Comparing published trial patients and non-trial patients in clinical practice, clinicians often ... more Comparing published trial patients and non-trial patients in clinical practice, clinicians often doubt whether critically ill patients are sufficiently represented in randomised clinical trials. This study evaluated the extent of infection with multidrug-resistant (MDR) pathogens, anti-microbial combination therapy, off-label use and targeted-treatment in trial patients versus non-trial patients. Tigecycline therapy was prescribed for off-label use in more than half of the non-trial patients; 77% of trial patients received study medication as first-line therapy in contrast to 25% of non-trial patients (p<0.001). Tigecycline therapy was targeted for 27% of trial patients versus 73% of non-trial patients (p<0.001). Ninety-six percent of non-trial patients were treated for nosocomial infections compared to 23% of trial patients (p<0.001). In one out of 22 (4.5%) trial patients an ESKAPE pathogen was found, whereas rates of vancomycin- resistant Enterococcus faecium, methicillin-resistant Staphylococcus aureus and extended spectrum-β lactamase- producing Enterobacteriaceae ranged between 13/165 (8%) and 23/165 (14%) for non-trial patients. Tigecycline was used for less critical populations in clinical trials than in clinical practice. Our findings confirm the particular need of potent substances such as tigecycline for critically ill patients.
Patients with malignant diseases are increasingly being treated with multimodal therapeutical con... more Patients with malignant diseases are increasingly being treated with multimodal therapeutical concepts based on the three major modalities surgery, radiotherapy and chemotherapy. The perioperative period is crucial within this multimodal concept as the prognosis of patients may be directly influenced by perioperative measures. In addition, it is of major importance to avoid complications in the perioperative phase, as these might worsen the prognosis of the patient and in order to prevent a delay in the beginning of planned adjuvant therapies. These aspects demonstrate the important role of anesthesia in the treatment of patients with cancer. Further studies defining the relevance of anesthesiologic measures in oncologic patients are needed.
Massive pulmonary embolism associated with cardiac arrest has an extremely high mortality in spit... more Massive pulmonary embolism associated with cardiac arrest has an extremely high mortality in spite of cardiopulmonary resuscitation maneuvers. An early diagnosis of pulmonary embolism as cause of cardiac arrest and a rapid specific therapy able to obtain a restoration of pulmonary flow can improve the prognosis. The authors report a case of cardiac arrest for massive pulmonary embolism promptly diagnosed by echocardiography and treated by thrombolytic therapy with an initial favourable outcome.
The imminent introduction of the DRG (diagnosis-related-group) system is putting hospitals in Ger... more The imminent introduction of the DRG (diagnosis-related-group) system is putting hospitals in Germany under considerable pressure. This requires that personnel are efficiently allocated by optimizing organizational procedures and that the limited resources be distributed in a cost-effective manner. One prerequisite for this is a marked cost-consciousness on the part of those who "incur costs" in providing a service. To increase the awareness of costs in clinical physicians, the cost structures must be transparent. In order to achieve this goal, a project was initiated at the Department of Anaesthesiology at the University Hospital of Heidelberg, which aimed to enhance the cost-consciousness of the staff by making price lists available to anaesthesiologists at the workplace. In addition to the price lists, the 25 most expensive medications and medical products were added as an ABC analysis. The departmental staff was interviewed by questionnaire as to whether this project was reasonable. After 1 year the interview was repeated. The results of the questionnaire showed that in the opinion of the staff, price lists are an effective tool, as cost-consciousness on the part of clinical physicians can be enhanced by making price structures transparent. This is a major prerequisite for individual motivation in the cost-effective management. Although the ABC analyses demonstrate no long-term effect of the price-transparency on the cost structures, the staff showed increased cost-consciousness and individual motivation for economic tasks.
The management of anaesthesia in patients suffering preeclampsia has to be selected individually.... more The management of anaesthesia in patients suffering preeclampsia has to be selected individually. There is a high rate of caesarean sections in patients with preeclampsia. Intubation anaesthesia or regional anaesthesia are commonly used methods and can be considered comparable and equally useful. In our opinion, the application of regional anaesthesia should be preferred, if the initial criteria, such as normal neurologic status and blood coagulation, are fulfilled. We believe in a considerable reduction of vital risks when using regional anaesthesia. Our aim was to figure out the risk-factors of preeclampsia and preterm maturity regarding anaesthesia management. Preeclampsia is a severe illness in pregnancy with a frequency of 5-10%. In 1997, we experienced 73 patients with praeeclampsia according to the definition of ISSPH. Mode of delivery was conventional in 10 patients, 2 patients had a vacuum extraction and 61 patients needed a caesarean section. The rate of epidural anesthesia for delivery was 51%. We used epidural anaesthesia in 6 spontaneous deliveries, in 2 vacuum extractions and in 30 caesarean sections. There were no problems with epidural anaesthesia and the outcome of mother and child was also considered to be excellent. We suggest to use regional anesthesia techniques whenever possible.
Background: Sepsis is well known to lead to the activation of multiple pro-inflammatory mark- ers... more Background: Sepsis is well known to lead to the activation of multiple pro-inflammatory mark- ers, like MCP-1 (Monocyte chemotactic protein 1), TNF-alpha (Tumor necrosis factor alpha), while the underlying genetic changes still remain poorly studied. Methods: We used human umbilical vein endothelial cells to test the reactions to nicotine or acetylcholine/pyridostigmine administration in regards to MCP-1 levels, gene regulation and
Purpose: This study establishes a new model of sustained pulmonary hypertension induced by recurr... more Purpose: This study establishes a new model of sustained pulmonary hypertension induced by recurrent microembolism in pigs and evaluates the effects of nitric oxide (NO) inhalation in this model.Materials and Methods: Fourteen pigs were embolized under general anesthesia with 300-μm microspheres intravenously three times over a period of 7 weeks. Four pigs served as untreated controls. Hemodynamic and gas exchange
Comparing published trial patients and non-trial patients in clinical practice, clinicians often ... more Comparing published trial patients and non-trial patients in clinical practice, clinicians often doubt whether critically ill patients are sufficiently represented in randomised clinical trials. This study evaluated the extent of infection with multidrug-resistant (MDR) pathogens, anti-microbial combination therapy, off-label use and targeted-treatment in trial patients versus non-trial patients. Tigecycline therapy was prescribed for off-label use in more than half of the non-trial patients; 77% of trial patients received study medication as first-line therapy in contrast to 25% of non-trial patients (p<0.001). Tigecycline therapy was targeted for 27% of trial patients versus 73% of non-trial patients (p<0.001). Ninety-six percent of non-trial patients were treated for nosocomial infections compared to 23% of trial patients (p<0.001). In one out of 22 (4.5%) trial patients an ESKAPE pathogen was found, whereas rates of vancomycin- resistant Enterococcus faecium, methicilli...
Metastatic liver resection following cytoreductive chemotherapy is an accepted treatment for olig... more Metastatic liver resection following cytoreductive chemotherapy is an accepted treatment for oligometastatic tumor diseases. Although pulmonary complications are frequently reported in patients undergoing liver surgery including liver transplantation, life-threatening acute respiratory failures in the absence of aspiration, embolism, transfusion-related acute lung injury (TRALI), pulmonary infection, or an obvious source of systemic sepsis are rare. We performed an extensive clinical review of a patient undergoing metastatic liver resection who had a clinical course compatible to an acute respiratory distress syndrome (ARDS) without an obvious cause except for the surgical procedure and multiple preoperative chemotherapies. We hypothesize that either the surgical procedure mediated by cytokines and tumor necrosis factor or possible toxic effects of oxygen applied during general anesthesia were associated with life-threatening respiratory failure in the patient. Discrete and subclini...
ABSTRACT Major cardiac complications presenting as myocardial infarction, myocardial ischemia, ca... more ABSTRACT Major cardiac complications presenting as myocardial infarction, myocardial ischemia, cardiac failure, or life-threatening dysrhythmias contribute significantly to perioperative morbidity and mortality. Preventive strategies are of major importance since even despite adequate treatment these events are associated with poor outcome.
Comparing published trial patients and non-trial patients in clinical practice, clinicians often ... more Comparing published trial patients and non-trial patients in clinical practice, clinicians often doubt whether critically ill patients are sufficiently represented in randomised clinical trials. This study evaluated the extent of infection with multidrug-resistant (MDR) pathogens, anti-microbial combination therapy, off-label use and targeted-treatment in trial patients versus non-trial patients. Tigecycline therapy was prescribed for off-label use in more than half of the non-trial patients; 77% of trial patients received study medication as first-line therapy in contrast to 25% of non-trial patients (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Tigecycline therapy was targeted for 27% of trial patients versus 73% of non-trial patients (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Ninety-six percent of non-trial patients were treated for nosocomial infections compared to 23% of trial patients (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). In one out of 22 (4.5%) trial patients an ESKAPE pathogen was found, whereas rates of vancomycin- resistant Enterococcus faecium, methicillin-resistant Staphylococcus aureus and extended spectrum-β lactamase- producing Enterobacteriaceae ranged between 13/165 (8%) and 23/165 (14%) for non-trial patients. Tigecycline was used for less critical populations in clinical trials than in clinical practice. Our findings confirm the particular need of potent substances such as tigecycline for critically ill patients.
Patients with malignant diseases are increasingly being treated with multimodal therapeutical con... more Patients with malignant diseases are increasingly being treated with multimodal therapeutical concepts based on the three major modalities surgery, radiotherapy and chemotherapy. The perioperative period is crucial within this multimodal concept as the prognosis of patients may be directly influenced by perioperative measures. In addition, it is of major importance to avoid complications in the perioperative phase, as these might worsen the prognosis of the patient and in order to prevent a delay in the beginning of planned adjuvant therapies. These aspects demonstrate the important role of anesthesia in the treatment of patients with cancer. Further studies defining the relevance of anesthesiologic measures in oncologic patients are needed.
Massive pulmonary embolism associated with cardiac arrest has an extremely high mortality in spit... more Massive pulmonary embolism associated with cardiac arrest has an extremely high mortality in spite of cardiopulmonary resuscitation maneuvers. An early diagnosis of pulmonary embolism as cause of cardiac arrest and a rapid specific therapy able to obtain a restoration of pulmonary flow can improve the prognosis. The authors report a case of cardiac arrest for massive pulmonary embolism promptly diagnosed by echocardiography and treated by thrombolytic therapy with an initial favourable outcome.
The imminent introduction of the DRG (diagnosis-related-group) system is putting hospitals in Ger... more The imminent introduction of the DRG (diagnosis-related-group) system is putting hospitals in Germany under considerable pressure. This requires that personnel are efficiently allocated by optimizing organizational procedures and that the limited resources be distributed in a cost-effective manner. One prerequisite for this is a marked cost-consciousness on the part of those who &quot;incur costs&quot; in providing a service. To increase the awareness of costs in clinical physicians, the cost structures must be transparent. In order to achieve this goal, a project was initiated at the Department of Anaesthesiology at the University Hospital of Heidelberg, which aimed to enhance the cost-consciousness of the staff by making price lists available to anaesthesiologists at the workplace. In addition to the price lists, the 25 most expensive medications and medical products were added as an ABC analysis. The departmental staff was interviewed by questionnaire as to whether this project was reasonable. After 1 year the interview was repeated. The results of the questionnaire showed that in the opinion of the staff, price lists are an effective tool, as cost-consciousness on the part of clinical physicians can be enhanced by making price structures transparent. This is a major prerequisite for individual motivation in the cost-effective management. Although the ABC analyses demonstrate no long-term effect of the price-transparency on the cost structures, the staff showed increased cost-consciousness and individual motivation for economic tasks.
The management of anaesthesia in patients suffering preeclampsia has to be selected individually.... more The management of anaesthesia in patients suffering preeclampsia has to be selected individually. There is a high rate of caesarean sections in patients with preeclampsia. Intubation anaesthesia or regional anaesthesia are commonly used methods and can be considered comparable and equally useful. In our opinion, the application of regional anaesthesia should be preferred, if the initial criteria, such as normal neurologic status and blood coagulation, are fulfilled. We believe in a considerable reduction of vital risks when using regional anaesthesia. Our aim was to figure out the risk-factors of preeclampsia and preterm maturity regarding anaesthesia management. Preeclampsia is a severe illness in pregnancy with a frequency of 5-10%. In 1997, we experienced 73 patients with praeeclampsia according to the definition of ISSPH. Mode of delivery was conventional in 10 patients, 2 patients had a vacuum extraction and 61 patients needed a caesarean section. The rate of epidural anesthesia for delivery was 51%. We used epidural anaesthesia in 6 spontaneous deliveries, in 2 vacuum extractions and in 30 caesarean sections. There were no problems with epidural anaesthesia and the outcome of mother and child was also considered to be excellent. We suggest to use regional anesthesia techniques whenever possible.
Background: Sepsis is well known to lead to the activation of multiple pro-inflammatory mark- ers... more Background: Sepsis is well known to lead to the activation of multiple pro-inflammatory mark- ers, like MCP-1 (Monocyte chemotactic protein 1), TNF-alpha (Tumor necrosis factor alpha), while the underlying genetic changes still remain poorly studied. Methods: We used human umbilical vein endothelial cells to test the reactions to nicotine or acetylcholine/pyridostigmine administration in regards to MCP-1 levels, gene regulation and
Purpose: This study establishes a new model of sustained pulmonary hypertension induced by recurr... more Purpose: This study establishes a new model of sustained pulmonary hypertension induced by recurrent microembolism in pigs and evaluates the effects of nitric oxide (NO) inhalation in this model.Materials and Methods: Fourteen pigs were embolized under general anesthesia with 300-μm microspheres intravenously three times over a period of 7 weeks. Four pigs served as untreated controls. Hemodynamic and gas exchange
Comparing published trial patients and non-trial patients in clinical practice, clinicians often ... more Comparing published trial patients and non-trial patients in clinical practice, clinicians often doubt whether critically ill patients are sufficiently represented in randomised clinical trials. This study evaluated the extent of infection with multidrug-resistant (MDR) pathogens, anti-microbial combination therapy, off-label use and targeted-treatment in trial patients versus non-trial patients. Tigecycline therapy was prescribed for off-label use in more than half of the non-trial patients; 77% of trial patients received study medication as first-line therapy in contrast to 25% of non-trial patients (p<0.001). Tigecycline therapy was targeted for 27% of trial patients versus 73% of non-trial patients (p<0.001). Ninety-six percent of non-trial patients were treated for nosocomial infections compared to 23% of trial patients (p<0.001). In one out of 22 (4.5%) trial patients an ESKAPE pathogen was found, whereas rates of vancomycin- resistant Enterococcus faecium, methicilli...
Metastatic liver resection following cytoreductive chemotherapy is an accepted treatment for olig... more Metastatic liver resection following cytoreductive chemotherapy is an accepted treatment for oligometastatic tumor diseases. Although pulmonary complications are frequently reported in patients undergoing liver surgery including liver transplantation, life-threatening acute respiratory failures in the absence of aspiration, embolism, transfusion-related acute lung injury (TRALI), pulmonary infection, or an obvious source of systemic sepsis are rare. We performed an extensive clinical review of a patient undergoing metastatic liver resection who had a clinical course compatible to an acute respiratory distress syndrome (ARDS) without an obvious cause except for the surgical procedure and multiple preoperative chemotherapies. We hypothesize that either the surgical procedure mediated by cytokines and tumor necrosis factor or possible toxic effects of oxygen applied during general anesthesia were associated with life-threatening respiratory failure in the patient. Discrete and subclini...
ABSTRACT Major cardiac complications presenting as myocardial infarction, myocardial ischemia, ca... more ABSTRACT Major cardiac complications presenting as myocardial infarction, myocardial ischemia, cardiac failure, or life-threatening dysrhythmias contribute significantly to perioperative morbidity and mortality. Preventive strategies are of major importance since even despite adequate treatment these events are associated with poor outcome.
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