Thrombolytic therapy during and/or after cardiopulmonary resuscitation.
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Cardiopulmonary Resuscitation↗
Biomedical subjects
E Martin
Publications and source records attributed to E Martin.
[Risk management in anesthesiology--a continuing challenge].
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Anesthesia↗
[Invasive emergency techniques (INTECH). A training concept in emergency medicine].
BACKGROUND: Introducing a chest tube is a routine emergency procedure in trauma victims. Emergency coniotomy or establishing an intraosseous access, however, are not often necessary, but in individual cases these techniques can be decisive for patient survival. The aim of this study was to present and evaluate a model for teaching these techniques, since the majority of emergency physicians do not have adequate experience in this area. METHODS: In November 2001 our institution organized the first workshop on "Invasive emergency techniques (INTECH): chest tube, emergency coniotomy, and intraosseous access" in collaboration with the Institute of Anatomy II of the University of Heidelberg. After presenting basic anatomy and also particular features of the relevant regions of the body, the techniques of introducing a thoracic drainage, performing a coniotomy, and establishing an intraosseous access were presented. Video demonstrations as well as practical exercises on corpses followed the theoretical part of the course. At the end of each lesson, the participants were asked anonymously why they took part in the workshop and about their previous experience with these emergency techniques in written form and also asked to assess the didactic concept of the workshop (scale 1=very good up to 6=very poor). RESULTS: Of the 86 participants, 66 completed the questionnaire (77%) and 40 of the participants had been working as emergency physicians for 6.5+/-6.3 years (range 0.5-22) with approx. 13+/-8 (range 4-30) interventions per month. The most common reason for participating was lack of practice (52%): prior to the workshop, 98% of the emergency physicians had never performed a coniotomy, 85% had never established an intraosseous access, and 28% had never introduced a chest tube in an emergency setting. The theoretical parts of the course received the following scores: "Basic anatomy" 2.3+/-0.8, "coniotomy" 1.7+/-0.7, "intraosseous access" 1.5+/-0.5, and "thoracic drainage " 1.7+/-0.7. In the practical part they were given the scores: "coniotomy" 1.9+/-0.7, and "intraosseous access" and "thoracic drainage" both 1.6+/-0.8. Finally, the "positioning demonstrations" were given scores of 1.7+/-0.8 and the practical exercises as a whole 1.4+/-0.7. CONCLUSIONS: These results show that even emergency physicians with many years of practice have too little knowledge about thoracic drainage, even though it is required in the management of trauma victims. Over 80% of the emergency physicians have no experience with certain other emergency measures recommended as lifesaving in individual cases. Despite the criticism that the participants of the workshop were a selected study group, these numbers seem to reflect reality: Institutions with emergency medicine departments have reported considerable and serious deficiencies in providing emergency care to patients with polytrauma. These gaps could be closed by implementing practice-oriented workshops in collaboration with anatomical institutes. As these institutes use fixated corpses for training purposes, the differences in working with living patients would have to be made clear. In spite of this minor restriction, practical exercises could counteract the deficits in the care of emergency patients and should therefore be integrated into a future educational concept on a long-term basis.
Chest Tubes↗
[Contribution of anesthesia to workflow operation].
The changes in our health care system caused by the introduction of DRGs make it necessary for us to abandon departmental process structures in favour of total hospital orientated process structures. An interdisciplinary approach is crucial to enable the most effective use of personnel and material resources. Future orientated information technology and organisational structures will enable us to process our patients effectively and efficiently from pre-admission to discharge. Anaesthesia has to be integrated into a patient management system for in- and out-patients. The essential matters for consideration are anaesthesia consulting hours, the common establishment of process structures for preoperative care, operation room management and postoperative patient care. Routine controls and analysis of the required teamwork reveal improvement potential and enable us to use the necessary control elements effectively.
Anesthesia Department, Hospital↗
[Locally advanced non-small-cell bronchial cancer: role of exclusive chemoradiotherapy].
Lung cancer is the most frequent form of malignant tumours. The prognosis is poor with a 5-year cure rate which increased from approximately 6% in the sixties to only 15% in the nineties. Surgery remains the reference treatment but only a small minority of patients (about 25%) present with operable disease. The post-surgical 5-year survival is only 25%, providing the rationale for the current research on adjuvant treatments for control of both local and metastatic disease. In that context, the combination of radiotherapy and chemotherapy, commonly referred to as chemo-radiotherapy, has assumed considerable importance: either exclusively in inoperable patients (inoperable tumour or patients inoperable for medical reasons), or pre-operatively. This article reviews the results of the pivotal definitive chemoradiotherapy studies in non-metastatic non-small-cell lung cancer. With exclusive chemoradiation, the concomitant scheme seems to be the most favourable, results issued from randomised studies are expected to confirm that point. An increased toxicity is observed, and the advent of conformal therapy may allow another survival gain. Optimal treatments integration will be necessary.
Antineoplastic Agents↗
[Preoperative chemotherapy and chemoradiotherapy for non-small-cell bronchial cancers].
The very disappointing results obtained by surgery in resectable non-small-cell lung cancer have led to a high active clinical research concerning pre- or postoperative treatment. Preoperative treatment has several distincts goals: to increase survival for patients suitable for surgery, to limit surgery or transform borderline or non resectable cancer into resectable tumors. Available datas on preoperative treatments for non-small-cell lung cancer provide from three types of therapeutics trials: 1/Some phase II studies of neoadjuvant chemotherapy have demonstrated that the neoadjuvant approach was feasible, and didn't compromise surgery. 2/Phase II trials of neoadjuvant chemoradiotherapy, performed for the majority on more extensive cancers, have demonstrated that this approach was also feasible at the expense of higher but still tolerable toxicity. 3/Phase III randomised published trials exclusively deal with preoperative chemotherapy with different results: two of them concerned a small number of patients presenting with non-small-cell lung stage IIIA cancer: they are positive. The third concerned 373 patients presenting with stage I, II, IIIA cancer: the three-year survival was increased by 11%, but this difference is not yet significant. The benefit essentially appeared for stage I and II. One trial comparing preoperative chemotherapy and radiochemotherapy has been reported, concluding to the superiority of the association. These observations suggest that the clinical research should now be different for stages I and II, and stage IIIA.
Antineoplastic Combined Chemotherapy Protocols↗
Gene transfer of NMDAR1 subunit sequences to the rat CNS using herpes simplex virus vectors interfered with habituation.
1. The aim is to study some roles of the hippocampal NMDA receptor, by modifying the expression of the essential NR1 subunit, with temporal and spatial restrictions in the central nervous system (CNS) of the rat. 2. Due to their neurotropism and the size of inserts they can accomodate, herpes simplex virus type-1 (HSV-1) derived amplicon vectors were used to transfer sequences, either in sense (+) or antisense (-) orientations, of the NR1 subunit gene, or of the green fluorescent protein (GFP) gene, into the CNS. 3. Vector expression in cell lines was followed by GFP autofluorescence, immunofluorescence and western blot. 4. The vectors were inoculated into the dorsal hippocampus of adult male Wistar rats, which were evaluated for habituation to an open field, and then, for expression of the transgenes, by autofluorescence and western blot; the expression mainly happened in pyramidal cells of CA1. 5. The animals injected with vectors carrying the NR1(+) transgene showed habituation to the new environment, as also happened with rats injected with vectors carrying only the GFP transgene. 6. In contrast, animals injected with vectors carrying NR1(-) sequence, did not show habituation. This might be retrograde amnesia or disability to record the trace, suggesting that the NR1 subunit in the dorsal hippocampus, is involved in habituation to a new environment. 7. HSV-1 derived amplicon vectors appear to be useful tools to modify endogenous gene expression, at a defined period, in restricted regions of the CNS.
Animals↗
Pulse contour analysis versus thermodilution in cardiac surgery patients.
BACKGROUND: Previous studies have demonstrated that there is a lack of agreement between intermittent cold bolus thermodilution (ICO) and a semicontinuous method with dilution of heat (CCO) in cardiac surgical patients following hypothermic extracorporeal circulation (HCPB). Therefore, the aim of the present study was to compare both ICO and CCO with continuous pulse contour analysis (PCCO): a method based on a fundamentally different principle of determining cardiac output (CO). METHODS: A prospective criterion standard study of 25 cardiac surgery patients undergoing HCPB. Cardiac output was determined using the three methods (ICO, CCO, and PCCO) before and after HCPB up to 12 h after arrival on the ICU. Bias and precision were evaluated. RESULTS: A total of 380 triple determinations of CO could be analyzed. During the entire study period bias PCCO-ICO was -0.14 l*/min (precision 1.16 l*/min) and bias CCO-ICO was -0.40 l*/min (precision 1.25 l*/min). Up to 45 min after bypass PCCO agreed with ICO (bias -0.21 l*/min, precision 1.37 l*/min), while bias CCO-ICO was -1.30 l*/min (precision 1.45 l*/min). CONCLUSION: The agreement between PCCO and ICO in contrast to CCO in the first 45 min after HCPB indicates that CCO underestimates CO during this period.
Adult↗
Thrombolytic therapy during cardiopulmonary resuscitation--is the initial cardiac rhythm a critical issue?
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Arrhythmias, Cardiac↗
Intraocular pressure more reduced during anesthesia with propofol than with sevoflurane: both combined with remifentanil.
BACKGROUND: Short-acting anesthetic agents are suitable and commonly used in ocular surgery. Propofol and remifentanil are known to reduce intraocular pressure (IOP), but no information is available regarding the effects of sevoflurane combined with remifentanil on IOP. METHODS: Therefore, a prospective, randomized study was conducted to compare the effects on IOP of two different anesthetic techniques: one based on a total intravenous anesthesia with propofol (Group P, bolus 1.5-2.0 mg/kg, maintenance 3.0-7.0 mg/kg/h); and the other based on sevoflurane (Group S, inhalational induction, end-tidal concentration 0.7-1.2 vol.%). An infusion of remifentanil (10 microg/kg/h) was used with both techniques. In ASA I-III patients with normal IOP undergoing elective cataract surgery, using an applanation tonometer, IOP was measured contralateral to the operated eye at nine predefined time points before, during and after anesthesia. RESULTS: The two groups (n=20 each) were comparable with regard to demographic data and hemodynamic variables. Baseline IOP was 14.2+/-2.8 mmHg (Group P) and 14.1+/-2.4 mmHg (Group S; NS). During and following the induction of anesthesia, IOP was reduced in both groups. Intraocular pressure was significantly lower in Group P (6.0+/-3.2 mmHg) than in Group S (8.9+/-3.4 mmHg) during the induction of anesthesia. CONCLUSION: In patients undergoing cataract surgery under general anesthesia with tracheal intubation, anesthetic regimens with propofol as well as with sevoflurane, both combined with remifentanil, decrease IOP significantly. The decrease in IOP was significantly more pronounced in the propofol group than in the sevoflurane group.
Aged↗
[The visualisation of dura perforation and blood patches with ultrasound].
The postdural puncture headache (PDPH) is a possible complication after spinal or epidural puncture. The therapeutic concept is usually organised step by step, but the epidural blood patch is the most reliable and effective therapy. In earlier studies myelographie, epidurographie and MRT were used, to visualise the localisation of the dural defect and to describe the effects of patching the epidural space. Our working group focused on the utilisation of ultrasound and we decided to use this technique for the visualisation of bloodpatches. With agreement of the local ethics committee we monitored the performance of 4 epidural bloodpatches in pregnant women, who suffered from PDPH. We used a General Electric LQ 400 ultrasonograph with a 7-MHz-probe. To ensure sterile conditions we used sterile ultrasound sleeves and sterile ultrasound gel. In 3 of 4 cases a continuity loss could be represented in the doppel layer signal of the dura. It had the size of the diameter of a Tuohy needle. In one case the defect of the dura was larger than in the preliminary investigations (2,5 - 3 mm). The ultrasonography of the epidural space was performed in the paramedian scan. All patches were placed by using the conventional loss of resistance technique with using online ultrasound support. The epidural puncture and the application of the blood patches were visualised simultaneously in all cases. With the injection of blood a brief expansion of the epidural space was seen. The patients recieved a mean injection volume of 17 ml sterile blood. 10 to 40 seconds after the injection of blood the disconituity of the dura doppel layer signal was no longer provable. Within a short time we could detect the increase of cerebrospinal fluid and the patients headache was treated sucessfully. The clinical use of this diagnostic technique can be found in the simultaneous presentation of the dura leakage and the intervention while performing an epidural bloodpatch. Since these informations are relevant for further clinical practice further investigations are warranted.
Adult↗
"Vanishing white matter" and ovarian dysgenesis in an infant with cerebro-oculo-facio-skeletal phenotype.
We describe a girl with intrauterine growth retardation, congenital cataracts, mild dysmorphic features and joint contractures. MRI performed at 1 week and 6 months, demonstrated postnatal cerebral and cerebellar atrophy and loss of white matter. The patient died at 10 months. Post-mortem examination revealed ovarian dysgenesis. There was normal development of neuronal and axonal structures, but lack of myelination in brainstem and cerebellum. Subcortical and deep white matter of the cerebral hemispheres were largely destroyed (cavitated), with preserved, but unmyelinated axons in other brain areas. These findings are compatible with a severe leukodystrophic process of pre- or perinatal onset. The exact pathogenesis is not known.
Abnormalities, Multiple↗
Comparison of caudal and intravenous clonidine in the prevention of agitation after sevoflurane in children.
BACKGROUND: In children, sevoflurane anaesthesia is associated with postanaesthetic agitation, which is treated mainly with opioids. We compared the effectiveness of epidural and i.v. clonidine in the prevention of this postanaesthetic agitation. METHODS: Eighty children aged 3-8 yr (ASA I-II) received standardized general anaesthesia with inhaled sevoflurane and caudal epidural block with 0.175% bupivacaine 1 ml kg-1 for minor surgery. The children were assigned randomly to four groups: (I) clonidine 1 microgram kg-1 added to caudal bupivacaine; (II) clonidine 3 micrograms kg-1 added to caudal bupivacaine; (III) clonidine 3 micrograms kg-1 i.v. and caudal bupivacaine; and (IV) caudal block with bupivacaine, no clonidine (control). A blinded observer assessed the behaviour of the children during the first postoperative hour. Secondary end-points were the time to fitness for discharge from the postanaesthesia care unit, and haemodynamic and respiratory variables. RESULTS: The incidence of agitation was 22, 0, 5 and 39% in groups I, II, III and IV respectively (P < 0.05 for groups II and III compared with group IV). During the first hour after surgery, patients in groups II and III had significantly lower scores for agitation than group IV patients. Time to fitness for discharge did not differ between the four groups. CONCLUSIONS: Clonidine 3 micrograms kg-1 prevented agitation after sevoflurane anaesthesia, independently of the route of administration. The effect of clonidine appears to be dose-dependent, as an epidural dose of 1 microgram kg-1 failed to reduce it.
Adrenergic alpha-Agonists↗
Fluorangiographic alterations in a dog with suspected iatrogenic partial carotid artery occlusion.
During routine fluorescein angiography, a healthy female dog demonstrated abnormal delayed filling of retinal and choroidal vessels. Fluorangiographic times were increased four- to fivefold with respect to reference values. Fluorescein angiography, using the same protocol, was repeated two weeks later and a fluorangiogram within reference values was obtained. The abnormal results in the first procedure were suspected to have resulted from partial occlusion of the carotid artery secondary to the restraining method used.
Animals↗
Thrombolytic therapy during cardiopulmonary resuscitation.
Recently, efforts have been undertaken to investigate the effects of thrombolysis during cardiopulmonary resuscitation (CRP) in patients suffering from massive pulmonary embolism or acute myocardial infarction. In up to 70% of patients with cardiac arrest, one of these two diseases is the underlying cause of deterioration. Nevertheless, thrombolysis has not been conducted during CPR because of the fear of severe bleeding complications. However, an increasing number of clinical studies suggest that thrombolytic therapy during CPR can contribute to haemodynamic stabilisation and survival in patients with massive pulmonary embolism and acute myocardial infarction, when conventional CPR procedures have been performed unsuccessfully. Apart from the specific causal action of thrombolytic agents at the site of pulmonary emboli and coronary thrombosis, experimental data indicate that thrombolysis during CPR can improve microcirculatory reperfusion, which may be most important in the brain. In accordance with these data, marked activation of blood coagulation without adequate activation of endogenous fibrinolysis has been demonstrated early after cardiac arrest. In summary, thrombolysis during CPR is presently a treatment strategy that can be performed on an individual basis in patients with pulmonary embolism or acute myocardial infarction. It may become a routine measure if positive results of randomised, controlled clinical trials will be available in the future.
Cardiopulmonary Resuscitation↗
Vasopressin and epinephrine for cardiac arrest.
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Emergency Medical Services↗
Characterization of neutralization epitopes of simian immunodeficiency virus (SIV) recognized by rhesus monoclonal antibodies derived from monkeys infected with an attenuated SIV strain.
A major limitation in the simian immunodeficiency virus (SIV) system has been the lack of reagents with which to identify the antigenic determinants that are responsible for eliciting neutralizing antibody responses in macaques infected with attenuated SIV. Most of our information on SIV neutralization determinants has come from studies with murine monoclonal antibodies (MAbs) produced in response to purified or recombinant SIV envelope proteins or intact SIV-infected cells for relatively short periods of time. While these studies provide some basic information on the potential immunogenic determinants of SIV envelope proteins, it is unclear whether these murine MAbs identify epitopes relevant to antibody responses elicited in monkeys during infection with either wild-type or attenuated SIV strains. To accomplish maximum biological relevance, we developed a reliable method for the production of rhesus monoclonal antibodies. In the present study, we report on the production and characterization of a unique panel of monoclonal antibodies derived from four individual monkeys inoculated with SIV/17E-CL as an attenuated virus strain at a time when protective immunity from pathogenic challenge was evident. Results from these studies identified at least nine binding domains on the surface envelope glycoprotein; these included linear determinants in the V1, V2, cysteine loop (analogous to the V3 loop in human immunodeficiency virus type 1), and C5 regions, as well as conformational epitopes represented by antibodies that bind the C-terminal half of gp120 and those sensitive to defined mutations in the V4 region. More importantly, three groups of antibodies that recognize closely related, conformational epitopes exhibited potent neutralizing activity against the vaccine strain. Identification of the epitopes recognized by these neutralizing antibodies will provide insight into the antigenic determinants responsible for eliciting neutralizing antibodies in vivo that can be used in the design of effective vaccine strategies.
Amino Acid Sequence↗
YC-1 activation of human soluble guanylyl cyclase has both heme-dependent and heme-independent components.
YC-1 [3-(5'-hydroxymethyl-2'furyl)-1-benzyl indazole] is an allosteric activator of soluble guanylyl cyclase (sGC). YC-1 increases the catalytic rate of the enzyme and sensitizes the enzyme toward its gaseous activators nitric oxide or carbon monoxide. In other studies the administration of YC-1 to experimental animals resulted in the inhibition of the platelet-rich thrombosis and a decrease of the mean arterial pressure, which correlated with increased cGMP levels. However, details of YC-1 interaction with sGC and enzyme activation are incomplete. Although evidence in the literature indicates that YC-1 activation of sGC is strictly heme-dependent, this report presents evidence for both heme-dependent and heme-independent activation of sGC by YC-1. The oxidation of the sGC heme by 1H-(1,2,4)oxadiazole(4,3-a)quinoxalin-1-one completely inhibited the response to NO, but only partially attenuated activation by YC-1. We also observed activation by YC-1 of a mutant sGC, which lacks heme. These findings indicate that YC-1 activation of sGC can occur independently of heme, but that activation is substantially increased when the heme moiety is present in the enzyme.
Base Sequence↗