Rapid communications - Applied Cardiopulmonary Pathophysiology

Transcription

applied cardiopulmonary pathophysiology
Vol. 10, November 2006
Skeleton agreement between DGAI and Quant
U. Schirmer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Supplementation of the extended data set for
cardiac anaesthesia
J.-U. Lüth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Postoperative patient visit and questionnaire as
a tool in quality assurance
J.-H. Schiff, L. J. Eberhart, A. Möllemann,
G. Hüppe, G. Pützhofen . . . . . . . . . . . . . . . . . . . . . . .7
USA: Departments of Anesthesiology and
Cardiac Anesthesia Divisions in different
health systems
I. Hollinger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Anesthesia Departments in International
Health Systems: Switzerland
B. Eberle, H.-U. Rieder . . . . . . . . . . . . . . . . . . . . . .12
TOE support for a percutaneous transluminal
implantation of a self-expanding valve
prothesis for interventional treatment of
aortic valve stenosis
B. Sauren, B. Zickmann, U. Gerckens,
E. Grube, T. Felderhoff, S. Iversen . . . . . . . . . . . . .24
Transesophageal echocardiographic monitoring
during transapical aortic valve implantation
J. Fassl, T. Walther, U. Birnbaum, F. W. Mohr,
J. Ender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Ethics and money in anaesthesia and intensive
care
J. Radke, L. Steudle, J. Soukup . . . . . . . . . . . . . . . .32
The role of sound scientific data for
evidence-based decision making
M. K. Diener . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
News from the clinic
TEE simulator - an introduction
M. Weidenbach, Leipzig
TEE for mitral valve repair
J. Ender, E. Krohmer, J. Fassl . . . . . . . . . . . . . . . . .15
Intraoperative echocardiography for aortic
valve repair surgery
J. M. Erb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Fast Track in New York
I. Hollinger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Risk of recent coronary artery stenting before
noncardiac surgery: On the edge between stent
thrombosis and surgical bleeding
H. Metzler, M. N. Vicenzi, A. Münch,
E. Mahla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
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Rapid communications
Fast Track Protocol in coronary artery bypass
patients – A safe and effective tool to save ICUcapacity
N. Anwar, U. Birnbaum, J. Fassl, J. Ender . . . . . . .43
Training simulator for extracorporeal circulation
A. Dietz, G. Haimerl, F. Moreau, B. Straub,
C. Benk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
Factor XII deficiency and cardiovascular
surgery
J. Grefer, A. Erasmi, M. Heringlake . . . . . . . . . . . .47
Intraoperative TEE monitoring during partial
resection of a tumour metastasis with infiltration
of right atrium and ventricle
M. Hansen, A. Blehm, G. Wagner, G. Klein . . . . . . .48
Influence of perioperative administration of
N-acetylcystein on postoperative renal
dysfunction in cardiosurgical patients suffering
from compensated renal insufficiency
M. Hawlicki, M. Torka, W. Karzai . . . . . . . . . . . . . .49
The effects of adrenaline and milrinone on
creatinine clearance and plasma levels of
cystatin-C in patients with myocardial
dysfunction after coronary artery bypass grafting
H. Heinze, J. Grünefeld, M. Wernerus,
J. Schön, M. Bechtel, M. Misfeld,
M. Heringlake . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
An algorithm for management of perioperative
hemostasis disorders in cardiac surgery
C. Jámbor, D. Bremerich, A. Moritz, E. Seifried,
B. Zwißler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Aprotinin in coronary surgery –
A retrospective application observation
M. Kluth, J.-U. Lüth, M. Lanzenstiel, K. Inoue . . . .53
Minimally invasive heart rate volume
measurement via VigileoTM Flow Trac Monitor
versus bolus thermodilution in cardiac surgery
patients
C. Kufner, A. Zimmermann, S. Hofbauer,
R. Schistek, J. Steinwendner, W. Hitzl,
S. Hargasser, G. Pauser . . . . . . . . . . . . . . . . . . . . . .53
Adrenaline but not milrinone induces
hyperlactatemia and tissue dysoxia in patients
with myocardial dysfunction after coronary
artery bypass grafting
J. Schön, M. Wernerus, J. Grünefeld,
H. Heinze, M. Bechtel, T. Hanke,
M. Heringlake . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Intraoperative TEE monitoring using
3-dimensional representation of mitral valve
prosthesis (SJM): Better and real-time
assessment of function, dysfunction and
assistance in intraoperative „surgical
decision-making“
A. Ziegler, C. Keyl, S. Laule, L. Günkel . . . . . . . . .56
List of authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
3
I. Uhlenbusch-Körwer, E. Bonnie-Schorn, A. Grassmann, J. Vienken
Understanding Membranes and Dialysers
The dialyser and its centrepiece, the membrane, play a central role in chronic renal replacement therapy. More
than 1000 different types of dialysers are currently available on the market. How are these characterised and
how do they differ? What are their special features and how do they contribute to acute and chronic effects in
the patient? Is there a link between morbidity and mortality and the use of a particular type of dialyser? This
book addresses these questions and attempts answers based on current scientific knowledge. In this context,
dialyser development and the basics of filter performance and biocompatibility assessment are reviewed.
616 pages, ISBN-10: 3-89967-005-1 / ISBN-13: 978-3-89967-005-9, Price: 48,- Euro
PABST SCIENCE PUBLISHERS
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E-Mail: [email protected] – Internet: www.pabst-publishers.com
Editors:
Uwe Schirmer, Dept. Cardiac Anesthesia, University Ulm, Steinhövelstr. 9, D-89075
Ulm, E-mail: [email protected]
Matthias Heringlake, Dept. Anesthesia, University of Lübeck, Ratzeburger Allee
160, D-23538 Lübeck, E-mail: [email protected]
B. Lachmann, Department of Anesthesiology, Erasmus University, P.O. Box 1738,
NL-3000 DR Rotterdam, The Netherlands
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Subject Editors
Anesthesiology
W. Erdmann (Rotterdam, The Netherlands)
F. Giunta (Pisa, Italy)
Oxygen Transport
N. S. Faithfull (San Diego, CA, USA)
K. Reinhard (Jena, Germany)
Cardiology
E. O. McFalls (Minneapolis, MN, USA)
P. Verdouw (Rotterdam, The Netherlands)
Pediatrics
M. Silverman (London, Great Britain)
H. Stopfkuchen (Mainz, Germany)
Intensive Care Resuscitation
N. Mutz (Innsbruck, Austria)
P. J. Papadakos (Rochester, NY, USA)
Pneumology
R. G. Spragg (San Diego, CA, USA)
N. F. Voelkel (Denver, CO, USA)
Neonatology
C. Speer (Tübingen, Germany)
O. Saugstad (Oslo, Norway)
Pulmonary Surfactant
L. M. G. van Golde (Utrecht, The Netherlands)
E. V. Cosmi (Rome, Italy)
Nuclear Medicine
F. Fazio (Milan, Italy)
P. Wollmer (Malmö, Sweden)
Shock
H. Redl (Vienna, Austria)
R. M. Strieter (Ann Arbor, MI, USA)
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The journal Applied Cardiopulmonary Pathophysiology is indexed/abstracted in Current Contents (CC), Science
Citation Index Expanded, Excerpta Medica/EMBASE, International Bibliography of the Social Sciences.
5
Uwe Schirmer
Department of Cardiac Anesthesia, University Hospital Ulm, Germany
An extended cardio anaesthetic data set has been published in 2000 by the Scientific Working Group in Cardiac Anaesthesia of the DGAI as prerequisite for data
collection in cardiac anaesthesia. Referring to this data set a skeleton agreement between the DGAI and the
company Quant has been prepared by the Lawyer of
the DGAI in close cooperation with the Working
Group and Quant. As professional institution Quant
has been choosen to collect the data sets from participating hospitals, to conduct the data pool and to carry
out statistical analysis.
The aim of the cooperation between DGAI, Quant
and the hospitals is a nationwide quality assurance in
cardiac anaesthesia which required a juristic foundation. The skeleton agreement between DGAI and
Quant described in this presentation represents this basic. All departments performing cardiac anaesthesia
are invited to accede to this contract and to take part in
the nationwide data collection and quality assurance.
The skeleton agreement contains the conditions
necessary for participation in quality assurance, the
conditions to accede to the skeleton agreement by an
individual contract and the termination of participation, the work of Quant including the standard and spe-
cial utilization of the data as prescribed by the DGAI,
measures of data protection and protection against use
of the data pool by a third party, conditions with regard
to the rights and the use of the data pool by the parties
of the agreement and their claims and duties.
All preparations until today have been realized by
the working group „Quality Assurance” within the Scientific Working Group in Cardiac Anaesthesia. To take
care of the responsibility and the work in the future a
new committee “Qualitätssicherung in der Kardioanästhesie” will be founded as representative of the
DGAI. The purpose of this committee and the rules of
procedure will be presented by our Lawyer Dr. Biermann in the next presentation. Another following presentation by Dr. Veit, manager of Quant, will present
technical details and procedures necessary for correct
data collection and delivery to Quant.
With the presentations given in this session we will
give you a complete overview about the planned quality assurance and all information necessary to take part
in the planned bench mark in cardiac anaesthesia.
Further information will be available from the
Working Group or from our web presentation at
www.ak-kardio.de.
6
J.-U. Lüth
Supplementation of the extended data set for cardiac anaesthesia
Jan-Uwe Lüth
Institut für Anästhesiologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
The version 2.0 core data set for quality documentation in anaesthesia of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) provides
a minimum definition of the parameters which have to
be documented for quality assurance purposes1. These
parameters are formulated for general anaesthesia but
do not meet all requirements for anaesthesia in cardiac
surgery operations. Therefore the Scientific Working
Group in Cardiac Anaesthesia of the DGAI presented
an extended cardio anaesthetic data set in 20002 which
was approved by the DAGI.
Now the Working Group presents the regulations
for the analysis of these data. A simple comparison of
the data does not lead to a quality assurance system.
For quality assurance purposes not the actual numbers
are important but the parameters influenced by anaesthesia. It does not make sense to compare the length of
anaesthesia without considering the covered operating
time. The amount of monitored values during anaesthesia might differ between institutions. This could reflect a different attitude towards the necessity of monitoring, e.g. pulmonary catheter, or different patient
characteristics, e.g. poorer left ventricular functions
(EF reduced). Therefore algorithms are defined to take
these differences into consideration.
A main part of the quality assurance system are perioperative anaesthesia-related incidents, events and
complications (Anästhesieverlaufsbeobachtung AVB).
The definition of these observations includes that they
happened during anaesthesia and required an intervention by the anaesthetist. The data from general anaesthesia outside noncardiac operations show a strong
correlation of the incidence of these AVBs to the ASA
score. This correlation is not useful in cardiac anaesthesia, since most of the cardiac surgery patients are in
the ASA classes 3 or 4. The presentation outlines this
problem. One solution will be the introduction of a
specific score for cardiac patients. This could be the
Cleveland Score3 or the Euroscore4. The required parameters are defined in the cardiac data-set.
The focus of quality assurance is set on several
tracer operations. For the analysis of the cardiac dataset these tracers are CABG, aortic- and mitral valve replacement and the combination of these procedures.
This will approximately represent 60 % of all cardiac
operations performed in Germany.
Conclusion: With the extended data set for cardiac
anaesthesia and the regulations of data analysis it
should be possible to start a quality assurance program
for cardiac anaesthesia in Germany.
References
1. „Runder Tisch Qualitätssicherung in der Anästhesie“ von DGAI
und BDA (1999) Modifikation des Kerndatensatzes, Anästhesie
Anästh Intensivmed 40: 649-658
2. Schirmer U, Dietrich W, Lüth J-U, Baulig W (2000) Erweiterter
Datensatz Kardioanästhesie – Version 2.1 / 2000. Anästh Intensivmed 41: 684-691
3. Higgins TL, Estafanous FG, Loop FD et al. (1992) Stratification
of morbidity and mortality outcome by preoperative risk factors
in coronary artery bypass patients. Clinical severity score. JAMA
267: 2344-8
4. Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S,
Salamon R (1999) European system for cardiac operative risk
evaluation (EuroSCORE). Eur J Cardiothorac Surg 16: 9-13
Postoperative patient visit and questionnaire as a tool in quality assurance
7
Postoperative patient visit and questionnaire as a tool in quality assurance
J.-H. Schiff1, L. J. Eberhart2, A. Möllemann3, G. Hüppe4, G. Pützhofen5
Department of Anesthesiology, University of Heidelberg, Germany; 2Department of Anaesthesiology & Intensive Care, University Gießen-Marburg, Campus Marburg, Germany; 3Department of Anaesthesiology & Intensive Care, University TU Dresden, Germany; 4Department of Anesthesiology, University Schleswig-Holstein,
Campus Lübeck, Germany; 5Department of Anaesthesiology & Intensive Care Dominikus-Krankenhaus, Düsseldorf, Germany
1
The evaluation of quality in medical processes becomes more and more important especially in view of
the actual discussion on healthcare.
As anaesthesiology provides medical services it
seems very important to keep and survey a high quality standard in order to supply other clinics with good
and continuous services. The dimensions of quality include quality of structure, procedures and the product.
All three dimensions depend on each other and need to
be assessed together.
Measuring the quality of medical services as provided by the anaesthesiology is made by internal and
external evaluation in combination with a customer
weighted evaluation: the patient satisfaction. This
quality aspect of product/outcome meets all requirements and shows in addition if the medical service
copes with the patient’s demands [1]. The DGAI (German association of Anaesthesiology and Intensive
care) advices to measure quality continuously, the
product/outcome quality in sample surveys [2].
In general postoperative inquiries provide valuable
data for utilization of services rendered in patient care,
and supply scientists and heathcare providers with information about patient preferences, satisfaction or
dissatisfying conditions, heath disturbances and demographic data.
There are many ways to receive information of patient outcome perception after anaesthesia. From the
postoperative visit with unstructured questioning to
telephone interviews with professional interviewers,
from unvalidated to systematically constructed questionnaires the utilisation of a wide range of more or
less valid measures seems imaginable. Questionnaires
combine the advantage of a standardised instrument
with less observer bias, they are easy applicable in the
routine care, easy to evaluate at lower costs compared
to stuctured interviews [3].
As a consequence of the availability of the aquired
data health care policy makers may implement new
strategies and sometimes even restrictions to access in
health care. Therefore it is arrogated that the instruments used and the data produced have to be highly
valid, reliable and applied as intended.
In anaesthesia satisfaction can be considered as a
useful indicator of the quality of the anaesthetic
process. Maybe more precious is the level of dissatisfaction as in areas of dissatisfaction one will be more
likely to find room for improvement in patient care.
Nevertheless, little is known about the patients perception and dissatisfaction as there is a lack of rigorous
psychometric approaches in studies devoted to patient
satisfaction with anaesthesia [4-6].
Patient satisfaction is a very complicated psychological construct [7]. Nowadays there are many rules
applying for the construction of questionnaires with a
more or less empirical backround, and many current
measures of patient satisfaction in anesthesia care suffer from lack of refinement and mostly have uncertain
reliability and validity [1].
Therefore a study has to focus on the development
of a valid and reliable questionnaire that ought to detect patient dissatisfaction correctly. In addition the
questionnaire has to meet the general requirements of
test questionnaires such as being easy to answer in adequate time, be stabil despite of potential confounders
and independend from the examiner (bias) [3].
A steering committee consisting of five aneasthetits and one psychologist at four universities and one
teaching hospital started with the preliminary identification of items. The construction of the questionnaire
8
J.-H. Schiff, L. J. Eberhart, A. Möllemann, G. Hüppe, G. Pützhofen
followed a rigorous protocol for the development of a
psychometrically designed, reliable and valid instrument to assess patient satisfaction [7-9]. In the first
step a total of 198 items could be identified utilising a
systematic literature review, the results of FocusGroup Interviews with a total of 438 patients and the
analysis of 1867 questionnaires. The items were reduced by manual and computerized textual analysis to
the anesthesia relevant items by excluding redundant
and not anesthesia related items. A pilot questionaire,
consisting of 53 questions was constructed and filled
out by 554 patients in 5 Clinics 6-48 hours after being
discharged of the recovery room or the ICU respectively. The questions are phrased in 3rd person singular
and worded positively as well as negatively and are
answered using a 4 scale likert response format. All of
the questions could be correlated to five dimensions
using factor analysis with principal component analysis, correlation matrix, a Scree-test for multiple factors
and Varimax-rotation. Inter item, item dimension and
inter dimension correlations were made to show independence of the dimensions. A missing value analysis
and the use of further statistical methods like SplitHalf-, Chi2-, T-Test/Transformation, Cronbach’s-α,
Pearson, Spearman’s correlation etc. will reduce the
size of the questionnaire to less than 30 questions reflecting five dimensions of the care given (atmosphere/ personal care, somatic disturbances, information gain, autonomie/restoration of health, miscellaneous). The reliability as expressed by the Cronbach’s
α is between 0.66 and 0.9 for the dimensions, > 0,75
for the total questionnaire. It is anticipated that the
questionnaire will be extended for regional anaesthesia
while its current use is limited to patients undergoing
general anaesthesia. A set of demographic data will
help to identify potential confounders. At present, this
instrument is being validated in a multi center study
and different survey procedures are evaluated in order
to keep the additional workload when implementing
the questionnaire as low as possible.
Die aktuelle Fort- und
Weiterbildung für Sie:
www.anaesthesie-cme.de
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Pabst Science Publishers
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E-mail: [email protected]
Internet: www.pabst-publishers.de
References
1. Fung D, Cohen MM (1998) Measuring patient satisfaction with
anesthesia care: a review of current methodology. Anesth Analg
87: 1089-97
2. Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin
(1995) Mitteilung der „DGAI-Kommission für Qualitätssicherung und Datenverarbeitung“. Anasth Intensivmed 36: 72
3. Geyer S (2003) Forschungsmethoden im Gesundheitswesen.
Weinheim: Juventa Verlag
4. Le May S, Hardy J-F, Taillefer M-C, Dupuis G (2001) Patient satisfaction with anesthesia services. Can J Anesth 48: 153-61
5. Sitzia J (1999) How valid and reliable are patient satisfaction data? An analysis of 195 studies. Int J Qual Health Care 11: 319-28
6. Sullivan M (2003) The new subjective medicine: taking the patient’s point of view on health care and health. Soc Sci Med 56:
1595-604
7. Pascoe G (1983) Patient satisfaction in primary health care. Literature review and analysis. Eval Program Plan 6: 185-210
8. Auquier P, Blache JL, Colavolpe C et al. (1999) Échelle de vécu
périoperatoire de l’anesthésie. I-Construction et validation. Ann
Fr Anesth Réanim 18: 848-57
9. Whitty PM, Shaw IH, Goodwin DR (1996) Patient satisfaction
with general anaesthesia. Too difficult to measure? Anaesthesia
51: 327-32
Departments of Anesthesiology and Cardiac Anesthesia Divisions in different health systems
9
Departments of Anesthesiology and Cardiac Anesthesia Divisions in
different health systems
Ingrid Hollinger
Mount Sinai School of Medicine, New York, NY, USA
There are 128 academic anesthesia departments in the
United States total anesthesiology training program is
142. 80% of anesthesia groups have an exclusive
arrangement with one or more hospitals. The academic centers can function in an academic medical center
model, a budgeted department model or independent
department functioning like private practice (1).
Our department is an academic department within
the medical center-practice with its own budget. The
majority of the departmental budget is generated from
private practice income. Aproximately 25% is returned
to the medical school as “dean’s tax”. Out of this and
the moneys collected from the hospital under part A reimbursement from Medicare (for teaching of residents) a small portion (approximately $ 16 000/ FTE)
is returned to the department through the CARTS
(clinical, administrative, research, teaching) mechanism. In 2003, the median support/FTE in a national
survey of anesthesia training programs was $ 75 000
or 6% of the departmental budget.
The faculty at the Mount Sinai School of Medicine
are full time or part time members of the group. The
chair is the chief of the group and responsible for providing qualified anesthesia services, overseeing the
training program, overseeing and encouraging the research efforts of the department and its members and
participating in the agenda of the medical school. In
addition the chair is responsible to assure that all sedation services in the institution are compliant with national standards.
The department has an executive vice-chair and
several vice-chairs. One for education, administration,
one for clinical affairs, one for affiliations/development, one for faculty development. The staff consists
of 70 attendings, 74 residents and fellows and 13 nurse
anesthetists. All attendings are required to be “in the
examination process” and to be board certified within
5 years from hire. There are several sub-specialty
groups within the department. The cardiac anesthesia
group has 10 members, 4 of whom work part time in
administration of the cardiac ICU. Thoracic is covered
by three attendings who also do general OR cases and
by the cardiac group. Other subspecialty groups include obstetric, neuroanesthesia, pediatric anesthesia,
ambulatory, office based, orthopedic/regional, livertransplant and pain. There are generally two people in
charge of the subspecialty who are responsible for the
resident curriculum for that subspecialty. They are also the liaison for the subspecialty surgeons.
There are 46 operating rooms, two endoscopy
anesthesia locations, two to three anesthetizing locations in radiology, one to two cath lab locations, 2-4
office based locations and a large obstetric service
which requires two attendings and three other anesthesia providers/day. The majority of care is in the anesthesia care model with a two to one supervision of residents and up to four to one supervision of CRNA’s.
The compensation model for our department was
revised by our present chairman within the last two
years. It is a productivity-based model. All benefits are
paid out of the departmental budget. The overhead /
FTE is 27.5 %. This includes supplement to health insurance and disability insurance and contribution to a
retirement fund (tax deferred contribution from income). Liability insurance is covered separately, also
through the departmental budget through a consortium
(FOJP = Federation of Jewish Philanthropies) and is a
separate fee per attending and CRNA (approximately
$11 000/person/year). Every member of the department is entitled to 20 vacation days and based on academic rank to 5-20 meeting days. Meeting days need
chairman approval. One meeting/year is reimbursed to
a maximum of $ 2000. Speakers at meetings are reimbursed for incurred costs at the discretion of the chair.
10
Components of total compensation are:
– Base Salary (based on rank and seniority + administrative add on for vice-chairs, division directors, departmental committee directors, institutional responsibility or medical school responsibilities)
– Supplemental compensation: point system
– Points for clinical work based on ASA relative value
guide unit values (RVU) taken from electronic anesthesia record
– Fixed points for work done in outlying areas without
electronic record
– All call is paid according to time demand (in-house
or out-of-house), sliding scale according to undesirability
– Pay for extra assignments, like working pre- or post
call, holidays etc
– Adjustment for double coverage maximal 60%
– Compensation for non-call work after 18:00
– Pain separate model to adjust for practice.
Separate bonus points for academic and teaching
work: lectures, publications, presentations, work on
committees of school or regional or national organizations.
Extra points for positive evaluation of quality of
teaching by the residents.
Additional points for positive professionalism
evaluation by senior peers or surgeons.
The cardiac group is covered by this model. Cardiac is a separate call.
The department has a separate budget within the
medical school as mentioned above, the large majority
of our income derives from private practice i.e. insurance reimbursements. Out of this budget not only all
attendings and the CRNA’s but also the administrators,
a number of secretaries, research assistants, system administrators and computer specialists are paid. Some
of the research assistants and faculty are partially paid
through grant money from outside grants. The majority of residents are paid through the hospital through
the graduate education moneys from the federal government. Since the maximal number of residents is
capped for the institution and the department, we are
paying some additional residents and all fellows in
non-ACGME approved fellowships from the private
practice.
In addition to the budget for salaries (which goes
through the medical school), we have a hospital budget, which covers equipment, technical staff and drugs.
I. Hollinger
The operations budget covers items like the technical
support personnel (all anesthesia assistants, supervisors and manager), disposables and drugs. The capital
budget covers all items costing more than $ 500 and
having a life span exceeding 2 years. These budgets
are prepared annually and processed through peri-operative services which has a separate vice-president of
the hospital. Particular expensive modalities can be
billed back to the patient or his/her insurance carrier.
With Medicare or Medicaid patients however this is
bundled into the total reimbursement. Intermittently,
the hospital will ask us to review the pharmacy and the
disposable budget to see whether we can reduce costs.
Since there is very little direct contact between the
providers and the financial data there is limited success with this. However, any new therapy or equipment request has to be run by a hospital committee,
which also looks at cost projections for the institution.
Not all expensive medications or equipment are approved.
Pre-operative contact: For cardiac: We see all patients either in pre-operative clinic several days before
surgery (less than 7 days because of state regulations).
One person of the faculty or a cardiac anesthesia fellow will do the interview and all pertinent labs are obtained at this visit. In general we do not require a cath
report, but a letter from the referring cardiologist or
surgeon. In-patients are seen the evening prior to surgery.
We do not have pre-operative surgical conferences
with the exception of pediatric cardiac surgery, which
runs a multidisciplinary pre-surgical conference once a
week attended by cardiology, surgery, anesthesia and
critical care.
Assignments are made by three members of the
cardiac anesthesia team on a rotating basis and take into account call status and the projected length of the
procedure. Because the group is small, in general
everybody works with every surgeon except the pediatric cardiac group who do all pediatric cardiac cases.
The cardiac intensive care unit is staffed at present by
three anesthesiologists, two cardiac anesthesiologists
and one general intensivist. There are 20-24 beds, 2-3
beds are shared with pediatric cardiac, which is run by
a pediatric intensivist.
The biggest difference with European academic
departments appears to be the primus inter pares philosophy of most US academic department chairs.
While monitoring, drugs and approach to transfusion
Departments of Anesthesiology and Cardiac Anesthesia Divisions in different health systems
is probably equivalent, there is less time off, the days
seem to be longer but remuneration seems to be more
egalitarian.
W. W. Minuth, R. Strehl
3-D-Kulturen
Zellen, Kultursysteme und
Environment
472 Seiten, Preis: 50,- Euro
ISBN-10: 3-89967-316-6
ISBN-13: 978-3-89967-316-6
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Tel. ++ 49 (0) 5484-308, Fax ++ 49 (0) 5484-550,
E-Mail: [email protected]
Internet: www.pabst-publishers.com
11
References
1. Tremper KK, Shanks A, Sliwiski M et al. (2004) Faculty and finances of United States anesthesiology training programs. Anesth
Anlag 99: 1185-92
Es gibt viele Bücher, in denen beschreiben wird,
wie Zellen kultiviert werden. Das Buch jedoch
zeigt, wie aus zweidimensionalen Zellkulturen
dreidimensionale (3-D) Gewebestrukturen entstehen können. Es bietet eine Einführung in die
Welt von innovativen 3-D-Kulturen, die in der Tumorbiologie, der pharmazeutischen Forschung, in
den verschiedenen Feldern der experimentellen
Biomedizin, im Bereich der zukünftigen Stammzelltherapie und beim Tissue engineering Verwendung finden. Das Buch ist leicht verständlich
geschrieben und somit besonders geeignet für
die im Labor arbeitenden technischen Mitarbeiter, für Studierende und junge Wissenschaftler/innen der Medizin, Biologie, Pharmazie, Biomaterialforschung und Biotechnologie.
Anschaulich wird zuerst der Übergang von der
klassischen Zellkultur zur 3-D-Kultur beschrieben.
Informiert wird über die unterschiedlichen Arten
der Zell- und Gewebekulturen, über die Auswahl
der Medien und über die verschiedenen Arbeitstechniken. In Verbindung mit vielen Abbildungen
werden möglichst anschaulich die technischen
Voraussetzungen, aktuelle Entwicklungen und
die biomedizinischen Perspektiven mit 3-D-Kulturen behandelt.
Besondere Bedeutung hat die kritische Bewertung der entstehenden 3-D-Kulturen. Ziel der Experimente ist, dass histiotypische Eigenschaften
in den 3-D-Kulturen entstehen und die Ausbildung von atypischen Eigenschaften vermieden
wird. Deshalb wird intensiv über die Bewertung
der Differenzierung in den entstehenden Geweben informiert. Besondere Bedeutung hat
diese Frage beim Arbeiten mit Stammzellen. Es
reicht nicht aus, die Stammzellen zu isolieren und
zu vermehren, vielmehr sollen daraus funktionelle Gewebe entstehen, die sicher und damit
risikolos angewendet werden können.
12
B. Eberle, H.-U. Rieder
Anesthesia Departments in international health systems: Switzerland
Balthasar Eberle, Heinz-Urs Rieder
Department of Anaesthesiology, Inselspital, University Hospital Berne, Switzerland
Background
Since 2000, German immigration to Switzerland has
roughly doubled (to 15 000/y in 2005). Particularly
since enaction of bilateral treaties with the EU in 2004,
the influx of foreign (predominantly German) higherlevel professionals has increased. In Zurich, for instance, about 25 % of ETH professors, and of physician as well as nursing staff of the University Hospital
carry German passports. At Inselspital Berne, 20 % of
employees are non-Swiss nationals. The recent influx
of mostly well-trained Germans is fostered by a perception of better salaries and working conditions, at
high quality of living (with Zurich and Geneve at the
international top), as well as a relative shortage of
Swiss academic, medical and executive professionals.
However, cost of living is decidedly higher than in
Germany: Switzerland ranks no. 3 among Europe´s
most expensive countries (trailing Norway and Iceland).
Anesthesia as a specialty in Switzerland dates, at
the earliest, from 1950 only, and of dedicated cardiac
anesthesia (Dr. R. Gattiker) from 1961. For 7.4 mio inhabitants, there are presently Departments of Anesthesiology (DA) at 5 university hospitals (Basle, Berne,
Geneve, Lausanne, Zurich), at 14 large cantonal nonuniversity hospitals, and at 37 regional hospitals. In
addition, a variety of private hospital organizations are
active. Cardiac surgery and anesthesia is offered in all
university, and 14 cantonal and private facilities. In
2005, about 7300 cardiac surgeries were performed,
among those 30-40 heart transplants in 3 centers.
Presently, only one unit does more than 1000 cases/y.
In general, case volume is stable or decreasing.
Departmental structures
University departments of anesthesiology are headed
by a full professor/university chair of anesthesiology,
with associate/extraordinariate professorships. These
faculty levels are university-funded; there is only 1 extraordinariate for cardiac anesthesia (USZ Zurich). All
other physician staff (with or without academic qualification) are employed by the (usually cantonal) hospital organization. Anesthesia departments at cantonal
hospitals are headed by a director (Chefarzt; in 20 %,
university-affiliated professors). Chairs and directors
head a team of several senior consultants (Leitende
Ärzte), who may act as division chiefs. The physician
team may be composed of staff anesthesiologists, and
at all public hospitals, also residents and interns. Private hospitals often maintain a system with partner
consultants, and employed house staff.
Professional training
Certification in anesthesiology requires 6 years, consisting of 1 year of non-anesthesia specialty training,
3.5 to 4 years of anesthesiology training in at least 2
institutions (one of them at a university hospital), 6-12
months of ICU training, and centrally administered
written (European Academy of Anaesthesiology written exam) and oral board exams. Going overseas for
part of the clinical training is very popular. Academic
achievement is virtually not possible without international research (and clinical) exposure.
Since 2002, intensive care medicine is a separate
board-certified specialty. Many junior anesthesiologists now train for double board certification, since the
majority of surgical ICUs is still managed by anesthesiologists. Specifically at Inselspital Berne, Anesthesiology and Interdisciplinary Intensive Care Medicine
are separate full professorships and chairs, but cooperate under an administrative “departmental” structure,
exchanging residents, staff and other resources. Swiss
anesthesia involvement in prehospital emergency
medicine is less intensive than in Germany, however,
several DA cooperate closely with, and provide physi-
13
Anesthesia Departments in international health systems: Switzerland
cian resources for surface- or air-based emergency
medical services (REGA, Sanitätspolizei etc.).
Anesthesia nursing teams are usually led by certified nurse anesthetists (2 years specialized training).
Anesthesia nursing is allowed to administer general
anesthesia under anesthesiologist supervision only.
Regional blocks and insertion of cv lines are usually
reserved for physicians.
Clinical process
In general, between professional groups, medical disciplines, and hierarchy levels, very high value is assigned to cooperativity, mutual communication and
consensual decisions. At Inselspital Berne, preliminary scheduling of elective patients by the cardiovascular surgeons is accessible for anesthesia weeks in
advance, and about 60 % of the available OR time is
booked electively; the remainder is filled by urgent
and emergent cases. Special patients (e.g., transplant
candidates, pediatric cardiac cases) are usually seen
and discussed weeks in advance at interdisciplinary
case conferences. Routine cardiac and vascular patients are hospitalized and seen by anesthesia 1 day
preop. The surgical threshold for preop cardiovascular
diagnostic workup (including echo/doppler studies,
coronarograms, CT, MRI, labs) is generally low, so
that additional tests are only rarely requested by anesthesia. Preop workups and OR schedules are presented
and fixed daily in a joint afternoon conference. There
is no central OR management yet at Inselspital, but it
is established and functional (e.g., with anesthesiology
background) in some other Swiss hospitals.
Cardiovascular anesthesia routines are, in general,
similar to other Central European countries, including
the usual heterogeneity between institutions (use of inhalational/i.v. agents on CPB, cardiac output and CNS
monitoring preferences etc.). For cardiac cases, intraoperative TEE is in almost ubiquitous use. In vascular
patients, the preference for regional anesthesia is
strong.
Specifically at Inselspital, postoperative and all interdisciplinary ICU patients are managed by the Department of Intensive Care Medicine, a separate chair;
however, many anesthesiologists hold joint staff positions in both departments. Intermediate (IMC) and
post-anesthesia care (PACU) units are run by their respective departments. In most other institutions, post-
operative intensive care is still managed by anesthesiologists either within their own, or within surgical departments.
Anesthesia on-call duty is organized according to
institutional level and preferences. At the Inselspital,
as a tertiary referral center for emergencies, several
dedicated anesthesia teams and 2 ORs are reserved
around the clock on a three-shift weekly schedule for
emergent / urgent cases. They are backed up by attending specialists on-call for cardiac, transplantation,
small infant and OB emergencies. Other institutions
use daily on-call schedules, without on-call specialist
resources for cardiac cases.
Economics
Among health systems of industrialized countries, the
Swiss ranks top (second to the US only) in expenditure, but somewhat lower in quality indicators (WHO
2005). Among others, inefficiencies due to Swiss foederalist (cantonal) structure, high price and wage levels
in medical, technological and pharmaceutical industries are discussed as reasons.
Public (also university) hospitals are run by their
cantons. Cantonally accredited hospitals are reimbursed for medical services to patients (according to
AP-DRGs since 2005) from insurance carriers and
cantonal taxpayers together. The Department of Anesthesiology is allocated a yearly budget by the hospital
administration, based on previous and recent financial
developments and strategic aims. This budget is distributed and managed usually at the departmental, but
not at divisional levels. At Inselspital, internal cost allocation is presently set up for (but not in) use. Large
investments and unusually expensive consumables undergo separate evaluation by drug evaluation committee, hospital administration or even cantonal bodies.
Cost consciousness and considerate resource utilization are ever-popular topics, but external pressures still
appear quite moderate in comparison to other countries.
Research funding
At university hospitals, there is some transfer of resources for research and education to the hospital by
separate funds of the cantons and their universities.
14
B. Eberle, H.-U. Rieder
Controlling of departmental allocation and utilization
of such transfers appears yet incomplete. Most research funding comes therefore from external sources
(Swiss National Science Foundation, medical and
pharmaceutical industry, national and international
professional organizations), and from departmental research funds, which are obligatorily generated from
privately-insured patient revenue.
Conclusion
professionals, due to fair salaries and working conditions, high standard of living and a very hospitable
professional and cultural environment. This attractivity is somewhat modified by relatively high costs of
living, and a comparably small number and size of
hospitals of all categories. “Subspecialty” trainees
cannot expect high-volume exposure to specific patient subgroups or technologies without training terms
abroad. Within this low-volume job market, career opportunities for cardiac anesthesiologists are and will
remain limited.
Switzerland appears as an attractive destination for
foreign (particularly EU) anesthesiology trainees and
Tanja Manser (Hrsg.)
Komplexes Handeln in der Anästhesie
Der adäquate Umgang mit Komplexität stellt mit Blick auf die Sicherheit und Qualität medizinischer Patientenversorgung eine der zentralen Anforderungen in der Anästhesie dar. Die Frage, wie dieser unterstützt und
gestaltet werden kann, eröffnet eine Reihe von Themenfeldern für die arbeitswissenschaftliche - im günstigen
Fall interdisziplinäre - Forschung.
Dieses Buch liefert aus der Perspektive unterschiedlicher Disziplinen heraus einen Einblick in die wissenschaftliche Auseinandersetzung mit Komplexität in der Anästhesie. Zu den hier vorgestellten sowohl
forschungs- als auch gestaltungsorientierten Ansätzen zählen:
– die differenzierte Analyse anästhesiologischen Handelns,
– die systematische Analyse kritischer Ereignisse,
– die Entwicklung und Evaluation von Simulatortrainings sowie
– die ergonomische Gestaltung der Rahmenbedingungen anästhesiologischen Handelns.
Das Buch richtet sich an Forschende sowie an Praktiker, die an einer multidisziplinären Auseinandersetzung mit
Komplexität in der Anästhesie interessiert sind. Dieses Interesse verlangt keine vertieften Kenntnisse des medizinischen Feldes, zumal die vorgetragenen Konzepte und Ergebnisse für verschiedene Forschungs- und Anwendungskontexte Relevanz besitzen.
330 Seiten, ISBN-10: 3-89967-076-0 / ISBN-13: 978-3-89967-076-9, Preis: 20,- Euro
Eichengrund 28, 49525 Lengerich, Tel. ++ 49 (0) 5484-308, Fax ++ 49 (0) 5484-550,
15
Joerg Ender, Eugen Krohmer, Jens Fassl
Department of Anaesthesiology and Intensive Care Medicine II, Heartcenter Leipzig, University of Leipzig,
Germany
TEE in cardiac anesthesia plays an important role. In
more than 10- 11 % of cardiac surgery patients transesophageal echocardiography results in changes of the
surgical plan and in 49 % TEE findings lead to a
change in medical treatment (1). This article points out
the important role of TEE in patients scheduled for mitral valve repair.
General considerations
Evaluation of the mitral valve is not only description
of the morphology of the leaflets, but must include examination of the whole mitral valve apparatus. It consists of the mitral ring, the anterior and posterior
leaflets, the chordae tendineae, papillary muscles and
the geometry of the left ventricle. Both leaflets have
nearly the same valve area, but are different in shape.
The anterior leaflet has a small base and more triangular shape with a longer basal-to free edge-distance than
the posterior leaflet, which has a broad base (2/3 of the
circumference). The chordae tendineae, which prevent
the leaflets from prolapsing into the left atrium during
systole insert to the free edge of the leaflets (primary
chords), the middle of the leaflets (secondary chords)
and to the base of the leaflets (tertiary chords). Chords
from the anterior papillary muscle insert from the anterolateral commissure to the middle portion, whereas
chords from the posterior papillary muscle insert from
the middle portion to the posteromedial commissure of
both leaflets. The posterior leaflet is divided by incisures into three scallops. Standard nomenclature is
that by Carpentier adopted by the Society of Cardiovascular Anesthesiologists and the American Society
of Echocardiography (2), where the segment close to
the anterolateral commissure is called P1, the middle
segment P2 and the segment close to the posteromedial commissure P3. The corresponding segments of the
anterior leaflet, although there are no incisures, are
called A1,A2 and A3.
Pathology of the mitral valve
Classification of mitral valve disease can be done according to the motion of the leaflets (3). Type I has
normal, type II excessive and type III restrictive motion (with IIIa structural and IIIb functional cause of
the restriction (see picture 2). The underlying pathology is important for the surgical procedure. Whereas
Typ I is corrected by insertion of an annuloplasty-ring,
Typ II is corrected by insertion of an annuloplasty-ring
and either by resection of the excessive tissue (3) or by
insertion of artificial loops (4), type III is corrected by
insertion of an ischemic annuloplasty-ring.
For echocardiographic evaluation the standard
views according to the guidelines of the American society of echocardiography and the society of cardiovascular anesthesiologists (2) and additionally the
midesophageal 5 chamber- view are used (Table 1).
Assessment of mitral regurgitation can be performed by different methods (table 2). Remember that
the degree of mitral regurgitation depends on preload
and afterload and that both are influenced by general
anesthesia, means that sometimes a volume and/or afterload challenge (by vasopressors) is necessary to determine the real degree of mitral regurgitation.
Important informations for the surgeon before
mitral repair
1. Underlying pathology :
Typ 1: - diameter of the native mitral ring
- localisation of a cleft
16
Tab.1: Standard views for mitral valve evaluation
J. Ender, E. Krohmer, J. Fassl
17
Tab. 2: Assessment of mitral regurgitation
Method
Graduation
(mild, moderate, severe)
Limitations
Regurgitation Jet Area
<3cm2 (<40% of atrium area),
3-6cm2 (40-60%)
>6cm2 (> 60%)
Only usable for mild to moderate
regurgitation. CAVE Changes in
preload and/or afterload
Proximal Isovelocity Surface Area
effective regurgitation area
<0,2cm2,
0,2-0,39 cm2,
? 0,4 cm2
Good quality of the colour coded
picture required, cave excentric regurgitation jet
Proximal Jet Diameter
("Vena contracta")
Nyquist Limit 50 - 60 cm/s !
<4 mm,
4-6 mm,
>6 mm
Good quality of the colour coded
picture required
Pulmonary venous flow
a) S > D
b) S < D
c) systolic flow reversal
unspecific (also in diastolic dysfunction)
Typ 2:
- exact localisation of the prolaps or flail
leaflet
A prolapse is present when the free edge of
the leaflet overrides the plan of the orifice
during systole and is directed to the left ventricle, whereas in the case of a flail leaflet the
free edge is directed to the atrium during systole.
- is there a ruptured chord or papillary muscle
Lambert et al (5) found in 13 prospectively
investigated patients a 96% agreement and in
11 retrospectively investigated patients a
76% agreement of the TEE finding as compared to the surgical finding. A retrospective
evaluation in our own institution for quality
assurance reason in 50 patients undergoing
mitral repair resulted in a 88% agreement
with the surgical finding, whereas agreement
was defined as pathology corrected by the
surgeon.
Typ 3a: - is there also calcification of the subvalvular
apparatus
- is the mitral ring heavily calcified
- which of the commissures is fused
Typ 3b: - which leaflet, which segment of the leaflet
is involved
- do secondary chordae exist, which prevent a
good coaptation (these should be cut)
- what is the coaptation depth
2. Is there a constellation, which favourizes Systolic
Anterior Motion (SAM)?
This constellation consists of a long posterior
leaflet (> 1,9 cm) and a C-sept of < 2,5 cm (6),
whereas C-sept is the closest distance between the
ventricular septum and the coaptation point of both
leaflets in systole. If this constellation exists, it is
necessary to choose a ring, which is not too small,
because otherwise the anterior mitral leaflet is
pushed towards the left ventricular outflow tract
(example see www.eacta.de “echo of the month
May 2005).
3. Length of the anterior mitral leaflet in the ME LAXview as a guideline for the size of the annuloplasty
ring
Relevant informations of the TEE-examination after mitral repair
– detection and graduation of a residual mitral regurgitation
18
J. Ender, E. Krohmer, J. Fassl
– length of the coaptation area (ME 4 chamber, ME
LAX)
- measurement of the residual mitral valve area
- measurement of the mitral valve area with the pressure half time method is easy to perform. Own retrospective data of 50 patients for quality assurance
purpose showed no significant difference in mitral
valve area calculation by PHT method immediately after cardiopulmonary bypass as compared with
measurements performed before discharge of the
patients from hospital 10-12 days after operation.
– Measurement of the pressure gradients through the
mitral valve
– Detection of regional wall motion abnormalities in
the posterior segments of the left ventricle due to
compromised flow in the circumflex artery. Compromised flow in the circumflex artery due to suture
necessary to fix the annuloplasty-ring is a rare but
possible complication in mitral valve repair (7) or replacement (8). This complication leads to myocardial infarction, if not recognized. In our center we
try to identify flow in the circumflex artery before
onset and after weaning from cardiopulmonary bypass to detect this complication.
Conclusion
TEE in mitral valve repair is a “conditio sine qua non”.
In the hand of an experienced examiner it can give relevant information to the surgeon before and after mitral valve repair.
References
1. Schmidlin D, Bettex D, Bernard E, Germann R, Tornic M, Jenni
R, Schmid ER (2001) Transoesophageal echocardiography in
cardiac and vascular surgery: implications and observer variability. Br J Anaesth 86: 497-505
2. Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL,
Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quiñones MA,
Cahalan MK, Savino JS (1999) ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination: Recommendations
of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular
Anesthesiologists Task Force for Certification in Perioperative
Transesophageal Echocardiography. J Am Soc Echocardiogr 12:
884-898
3. Carpentier A, Deloche A, Dauptain J, Soyer R, Blondeau P, Piwnica A, Dubost C, McGoon DC (1971) A new reconstructive operation for correction of mitral and tricuspid insufficiency. J Thorac Cardiovasc Surg 61: 1-13
4. Von Opell UO, Mohr FW (2000) Chordal replacement for both
minimally invasive and conventional mitral valve surgery using
premeasured gore-tex loops. Ann Thorac Surg 70: 2166-68
5. Lambert AS, Miller JP, Merrick SH, Schiller NB, Foster E, Muhiudeen-Russel I, Cahalan MK (1999) Improved evaluation of the
localisation and mechanism of mitral valve regurgitation with a
systematic transesophageal echocardiography examination.
Anesth Analg 88: 1205-12
6. Maslow AD, Regan MM, Haering M, Johnson RG, Levine RA
(1999) Echocardiographic predictors of left ventricular outflow
tract obstruction and systolic anterior motion of the mitral valve
after mitral valve reconstruction for myxomatous valve disease. J
Am Coll Cardiol 34 (7): 2096-104
7. Tavilla G, Pacini D (1998) Damage to the circumflex coronary artery during mitral valve repair with sliding leaflet technique. Ann
Thorac Surg 66 (6): 2091-3
8. Speziale G, Fattouch K, Ruvolo G, Fiorenza G, Papalia U, Marino
B (1998) Myocardial infarction caused by compression of anomalous circumflex coronary artery after mitral valve replacement.
Minerva Cardioangiol 46 (11): 455-6
Unser zusätzliches Informationsangebot:
www.anaesthesie-intensivmedizin.com
19
Intraoperative echocardiography for aortic valve repair surgery
Joachim M. Erb
Universitätsklinik für Anästhesiologie und operative Intensivmedizin, Campus Charité Mitte, Berlin, Germany
The aim of this summary is to review the intraoperative echocardiographic assessment of the aortic valve,
its pathology and the results of aortic valve repair techniques for the clinician with basic experience in
echocardiography. As the most common approach for
this is the use of transoesophageal echocardiography
(TOE), all descriptions of imaging planes and measurements in this paper are based on TOE and the standard imaging planes as defined in the literature [1].
The use of epicardial echocardiography, although advisable in some cases, is not covered, and transthoracic
echocardiography is usually not feasible in the intraoperative setting.
Normal aortic valve anatomy and function
The aortic valve sits at the junction of the left ventricular outflow tract and the ascending aorta and has the
task to connect (in systole) as well as separate (in diastole) these two areas, dependent on the heart cycle.
Anatomically and functionally, it forms a part of the
aortic root. This fact is important in understanding aortic valve function, pathology and surgical repair techniques. The aortic root has a green onion shaped figure, where we discriminate between the aortic annulus,
the sinuses of Valsalva, the sino-tubular junction, and
the ascending aorta. The diameters of these sections
differ, with the mid-sinus diameter being the largest
and the sino-tubular junction diameter being the smallest, therefore also called sino-tubular ‘ridge’. Anatomic studies have shown that a sino-tubular diameter of
85% of the annular diameter describes normal aortic
root anatomy [2]. Three semilunar leaflets or cusps
form the aortic valve. The free rim of the leaflets is oriented towards the ascending aorta, with the edges attached on either side to the aortic wall at the level of
the sino-tubular junction, while the base is anchored in
an U-shape fashion to the aortic annulus. The free edge
has a length of 1.2 times the diameter of the sino-tubu-
lar junction and carries a fibrous nodule, the node of
Arantius, in the middle, at the central point of coaptation of all three cusps. Together with the wall of the sinuses of Valsalva each semilunar leaflet forms a little
sack. The semilunar leaflets are pushed open and towards the sinus of Valsalva portion of the aortic wall
by the blood ejected from the left ventricle in systole.
The convex shape of the aortic wall in the sinuses and
the presence of the sino-tubular ridge allows for the Da
Vinci sinus currents which prevent that the leaflets hit
the wall during each systole when opening. Ejection is
also accompanied and supported by sequential expansion of the aortic root in relation to ventricular dynamics [3]. When ejection is completed and the ventricle
relaxes at the beginning of diastole, blood starts flowing backwards towards the left ventricular outflow
tract, thereby filling the little sacks formed by the
semilunar leaflets and pushing them towards the middle and against each other, thus closing the aortic valve
and preventing diastolic backflow. As the diastolic
blood pressure builds up in the leaflet sacks, it presses
the closing rims together and supports tight sealing.
Echocardiographic assessment of the aortic valve
and aortic root
The midoesophageal short axis and long axis planes of
the aortic valve, acquired with the TOE probe positioned behind the left atrium, are the best views to
sample anatomical and functional information of the
aortic valve and the aortic root in the two-dimensional
(2D) mode. In these views, the aortic valve is in the
near field of the transducer, just separated from the oesophagus by the left atrium. The use of colour flow
Doppler in these views will contribute useful information about the location of flow velocities, but it needs
to be noted that the measured velocities will differ
markedly from the existing velocities due to the large
angle mismatch and must not be used for calculations.
20
Likewise, useful spectral Doppler information of
blood flow through the aortic valve cannot be acquired
in these planes. Normally, laminar flow is seen in systole with no diastolic flow present. Turbulent systolic
flow and more than trivial diastolic flow are signs of
valve pathology.
The short axis view of the aortic valve normally
shows three symmetrical leaflets, which are identified
as the noncoronary cusp oriented towards the interatrial septum, the left coronary cusp oriented towards the
left atrium and the right coronary cusp oriented towards the right ventricle. The anatomy and motion of
the leaflets is easily assessed in this view. In diastole
the closure lines between the three cusps form a symmetrical star displaying three arms at 120-degree angles. In systole, the rims of the leaflets form a triangular to circular symmetrical opening, the area of which
can easily be measured by planimetry. Changes from
this symmetrical appearance and motion are indications for structural and functional abnormalities,
whether congenital or acquired, and should be precisely described. The most frequent congenital abnormality is the bicuspid valve, where only two usually asymmetric leaflets are present, the larger of which often
displays a raphe as indication of a fusion of two initially developing cusps into one. Asymmetry of the valve
and abnormal motion can also be the result of commissural fusion in rheumatic valve disease, displacement
of cusps in cusp prolapse, destruction of cusps after
endocarditis, sclerotic and calcific changes in aortic
valve stenosis or appearance of masses caused by
valve thrombosis, endocarditic vegetations, fibromas
and other tumours.
The long axis view shows the aortic valve and the
ascending aorta as well as their relationship and interdependence. In the long axis view, only two of three
cusps are visible in the imaging plane at any one time,
with the more distant, on the lower part of the monitor
screen appearing leaflet always being the right coronary cusp, while the upper, closer to the transducer located cusp is either the left or non coronary cusp. Cusp
anatomy and motion can be assessed using this plane,
and especially the coaptation zone between the cusps
can be well visualized and its length measured. Besides information on the cusps themselves, this imaging plane allows the important measurements of the
following diameters: aortic valve annulus, aortic sinuses, sino-tubular junction and tubular part of the ascending aorta.
J. M. Erb
The transgastric long axis view and the deep transgastric view are the appropriate planes to interrogate
the aortic valve using all Doppler modalities. This is
due to the near parallel alignment of flow direction and
ultrasound beam in these views, allowing for only
minimal errors caused by angle mismatch. Certainly
2D anatomical and functional information can also be
acquired in these views, but usually is inferior in quality to the information obtained in the midoesophageal
views due to a larger distance between valve and ultrasound probe and much more tissue interposition.
Normal flow across the aortic valve is only detectable in systole. Using colour flow Doppler, the signal colour is usually blue, but single aliasing into red
is in the normal range, depending on the achievable
Nyquist limit of the equipment and the angle of interrogation. Turbulent systolic flow is always suspicious
for valve stenosis or marked deformation of the opening geometry. The form, size and direction of the jet
give valuable information about the underlying pathology. Diastolic flow across the aortic valve should always raise suspicion for pathology leading to valve incompetence, as only in 5% of all normal aortic valves
minimal, trivial aortic insufficiency can be detected,
most often originating centrally and always limited to
a very narrow jet with minimal penetration into the left
ventricular outflow tract. To quantify aortic insufficiency using colour flow Doppler information, jet
width or jet cross-sectional area in the left ventricular
outflow tract, vena contracta width and the proximal
isovelocity surface area (PISA) method are reliable parameters for quantification.
The use of spectral Doppler interrogation of velocities across the aortic valve has a higher timely resolution and allows measurements of velocities throughout
the cardiac cycle. This information can be used for the
calculation of systolic gradients across the aortic valve
using the simplified Bernoulli equation or the calculation of systolic valve orifice using the continuity equation, thereby enabling the quantification of aortic
valve stenosis. Diastolic regurgitant orifice size can be
approximated using the pressure half time method or
the PISA method when combined with information
from the colour flow Doppler investigation.
For more detailed information on the quantification of valvular stenosis and regurgitation the reader is
referred to the respective literature [4,5].
21
Aortic valve pathology suitable for surgical repair
Independent of the underlying pathology, the two basic resulting aortic valve dysfunctions are aortic stenosis or aortic insufficiency or a combination of both.
Regarding surgical interventions, aortic stenosis can
be only rarely taken care of by aortic valve repair. For
genuine aortic valve stenosis, repair procedures are
usually restricted to mild or moderate stenosis due to
commissural adhesions, mild calcifications, and obstructions of the valve opening by non-destructing tumours or thrombosis. Other reasons are membranous
obstructions at the level of the aortic valve.
Aortic insufficiency, on the other hand, is more often suitable for surgical repair. Recent literature defined three types of pathologies in a functional classification of aortic regurgitation [6]:
Type 1: normal cusp motion
1a: dilatation of sino-tubular junction
1b: dilatation of sino-tubular junction and sinuses of Valsalva
1c: annular dilatation
1d: leaflet defect (perforation)
Type 2: cusp prolapse
Type 3: restricted cusp motion
Type 1 pathologies are found to be most likely addressable with surgical, valve-sparing and valve-conserving repair procedures, type 2 pathologies are much
more difficult to repair, while there are very few indications for surgical repair procedures in type 3
pathologies.
Aortic valve repair procedures
As it will be beyond the scope of this short review to
cover the wide field of aortic valve repair procedures
in detail, the aim is to create a basic understanding for
the main differences in procedures. For detailed information and illustration, the reader is referred to the
specific literature [7,8].
comes have not been satisfactory in severe valvular
stenosis. Today, these techniques are sometimes used
to address additional moderate stenosis in the presence
of other leading pathologies of the aortic valve.
Aortic valve repair procedures for aortic
regurgitation caused by type 1 pathology
For type 1a pathology, reconstruction focuses on
restoration of the function of the sino-tubular ridge
with or without replacement of the ascending aorta as
early described by Frater [11] and modified by many
others since. The focus thereby is to restore the dilated
sino-tubular junction to its physiological diameter in
relation to the annular and sinus dimensions.
To address type 1b and 1c pathologies, various
variations of aortic root remodelling techniques initially described by Yacoub and David [12,13] have been
published. They all include replacement of the dilated
ascending aorta by a tube graft including the resection
of the sinuses, re-suspension of commissural pillars into the tube graft and reinsertion of the coronary arteries.
Leaflet defects (type 1d) can be repaired using
patch repairs or pericardial cusp extensions.
regurgitation caused by type 2 and type 3 pathology
Shortening of the leaflets and resuspension of the pillars have been described as repair procedures where sinus of Valsalva aneurysms lead to excess tissue causing loss of effective coaptation due to prolapse of the
leaflet edge. Other methods to deal with cusp prolapse
include triangular resection, commissural plication
and synthetic or pericardial reinforcements.
Restricted cusp motion can be addressed with
methods of pericardial cusp extension or leaflet replacement [14].
Aortic valve repair procedures for stenosis
Intraoperative echocardiographic evaluation and
support of decision making
Aortic commissurotomy, aortic valvulotomy and decalcification have been early described as techniques
in aortic valve stenosis [9,10], but in general, the out-
A thorough examination as described above, using all
obtainable imaging planes and imaging modalities is
required intraoperatively before, during and after the
22
surgical valve repair procedures. All available information should be gathered at any time. This will always be based on a most thorough anatomical description of the nature, extent and location of the pathology
based on a high quality 2D examination combined
with Doppler data and respective calculations using
these data. This section will focus on specific information and measurements the surgeon might depend on
related to the individual pathology and intended surgical repair. If not otherwise stated, all parameters are
evaluated before and after the repair and compared to
each other.
Aortic valve repair procedures for stenosis
The extent and location of commissural fusion and calcifications have to be precisely described. If possible,
the orifice area should be measured using planimetry,
otherwise calculated with the continuity equation.
Pressure gradients should routinely be obtained, but
are difficult to compare before and after reconstruction, as marked differences in contractility, volume
status and vascular resistance as well as haematocrit
before and after cardiopulmonary bypass will influence these measurements. Special focus needs to be on
the exclusion respective detection and grading of
valvular insufficiency or shunt flow into surrounding
structures, most often the right cardiac cavities or the
pericardium.
Problems / challenge: Separated leaflet rims are often stiff, showing insufficient coaptation leading to
valvular regurgitation. The challenge is to settle for the
right degree of reduction in valvular stenosis without
causing insufficiency.
regurgitation caused by type 1 pathology
Precise diameters of the annulus, the sinuses of Valsalva, the sino-tubular junction and the ascending aorta
need to be measured. The length of the coaptation distance of the cusps and its position in relation to the annulus should be measured as well. For type 1d defects,
location and extent need to be described. The regurgitant jet is precisely described in its three-dimensional
extension and classified using the established parameters [5]. Leakage at graft anastomosis sites is frequent-
J. M. Erb
ly a problem and can be detected echocardiographically, often with the use of colour flow Doppler. If the native aorta is closed around the tube prosthesis, the
forming haematoma can lead to compression of the
graft causing significant gradients, which needs to be
detected. In all repairs for this indication, flow in both
coronary arteries needs to be documented and quantified, as obstruction, torsion and also dissection can impair coronary flow significantly. Wall motion analysis
will give additional clues. Aortic dissection, most likely starting from the distal graft anastomosis extending
into the upper ascending aorta and arch, always needs
to be excluded.
Problems / challenge: After the repair, the aortic
valve is expected to be patent, with no or only minimal
regurgitation detectable. Torsion or size mismatch of
the prosthesis leads to valvular regurgitation. This is
difficult to correct.
regurgitation caused by type 2 and type 3 pathology
In these repairs, evaluation of the regurgitant orifice
location and geometry as well as the extension and
three-dimensional orientation of the regurgitant jet is
the main task. This should always be combined with
measurements of the length of the coaptation zone between the cusps and its position in regard to the annulus. Cusp symmetry should be judged. Complications
of these procedures are dissections, wall haematoma
and perforations with shunt flow into surrounding
structures, which need to be detected. If the coronary
ostia are affected, this can lead to impaired coronary
blood flow.
Problems / challenge: Difficult surgical repairs, often with less than perfect results. The challenge is to
settle for an acceptable degree of residual valvular insufficiency, the evaluation of which is often complicated by complexly oriented and multiple jets.
References
1. Shanewise JS, Cheung AT, Aronson S, Stewart WT, Weiss RL et
al. (1999) ASE/SCE guidelines for performing a comprehensive
intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of
Echocardiography council for intraoperative echocardiography
and the Society of Cardiovascular Anesthesiologists task force
23
for certification in perioperative transesophageal echocardiography. J Am Soc Echocardiogr 12: 884-900
2. Kunzelman KS, Grande J, David TE, Cochran RP, Verrier E
(1994) Aortic root and valve relationships: Impact on surgical
repair. J Thorac Cardiovasc Surg 107: 162-70
3. Thubrikar M, Bosher LPNS (1979) The mechanism of opening
of the aortic valve. J Thorac Cardiovasc Surg 77: 863-70
4. Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA
(2002) Recommendations for quantification of Doppler
echocardiography: a report from the Doppler quantification task
force of the nomenclature and standards committee of the American Society of Echocardiography. J Am Soc Echocardiogr 15:
167-84
5. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft
CD et al. (2003) Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and
Doppler echocardiography. J Am Soc Echocardiogr 16: 777-802
6. El Khoury G, Glineur D, Rubay J, Verhelst R et al. (2005) Functional classification of aortic root/valve abnormalities and their
correlation with etiologies and surgical procedures. Curr Opinion Cardiol 20: 115-21
7. Duran CMG (1996) Aortic valve repair and reconstruction. In:
Cox JL, Sundt TM (Eds.) Operative techniques in cardiac and
thoracic surgery: A comparative atlas (Vol. 1, pp. 15-29)
8. Cosgrove DM, Fraser CD (1996) Aortic valve repair. In: Cox JL,
Sundt TM (Eds.) Operative techniques in cardiac and thoracic
surgery: A comparative atlas (Vol. 1, pp. 30-37)
9. Lewis F, Shumway NE, Niazi SA, Benjamin RB (1956) Aortic
valvotomy under direct vision during hypothermia. J Thoracic
Surg 32: 481-99
10. Harken D (1958) The surgical treatment of acquired valvular
disease. Circulation 4: 128-30
11. Frater RW (1986) Aortic valve insufficiency due to aortic dilatation: correction by sinus rim adjustment. Circulation 74: I136-42
12. Sarsam LAJ, Yacoub M (1993) Remodeling of the aortic valve
annulus. J Thorac Cardiovasc Surg 105: 435-8
13. David TE, Feindel CM, Bos J (1995) Repair of the aortic valve
in patients with aortic insufficiency and aortic root aneurysm. J
Thorac Cardiovasc Surg 109: 345-52
14. Haydar HS, He GW, Hovaguimian H, McIrvin DM, King DH,
Starr A (1997) Valve repair for aortic insufficiency: surgical classification and techniques. Eur J Cardiothorac Surg 11: 258-65
F. Salomon
Leben und Sterben in der Intensivmedizin
Eine Herausforderung an die ärztliche Ethik
Die Leistungsfähigkeit der Medizin drängt uns zunehmend die Frage nach den Maßstäben unseres Handelns
auf. Eine aufwendige Medizin bewahrt immer mehr Menschen vor dem unmittelbaren Sterben. Sie sind jedoch
nicht alle gesund, sondern müssen vermehrt auch als Kranke, Behinderte und Leidende ihr weiteres Leben
führen. Als Behandlungsergebnisse der leistungsfähigen, aber nicht allmächtigen Medizin dürfen sie nicht aus
dem Blick verloren werden. Für eine verantwortliche Intensivmedizin sind ethische Leitlinien unentbehrlich.
Ohne sie besteht die Gefahr, einem inhumanen Automatismus zu verfallen.
Untersuchungen auf einer operativen Intensivstation zur Teamarbeit, zum Umgang mit den Patienten, der Verarbeitung schwerster Erkrankungen und den Behandlungsergebnissen, dem Reden über das Sterben, der Erfahrung des Todes sowie zu Therapieentscheidungen bilden den empirischen Ausgangspunkt dieser Darstellung. Aus einem Entwurf eines Menschenbildes, in dem der Mensch mehrdimensional als Ganzheit, als Mitmensch, als geschichtliches und in einen Sinnzusammenhang außerhalb seiner selbst eingeordnetes Wesen verstanden wird, leitet der Autor Folgerungen für die intensivmedizinische Arbeit ab.
Der ethische Entwurf trägt dazu bei, Ängste vor einer als bedrohlich empfundenen Medizin zu relativieren und
die Kritikbereitschaft an einer erfolgsorientierten Medizin zu stärken. Er unterstützt dadurch die sachliche
Diskussion über einen wichtigen Zweig heutiger Medizin.
24
B. Sauren, B. Zickmann, U. Gerckens, E. Grube, T. Felderhoff, S. Iversen
TOE support for a percutaneous transluminal implantation of a
self-expanding valve prothesis for interventional treatment of aortic valve
stenosis
Barthel Sauren1, Bernfried Zickmann1, Ulrich Gerckens2, Eberhard Grube2,
Thomas Felderhoff3, Stein Iversen3
Anästhesie; 2Kardiologie; 3Herzchirurgie, HELIOS Klinikum Siegburg, Germany
1
Context
Percutaneous aortic valve replacement is a novel technology for patients with significant aortic valve stenosis. We present data on the first implantation of the
self-expanding CoreValve aortic valve prothesis,
which is composed of three bovine pericardial leaflets
within a self-expanding nitinol stent (Fig. 1).
Patient
73-year old female patient with severe symptomatic
aortic valve stenosis with dyspnea at rest (NYHA IV).
Transthoracic and transesophageal echo indicated a severely calcified aortic valve (Fig. 2 a) with a mean
transvalvular gradient of 45mmHg, a valve area of 0.7
cm² and an ejection fraction of 45%. Surgical valve replacement had been refused by the patient due to comorbidities, including previous bypass surgery, renal
insufficiency and breast cancer.
Figure 1
procedure. Clinical and echocardiographic follow-up
at day 1, 2 and 14 post procedure was acquired to evaluate short term outcome.
Intervention
Procedural method
Initially balloon valvuloplasty was performed to optimise the valve area for device placement. After neurological evaluation excluded any evidence of embolic
events, general anaesthesia was started. The procedure
was performed with TOE guidance. A retrograde approach via the common iliac artery was used for valve
deployment. The contralateral femoral vessels were
used for a temporary extracorporal circulation, particularly to unload the left ventricle during the stent expansion. Clinical, hemodynamic, and echocardiographic parameters were assessed serially during the
Hemodynamic monitoring consisted of transesophageal echocardiography, arterial line, pulmonary
artery and transvenous pacing catheters.
General anaesthesia was started with midazolam,
pancuronium and an infusion of remifentanil. After
surgical cutdown to the right common iliac artery (for
the delivery catheter) as well as the left common
femoral artery and vein cannulation for the extracorporal circulation, a stiff wire was placed into the left ventricle from the right iliac access. There was a moderate
increase of aortic regurgitation shortly after the bal-
TOE support for a percutaneous transluminal implantation of a self-expanding valve prothesis
Figure 2
25
26
B. Sauren, B. Zickmann, U. Gerckens, E. Grube, T. Felderhoff, S. Iversen
loon-dilatation and a grade 2 to 3 worsening of mitral
valve insufficiency during bypass. The device was positioned within the native valve (Fig.2 c). After the deployment of the self-expanding prothesis, the procedure finished with a balloon-dilatation for modelling
the stent prothesis into the aortic root (Fig. 2 d).
Transeophageal echocardiography confirmed the exact
device placement (Fig.2 b,e) without evidence for significant regurgitation (Fig.2f), according with the angiogram (Fig.2 g,h).
Results
The prosthesis was successfully deployed within the
diseased native aortic valve, with accurate and stable
positioning, no impairment of the native coronary ar-
tery or vein graft blood flow. 2D and doppler echo immediately after device deployment showed a significant reduction in transaortic mean pressure gradient
(from 45 to 8 mmHg) without evidence of aortic or mitral valve insufficiency. Respirator weaning on the
ICU took less than 5 hours, the patient was mobilized
8 hours later.
Conclusion
This case report demonstrates a successful percutaneous implantation of the self-expanding CoreValve
aortic valve prothesis with remarkable functional and
clinical improvements in the acute and short-term outcome.
K. Rockenbauch, O. Decker, Y. Stöbel-Richter (Hrsg.)
Kompetent kommunizieren in Klinik und Praxis
Eine gelungene Kommunikation in Klinik und Praxis kommt dem persönlichen Befinden aller Beteiligten
zugute - mit günstigen Folgen für therapeutische und ökonomische Ergebnisse.
Das Buch "Kompetent Kommunizieren" leitet leicht verständlich (angehende) Mediziner/innen, Pflegende
sowie Lehrende in der medizinischen Ausbildung an, gute Gespräche zu führen.
Die Schwerpunkte:
- Spezifische Grundlagen der Interaktion zwischen Ärztinnen/Ärzten und Patientinnen/Patienten
- Generelle Grundlagen der Kommunikation
- Gesprächstechniken und Gesprächsarten
- Gruppen
- Rollen- und andere Spiele
Der Band eignet sich ebenso zur Unterrichtsvorbereitung für Lehrende wie als Ratgeber und Nachschlagewerk für Ärztinnen/Ärzte, Pflegende und Angehörige verwandter Berufsgruppen.
27
Transesophageal echocardiographic monitoring during transapical aortic
valve implantation
J. Fassl1, T. Walther2, U. Birnbaum1, F. W. Mohr2, J. Ender1
Heartcenter Leipzig, 1Department of Anesthesiology and Intensive Care II; 2Department of Cardiovascular
Surgery, University of Leipzig, Germany
Introduction
Pre-surgical TEE evaluation
Aortic valve stenosis is the most frequent acquired
heart valve disease. More than 11,000 patients per year
are treated in Germany receiving aortic valve replacement [1]. Conventional surgical valve replacement
therapy that has been performed for more than five
decades is the golden standard with excellent results at
present. Mechanical valves as well as xenografts with
excellent hemodynamic function and good durability
have been developed.
In line with an increasing patient age at operation
anesthesiologists and surgeons are confronted with an
increasing risk profile. This is due to severe comorbidities besides patient age alone, especially compromised left ventricular function, pulmonary hypertension, severe respiratory dysfunction, renal insufficiency, general atherosclerosis and eventual neurological
dysfunction. All these are important factors affecting
the perioperative and postoperative outcome of the patients. Thus it is of utmost interest for all anesthesiologists, intensivists and surgeons to further improve
therapeutic options in order to minimize the perioperative trauma and thus improve postoperative patient
outcome. In search for less invasive techniques to treat
high risk patients with severe symptomatic aortic
stenosis multiple research efforts have been performed
by several groups during the past years. The common
aim of all these efforts is to develop a truly minimally
invasive procedure avoiding the sternotomy approach,
implanting an aortic valve prosthesis on the beating
heart (thus avoiding cardiac arrest) and eventually to
perform aortic valve implantation completely offpump without using extracorporeal circulation at all.
Aim of this overview is to describe the specific transesophageal aspects associated with the new techniques
of minimally invasive transapical transcatheter aortic
valve implantation.
Pre-surgical TEE evaluation is performed after induction of anesthesia in the operating room. Aim of this
additional evaluation is to identify any myocardial and
valvular abnormalities to delineate the “baseline” before surgical repair. In addition to these standard measurements determination of the aortic annulus diameter
is essential for valve size selection and thus for the
whole procedure of transapical valve implantation.
In the literature it has been shown that intraoperative TEE may lead to an alteration of the surgical plan
in 13% of patients [2]. For the pre-surgical evaluation
the standard views according to the guidelines of the
American Society of echocardiography and the society of cardiovascular anesthesiologists are used [3]. The
transgastric short axis view (TG mid SAX) is chosen
initially to estimate the left ventricular function and
screen for regional wall motion abnormalities in the
left ventricle. To quantify ventricular function the fractional area change (FAC) is calculated. Reliable and
valid assessments of the degree of aortic stenosis can
be made by using Doppler measurements in the transgastric long axis view (TG LAX) or in the deep transgastric long axis view (deep TG LAX). We prefer
measurements in the transgastric long axis view, because this view is easier to get in the daily routine.
Pressure gradients should be measured under constant
and optimal loading conditions. In addition left ventricular outflow tract blood flow profiles are registered
using pulsed wave Doppler in order to exclude any
subvalvular stenosis. Aortic valve orifice area is calculated using the continuity equation based on the measurement of the velocity time integrals. The evaluation
is completed by measurement of left ventricular outflow tract and aortic root diameters.
For further evaluation of the aortic valve the
midesophageal av long axis (ME AV LAX) and mid-
28
esophageal short axis (ME AV SAX) views are applied. The midesophageal short axis view allows the
leaflets to be examined for morphology. For measuring aortic valve orifice area (AVA/cm2) during systole
the planimetry is possible in this view with the limitation due to shadowing in the case of severe calcification. The annulus of the diseased valve also should be
inspected for the presence of calcification. The most
important view for transapical aortic valve implantation is the midesophageal long axis view (ME AV
LAX). It is used for standard measurement of aortic
root diameter as well as the diameters of the sinus of
valsalva, the sinotubular junction and the ascending
aorta (Figure 1). The aortic root diameter is the most
important diameter for correct sizing of the transapical
aortic valve. The measurement in a normal valve is
made from the hinge of one leaflet to the hinge point
of the opposite leaflet of the opened valve during systole. To ensure that the long axis plane is correct, we
put the sample volume of the cursor through the center of the aortic valve in the midesophageal long axis
view (ME AV LAX). Then we rotate back about 90°,
so that we can control the position of the sample volume in the midesophageal long axis view (ME AV
SAX) plane. Figures 2 and 3 show the correct measurement for the aortic annulus. To improve the estimate, multiple measurements should be made and averaged. In the midesophageal long axis view (ME AV
LAX) under application of colour flow Doppler possible regurgitation jets can be visualized. Peri-procedur-
J. Fassl, T. Walther, U. Birnbaum, F. W. Mohr, J. Ender
Fig. 2: Midesophageal av long axis view, control of the
annulus
Fig. 3: Midesophageal av long axis view, control of the
annulus
al visualization is mainly performed by continuous
monitoring of the aortic root using the midesophageal
long axis view (ME AV LAX).
Oversizing
Fig. 1: Measurements of aortic annulus [A], diameter
of sinus of valsalva [B], diameter of the sinotubular
junction [C] and the aorta ascendens [D].
Transapical valve implantation implied the dilatation
of a stent-fixed xenograft within the native, usually
calcified aortic valve cusps. As such no firm surgical
insertion comparable to the conventional suturing
technique is used. The valve, however, needs to be
firmly positioned into the annulus. In order to achieve
stable and safe positioning we apply an oversizing
technique of approximately 2 to 3 mm. Based on the
pre-surgical transesophageal echocardiographic measurements of the diameter of the aortic annulus the size
of the prosthesis is chosen.
Surgical technique and transesophageal
monitoring
Transcatheter aortic valve implantation is a quite logical technique taking advantage of the relatively short
distance with a straight pathway between the left ventricular apex and the heart. Based on longstanding surgical experience to apically de-airing the heart via the
apex this approach was chosen. In addition during substantial experimental evaluations the transapical approach was proven to be safe and efficacious [4;5].
Access to the left ventricular apex can be easily obtained through a left anterolateral minithoracotomy in
the fifth intercostal space. Then the pericardium is incised over the apex and retained with stay sutures. Two
Teflon reinforced purse-string sutures (Prolene 2-0)
are applied at the apex. In addition a temporary epicardial pacing wire is placed, connected and tested for
rapid ventricular pacing. With the heart continuously
beating the apex is punctured and the valve passed antegradely using a soft guidewire. Figure 4 shows the
midesophageal long axis (ME AV LAX) view during
this phase of operation. Then a soft 14F sheath is inserted. This is followed by insertion of a superstiff
guidewire (Amplatz super-stiff; 260cm, Boston Scien-
Fig. 4: Midesophageal av long axis view with guide
wire (arrow)
29
tific) that is positioned across the aortic arch and anchored in the descending aorta.
The sheath was partially withdrawn and a 20mm
balloon valvuloplasty catheter positioned under fluoroscopic and echocardiographic guidance. Balloon
valvuloplasty is performed under rapid ventricular
pacing (150/min). Figure 5 shows the valvuloplasty
controlled by Transesophageal echocardiography. Balloon catheter and apical sheath are withdrawn and a
33F transapical delivery sheath inserted bluntly, followed by the valve within the application system. After careful de-airing the valve is positioned so that the
annulus bisects the stent under transesophageal and
fluoroscopic guidance. Correct valve position is confirmed by single shot aortic root angiography. During
a second brief episode of rapid ventricular pacing the
valve is instantaneously implanted using rapid balloon
inflation. Figure 6 shows valve implantation using rapid balloon inflation controlled by x-ray. Rapid pacing
is stopped and hemodynamic function recovers. Repeat dilatation is indicated in presence of moderate
paravalvular leakage. Valve function is immediately
assessed using transesophageal echocardiographic visualization and angiography. The transapical sheath is
removed and the apex securely closed with the pursestring sutures. Eventually ECC is weaned, cannulas removed and protamine given. Intercostal blockade is
performed using Ropivacaine. The incision is closed
in a standard fashion. Postoperative device specific
medical therapy consists of aspirine 100mg daily only.
Fig. 5: Balloon valvuloplasty controlled by TEE, circle shows the balloon and the arrow indicate the heart
rate during rapid pacing.
30
J. Fassl, T. Walther, U. Birnbaum, F. W. Mohr, J. Ender
Fig. 6: Valve implantation using rapid balloon inflation controlled by x-ray, circle indicates the valve
stent, arrows indicate the valve transducer.
All these specific points can be easily addressed
when performing a standard transesophageal echocardiography examination after implantation. In addition
to the conventional examination performed during any
conventional aortic valve implantation additional
knowledge about the specific aspects of transapical
aortic valve implantation as described previously are
extremly helpful to judge optimal valve function. Any
echocardiographer should keep the one most important
difference to conventional aortic valve replacement in
mind: The sutureless implantation technique of stentfixed aortic valve prosthesis with an inherent slightly
higher risk of having some – even minor – paravalvular leakage. Such paravalvular leakage needs special
attention during the TEE assessment. Most importantly the potential hemodynamic consequences should be
judged. Thus perioperative transesophageal echocardiography is a baseline assessment valuable for instantaneous valve assessment as well as for further comparisons during transthoracic echocardiographic follow-up measurements.
Post-surgical TEE investigation
Conclusion
During transapical aortic valve implantation transesophageal echocardiography is very useful for immediate control of correct valve function. There are several aspects that deserve attention during echocardiography assessment of the prosthesis:
– detection and graduation of trans- or paravalvular
leckage in midesophageal long axis view (ME AV
LAX),
- by pressure half time (TG LAX or deep TG LAX)
- by measurement of the width of the regurgitation
jet in relating to the width of the left ventricular
outflow tract (ME AV LAX)
- the length of the detected regurgitation
- in relation to the total circumference of the aortic
valve in ME AV SAX view
– effective orifice area of the aortic valve by planimetry (ME AV SAX),
– measurements of the pressure gradients through the
implanted aortic valve (TG LAX or deep TG LAX),
– detection of regional wall motion abnormalities of
the left ventricle in transgastric short axis view (TG
mid SAX)
– visualisation of flow in the coronary arteries by
colour Doppler in ME AV LAX,
Transapical aortic valve implantation is a new technique different to conventional aortic valve replacement surgery that may have some important advantages, especially for high risk patients. Valve implantation is performed via a small anterolateral thoracotomy
on the beating heart and eventually completely without
extracorporal circulation. These are important factors
that require full attention of the anesthesiologist.
Transesophageal echocardiography is a very useful
tool for perioperative monitoring of these patients in
order to obtain stable hemodynamics. These aspects
are important, especially issues of ventricular filling
(Pre-load) in these critical patients usually presenting
with severe ventricular hypertrophy. In comparison to
the conventional on-pump approach this is even more
important as episodes of rapid ventricular pacing may
lead to hemodynamic deterioration. Transesophageal
echocardiography plays a crucial role not only for presurgical assessment. Transesophageal echocardiography is an intra- and postoperative tool for a successful
implantation of transapical aortic valves. With the help
of perioperative transesophageal monitoring transapical valve implantation can be performed safely.
31
References
1. Gummert JF, Funkat A, Krian A (2005) Cardiac surgery in Germany during 2004: a report on behalf of the German society for
thoracic and cardiovascular surgery. Thorac Cardiov Surg 53:
391-9
2. Nowrangi SK, Connolly HM, Freeman WK, Click RL (2001) Impact of intraoperative transesophageal echocardiography among
patients undergoing aortic valve replacement for aortic stenosis. J
Am Soc Echocardiogr 14: 863-6
3. Shanewise JS, Cheung AT, Aronson S, Stewart WJ; Weiss RL,
Mark JB Savage RM, Sears-Rogan P, Mathew JP, Quinones MA,
Cahalan MK, Savino JS (1999) ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Trans-
T. Gutmann, A. S. Daar, R. A. Sells,
W. Land (Eds.)
Ethical, Legal, and
Social Issues in Organ
Transplantation
esophageal Echocardiography Examination: Recommendations
of the American Society of echocardiography Council for intraoperative Echocardiography and the Society of cardiovascular
Anesthesiologists Task Force for Certification in Perioperative
Transesophageal Echocardiography. J Am Soc Echocardiogr 12:
884-898
4. Walther T, Dewey T, Wimmer-Greinecker G, Doss M, Hambrecht
R, Schuler G, Mohr FW, Mack M (2006) Trans-apical approach
for sutureless stent-fixed aortic valve implantation: Experimental
results. Eur J Cardiothorac Surg 29: 703-8
5. Dewey T, Walther T, Doss M, Brown D, Ryan WH, Svensson L,
Mihaljevic T, Hambrecht R, Schuler G, Wimmer-Greinecker G,
Mohr FW, Mack M (2006) Transapical aortic valve implantation:
An animal feasibility study. Ann Thorac Surg 82: 110-6
Issues in organ replacement therapy represent a
paradigm for ethics and questions of justice in
mod-ern medicine.
The book - based on the December 2002 Munich
International Congress on Ethics of Organ Transplan-tation - delivers an overview of current
worldwide achievements, analyses, controversies, and dilem-mas. It deals with the topics Equitable Allocation of Organs, Living Organ Donation around the World, Financial Incentives and
Commerce in Organ Transplantation, Embryonic
Stem Cell Biology / Cloning of Individuals, Genetic Engineering of Organs / Xenotransplantation, and Regenerative Medicine, which are intensely discussed among medical, ethical, and
legal experts, and by the general public.
The question is raised: How to define the acceptable? And is there a single universal set of
ethical norms the everyone worldwide could
and should accept?
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32
J. Radke, L. Steudle, J. Soukup
Ethics and money in anaesthesia and intensive care
Department of Anesthesiology and Critical Care; Martin Luther University, Halle-Wittenberg, Halle, Germany
Since the middle of the nineties, it has been becoming
more and more clear that the present German health
system with its premise of unlimited service provision
based on the principle of solidarity can no longer be financed. For example the health service costs per person have increased over a period of 10 years from
1992 to 2002 by 35,6% (2020 € vs. 2740 €). Based on
a further annual increase of the hospital costs this
would lead to a total sum of 337 billion € (+244%
present sum 138 billion €) by 2050. The latest figures
published by the Federal Statistical Office estimate the
costs of the German health care system in 2003 at 240
billion €. For the same period of time however, the annual income of the compulsory health insurance system shows a mere increase of 31.8% (2263 € vs. 2983
€). By 2050, the average rate of contribution of the
health insurance companies could increase by even up
to 44%.
The reason for the deficits are complex. In discussion the main argument is the demographic development and as a direct result the unbalanced state of the
“Age Pyramid” of the population. In addition to a far
too low birth-rate the achievements of modern medicine have resulted in higher life expectancy (“double
aging effect”) which we, however often pay for with
multi-morbidity. We do therefore, find ourselves dealing with more and more old and ill people in our daily
medical work. Because of this age tends to play a minor role in the peri-operative area when making decisions about the actual risks of anaesthesia. Daily contact with elderly patients makes unaware of this particular situation. Decisions pro or contra surgery are
mainly dictated by what is medically possible. But the
limits of therapy have been stretched further and further as a result of present-day possibilities in the fields
of emergency and intensive care medicine. Reducing
the problems down to the field of medicine alone
would, admittedly, only be a very unsatisfactory way
of regarding the eligibility for financing of the health
service system in its complexity. It is more an interplay
of medical development and social changes marked in
the attitude to illness but also to dying. In Germany
too, the subject of dying returned to public interest after the media-dominated debate about the American
coma patient Terri Shivo went through the press.
The agreement on the necessity of a reform of the
health service (economy) quickly disintegrates when
the question arises of finding definitions for “medically necessary” (ethics) and for the budgeting limits of
the costs involved for the health service system (economy). When it is a matter of moral and ethical claims
the legal aspect is of paramount discussion. The highest value guaranteed in the constitution namely the
dignity and physical integrity of each and every individual and the subsequent right of self-determination
of every human being should be valued as untouchable
and as the basis of any discussion on the subject.
Ethics as a limit
Ethics is the philosophy of the norms for human behavior and their justification. The imperative to act for
the well-being of the patient as stated in the Hippocratic Oath forms the basis of medical ethical thought and
action. Not long ago, this well-being of the patient in
everyday emergency and intensive medicine was dominated by the utmost necessity of keeping patients
alive at all costs. This is now gradually changing into
the following question: Should life be preserved at all
costs? Teams responsible for this intensive treatment
made up of doctors and nursing staff are faced almost
daily with difficult decisions as a result of the possibilities available through modern medical intensive care.
This is particularly the case when patients are confronted with suffering. Sometimes the fight for survival stands in direct opposition to the risk of permanent damage. This situation is aggravated by the fact
that the condition of the patient involved does often
not allow questions as to individual wishes. This con-
33
flict is becoming more and more acute with each new
technical development and with the increasing possibilities of operative measures irrespective of age. The
question of the limits as to what is possible or even
sensible is postponed centrally and to a certain extent
to as early as the preoperative phase.
Modern anaesthesia is as safe as it has never been
before. Throughout the world about 100 million operations are performed every year under general or local
anaesthetic. Nowadays the actual risk of anaesthesia is
very low thanks to modern anaesthetic procedures,
progressive medical technology and safe drugs. Unexpected complications arise in only 1 out of a 100
anaesthetics. Cases of death linked to an anaesthetic
are even more seldom. Figures show one case in
250,000 to 400,000 anaesthetics. The perioperative
risk is determined less by the anaesthetic itself as by
the secondary illnesses of the patient and by the kind
of operation. The main reasons for casualties are defects in the equipment (12.7%), carelessness (11.9%),
time pressure (11.5%) and lack of experience (11.4%).
Regarding dependence on age alone, there is no clear
evidence pertaining to age itself that can be found.
However, high age can be linked to a higher co-morbidity (diabetes mellitus, arterial hypertension, chronic obstructive lung disease). This does in turn have essential influence on the further course of illness. Postoperative complications are mainly pulmonary and
they again bear evidence to a clear correlation to age.
It has been observed that the incidence started at 5% of
patients < 65, rose to 12% of patients between 75 to 85
and reached its maximum peak of 15% recorded patients over the age of 85. It also entails a longer retention period in hospital as well as a six times higher
mortality rate particularly in the case of an emergency
operation. In the case of an elective operation, even if
it is possible to optimize secondary disorders by preoperative preparation and to improve the situation by
an additional thorough doctor-patient conversation in
which adequate information is given to the patient
speaking openly about the realistic prognosis expected, even if the operation is to be performed on the patient in the best possible state of health and if the patient him- or herself states the wish for the operation
there are, in the case of emergency treatment obvious
limitations in this respect. The majority of this group
of patients then has to undergo tedious, intensive medical treatment (e.g. because of sepsis) without having
wanted or considered it. In rare cases these complica-
tions are discussed before the operation; the question
of the wish for therapeutic limitation in extreme medical situations (cardiopulmonary resuscitation, longterm artificial respiration etc.) is discussed even more
rarely.
In summary it can be said that age can no longer be
seen as the sole determiner of operative medicine in so
far as it is an elective operation. Possible co-morbidity can be improved to a large extent in the preoperative
stage. After a thorough clarifying with the physician
about the treatment planned, possible complications
and related problems, the patient can express his own
personal wishes. On the other hand it is necessary to
recognize the limits of intensive care medicine taking
into consideration the increasing number of emergency cases needing intensive care treatment and the
limited prospects of probable success. What is medically possible must be brought into line with what is
ethically acceptable. What is medically possible must
be done with consideration of the chances of success
and with results that fit the life perspective of the patient. The basic ethical values must be held high hereto, the presumed will of the patient insofar as it is
known must be respected.
Economy as a limit
With the implementation of the Health Service Reform
Law of 2000 work is being done on the adaption and
further development of the Australian Refined Diagnosis Related Groups (AR-DRGs) for German conditions – German Diagnosis Related Groups (G-DRG).
The reform aims at reducing costs. The Red-Green
Federal Government promised at that time to save up
to 1.5 billion € per annum. The reason for this was a
general suspicion that Germany’s hospitals were misusing the compensation system of the time by keeping
patients longer than necessary in hospital from a medical point of view because every extra day spent in the
ward would bring in extra money. This change in the
conception of the original form of the DRGs made as
far back as the end of the 60s at Yale University in the
USA marks the beginning of a higher transparency of
costs of treatment, treatment profits as well as treatment quality. It also shows diagnosis complexes whilst
considering a patient-specific co-morbidity. Knowledge of these “costs of illness” is of particular interest
in planning resources in the health service system. The
34
doctor is becoming an entrepreneur. The patient is a
customer in this business.
This change of position of the physician is in daily
discussion and a return to a single course of action by
all is not to be expected. But should we readily take a
positive attitude to the knowledge of economic fundamentals and their application in everyday medical
work? At present, economic thought dominates a large
extent of the world of business and industry. Why
should this not apply to the field of medicine? It can
not be denied that the Welfare State Germany has lived
beyond its means during the past years. The greed
mentality of exhausting all that welfare and health systems can offer has led to doubt of the solidarity principle. Furthermore, as physicians we have probably
gone over limits by implementing an armada of endless medically possible types of treatment.
The economy of the DRGs Do ethics and economy exclude each other?
”Aegroti salus suprema lex” - this might not be the
first thought when faced with terms such as “economy” and “cost efficiency”. As already discussed the
patient defines his desired state of well-being within
the limits of his self-determination. The problems in
intensive care medicine particularly when self-determination is no longer possible have already been discussed in the former paragraphs. The way of attaining
the well-being of the patient is chosen and carried out
individually by the doctor responsible. This course of
treatment is financed by the Diagnosis Related Group
(DRG) system. The DRG system is a medical and economic classification of patients and is on one hand according to medical criteria (system of organs, cause of
illness) and on the other according to the amount of
economic resources needed for treatment. Financial attractions should arise for hospitals. It is however only
profitable, when a large number of critically ill patients are treated and discharged from hospital shortly
after exceeding the lower limit for stationary treatment
(“ill short-time patients”). The medical no-man’s land
called “intensive care medicine” suffers as costing factor no. 1 in any hospital from the lack of cost equivalence to the high services rendered under DRG conditions. The length of hospital retention and the quality
of treatment are not taken into consideration; realistic
financial incentives are more or less non-existent. The
question of the influence on medical therapeutic decisions on grounds of enormous cost pressure is unavoidable.
The health care system now faces the problem that
what is medically possible is not automatically financially possible. The discussion of an almost inevitable
rationing of medical services is dominated by the economic aspect. Of equal importance however, is how to
share out the more and more limited health service resources (medical-ethical aspect). Initially the canalisation of services, competition, cost/benefit analysis, effectivity proved through controlled treatment studies,
budgets or similar concepts play no part in this consideration. The economic pressure of the past years since
the introduction of DRGs and the resulting conflict between endless therapy and its financial feasibility has
forced physicians to think a little closer about the effectiveness of their work (Economy). The question of
a possible union of both spheres, ethics and economy
must be answered with a mixed “Yes/No”.
Today the medical ethics founding all medical
work must be widened to cover the principles for the
well-being of the patient and of informed independence on the subject of the shortage of resources. Accordingly the hospital doctor is not only a performer of
medical services but also someone who looks after the
needs of the patients and the staff in his ward/department regarding both organization and financial matters. Particularly the latter point is subject of present
discussion between those colleagues who are practitioners. It can so be said that all medical decisions
made in course of hospital treatment are automatically
economic decisions with all due consequences. These
can go far beyond the actual job itself.
It is therefore not unethical to look very closely at
the economic aspect of medical treatment. In the end,
economy does not only mean the pursuit of financial
profit but also implies a certain economic thought. In
so far as quality and efficiency do not comply to the
generally acknowledged standards of medical knowledge including medical progress there are cases of violation of the economy imperative as it is stated by
law. By definition this would be deemed “unethical”.
Indeed, there is a shift of values amongst doctors
towards using expensive treatment options. These
however, lie beyond the framework of medical freedom of therapy. Consequently it is much more ethical
to familiarize oneself with the basic and fundamental
principles of health economy so as not to lose the
35
chance of further maintaining medical ethics whilst
still respecting the basic rules of economics. The concentration of services seen in the context of the business relationship between doctor and patient and the
careful balancing of the pros and cons of all enforced
therapy lead to a more effective use of the resources
available. This principle implies an acceptable solution to the effective new organisation of the work of
the medical profession. Before attempting to define
the dimension of the basic services of a physician it is
necessary to find a general consensus on ethics. Ethics
must stand at the beginning of all decisions if realistic
values for health are to be determined. Demographic
development should not primarily be the main argument for a limitation of fundamental services. Rather,
more attention must be paid to an existent co-morbidity of the patient and to the patient’s own will or presumed wish when planning therapeutic services. Considering the extent and prognosis of the illness and the
individual situation of the patient, it is possible to discover constellations which come into question for a
limitation of therapy.
Conclusion
Acute and intensive medical care and the regular operative treatment needed here make these areas most
sensitive for every hospital because of their enormous
costs. At the same time it is here that the borderline between life and death, medical–technical possibilities
and ethical-human decisions lie very close to each other. It is daily necessary to redefine what is responsible
from a humane point of view and what is possible
from a legal standpoint. It can be ethically justified
that intensive care doctors are at present developing a
system whereby reliable indicators can be developed
for ending further therapeutic measures so as to avoid
prolonged dying when primary hopeless prognosis has
been made. Equally the acceptance of the patient’s will
can be justified in so far as this is explicitly formulated and the prevailing critical state of health allows
such a decision. A positive side-effect is the possible
reduction in costs in intensive medical treatment. It is
unacceptable to undergo an intensive “triage” merely
on grounds of age. However, such decisions should be
made in acknowledgment of the patient
– in his entirety
– as an individual
– in his social structure
– in his relation to a context (religion)
– in his finite nature.
The application of the DRG´s in routine hospital
work enable financially justified therapeutic decisions
whilst recognizing the limitations of individual categorizations e.g. length of artificial respiration. On the
other hand the achievement-orientated financial incentives of the DRG system needed for the high-quality
treatment are lacking. Decisions on the reduction of
medical services or on the withholding of innovative,
new forms of therapy base mainly on the subjectivity
of the doctors involved and the ability of hospitals to
supply necessary funding. Objective and safe support
systems to help decision making lack completely.
Taking this into account, the quality reports as required by law gain a special importance. Although
their information according to present requirements
must be regarded as being completely inadequate, they
could in future years really document the transparency
and effectiveness of the medical resources employed.
The content of the quality reports must be extended to
include real medical quality parameters (i.e. outcome,
length of retention period, case-mix index, costs of
treatment). In future years it will not be possible for
physicians to avoid dealing with economic questions
in the field of medicine.
On the fundament of our professional ethos as
physicians we should see it as a chance to bring in our
systems of value and our ideas of quality to this discussion on economy or even to avoid erroneous trends.
In so doing we should also make use of ethical thought
to define the framework conditions of our decisions. It
is acute and intensive medicine that daily experiences
the borderline situation between life and death, between what is medically possible and necessary and
which stands under high cost-pressure as one of the
most expensive areas of any hospital. Only the positive co-operation of ethics and economy can form the
basis of a high quality and eligibility for financing intensive medicine in the interest of our patients.
Economy can help to develop strategies for rationalization. It can identify and avoid what is superfluous
and unnecessary without having to ration.
Economy continues to make ethics possible, that
is: makes it possible again!
36
M. K. Diener
The role of sound scientific data for evidence-based decision making
M. K. Diener
German Cochrane Centre, Institute for Medical Biometrics and Medical Informatics, University Hospital
Freiburg, Germany
Medical practice should be based on comprehensive
knowledge about diagnostic tests and therapeutical
procedures that could be offered to patients in specific
situations. Within this concept, knowledge has to be
based on valid results from sound, patient-oriented
clinical research to reduce the misleading influence of
biases and the play of chance. However, this
favourable approach is challenged from several sides.
Firstly, even in times of global communication, the
profusion of publications in scientific and biomedical
journals makes it difficult or impossible for busy clinicians, educators and investigators to keep abreast of
new developments. Hence, the steadily growing
source of evidence is separated from the utilization of
the existing evidence by a barrier often asterisked as
the “Know-Do-Gap” (1). Secondly, much of the available literature is of questionable quality (2). As a result, information overload and poor quality necessitate
efficient strategies to separate junk from valuable research data and reliable assessment of the latter to
come to an overall conclusion that can be used for decision making. Quality assessment (Critical Appraisal)
is an important step when preparing systematic reviews but also for the daily evidence-based medical
practice (3). Therefore, it cannot be emphasized
enough that the quality of the studies is the “Achilles
heel” of healthy medical decisions. Bias minimization
and controlling variability and the play of chance are
the leading principles to judge whether trial results can
be trusted. Randomization, blinding, concealing the
sequence of treatment allocations, adequate treatment
of drop-outs in the analysis are particularly relevant
for bias protection, but there are others which also
have to be considered. Thus, when assessing an article
dealing with therapeutical interventions, one can usefully pose at least the three following questions (4):
1. Are the results of the study valid?
This question has to do with the internal validity of the
presented study results. By appraising the randomization procedure (or the assessment whether it was done
at all), blinding of the patients and/or investigators and
comparability of the study patients and study interventions between the compared groups methodological
soundness of the study can be estimated.
2. What were the results?
If the results are likely to be valid and if we can anticipate a more or less unbiased assessment of treatment
effect, the reader has to appraise the size of the treatment effect and its precision. Since the “true effect”
can never be known the point estimate of the treatment
effect observed in the study is the best we have. Assuming that the true value lies somewhere in its neighbourhood, it is fundamentally important to know the
precision of the point estimate, that is the confidence
interval. A 95% confidence interval can be simply interpreted as defining the range that includes the true
value 95% of the time (5).
3. Will the results help me in caring for my
patients?
Having assessed internal validity and the size of the
treatment effect, the clinical usefulness of the findings
has to be interpreted. In this context, the terms external validity, generalisability or applicability are often
mentioned (6). Relevance of the findings strongly depends on external validity, which is the prerequisite for
a reasonable application of the trial results to a definable group of patients in a particular clinical setting in
routine practice. Amongst other things, we have to de-
37
The role of sound scientific data for evidence-based decision making
cide, whether all clinical relevant outcome parameters
were considered and whether the likely treatment benefits are worth the potential harms and costs.
Methods for critical appraisal of research findings
can be learned. They help clinicians to protect themselves and their patients from potentially misleading
presentations and interpretations of clinical trials (7).
However, standardized reporting of scientific data is a
basic requirement for a valid assessment. Thus, approved guidelines such as the CONSORT Statement
for randomized controlled trials have to be followed
rigorously when preparing a manuscript (8).
References
3. Straus SE, Richardson WS, Glasziou P (2005) Evidence-Based
Medicine: How to Practice and Teach EBM. Third ed. Churchill
Livingstone
4. Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook DJ, Cook
RJ (1995) Users’ guides to the medical literature. IX. A method
for grading health care recommendations. Evidence-Based Medicine Working Group. JAMA 274 (22): 1800-4
5. Altman DG (1998) Confidence intervals for the number needed to
treat. BMJ 317 (7168): 1309-12
6. Rothwell PM (2005) External validity of randomised controlled
trials: „to whom do the results of this trial apply?“. Lancet 365
(9453): 82-93
7. Montori VM, Jaeschke R, Schunemann HJ, Bhandari M, Brozek
JL, Devereaux PJ et al. (2004) Users’ guide to detecting misleading claims in clinical research reports. BMJ 329 (7474): 1093-6
8. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF
(1999) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of
Reporting of Meta-analyses. Lancet 354 (9193): 1896-900
1. Antes G, Diener MK (2006) The role of systematic reviews in evidence-based healthcare. Chin J Evid-based Med 6 (7)
2. Altman DG (1994) The scandal of poor medical research. BMJ
308 (6924): 283-4
Günter Schütze
Epiduroskopie
Ein praxisorientierter Leitfaden zur epiduroskopischen Diagnostik und
Therapie rückenmarksnaher Schmerzsyndrome
Die Epiduroskopie (EDS) stellt ein effizientes und zukunftsorientiertes minimal-invasives endoskopisches Verfahren zur Diagnostik und Therapie rückenmarksnaher Schmerzsyndrome dar. Die epiduroskopische Identifizierung dorsaler bzw. ventraler pathologisch-anatomischer Strukturen sowie
die Realisierung eines epiduralen Schmerzprovokationstests zur Schmerzbeurteilung sind von
großer therapeutischer Relevanz. Die Epiduroskopie ermöglicht eine zielgerichtete Therapie betroffener schmerzrelevanter Regionen. Auch eine Platzierung von Kathetern, lasergestützter Lösung von
Narbenfeldern und Unterstützung bei weiteren invasiv-interventionellen Eingriffen erweitern bei
Schmerzpatienten die vorhandenen therapeutischen Möglichkeiten.
ca. 40 Farbabbildungen, 152 Seiten, ISBN-10: 3-89967-252-6 / ISBN-13: 978-3-89967 -252-7
Preis: 35,- Euro
38
I. Hollinger
Ingrid Hollinger
Mount Sinai School of Medicine, New York, NY, USA
Fast track recovery protocols lead to shorter hospital
stay and decreased cost (1). In addition, fast track patients appear to require less resource use during the
first three months and the first year following coronary artery bypass grafting (CABG) surgery (2). In addition, early extubation allows an increase in case load
since cancellations because of lack of ICU beds are reduced. Although the primary impetus for fast-tracking
was financial, early extubation has also medical benefits. Reduced pulmonary complications, reduction in
ventilator associated pneumonia, reduced hemodynamic stress from manipulations of the endotracheal
tube and increased patient satisfaction (3). Introduction of a fast-tracking protocol is essential for success
(4). One of the essential elements is provision of adequate postoperative pain relief without excessive sedation. The use of short acting anesthetic drugs in combination with neuraxial techniques, either single shot
or with an indwelling catheter, and the use of alpha-2
agonists such as clonidine or dexmedetomidine in the
immediate postoperative period have been described
(5). Because a majority of patients presenting for cardiac surgery in our institution are either on platelet inhibitors or anticoagulated for rhythm disorders, neuraxial techniques are mostly contraindicated (6).
At The Mount Sinai Medical Center we do not
have a formal fast-track protocol for adult patients. Patients after routine CABG or aortic valve surgery are
usually extubated within 6 hours of the end of surgery.
Patients who underwent mitral valve repair are mostly
extubated within 8-12 hours, while major aortic
aneurysm surgery patients typically require longer
postoperative mechanical ventilation. Our main sedation modality for fast track patients is an infusion of
dexmedetomidine at a rate of 0.4-0.8 mcg/kg/hour.
In 1997 we introduced a fast-track protocol for
pediatric cardiac patients at The Mount Sinai Medical
Center. Early extubation in pediatrics has been advocated since 1980 (7). Delayed extubation in children
has been linked to an increased incidence of postoper-
Surgical Volume MMS 2005( Jan1-Dec 31),2006 (Jan
1-Sept 23)
Total pump cases 1754
MVA
354
OpCAbBG
40
MVR
111
TVA
20
MVR (redo)
AVR
AVR (redo)
7
220
88
CABG
545
CABG (redo)
254
TVA (redo)
221
Aneurysm
280
Peds
315
ative complications. In addition, early resumption of
spontaneous ventilation is of particular benefit in single ventricle physiology by improving cardiac output
(8). The anesthetic technique preferred by us has been
an inhalation-based anesthetic technique supplemented by very low dose narcotics, and caudal or spinal
morphine. In addition, all patients undergo modified
ultrafiltration. Close to 80% of patients leave the operating room with the endotracheal tube removed. Exclusion from fast track are critical ill neonates, patients
who were mechanically ventilated preoperatively, and
patients who are hemodynamically unstable following
cardiopulmonary bypass. Our results compare favorably with published data (9, 10).
The attached table shows the results of this strategy.
Multiple logistic regression revealed that not proceeding with planned extubation was associated with
younger age, longer cardiopulmonary bypass time (>
150 min), male gender and higher inotropic support
(11). None of the patients who were extubated required re-intubation for respiratory depression.
39
Table 1
Type/Procedure
Extubated/
cases performed
Type/Procedure
Extubated/
cases performed
ASD
31/34 (91%)
Complete AV canal
4/10 (40%)
VSD
41/54 (76%)
Subvalvular AS
11/12 (92%)
TOF
17/21 (81%)
Supravalvar AS
3/4 (75%)
bi.-Glenn
11/17 (65%)
MV/TV repair
12/12 (100%)
Fontan
28/29 (97%)
TAPVR
2/4 (50%)
RV-PA conduit
11/11 (100%)
ALCAPA
1/4 (25%)
Partial AV canal
3/5 (60%)
Miscellaneous
3/7 (43%)
Total
178/224 (79%)
References
1. Toraman F, Evrenskaya S, Yuce M et al. (2005) Fast Tract recovery in non-coronary cardiac surgery patients. Heart Surg Forum
8: E61-4
2. Cheng DCH, Wall C, Djaiani G et al. (2003) Randomized assessment of resource use in fast-track cardiac surgery 1-year after hospital discharge. Anesthesiology 98: 65107
3. Flynn M, Reddy S, Shepherd W et al. (2004) Fast-tracking revisited; routine cardiac surgical patients need minimal intensive
care. Eur J Cardiothorac Surg 25: 116-22
4. Van Mastright GAPG, Maessen JG, Heijmans J et al. (2006)
Does fast-track treatment lead to a decrease in intensive care
unit and hospital length of stay in cornary artery bypass patients? A meta-regeression of randomized clinical trials. Critical
Care Med 34: 1624-34
5. Lena P, Balarac N, Arnulf JJ et al. (2005) Fast-track cornary artery bypass grafting surgery under general anesthesia with
remifentanil and spinal analgesia with Morphine and Clonidine.
J cardiothoracic Vasc Anesth 19: 49-53
6. Horlocker TT, Wedel DJ, Benzon H, Brown DL et al. (2003) Regional anesthesia in the anticoagulated patient: defining the risks
(the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation).Reg Anesth Pain Med 281: 72-97
7. Barash PG, Lescovich F, Katz JD et al. (1980) Early extubation
following pediatric cardiothoracic operations; A viable alternative. Ann Thorac Surg 29: 228-33
8. Schuller J, Sebel P, Bovill J et al. (1980) Early extubation after
Fontan operation. Br J Anaesth 52: 999-04
9. Vricella LA, Dearani JA, Gundry SR et al. (2000) Ultra fast
track in elective congenital cardiac surgery. Ann Thorac Surg 69:
865-71
10. Kloth RL, Baum VC (2002) Very early extubation in children after cardiac surgery. Crti Care Med 30: 787-91
11. Mittnacht AJC, Thanjan M, Hossain S et al. (2006) Rapid operating room extubation after congenital heart disease surgery in
children. ASA abstract A-1709
Retrospective review of all cases qualifying for early
extubation from July 2002-May 2005
40
H. Metzler, M. N. Vicenzi, A. Münch, E. Mahla
Risk of recent coronary artery stenting before noncardiac surgery:
On the edge between stent thrombosis and surgical bleeding
Universitätsklinik für Anästhesiologie und Intensivmedizin, LKH-Univ.-Klinikum Graz, Austria
Perioperative risk
Coronary artery stenting in patients before noncardiac
surgery (NCS) is associated with increased perioperative morbidity and mortality resulting either from stent
thrombosis, myocardial infarction and cardiac death or
from major microvascular bleeding (1-12). Kaluza et
al reported an alarming 20% perioperative mortality
rate (2).
In 2003 Wilson et al published a retrospective
study of 207 patients. 4% of them suffered from cardiac events inclusive of 6 patients, who died (3).
In a retrospective study Satler et al analysed all patients who underwent noncardiac surgery within 90
days of coronary stent placement (7). Their observation was that during the first three weeks after percutaneous coronary intervention (PCI) the interruption of
thienopyridines resulted in a group with the highest
mortality.
Recently, Vicenzi et al published a prospective outcome study enrolling all patients with a coronary artery stent within one year before NCS. 44% suffered
from complications after surgery, 4.9% died (12, fig.
1). All, but two (bleeding only) adverse events were of
cardiac nature. The risk of suffering an event was 2.11
fold greater in patients with recent stents (< 35 days
before surgery) as compared with PCI more than 90
days before surgery.
In the nonsurgical setting cardiologic trials documented greater bleeding risk when clopidogrel and aspirin were combined, compared to aspirin alone (13).
Most of the surgical data comes from clinical studies
in patients undergoing CABG-surgery (14, 15). Clopidogrel, a thienopyridin, inhibits platelet aggregation
by irreversible blockade of adenosin diphosphat mediated platelet function. Normalization depends on the
new platelet population. Most CABG-studies demonstrated that clopidogrel given within 4 to 5 days before
Fig. 1: Kaplan-Meier event time curve (combined
coronary and bleeding events) of 103 patients receiving a coronary artery stent within 1 year before noncardiac surgery (12).
CABG-surgery increased transfusion requirements
and prolonged ICU-stay (14, 15).
Recommended dual antiplatelet drug regime after
stent implantation
The ACC/AHA Guidelines from 2002 concluded that
there is uncertainty regarding how much time should
pass between PCI and NCS procedures. If a coronary
stent is used, a delay of least two weeks and ideally 4
to 6 weeks should occur before NCS to allow 4 full
weeks of dual antiplatelet therapy and reendothelialization of the stent to be completed or nearly so (16).
The new Guidelines of the European Society of
Cardiology for percutaneous coronary artery intervention recommend that after implantation of a bare metal stent clopidogrel must be continued for 3 to 4 weeks
and ASA lifelong, after drug-eluting stents clopidogrel
and ASA should be administered for 6 to 12 months to
avoid late vessel thrombosis (17).
41
Risk of recent coronary artery stenting before noncardiac surgery
The new ACC/AHA 2005 Guideline update for
percutaneous coronary intervention recommends that
in patients who have undergone PCI, clopidogrel 75
mg daily should be given for at least 1 month after
bare-metal stent implantation (unless the patient is at
increased risk for bleeding; then it should be given for
a minimum of 2 weeks), 3 months after sirolimus stent
implantation, and 6 months after paclitaxel stent implantation, and ideally up to 12 months in patients who
are not at high risk of bleeding (level of evidence B)
(18).
Perioperative management
Currently, many case reports and retrospective studies
are available but no large prospective randomized trials. Therefore, we have to rely on recommendations of
task forces and expert opinions (16 - 19).
Basically, when assessing the perioperative risk of
patients with recent coronary artery stenting before
noncardiac surgery we have to plot the risk of thrombosis vs. the risk of bleeding (fig. 2). Dual antiplatelet
regime can be stopped, changed or continued according to this assessment. Figure 3 shows the algorithm
for the preoperative management according to the urgency of noncardiac surgical procedures. Depending
on the calculation of the thrombosis/bleeding risk 3
options are possible:
1. Continue clopidogrel + aspirin
e.g. peripheral vascular surgery can be performed
under dual antiplatelet drug regime because vascular surgeons are familiar with such situations.
2. Continue aspirin, stop clopidogrel
This concept balances in many cases the risk benefit ratio
3. Stop clopidogrel, stop aspirin
This option should be strictly restricted to high
bleeding procedures, like urologic, intracranial and
some types of tumor surgery.
Essentially, patients with recent coronary artery
stents and dual antiplatelet therapy scheduled for noncardiac surgery benefit from a close cooperation between the surgeon, the anaesthesiologist and the cardiologist.
Fig. 2: Schematic assignment of surgical patients under dual antiplatelet therapy according to the risk of
thrombosis and bleeding.
*indicates a patient with a drug eluting stent 4 weeks
ago, who is scheduled for prostatic surgery
Fig. 3: Algorithm for preoperative management of patients after PCI with dual antiplatelet drug therapy.
References
1. Vicenzi MN et al. (2001) Coronary artery stenting before noncardiac surgery: More threat than safety? Anesthesiology 94:
367-68
2. Kaluza GL et al. (2000) Catastrophic outcomes of noncardiac
surgery soon after coronary stenting. J Am Coll Cardiol 35:
1288-1294
3. Wilson SH et al. (2003) Clinical outcome of patients undergoing
non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 42: 234-40
42
4. Fléron MH et al. (2003) Non cardiac surgery in patients with
coronary stenting: think sirolimus now! Ann Franc Anesth Rean
22: 733-35
5. Marcucci C et al. (2004) Fatal myocardial infarction after lung
resection in a patient with prophylactic preoperative coronary
stenting. Br J Anaesth 92: 743-7
6. Sharma AK et al. (2004) Major noncardiac surgery following
coronary stenting: When is it safe to operate? Cathet Cardiovasc
Interventions 63: 141-5
7. Satler LF (2004) Recommendations regarding stent selection in
relation to the timing of noncardiac surgery postpercutaneous
coronary intervention. Cathet Cardiovasc Interventions 63: 1467
8. Dupuis JY, Labinaz M (2005) Noncardiac surgery in patients
with coronay artery stent: what should the anesthesiologist
know? Can J Anesth 52: 356-61
9. Reddy PR, Vaitkus PT (2005) Risk of noncardiac surgery after
coronary stenting. Am J Cardiol 95: 755-57
10. Murphy JT, Fahy BG (2005) Thrombosis of sirolimus-eluting
coronary stent in the postanesthesia care unit. Anesth Analg 101:
971-3
11. Brilakis ES et al. (2005) Outcome of patients undergoing balloon angioplasty in the two months prior to noncardiac surgery.
Am J Cardiol 96: 512-14
12. Vicenzi MN et al. (2006) Coronary artery stenting and non-cardiac surgery - a prospective outcome study. Br J Anaesth 96:
686-93
13. Yusuf S et al. (2001) Effects of clopidogrel in addition to aspirin
in patients with acute coronary syndromes without ST-segment
elevation. N Engl J Med 345: 494-502
14. Chu MWA et al. (2004) Does clopidogrel increase blood loss
following coronary artery bypass surgery? Ann Thorac Surg 78:
1536-41
15. Ascione R et al. (2005) In-hospital patients exposed to clopidogrel before coronary artery bypass graft surgery: A word of caution. Ann Thorac Surg 79: 1210-6
16. ACC/AHA Guideline Update for Perioperative Cardiovascular
Evaluation for Noncardiac Surgery - Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2002; 39:
542-53
17. ESC Guidelines. Guidelines for Percutaneous Coronary Interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 2005;
26: 804-47
18. ACC/AHA/SCAI 2005 Guidelines Update for Percutaneous
Coronary Intervention - Summary Article: A report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary
Intervention). J Am Coll Cardiol 2006; 47: 216-35.
19. Auerbach A, Goldman L (2006) Assessing and reducing the cardiac risk of noncardiac surgery. Circulation 113: 1361-76
K. Matschke, M. Knaut, F. Jung (Hrsg.)
23. Jahrestagung der Deutschen Gesellschaft für Klinische Mikrozirkulation und
Hämorheologie
Myokardiale Mikrozirkulation
Entzündungsreaktionen zuzüglich begleitender Veränderungen des Hämostasesystems und der Mikrozirkulation können weder teleologisch noch klinisch getrennt voneinander betrachtet werden. Funktionen der Mikrozirkulation, der Hämostase und der Zellen im Gefäßsystem interagieren miteinander.
Jede Entzündung, insbesondere die systemische Form, ist eine Erkrankung der Mikrozirkulation.
Der aktuelle Aufsatzband zur Mikrozirkulation bietet neben Beiträgen aus der Grundlagenforschung klinisch relevante Aufsätze mit unmittelbarem Anwendungsbezug - z.B. zum Katheter-Einsatz oder zur Thrombosetherapie.
43
Fast Track Protocol in coronary artery
bypass patients – A safe and effective tool
to save ICU-capacity
N. Anwar, U. Birnbaum, J. Fassl, J. Ender
Tab. 1: Demographic data of both groups, CT (conventional track group), FT (fast track group), values
are given as mean.
Group CT
Group FT
male/female
66/14
67/13
age (years)
67,8
67,3
Introduction
euroscore
5
4,90
Rising medical costs mandate a close look at our practices to assess the possibility of costs savings without
comprising the quality of care [1]. Numerous studies
showed that early extubation or fast track treatments of
the coronary artery bypass grafting (CABG) patients
resulted in a decrease in ICU and hospital stay and
subsequently a reduction of cost of hospitalization in
these patients [2-7].
For this purpose a recovery room was built up with
three beds at our center, adjacent to the operation
rooms, managed by the anesthesia team and working
as a free standing unit, that directly admits postoperative cardiac surgery patients.
After implementation of a fast track protocol we wanted to proof its effectiveness and safety for patients
scheduled for elective coronary bypass grafting.
ejection fraction (%)
60
61,05
cross clamping (min)
61,28
65,66
CPB time (min)
97,92
97,32
Department of Anesthesiology and Intensive care II,
Heartcenter Leipzig, University of Leipzig, Germany
Methods
After 6 months of implementation of the recovery
room, we looked retrospectively on patients scheduled
for elective conventional coronary artery bypass grafting (CABG) operation with the use of cardiopulmonary bypass in mild hypothermia, who were treated
with the fast track protocol (FT-group).
The FT group was compared with the same number of
patients treated with the conventional routine protocol
(CT-group), matched by criterias listed in table 1.
The fast track group (FT) oral premedication included
dikaliumclorazepat the evening before and clonidine
on the day of surgery. The induction of anesthesia was
performed with propofol (1 – 2 mg/kg), sufentanil (0.5
– 1 µg/kg) and rocuronium (0.6 mg/kg). For the maintenance of anesthesia during the pre- and postcardiopulmonary bypass (CPB) period continuous infusion of remifentanil (0.2 μg/kg/min) and sevoflurane
(0.8 - 1.1 MAC) was used, during the CPB continuous
propofol infusion (3 mg/kg/h) was used along with the
ongoing remifentanil infusion.
The conventional track group (CT) patients were premedicated with dikaliumclorazepat the evening before
and with midazolam on the day of surgery. Anesthesia
was induced with midazolam ( 5 mg), propofol (1 – 2
mg/kg), sufentanil (0.5 – 1 µg/kg) and pancuronium
(0.1 mg/kg) and maintained with continuous sufentanil
(1 – 2 µg/kg/h) and propofol infusion (3mg/kg/h). At
the end of the operation FT patients were transferred to
the RR, CT patients to the ICU (fig.1).
The criteria for shifting the patients of FT group to
IMC were defined. Patients of CT group were assessed
at 7:00 AM on the first postoperative day for the shifting according to the conventional management protocol.
Besides the collected demographic data in both groups
we looked for the time to extubation, Length of stay at
ICU (LOSICU) respectively length of stay at the recovery room (LOSRR), Length of stay at IMC
(LOSIMC) and Length of stay at hospital (LOSH).
44
800
600
CT group
400
FT group
200
0
Extubation tim e (m in)
Fig. 2: Time to extubation in both groups. CT (conventional track) group, FT (fast track) group.
P < 0,001
P > 0,13
P < 0,0041
40
35
30
25
20
15
10
5
0
Fig. 1: Cardiac anesthesia pathways, group CT (conventional track group), group FT (fast track group),
OR (operating room), ICU (intensive care unit), RR
(recovery room), IMC (intermediate care unit).
The secured data are expressed as mean values. For the
significance the Student´s t-Test was performed.
CT group
FT group
LOSICU/LOSRR (h)
LOSIMC (h)
LOSH (d)
Fig. 3: Comparison of both groups (CT - conventional
track, FT - fast track) in regards to their length of stay
at intensive care unit (LOSICU) and in recovery room
(LOSRR), in the intermediate care unit (LOSIMC) in
hours and the total length of stay in the hospital
(LOSH) in days.
Discussion
Results
80 patients were included in each group. There were
no significant differences between the two groups with
respect to demographic and clinical data (table 1).
The mean time to extubation in the FT group was 84
min vs 732 min in the CT group. For CT group
LOSICU was 37.8 h vs LOSRR 3.9 h for FT group.
LOSIMC was 37.3 h for CT group vs 30.9 h for FT
group (p > 0.13). There was a significant difference
between CT group and FT group regarding the total
length of stay in hospital, 12.4 days for CT vs 10.3
days for FT, (p < 0.004 (fig. 2 and fig. 3).
Twelve patients (15%) of the FT group and eleven patients (13.75%) of the CT group had to be readmitted
to the intermediate care unit after transfer to the general ward (n.s.).
Cost containment and efficient resource use have
forced anesthesiologists to rethink their management
strategies for cardiac surgery [8, 9]. On the other hand
it is important to recognize that control of perioperative costs must not only include improved efficiency
but also no increase in morbidity and mortality.
Thanks to the lots of research work, new short acting
anesthetic drugs and new surgical techniques it is possible to extubate cardiac patients postoperatively on
the operating table. But the patient is at this stage very
much vulnerable to hypothermia, bleeding and cardiorespiratory instability. On the other hand the delays
in operating rooms caused by the time to fully awaken
and extubation of the patients in the operating room
would lengthen the closing time in operation theatre.
These patients should, at least in our opinion, be as-
45
sessed in an extra room with all the facilities of an ICU
with a concept of early extubation and intensive management until further transfer of the patient.
Many authors have found that the time to extubation
after cardiac surgery is the main key to the further
transfer of the patient from the ICU/RR [5-14].
The patients of the FT group could be extubated as early as 84 min in mean after admission in the RR. This
very short time to extubation compared to the literature [4, 5, 10-15] results from our whole concept of the
fast track, beginning from the premedication through
intraoperative anesthesiological management up to the
postoperative care in the RR. Our FT group patients
were also ready for transfer to the IMC after 2 to 3
hours of stay in the RR after extubation.
In this context we also have to consider the number of
doctors and nursing staff per patient in such units. In
the RR one anesthetist and one nurse are responsible
for the three beds, whereas at the ICU one doctor is responsible for more than 6 patients and a nurse for 2 patients. That is one main issue, that time to decision in
the RR is much shorter than in the ICU due to this constellation.
There was no significant difference between both
groups regarding the length of stay at the intermediate
care unit. This may be due to the fact, that on the general wards no telemetric monitoring is available, so
that for security reasons the patients were monitored at
least 24 hours at IMC.
Cheng et al. have already shown that the early extubated patients recover to baseline performance in the mini-mental state (MMS) test 24 h before the conventional extubation group [16]. This accelerated improvement in mental status allows earlier chest tube
removal, mobilization, and oral intake of food, resulting in reduced ICU and hospital LOS.
Due to the gain of time through bypassing the ICU
and earlier mobilization on the ward, the patients of
the FT group could be discharged significantly earlier
from the hospital. On the other hand we could spare
highly cost intensive ICU beds, which subsequently
means reduction of costs in management of these patients. Another aspect is that these beds could be used
for patients who really need intensive care management.
Regarding the morbidity we did not observe any increase in morbidity in the postoperative phase of the
FT group patients due to implementation of our fast
track protocol.
In conclusion we can say that our fast track protocol
reduces not only the time to extubation and the postoperative recovery time but also the total length of stay
in the hospital. It is also an effective instrument to save
ICU capacity for those patients, who really need it.
References
1. Vander Salm TJ, Blair SA (1984) Effect of reduction of postoperative days in the intensive care unit after coronary artery bypass.
J Thorac Cardiovasc Surg: 558-561
2. Cheng DC, Karski J, Peniston C et al. (1996) Early tracheal extubation after coronary artery bypass graft surgery reduces costs
and improves resource use: A prospective, randomized, controlled
trial. Anesthesiology 85: 1300-1310
3. Van Mastrigt GAPG, Maessen JG, Heijmans J et al. (2006) Does
fast-track treatment lead to a decrease of intensive care unit and
hospital length of stay in cornary artery bypass patients? A metaregression of randomized clinical trials. Crit Care Med 34 (6):
1624-1634
4. Engoren M, Luther G, Fenn-Buderer N (2001) A comparison of
fentanyl, sufentanil, and remifentanil for fast-track cardiac anesthesia. Anesth Analg 93: 859-864
5. Cheng DC, Newman MF, Duke P et al. (2001) The efficacy and
resource utilization of remifentanil and fentanyl in fast-track
coronary artery bypass graft surgery: A prospective randomized,
double blinded controlled, multi-center trial. Anesth Analg 92:
1094-1102
6. London MJ, Shroyer ALW, Grover FL (1999) Fast tracking into
the new millennium: An evolving paradigm. Anesthesiology 91:
911-914
7. Wong DT, Cheng DCH, Kustra R et al. (1999) Risk factors of delayed extubation, prolonged length of stay in the intensive care
unit, and mortality in patients undergoing CABG with fast track
cardiac anesthesia: A new cardiac risk score. Anesthesiology 91:
936-944
8. Myles PS, Daly DJ, Djaiani G et al. (2003) A systematic review
of the safety and effectiveness of fast-track cardiac anesthesia.
Anesthesiology 99: 982-987
9. Cheng DC, Wall C, Djaiani G et al. (2003) Randomized assessment of resource use in fast-track cardiac surgery 1-year after
hospital discharge. Anesthesiology 98: 651-657
10. Chong JL, Grebenik C, Sinclair M et al. (1993) The effects of a
cardiac surgical recovery area on timing of extubation. J Cardiothorac Vasc Anaesth 7: 137-141
11. Engelmann RM, Rousou JA, Flack JE 3rd et al. (1994) Fasttrack recovery of the coronary bypass patient. Ann Thorac Surg
58: 1742-1746
12. Higgins TL (1992) Pro: Early extubation is preferable to late extubation in patients undergoing coronary artery surgery. J Cardiothorac Vasc Anesth 6: 488-493
13. Silbert BS, Santamaria JD, O´Brien JL et al. (1998) The fast
track cardiac care team: Early extubation following coronary artery bypass surgery: A prospective randomized controlled trial.
Chest 113: 1481-1488
46
14. London MJ, Shroyer AL, Coll JR et al. (1998) Early extubation
following cardiac surgery in a veterans population. Anesthesiology 88: 1447-1458
15. Prakash O, Jonson B, Meij S et al. (1977) Criteria for early extubation after intracardiac surgery in adults. Anesth Analg 56:
703-708
16. Cheng DCH, Karski J, Peniston C et al. (1996) Morbidity outcome in early versus conventional tracheal extubation following
coronary artery bypass graft (CABG) surgery: A prospective
randomized controlled trial. J Thorac Cardiovasc Surg 112: 755764
Training simulator for extracorporeal
circulation
A. Dietz, G. Haimerl, F. Moreau, B. Straub,
C. Benk
Hochschule Furtwangen, Fachbereich MUV, Zentrum
für Angewandte Simulation, VS-Schwenningen
Since 2001, the „Zentrum für Angewandte Simulation“ (Center for Applied Simulation) at the University of Furtwangen is developing a simulation center for
training of extracorporeal circulation with heart-lung
machine (HLM) and cardiac anesthesia. This simulator is used for education and training of cardio-technicians, cardiac anesthesia as well as for „crew coordination“ training in the operating room. Since 2005,
this simulator is evaluated for education of medical
technology students (Op engineering / cardiotechnology) and is subjected to ongoing development within a
research project.
View from trainer room to Op simulator
Development of anesthesia simulation
Institutions involved in the development of the simulator are: Dept. of Cardiac and Visceral Surgery at
University of Freiburg, Heart Center Bodensee as well
as several local hospitals and further heart centers in
Southern Germany.
The training simulator can provide simulation of an
ongoing cardiac surgery within a realistic operating
setting. This simulated surgery is controlled by a trainer, who is attending the procedure in a neighboring
monitoring room, by use of several monitors and a
window wall. The required software was developed at
the university on the basis of „LabVIEW“ and specially designed for this simulator.
The simulator consists of a patient dummy with integrated pulsatile circulation. It can be controlled via
software and is provided, at the relevant sites, with
ports for HLM cannulas and with an access for insertion of IABP. All set values and messured values of
circulation, HLM, syringe pumps, hypothermia device
and anesthesia device as well as administration of
medication are transmitted to the trainer workplace
and displayed on the trainer monitors. The trainer or
set models react accordingly and the generated data
will be sent to the Op workplaces as monitoring data,
or negative events (obstruction of oxygenator, air
block, pump failure, etc.) will be intiated by electrical
control. The simulator thus can allow for a variety of
different scenarios.
New technologies, e.g. minimized systems, can be optimized and their application can be trained in the simulator before first patient use.
Our simulation center can be used for training, education, research and development.
47
Factor XII deficiency and cardiovascular
surgery
J. Grefer1, A. Erasmi2, M. Heringlake1
genic blood products were transfused. The patient was
transferred to the ICU and recovered uneventfully.
Klinik für Anaesthesiologie and 2Klinik für
Herzchirurgie, Universitätsklinikum SchleswigHolstein, Campus Lübeck, Germany
Discussion
1
Introduction
Upon contact with proteolytic enzymes, notably
kallikrein, plasmin, and trypsin, or with negatively
charged surfaces, FXII (Hageman factor) activates the
intrinsic coagulation cascade (1). Surprisingly, patients with a FXII deficiency have no greater risk for
clinical bleeding but in fact may even be more susceptible to thrombo-embolic complications due to impaired activation of the fibrinolytic system (2).
Since standard laboratory tests evaluating the intrinsic
coagulation cascade depend upon the activation of
FXII, many of these tests are impracticable for monitoring anticoagulation with heparin in patients with
FXII-deficiency. We report coagulation monitoring in
a patient with FXII-deficiency undergoing Off-Pumpcoronary artery bypass (OP-CAB) surgery using TT.
Case history
A 51 year-old patient with 2-vessel coronary artery
disease (CAD) and scheduled for OP-CAB surgery
presented with preoperative laboratory tests that revealed a pathologic partial thromboplastin time (PTT:
normal range: 24-35 sec) of more than 100 sec. The
thrombin time (TT: 12-20 sec) was 25 sec. The INR
was 0,93 (0,85-1,15), platelet count 227 /nl. FXII-activity was less than 1 % (70-120 %).
Prior to surgery, ACT (70 -180 sec) was 802 sec. and
TT was 41 seconds during continuous infusion of heparin 500 IU/h. Following standard anesthesiological
and surgical preparation, the left internal mammary artery and left radial artery were harvested as coronary
artery bypass grafts and a standard dose of 300 IU/kg
heparin was administered. The ACT increased to over
999, TT to more than 100 seconds. Following successful and uncomplicated OP-CAB grafting, a standard
dose of protamin (300 IU/kg) was given. ACT decreased to 782, TT to 23 sec. Total operating time was
190 minutes. 500 ml of cell-saver blood but no allo-
FXII is a single chain ß-globulin with a molecular
weight of approximately 80.000. Contact with a negatively charged surface causes FXII to be cleaved and
fragmented with subsequent activation of its enzymatic activity. FXIIa catalyzes the activation of
prekallikrein (itself an activator of FXII), factor XI,
plasmin and additional FXIIa.
FXII-deficiency is relatively common in the general
population (2.3%) (3) and is more prevelant in patients
with CAD (4), although severe FXII-deficiency is rare.
It is inherited as a homozygous trait with heterozygous
individuals expressing decreased but physiologically
adequate levels of this clotting factor.
There have been previously reported cases of CABG
in patients with FXII-deficiency (5-10). In some instances, no monitoring of anticoagulation after administering a standard dose of heparin was performed. In
other cases, monitoring of anticoagulation was managed by obtaining an unmodified baseline ACT and
subsequently confirming a heparin effect by monitoring prolongation of the ACT (6,7). But since ACT is
abnormally elevated, interpretation of the ACT after
heparin administration is highly speculative; especially if the ACT-monitor – as at our institution - has an
upper measurement range of 999 sec.
Another strategy of monitoring the anticoagulation
status has been to increase the patients FXII level by
administering FFP, a method that bares the attendant
risks of transfusion (8).
A fourth method is to use a modified ACT test to monitor anticoagulation by measuring the ACT after mixing the patient’s blood with various amounts of donorFFP to identify the assay conditions that provide sufficient FXII activity to achieve normal baseline ACT
(9). This method has the disadvantage of being difficult to perform and to be truly “experimental”; i.e. to
be no validated laboratory test. Another problem is
that differences between donor and patient plasma protein and/or AT III levels may affect the validity of this
test (8).
We chose to use the TT to monitor anticoagulation. TT
assesses the coagulation system through the common
pathway (10) and therefore does not require the pres-
48
ence of FXII. TT in our case was normal before operation and returned back to normal after protamin.
Since we usually aim for an ACT greater than 400 sec.
(three to four times the normal range) we assumed a
TT of greater than 100 sec. would be an adequate goal
for anticoagulation during surgery. And indeed, the patient neither presented with any signs of excessive coagulation nor with extensive bleeding after surgery.
This suggests that TT is an appropiate, safe, and convenient method for monitoring anticoagulation in patients with FXII-deficiency during cardiac surgery.
References
1. Cochrane CG, Revak SD, Wuepper KD (1973) Activation of
Hageman factor in solid and fluid phases. A critical role of
kallikrein. J Exp Med 138 (6): 1564-83
2. Levi M, Hack CE, de Boer JP, Brandjes DP, Buller HR, ten Cate
JW (1991) Reduction of contact activation related fibrinolytic
activity in factor XII deficient patients. Further evidence for the
role of the contact system in fibrinolysis in vivo. J Clin Invest 88
(4): 1155-60
3. Halbmayer WM, Haushofer A, Schon R, Mannhalter C,
Strohmer E, Baumgarten K, Fischer M (1994) The prevalance of
moderate and severe FXII (Hageman factor) deficiency among
the normal population: Evaluation of the incidence of FXII deficiency among healthy blood donors. Thromb Haemostas 71
(1): 68-72
4. Halbmayer WM, Haushofer A, Radek J, Schon R, Deutsch M,
Fischer M (1994) Prevalance factor XII (Hageman factor) deficiency among 426 patients with coronary heart disease awaiting
cardiac surgery. Cor Art Disease 5: 451-4
5. Kelsey PR, Bottomley J, Grotte GJ, Maciver JE (1985) Congenital factor XII deficiency: successful open heart surgery and anticoagulation. Clin Lab Haematol 7 (4): 379-81
6. Salmenpera M, Rasi V, Mattila S (1991) Cardiopulmonary bypass in a patient with factor XII deficiency. Anesthesiology 75
(3): 539-41
7. Moorman RM, Reynolds DS, Comunale ME (1993) Management of cardiopulmonary bypass in a patient with congenital
factor XII deficiency. J Cardiothorac Vasc Anesth 7 (4): 452-4
8. Wallock M, Arentzen C, Perkins J (1995) Factor XII deficiency
and cardiopulmonary bypass. Perfusion 10 (1): 13-6
9. Gerhardt MA, Greenberg CS, Slaughter TF, Stafford Smith M
(1997) Factor XII deficiency and cardiopulmonary bypass: use
of a novel modification of the activated clotting time to monitor
anticoagulation. Anesthesiology 87 (4): 990-2
10. Huyzen RJ, van Oeveren W, Wei F, Stellingwerf P, Boonstra PW,
Gu YJ (1996) In vitro effect of hemodilution on activated clotting time and high-dose thrombin time during cardiopulmonary
bypass. Ann Thorac Surg 62 (2): 533-7
Intraoperative TEE monitoring during
partial resection of a tumour metastasis
with infiltration of right atrium and
ventricle
M. Hansen1, A. Blehm2, G. Wagner1,
G. Klein1
Department of Anesthesia, 2Department of Cardiac
and Visceral Surgery, Robert-Bosch-Hospital,
Stuttgart, Germany
1
Incidence of malignant infiltrating cardiac tumour is
low (1,2). We present a case-report of a 75 year-old female patient suffering from cardiac arrythmia (SVES,
VES) and dyspnea during mild exercise. Transthoracic
echocardiography (TTE) revealed a tumour in the right
atrium (tumour extension was 7,0 x 2,6 x 2,5 cm),
pericardial efflux of 2 cm, normal left ventricular functioning and no signs of a relevant valve disease. Coronary angiography further disclosed an obstruction of
the right coronary artery (RCA). For this reason the
patient was scheduled for tumour resection and aortocoronary bypass surgery (ACB) to be performed with
heart-lung-maschine perfusion.
Upon induction of anesthesia and insertion of the
transesophageal echo (TEE) stylet, we noticed that the
tumour was not only infiltrating the atrium, but also
the right ventrical for a length of 2,5 cm. Furthermore,
the tumour was almost completely obstructing the lumen of the right atrium. Upon opening the pericardium, we noticed that all of the right ventricle was inflitrated superficially and that RCA was obstructed due
to tumour infiltration. For this reason, neither complete tumour resection nor ACB were possible. Short
circulatory arrest with clamping of vena cava inferior
and superior under TEE control was used to perform
partial resection of tumour in the right atrium, and normal blood flow could be restored.
During the remaining course of surgery, intensive care
and hospital stay, no problems were noted and the patient could be transfered to the oncology ward of her
local hospital on day 8 postoperatively.
Laboratory tissue examination revealed adenocarcinoma. Primary source of tumour was a colon carcinoma
which was removed 3 years ago. Despite the fact that
such cardial metastases of a colon carcinoma are
scarce, this case-report shows that in these cases generous indication is correct and perioperative echocardiographic monitoring is very useful. Contrary to pre-
49
operative TEE examination, only intraoperative TEE
scan was able to detect the whole extent of the tumour.
References
1. Oneglia C, Negri A, Bonora-Ottini D et al. (2005) Congestive
heart failure secondary to right heart ventricular metastasis of
colon cancer. Ital Heart J 6: 778-781
2. Lynch M, Clements SD, Shanewise JS et al. (1997) Right-side
cardiac tumors detected by transesophagial echocardiography and
its usefulness in differentiating in benign from malignant ones.
Am J Cardiol 79: 781-784
Influence of perioperative administration
of N-acetylcystein on postoperative renal
dysfunction in cardiosurgical patients
suffering from compensated renal
insufficiency
M. Hawlicki, M. Torka*, W. Karzai
Klinik für Anästhesie und Intensivmedizin, *Klinik für
Kardiochirurgie, Zentralklinik Bad Berka, Germany
tion of anesthesia and 5 dosis of 600 mg NAC every
12 hours until p.o. day 3 on the intensive or intermediate care unit.
Demographic data, relevant conditions, prevalent
medication, clinically relevant laboratory findings,
postoperative complications and mortality were noted.
Pre- and postoperative creatinine clearance was calculated by Cockroft formula and creatinine clearance
was measured postoperatively.
Results
Demographic parameters were comparable in both
groups. Two patients of the placebo group and 3 patients of the NAC group had dialysis treatment during
intensive therapy. Plasma creatinine raised slightly in
both groups until day 4, without any significant differences between the two groups. Urea and Cockroft creatinine clearance also remained on a comparable level
in both groups during the observation period. Sensitive
C-reactive protein (CRP) and leucocyte levels were increasing in both groups, however difference between
the groups was not significant.
Conclusion
Aim
Preoperative compensated renal failure is commonly
diagnosed in cardiosurgical patients. N-acetylcysteine
(NAC), an antioxidant, was able to prevent increase in
plasma creatinine as well as decrease in creatinine
clearance during application of contrast media in patients with compensated renal insufficiency (1). We
examined whether perioperative administration of
NAC could prevent increase in plasma creatinine and
decrease in creatinine clearance in this particular patient population.
Methods
We evaluated 100 cardiosurgical patients with preoperative creatinine ≥ 110 mmol/l in a randomized double-blind study which was approved by the ethics
committee. We included patients who were undergoing surgery by use of heart-lung machine. Total NAC
administered was 4,5 g, 1200 mg NAC during induc-
Perioperative administration of 4,5g NAC (total) did
not show significant influence on plasma creatinine,
Tab. 1: Plasma creatinine (mmol/l) and creatinine
clearance (ml/min)
Plasma creatinine
(mmol/l)
Preop.
op Day
Day 1
Day 2
Day 3
Day 4
Creatinine
clearance
(Cockrof) ml/min
Placebo
NAC
Placebo
NAC
146 ± 4
113 ± 5*
143 ± 5*
152 ± 7
159 ± 9
165 ± 10
148 ± 6
113 ± 6*
132 ± 7*
143 ± 10
143 ± 8
153 ± 12
45 ± 2
60 ± 3*
47 ± 2*
46 ± 3
46 ± 3
43 ± 3
49 ± 3
67 ± 4*
57 ± 4*
55 ± 4
53 ± 3
51 ± 4
* P<0,05 for Op-day and day 1 compared to preoperative value; no
significant differences between groups.
50
Tab. 2: C-reactive protein (CRP)
CRP (mg/l)
Preop.
OP Day
Day 1
Day 2
Day 3
Day 4
Placebo
NAC
8±2
–
10 ± 3
65 ± 5*
167 ± 9*
174 ± 13*
12 ± 3
–
14 ± 4
66 ± 5*
170 ± 10*
175 ± 13*
* P<0,05 compared to preoperative value; no significant differences
between groups.
Cockroft creatinine clearance, plasma urea, CRP and
leucocyte levels. Perioperative administration of NAC
in cardiosurgical patients suffering from compensated
renal insufficiency did not offer clinically relevant
reno-protective effects.
References
estimated creatinine clearance (CClE) and the plasma
levels of cystatin-C (Cys-C) as a plasmatic marker of
changes in glomerular filtration rate in patients needing inotropic support after coronary artery bypass
grafting (CABG).
Methods
The present study is a partial analysis of the AMORI
project investigating the effects of Adrenaline and
Milrinone On Renal function and Inflammation. During an 18 month period, 251 patients were screened for
low-cardiac-output upon ICU-admission after elective,
isolated CABG surgery. Patients presenting with a cardiac index (CI) < 2.2 l/min/m2 upon ICU-admission despite adequate mean arterial and filling pressures were randomized to treatment with adrenaline (n=7) or
milrinone (n=11) to achieve a CI > 3.0 l/min/m2. 20
patients not needing inotropes served as controls (C).
Hemodynamics were recorded until 14 hours after
ICU-admission. Plasma Cys-C and creatinine levels for determination of the CClE by the Cockcroft-Gaultequation - were determined at ICU-admission (t0) and
after 14 and 48h (t14 and t48, respectively).
1. Tepel M et al. (2000) N Engl J Med 343: 180-184
Results
The effects of adrenaline and milrinone
on creatinine clearance and plasma levels
of cystatin-C in patients with myocardial
dysfunction after coronary artery bypass
grafting
H. Heinze1, J. Grünefeld1, M. Wernerus1,
J. Schön1, M. Bechtel2, M. Misfeld2,
M. Heringlake1
Dept. of Anesthesiology and 2Cardiac Surgery,
University of Luebeck, Germany
1
Background
Renal dysfunction after cardiac surgery is a clinically
relevant problem [1] and has been associated with a
worse prognosis [2]. The present study was designed
to examine the effects of adrenaline and milrinone on
Demographic and surgical data were comparable in
both groups (table 1). After 2 to 4 hours, target CI was
Tab. 1: Demographic and surgical variables
Adrenaline Milrinone
group
group
Age (years)
Control
group
66 ± 9
69 ± 9
63 ± 9
228 ± 33
215 ± 31
210 ± 41
Cross-clamp time
(min.)
60 ±16
64 ± 16
59 ± 17
ECC time (min.)
89 ± 19
89 ± 24
80 ± 20
LVEF (%)
64 ± 16
52 ± 19
61 ± 16
Duration of
surgery (min.)
ECC, extracorporal circulation; LVEF, left ventricular ejection fraction. ANOVA with posthoc Fisher's PLSD revealed no significant
between group differences.
51
[l/min/m 2]
[ng/ml]
Cardiac index
4,25
2800
4
3,75
Cystatin - C
*&
2600
Adrenaline
2400
Milrinone
Control
2200
3,5
#
3,25
2000
1800
3
1600
#
2,75
1400
2,5
*#
2,25
Adrenaline
1200
Milrinone
1000
Control
2
600
t2
t4
t6
t8
t10
#
#
800
1,75
t0
*
t12
t14
Fig. 1: The time course of cardiac index in patients
with myocardial dysfunction after CABG surgery
treated with adrenaline (n = 7), milrinone (n = 11),
and in control patients (n = 20) not needing inotropic
support. Data are given as mean ± standard error of
the mean (SEM). *: significant difference (p < 0.05)
between adrenaline and control group; #: significant
difference (p < 0.05) between milrinone and controlgroup (ANOVA with posthoc Fisher's PLSD).
t0
t 14
t 48
Fig. 3: The time course of plasma cystatin-C levels in
patients with myocardial dysfunction after CABG surgery treated with adrenaline (n = 7), milrinone (n =
11), and in control patients (n = 20) not needing inotropic support. Data are given as mean ± standard
error of the mean (SEM). *: significant difference (p <
0.05) between adrenaline and control group; &: significant difference (p < 0.05) between adrenaline and
milrinone-group; #: significant difference (p < 0.05)
between milrinone and control-group (ANOVA with
posthoc Fisher's PLSD).
[ml/min/1,73m 2]
130
CClE
achieved in both intervention groups and maintained
during the observation period (figure 1). The course of
CClE (figure 2) did not reveal significant between
group differences. Cys-C levels (figure 3) at t0 were
significantly higher in patients needing inotropes than
in control patients, remained unchanged at t14 and
were significantly (p<0.05) increased in adrenaline vs.
milrinone-treated and control-patients at t48.
120
110
100
90
80
Adrenaline
Milrinone
70
Control
Conclusions
60
Pre-OP
t0
t14
t48
Fig. 2: The time course of estimated creatinine-clearance calculated from plasma creatinine levels by the
Cockgroft-Gault formula in patients with myocardial
dysfunction after CABG surgery treated with adrenaline (n = 7), milrinone (n = 11), and in control patients
(n = 20) not needing inotropic support. ANOVA with
posthoc Fisher's PLSD revealed no significant between group differences.
This suggests that the use of adrenaline for the treatment of postoperative myocardial dysfunction - in
contrast to milrinone - may be associated with a reduction in glomerular filtration rate that is not detectable
by changes in CClE. With respect to the pilot character and the small sample size of the present study these
findings have to be confirmed in a larger series of patients by direct measurements of glomerular filtration
and renal blood flow.
52
References
1. Heringlake et al. (2006) Renal dysfunction according to the
ADQI-RIFLE system and clinical practice patterns after cardiac
surgery in Germany. Minerva Anestesiol 72: 645-54
2. Lassnig A et al. (2004) Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 15: 1597-605
This study was supported by grant F17/02 by the German foundation for heart research.
An algorithm for management of
perioperative hemostasis disorders in
cardiac surgery
C. Jámbor1, D. Bremerich2, A. Moritz3,
E. Seifried4, B. Zwißler1
Klinik für Anästhesiologie, Intensivmedizin und
Schmerztherapie, Johann-Wolfgang-Goethe-Universität Frankfurt am Main, Germany; 2Abteilung für
Anästhesiologie und operative Intensivmedizin, St.
Vincenz-Krankenhaus Limburg, Germany; 3Klinik für
Thorax-, Herz- und thorakale Gefäßchirurgie, Johann-Wolfgang-Goethe-Universität Frankfurt am
Main, Germany; 4DRK Blutspendedienst BadenWürttemberg - Hessen gGmbH, Institut für Transfusionsmedizin und Immunhämatologie, Frankfurt am
Main, Germany
1
(blood gas analysis, ACT, point of care Quick value,
PTT and platelet count).
Result
An extensive bleeding history should be accomplished
before surgery to discover mild abnormalities of primary hemostasis. Prophylactic antifibrinolytic treatment should be routinely performed with tranexamic
acid and only patients at very high risk of bleeding
should be given high-dose aprotinin. In case of ongoing microvascular bleeding after adequate heparin removal and surgical hemostasis, 15-20 ml/kg of FFP or at risk of volume overload - FFP combined with
PCC (prothrombin complex concentrate) should be
administered, if Quick value is below 50% and/or PTT
above 50 sec. Platelets should be administered at a
platelet count lower than 80/nl or independent of the
platelet count if a severe acquired platelet dysfunction
is suspected. In case of primary hemostasis disorders
associated with renal insufficiency, liver impairment
and pre-treatment, a desmopressin bolus of 0,3 mcg/kg
should be infused. At sustained microvascular bleeding, fibrinogen concentrate should be given if the fibrinogen level is below 100 mg/dl or preoperative fibrinogen content was low (<250 mg/dl). Application of
rFVIIa should be restricted to refractory bleeding after
abundant substrate substitution.
Conclusion
Aims
After cardiac surgery, approximately 20% of all patients show significant bleeding and 5% require re-intervention. In 50% of patients undergoing re-operation, no surgical cause can be determined, suggesting
multifactorial coagulopathy after cardiopulmonary bypass.Therefore, we developed a clinical algorithm for
the perioperative treatment of coagulopathy to guide
transfusion of blood products and hemostatic therapy.
Method
We used the evidence currently available and the point
of care methods routinely accessible in our institution
Increased mortality and morbidity associated with surgical re-intervention and transfusion requirements emphasize the importance of an algorithme based coagulation management.
53
Aprotinin in coronary surgery –
A retrospective application observation
M. Kluth, J. U. Lüth, M. Lanzenstiel,
K. Inoue
Institute for Anesthesiology, Heart and Diabetes
Center NRW, Bad Oeynhausen
chemia was significantly reduced in period Z 2 (28 vs.
8 [2,1 vs. 0,7%]). Postoperative kidney failure (as diagnosed by need of hemofiltration / dialysis) was significantly reduced (57 vs. 26 [4,3 vs. 2,3 %]). In-hospital death occurred in 34 (Z 1) versus 22 patients (Z
2) [2,5 vs. 2 %].
Aim
Conclusion
Application of Aprotinin is an established treatment
component to reduce perioperative blood loss and
blood transfusions. During an observation study
Mangano et al. demonstrated dose-dependent side-effects of aprotinin use in patients undergoing cardiac
surgery. In comparison to patients without aprotinin
administration there was an increased incidence of ischemic events in kidney, heart and brain [1]. This
study aimed at evaluating the implications of Mangano
et al’s study at our hospital.
After publication of Mangano et al. [1], application of
Aprotinin has been dramatically restricted at our hospital. Reduced percentages of laparotomies and hemodialysis can be discussed as a reduction of ischemic
events. These positive results are, however, confronted
by an increase in postoperative drain volume and
blood transfusion, latter being associated with reduced
long-term survival [2]. Application of other antifibrinolytics should be considered perspectively. Tranexam
acid seems to display a better risk profile, but identical
efficacy [1,3].
Methods
References
For this retrospective study we analysed our data bank
(Copra) looking for patients with coronary surgery
from August 1st, 2005 until January 31st, 2006 (Z 1)
and from February 1st, 2006 until July 31st, 2006 (Z
2). Statistical analyses were performed with student ttest and chi-square test using SPSS.
Results
1336 (Z 1) and 1100 patients (Z 2) were enroled in this
study. Patient characteristics were comparable in both
groups. Before publication of Mangano et al’s study
[1], percentage of intraoperative use of aprotinin (2
million KIE added to the „Priming volume“ of the
HLM) was approx. 80 % at our hospital (Z 1). After
that, there was a dramatic reduction in aprotinin use
(approx. 9%) without substitution of another fibrinolytic agent. During period Z 2 a significant increase
in mean post-operative drain volume (623 vs. 840 ml)
was observed as well as an increased need of perioperative blood infusions (2,5 vs. 3,3 EK). Percentage of
re-thoracotomies due to post-surgical bleeding was
comparable in both periods (27 vs. 22 [ 2%]), whereas percentage of laparotomies due to ileus or colon is-
1. Mangano DT et al. (2006) N Engl J Med 354: 353-365
2. Koch CG et al. (2006) Ann Thorac Surg 81: 1650-1657
3. Karkouti K et al. (2006) Transfusion 46: 327-338
Minimally invasive heart rate volume
measurement via VigileoTM Flow Trac
Monitor versus bolus thermodilution in
cardiac surgery patients
C. Kufner, A. Zimmermann, S. Hofbauer,
R. Schistek, J. Steinwendner, W. Hitzl,
S. Hargasser*, G. Pauser
Universitätsklinik für Anästhesiologie, perioperative
Medizin und allgemeine Intensivmedizin, Paracelsus
Medizinische Privatuniversität, Salzburg, Austria;
*Technische Universität München, Germany
Introduction
VigileoTM Monitor and Flow Trac Sensor (EdwardsLifesciences, Software Version 01.01) (Vig) is a mini-
54
6,00
4,00
2,862
2,00
0,00
0,00
-0,134
1,00
2,00
3,00
4,00
5,00
6,00
7,00
8,00
9,00
10,00
-2,00
-3,130
-4,00
-6,00
MW (Vig-PA)
Figure: Bland-Altmann Analysis, Mean difference of Methods 0,13 l/min; 1,96-fold standard deviation 2,99 l/min
mally invasive system for continuous monitoring of
heart rate volume (HZV) by pulse contour analysis.
The study aims at comparing the Vig system with
HZV monitoring via bolus thermodilution (PA).
Results
174 data sets could be analysed. Degree of conformity
of methods was independent from measurement time.
Heart rate volume (MW ± SD) at Vig was 5,7 ± 1,5
l/min ranging from 2,4 to 10,5 l/min.
Methods
On approval of the ethics committee and written consent of the patients, comparative measurements were
performed in 30 cardiac surgery patients in the operating theatre and in the ICU at the following time-points:
1. after induction of anesthesia, 2. before cannulation
for cardiopulmonary bypass, 3. after successful weaning from cardiopulmonary bypass, 4. at the end of surgery (skin suture), 5. one hour after admission to the
ICU, 6. three hours after admission to the ICU, 7. on
the morning of first post-operative day. Measurements
were taken by two independent researchers. Statistical
analysis was performed at each time-point. Bland-Altman analysis was performed cumulatively for all timepoints.
Discussion
Differences observed between Vig and PA suggest not
to recommend the present version of the Vig system as
a basis for therapeutic decisions in cardiac surgery patients.
References
1. Lester, Crichley et al. (1999) A Meta-Analysis of studies using
Bias and Precision statistics to compare output measurement techniques. J Clin Monit 15: 85-91
55
Adrenaline but not milrinone induces
hyperlactatemia and tissue dysoxia in
patients with myocardial dysfunction
after coronary artery bypass grafting
J. Schön1, M. Wernerus1, J. Grünefeld1,
H. Heinze1, M. Bechtel2, T. Hanke2,
M. Heringlake1
[1]. The present study was designed to examine the effects of adrenaline and milrinone on plasma lactate,
pyruvate, and glucose levels in patients needing inotropic support after coronary artery bypass grafting
(CABG).
Methods
Dept. of Anesthesiology and 2Cardiac Surgery,
University of Luebeck, Germany
1
Background
Increased plasma lactate levels in patients after cardiac
surgery have been associated with a worse prognosis
[mmol/l]
[mmol/l]
200
7
6
lactate
adrenaline
milrinone
180
pyruvate
160
control
5
140
120
4
*
80
*
&
*&
2
*
100
*
&
3
60
*&
1
0
The present study is a partial analysis of the AMORI
project investigating the effects of Adrenaline and
Milrinone On Renal function and Inflammation. During an 18 month period, 251 patients were screened for
low cardiac output upon ICU-admission after elective,
isolated CABG surgery. Patients presenting with a cardiac index (CI) < 2.2 l/min/m2 upon ICU-admission -
40
20
t0
t2
t6
t 10
t0
t 14
t2
t6
t 10
t 14
[rel. U]
37,5
[mg/dl]
lactate-pyruvate-ratio
glucose
240
35
32,5
220
30
200
27,5
*&
25
*
*&
22,5
180
*
160
20
17,5
140
15
120
12,5
10
100
t0
t2
t6
t 10
t 14
t0
t2
t4
t6
t8
t10
t12
t14
Fig. 1: The time course of plasma lactate, pyruvate, lactate-pyruvate ratio, and glucose in patients with myocardial dysfunction after CABG surgery treated with adrenaline (n = 7), milrinone (n = 11), and in control patients
(n = 20) not needing inotropic support. Data are given as mean ± SEM. *: significant difference (p < 0.05) between the adrenaline and the control group; &: significant difference (p < 0.05) between the adrenaline and the
milrinone-group (ANOVA with posthoc Fisher's PLSD).
56
despite adequate mean arterial and filling pressures were randomized to treatment with adrenaline (n=7) or
milrinone (n=11) to achieve a CI > 3.0 l/min/m2. 20
patients not needing inotropes served as controls (C).
Plasma lactate, pyruvate, glucose, hemodynamics,
acid-base status, and insulin requirements were determined until 14 hours after ICU-admission.
Results
After 2 to 4 hours, target CI was achieved in both intervention groups and maintained during the observation period. Plasma lactate, pyruvate, and the lactatepyruvate ratio increased during adrenaline treatment
and were higher than during milrinone or control conditions (figure 1). Plasma glucose (figure 1) and insuline doses (figure 2) were higher in adrenaline-treated
patients than in the control or milrinone-treated patients.
This suggests that the use of adrenaline for the treatment of postoperative myocardial dysfunction - in
contrast to milrinone - is associated with unwarranted
metabolic effects. Additionally, the increased lactatepyruvate ratio despite seemingly normalized hemodynamics is suggestive of moderate tissue dysoxia [2].
Both effects question the appropriateness of using
adrenaline as a first line agent for the treatment of myocardial dysfunction after coronary bypass surgery.
References
1. Maillet JM et al. (2003) Frequency, Risk Factors, and Outcome of
Hyperlactatemia After Cardiac Surgery Chest 123: 1361-1366
2. Weil MH et al. (1970) Experimental and clinical studies on lactate
and pyruvate as indicators of the severity of acute circulatory failure (shock). Circulation 41: 989-1001
This study was supported by grant F17/02 by the German foundation for heart research.
insuline doses
[U/h]
Conclusions
*&
9
*
8
adrenaline
*
7
milrinone
*&
control
6
5
*
4
*
3
#
2
#
#
#
1
0
t0
I2
I4
I6
I8
I 10
I 12
I 14
Fig. 2: The time course of intravenous insulin doses in
patients with myocardial dysfunction after CABG surgery treated with adrenaline (n = 7), milrinone (n =
11), and in control patients (n = 20) not needing inotropic support. Data are given as mean ± standard
error of the mean (SEM). *: significant difference (p <
0.05) between adrenaline and control group; &: significant difference (p < 0.05) between adrenaline and
milrinone-group; #: significant difference (p < 0.05)
between milrinone and control-group (ANOVA with
posthoc Fisher's PLSD).
Intraoperative TEE monitoring using
3-dimensional representation of mitral
valve prosthesis (SJM)
Better and real-time assessment of
function, dysfunction and assistance in
intraoperative “surgical decision-making“
A. Ziegler1, C. Keyl1, S. Laule1, L.Günkel2
1
Anaesthesie and 2Herzchirugie, Herzzentrum Bad
Krozingen, Germany
Introduction
Transesophageal echocardiography as an intraoperative monitoring in cardiac surgery has become a
worldwide standard procedure.
Positive effects of this kind of perioperative monitoring on postoperative outcome have been confirmed by
a range of scientific evaluations. Since more than one
year, the cardiac anesthesia team can profit from newer technologies like 3-dimensional TEE imaging.
57
Several scientific evaluations have demonstrated a significant advantage of this technology compared to 2dimensional imaging in mitral valve examination.
Method
By means of a case illustration this poster demonstrates the possibility to identify a para-valvular leakage in a just implantated plastic prosthesis using 3-dimensional transesophageal echocardiography while
still on heart-lung machine. Furthermore exact location of leakage (mapping) could be specified and exact
details could be provided for surgical decision-making.
Conclusion
3-dimensional representation by use of intraoperative
TEE monitoring allows real-time evaluation of mitral
valves (native valves as well as prosthetic valves) and
provides detailed intraoperative information on physiology and pathology of mitral valve position.
References
1. Mcnab A et al. (2004) Eur J Echocardiography 5: 212-222
Christian Geßner
Das Atemkondensat - nicht-invasiv gewonnene
biochemische Informationen aus der Lunge
Für die nicht-invasive Gewinnung von Informationen aus der Lunge erlangt das Atemkondensat zunehmend an
Bedeutung. Es enthält neben Wasser - dem Hauptbestandteil - eine Vielzahl chemischer und biochemischer Bestandteile, die sich als Gas im Atemkondensat lösen können, mit dem Wasser verdampfen oder als Aerosol aus
dem "epithelial lining fluid" der Lunge herausgelöst werden und so in das Atemkondensat gelangen. Bisher
wurde bereits eine Vielzahl von Markern im Atemkondensat nachgewiesen und deren Veränderungen bei verschiedenen, vor allem aber entzündlichen Lungenerkrankungen, erforscht.
In der Arbeit werden sowohl methodische Aspekte der Atemkondensatentstehung als auch verschiedene Marker auf ihre Bedeutung bei unterschiedlichen Lungenerkrankungen untersucht. Schwerpunkte dabei sind die
Charakterisierung des aktuellen Entzündungsgeschehens bei akutem Lungenversagen oder der COPD bzw. des
mechanischen Stresses bei Beatmung sowie das Erkennen von malignen Veränderungen aus nicht-invasiv gewonnenem Untersuchungsmaterial von Patienten mit einem Lungenkarzinom.
Somit stellt das Atemkondensat eine hervorragende Erweiterung der Möglichkeiten dar, biochemische, immunologische und molekularbiologische Informationen aus der Lunge zu gewinnen. Es bietet alle Voraussetzungen, in wenigen Jahren ein unverzichtbares Werkzeug pneumologischer Diagnostik zu werden.
58
List of authors
List of authors
Anwar, N., Dr. med.
Abteilung Anästhesiologie und Intensivtherapie,
Herzzentrum Leipzig GmbH, Strümpellstr. 39, 04289
Leipzig
Phone: 0341-8651438
[email protected]
Balogh, Doris, Prof. Dr. med.
Univ. Klinik f. Anaesthesie und Allgemeine Intensivmedizin, Anichstr. 35, A-6020 Innsbruck, Austria
Phone: +43 (512) 504 80390
[email protected]
Biermann, Elmar, Dr. jur.
Justitiar DGAI und BDA , Geschäftsstelle der DGAI/
BDA, Roritzerstr. 27, 900419 Nürnberg
Phone: 0911-9337818
[email protected]
Blettner, Maria, Prof. Dr. rer.nat.
Direktorin Institut für Medizinische Biometrie, Epidemiologie und Informatik, Obere Zahlbacherstr. 69,
55101 Mainz
Phone: 06131-177369
[email protected]
Burgard, Gerald, Dr. med.
Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, HELIOS Klinikum Erfurt, Nordhäuser Str.
74, 99089 Erfurt
Phone: 0361-781-2051
[email protected]
Diener, Markus, Dr. med.
Deutsches Cochrane Zentrum, c/o Universitätsklinikum Freiburg, Institut für Med. Biometrie & Med.
Informatik, Abt. med. Biometrie & Statistik, StefanMeier-Str. 26, 79104 Freiburg
Phone: 0761-2036691
[email protected]
Dietrich, Wulf, Prof. Dr. med.
Deutsches Herzzentrum München, Institut für Anästhesiologie, Lazarettstr. 36, 80636 München
Phone: 089-12184628
[email protected]
Dietz, Andreas, Dipl. Ing.
Technischer Laborleiter, Hochschule Furtwangen Abt.
VS, Fachbereich MUV - Ansprechpartner BME, Zentrum für Angewandte Simulation, Jakob-Kienzlestr.
17, 78054 VS-Schwenningen
Phone: 07720-307-4394
[email protected]
Eberle, Baltharsar, Priv.- Doz. Dr. med.
Abteilungsleiter Kardioanästhesie, Klinik und Poliklinik für Anästhesiologie, Inselspital Bern, CH-3010
Bern, Switzerland
Phone: +41-31-6322483
[email protected]
Ender, Jörg, Dr. med.
Chefarzt der Abteilung Anästhesiologie und Intensivtherapie, Herzzentrum Leipzig GmbH, Strümpellstr. 39, 04289 Leipzig
Phone: 0341- 865 1438
[email protected]
Erb, Joachim, Dr. med.
Universitätsklinik für Anästhesiologie und operative
Intensivmedizin, Campus Charité Mitte, Charitéplatz
1, 10117 Berlin
Phone: 030-450531012
[email protected]
Faßl, Jens, Dr. med.
Abteilung Anästhesiologie und Intensivtherapie,
Herzzentrum Leipzig GmbH, Strümpellstr. 39, 04289
Leipzig
Phone: 0341-8651438
[email protected]
List of authors
59
Grefer, Jochen, Dr. med.
Klinik für Anaesthesiologie, Universitätsklinikum
Schleswig-Holstein, Campus Lübeck, Ratzeburger
Allee 160, 23538 Lübeck
Phone: 0451-5003631
[email protected]
Kazmaier, Stephan, Dr. med.
Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität Göttingen,
Robert-Koch-Str. 40, 37075 Göttingen
Phone: 0551-392995
[email protected]
Greim, Clemens, Prof. Dr. med.
Klinikum Fulda gAG, Pacelliallee 4, 36043 Fulda
Phone: 0661-84-0
Kluth, Mario, Dr. med.
Institut für Anästhesiologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Georgstr. 11, 32545 Bad
Oeynhausen
Phone: 05731-973206
[email protected]
Hansen, Matthias, Dr. med.
Abteilung für Anästhesie, Robert-Bosch-Krankenhaus
Stuttgart, Auerbachstr. 110, 70379 Stuttgart
Phone: 0711-8101-3484
[email protected]
Heinze, H.
Phone: 0451-5003631
[email protected]
Hollinger, Ingrid, Prof. Dr. med.
Department of Anesthesiology, Mt. Sinai Hospital,
1450 Madison Avenue, NY 10029, New York, USA
Phone: +1-212-241-6426
[email protected]
Jámbor, Csilla, Dr. med.
Klinik für Anästhesiologie, Intensivmedizin und
Schmerztherapie, Klinikum der Johann-WolfgangGoethe-Universität, Theodor-Stern-Kai 7, 60590
Frankfurt
Phone: +49-69-6301-5998
[email protected]
Karzai, W., Priv.-Doz. Dr. med.
Klinik für Anästhesie und Intensivmedizin, Zentralklinik Bad Berka, Robert-Koch-Allee 9, 99437 Bad
Berka
Phone: 036458-51001)
[email protected]
Kopp, Ina, Priv.-Doz. Dr. med.
Institut für theoretische Chirurgie, Philipps-Universität Marburg, Baldingerstraße, 35043 Marburg
Phone: 06421-2862249
[email protected]
Kufner, Christine, Dr. med.
Universitätsklinik für Anästhesie, Perioperative Medizin und Intensivmedizin, Müllnerstr. 48, 5020
Salzburg, Austria
[email protected]
Lüth, Jan-Uwe, Dr. med.
Institut für Anästhesiologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Georgstr. 11, 32545 Bad
Oeynhausen
Phone: 05731-973206
[email protected]
Markewitz, Andreas, Prof. Dr. med., OFA
Abt. Herz- und Gefäßchirurgie, Bundeswehrzentralkrankenhaus, Rübenacherstr. 170, 56072 Koblenz
Phone: 0261-281-3730 or - 3715
[email protected]
Metzler, Helfried, Univ. Prof. Dr. med.
Univ. Klinik für Anästhesiologie und Intensivmedizin
LKH-Univ. Klinikum Graz, Auenbruggerplatz 29,
8036 Graz, Austria
Phone: +43-316-3854663
[email protected]
60
Pützhofen, Georg, Dr. med.
Chefarzt der Abteilung für Anästhesiologie und interdisziplinäre Intensivmedizin, Dominikus-Krankenhaus, Am Heerdter Krankenhaus 2, 40549 Düsseldorf
Phone: 0211/567-2601
[email protected]
Radke, Joachim, Prof. Dr. med.
Direktor der Universitätsklinik für Anästhesiologie
und operative Intensivmedizin, Universitätsklinikum
der Martin-Luther-Universität Halle-Wittenberg,
Ernst-Grube-Str. 40, 06120 Halle
Phone: 0345-5572322
[email protected]
Sauren, Bartel, Dr. med.
Abteilung Kardioanästhesie, HELIOS Klinikum Siegburg, Ringstr. 49, 53721 Siegburg
Phone: 02241-18-2933
[email protected]
Schelling, Fritz
Abteilungsleiter Personal, Universitätsklinikum Ulm,
Albert-Einstein-Allee 29, 89081 Ulm
Phone: 0731-50066110
[email protected]
Schirmer, Uwe, PD Dr. med.
Abteilung Kardioanästhesiologie, Universitätsklinikum Ulm, Steinhövelstr. 9, 89075 Ulm
Phone: 0731-50055401
[email protected]
Schlack, Wolfgang, Prof. Dr. med., D.E.A.A.
Chair Department of Anesthesiology, University of
Amsterdam (AMC), Meibergdreef 9, Postbus 22660
H1Z-112, 1100 DD Amsterdam, The Netherlands
Phone: +31 (0) 205662533
[email protected]
Schleppers, Alexander, Dr. med.
Ärztl. Geschäftsführer, Geschäftsstelle der DGAI /
BDA, Roritzerstr. 27, 90419 Nürnberg
Phone: 0911-933 78-0
[email protected]
List of authors
Schmid, Edith, Prof. Dr. med.
Abteilung Kardioanästhesie, Universitätsspital Zürich,
Rämistr. 100, CH-8091 Zürich, Switzerland
Phone: +41 (1) 2553376
[email protected]
Schön, Julika, Dr. med.
[email protected]
Veit, Christoph, Dr. med.
Geschäftsführer, Quant-Service Gesundheitssysteme
GmbH, Wendenstr. 309, 20537 Hamburg
Phone: 040-25407831 oder - 40
[email protected]
Weidenbach, Michael, Dr. med.
Klinik für Kinderkardiologie, Herzzentrum Leipzig
GmbH, Strümpellstr. 39, 04289 Leipzig
Phone: 0341-865-1036 o. -1037
[email protected]
Werner, Christian, Prof. Dr. med.
Direktor der Klinik für Anästhesiologie, Klinikum der
Johannes-Gutenberg-Universität, Langenbeckstr. 1,
55131 Mainz
Phone: 06131-177117
[email protected]
Ziegler, Andreas, Dr. med.
Anästhesie, Herzzentrum Bad Krozingen, Südring 15,
79189 Bad Krozingen
Phone: 07633-402-590
[email protected]

Rapid communications - Applied Cardiopulmonary Pathophysiology

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