish the relevance of detected embolic signals. Transcranial Doppler (TCD) technology has not yet fully succeeded in characterizing the composition of microemboli unambiguously. Recently, the authors proposed a new approach to detect, characterize and size gaseous emboli. The method is based on the nonlinear properties of gaseous bubbles. The application of this approach requires a dedicated transducer with the ability to transmit the adequate frequencies and simultaneously receive the high frequency scattered nonlinear components. The paper presents a multifrequency emboli transducer composed of two independent transmitting elements and a separate receiving part. The transmitting part can cover a frequency band between 100 kHz and 600 kHz. The reception of the signal is performed by a 110 μm PVDF layer sensitive over a frequency band ranging from 50 kHz to 2 MHz. Experimental results show that a specific range of gaseous embolus size was detected by each transmitting element. Using the 130 kHz outer element in transmission, microemboli between 35 μm and 105 μm can be discriminated through their second harmonic or subharmonic emissions while gaseous microemboli between 10 μm and 40 μm were accurately classified using the 360 kHz inner element. The in vitro results demonstrate that nonlinear properties of microemboli combined with the new transducer offer a real opportunity to characterize and size microemboli.
    No preview · Conference Paper · Sep 2004
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    ABSTRACT: Levels of glucose and lactate were measured in the brain by means of microdialysis in order to evaluate the effects of ventilator-induced hypocapnia and hypercapnia on brain metabolism in healthy non-brain-traumatized animals. Prospective animal study in a university laboratory. Eight adult Landrace/Yorkshire pigs. The microdialysis probe was inserted in the brain along with a multiparameter sensor and intracranial pressure (ICP) probe. The animals were ventilated in a pressure-controlled mode according to the open lung concept with an inspired oxygen fraction of 0.4/1.0. Starting at normoventilation (PaCO(2) +/-40 mmHg) two steps of both hypercapnia (PCO(2) +/- 70 and 100 mmHg) and hypocapnia (PaCO(2) +/- 20 and 30 mmHg) were performed. Under these conditions, brain glucose and lactate levels as well as brain oxygen (PbrO(2)), brain carbon dioxide (PbrCO(2)), brain pH (brpH), brain temperature and ICP were measured. At hypercapnia (PaCO(2) = 102.7 mmHg) there were no significant changes in brain glucose and lactate but there was a significant increase in PbrCO(2), PbrO(2) and ICP. In contrast, at hypocapnia (PCO(2) = 19.8 mmHg) there was a significant increase in brain lactate and a significant decrease in both brain glucose and PbrCO(2). Hypocapnia decreases brain glucose and increases brain lactate concentration, indicating anaerobic metabolism, whereas hypercapnia has no influence on levels of brain glucose and brain lactate.
    No preview · Article · Aug 2004 · Clinical physiology and functional imaging

Publication Stats

709 Citations
86.28 Total Impact Points

Institutions

  • 2002-2011
    • Erasmus MC
      • • Department of Anesthesiology
      • • Department of Cardiology
      Rotterdam, South Holland, Netherlands
  • 2000-2011
    • Erasmus Universiteit Rotterdam
      • • Department of Anesthesiology
      • • Department of Cardiology
      Rotterdam, South Holland, Netherlands