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Biomedical subjects

M Tryba

Publications and source records attributed to M Tryba.

At least 37 records · Page 2Linked to original sources
PubMed1995

[Stress bleeding. 2. Prophylaxis].

Preventive strategies aim to reduce gastric acidity (H2-antagonists, antacids), to strengthen mucosal defence mechanisms (sucralfate, antacids, pirenzepine) and to normalize gastric mucosal microcirculation (sucralfate, pirenzepine). Thus, the most important prophylactic measure is an optimized emergency and ICU regime aiming to improve oxygenation and microcirculation. All specific drugs used for stress ulcer prophylaxis have been shown to be effective in prospective controlled studies. Furthermore, pirenzepine has been found to be superior to H2-antagonists, at least in neurosurgical patients. Insufficient or no data exist to support the use of prostaglandins or omeprazole for stress ulcer prophylaxis. The most important adverse effect of stress ulcer prophylaxis is nosocomial pneumonia due to gastric alkalinization. This may occur in long-term ventilated patients with a gastric pH > 4 and may account for up to 50% of all nosocomial pneumonias in certain groups of patients. Mortality is not influenced by antacids or H2-antagonists, while sucralfate has been shown to reduce mortality, most probably by inhibition of bacterial translocation.

Animals↗
PubMed1995

Severe undertreatment of cancer pain: a 3-year survey of the German situation.

The aim of this survey was to determine the prescribing patterns of German physicians in the treatment of cancer pain. The computerized patient records of 330 practices, which treated a total number of 1,104,435 patients over a 3-year period, were analyzed. "Strong" opioids, widely accepted in the management of severe cancer pain, were prescribed to just 322 of 16,630 cancer patients (1.9%). Only 99 (0.6%) patients received more than three prescriptions during more than 3 weeks of treatment. Additionally, many prescriptions mandated inadequate time intervals for the dosing, and 12% of the prescriptions were given "as required." From these data, it can be concluded that the majority of cancer patients in Germany are not treated for pain at all, and that those patients who receive treatment are treated inadequately. Germany is still a developing country in terms of pain therapy. This situation is symptomatic of many countries and reflects the continuing prejudice against opioids.

Analgesics, Opioid↗
PubMed1995

Dose-response effects of intravenous clonidine on stress response during induction of anesthesia in coronary artery bypass graft patients.

This study was designed to evaluate the dose-response effects of different doses of clonidine on the stress response to laryngoscopy and endotracheal intubation. In a randomized, double-blind study, 48 coronary artery bypass grafting (CABG) patients received 0, 2, 4, or 6 micrograms/kg clonidine as an intravenous (IV) infusion during a 15-min period 30 min prior to induction of anesthesia with etomidate (0.3 mg/kg), fentanyl (5-7 micrograms/kg), and pancuronium (0.1 mg/kg). Sedation was assessed prior to induction of anesthesia. Cardiovascular variables and catecholamine plasma levels were measured at predefined intervals. Additional bolus doses of etomidate and fentanyl for suppression of stress-induced reactions were administered if predefined limits of heart rate and blood pressure were exceeded. Clonidine 4 and 6 micrograms/kg significantly attenuated hemodynamic and adrenergic reactions to stress, reduced pharmacologic interventions, and increased sedation. However, clonidine 6 micrograms/kg was not more effective than 4 micrograms/kg, and clonidine 2 micrograms/kg was equally effective as placebo. We conclude that clonidine 4 micrograms/kg IV is the appropriate dose to attenuate the stress response to laryngoscopy in CABG patients. Side effects limiting the use of IV clonidine were not observed.

Blood Pressure↗
PubMed1995

Gastric alkalinization, pneumonia, and systemic infections: the controversy.

BACKGROUND: Gastric alkalinization has been suspected as a cause of pneumonia in critically ill patients. Although meta-analysis of the available data confirms an association between the administration of antacids/H2-antagonists and the risk of pneumonia, controversy remains whether stress ulcer prophylaxis with sucralfate reduces the risk of pneumonia. We hypothesized that the conflicting study results may be due to differences in patient population and general treatment regimens. RISK FACTORS: Microbiological studies have shown that a gastric pH > 4 is crucial for overgrowth of gastric gram-negative but not gram-positive bacteria. Sucralfate mainly influences the growth of gram-negative bacteria. Thus, in patient groups with a high frequency of gram-positive pneumonia, preservation of gastric acidity does not influence the pneumonia rate. Since 40-60% of critically ill patients show gastric pH values > 4 even without administration of acid-neutralizing agents, an increased risk of nosocomial pneumonia with antacids/H2-antagonists can only be expected if these agents substantially increase the frequency of patients with gastric pH > 4. No influence of stress ulcer prophylaxis on the pneumonia rate can be expected in patients on enteral nutrition, especially if administered continuously. In non-ventilated patients or in those with a short duration of ventilation no significant influence of stress ulcer prophylaxis on nosocomial pneumonia rate can be expected. The same is true for patient groups where regurgitation of gastric content is prevented, e.g. head-up position in neurosurgical patients. Furthermore, in patient groups with primary lung injury nosocomial pneumonia occurs due to specific pathomechanisms, e.g. lung contusion or inhalation injury. Based on these factors we have developed a scoring system and have performed a regression analysis between the sum of the risk scores and the odds ratio of nosocomial pneumonia of all available stress ulcer studies dealing with nosocomial pneumonia. RESULTS: A highly significant correlation (p < 0.0001) could be demonstrated between the sum of the risk score and the odds ratio for pneumonia. An increased risk of nosocomial pneumonia due to stress ulcer prophylaxis with antacids/H2-antagonists occurred in patient groups with a risk score of > or = 2. CONCLUSIONS: This analysis supports the hypothesis that gastric alkalinization significantly increases the risk of nosocomial pneumonia in long-term ventilated patients. However, this analysis also shows that only specific subgroups of patients benefit from acid-independent stress ulcer prophylaxis relative to nosocomial pneumonia. Furthermore, recent experimental and clinical studies support the hypothesis that gastric alkalinization may increase the risk of systemic infections and that sucralfate may have significant protective effects.

Acid-Base Equilibrium↗
PubMed1994

[Stress bleeding. 1. Pathogenesis, clinical picture and therapy].

Acute upper gastrointestinal bleeding in ICU patients has many possible causes: ulcer, adverse drug effects, gastric tube lesion, acute renal or liver failure, or stress-induced gastric mucosal lesion. Stress-induced gastric mucosal lesions typically are multiple superficial erosions, while ulcerations typically occur in patients with head trauma, neurosurgical operation or severe burns. Head trauma and neurosurgical patients are the only ones with increases gastric acid secretion; in general reduced acid secretion can be observed in ICU patients. An active acid secreting stomach has been shown to be more resistant against mucosal damage than a stomach with basal activity. Active acid secretion depends on sufficient oxygen supply and mucosal ATP content. Hypotension and shock results in gastric mucosal ischaemia. These are the most important risk factors of stress bleeding.

Critical Care↗
PubMed1994

[Preventing blood transfusion in a severely burned Jehovah's witness].

The treatment rationale of a burn victim (35% TBSA) who was child of Jehova's witnesses is described. Following a combined approach including erythropoetin and blood saving surgical techniques we were able to excise and graft the burn areas without blood transfusion. An extremely low hemoglobin of 3.4 g/dl was tolerated postoperatively and showed an increase to 10.9 g/dl 25 days later when the child was dismissed from the burn unit in stable condition. Possibilities to minimize blood loss and to avoid blood transfusions are discussed.

Blood Loss, Surgical↗
PubMed1994

Rapid-sequence orotracheal intubation with rocuronium: a randomized double-blind comparison with suxamethonium--preliminary communication.

Eighty ASA I-III patients were randomly assigned to four groups. Group I patients received rocuronium 0.6 mg kg-1 immediately prior to thiopentone, while patients in group II received the same dose immediately after the induction agent. In groups III and IV a priming dose of rocuronium 0.04 mg kg-1 was administered prior to induction. Group III patients received rocuronium immediately prior to thiopentone. In group IV, suxamethonium 1.5 mg kg-1 was administered immediately after thiopentone. Intubation conditions were scored by a blinded investigator. An intubation time of > 60 s was defined as a failure. All patients could be intubated within 60 s. Priming with rocuronium did not improve intubation conditions. Total intubation scores > 6 occurred significantly more often in group II (P < 0.01 vs. all other groups). A single bolus dose of rocuronium 0.6 mg kg-1 (2 x ED95) administered immediately prior to thiopentone 6 mg kg-1 offers the same intubation conditions as suxamethonium 1.5 mg kg-1.

Adult↗
PubMed1994

Plasma aluminum concentrations in long-term mechanically ventilated patients receiving stress ulcer prophylaxis with sucralfate.

OBJECTIVES: To determine plasma aluminum concentrations and 24-hr urine aluminum excretion rate in long-term mechanically ventilated patients treated with 6 g of sucralfate daily for stress ulcer prophylaxis. DESIGN: Prospective study in long-term mechanically ventilated critically ill patients. SETTING: A surgical intensive care unit at a university hospital. PATIENTS: Eleven long-term mechanically ventilated patients (multiple trauma [n = 8], abdominal surgery [n = 3]) were included in the study. The mean age of the patients was 57.2 +/- 10.8 yrs and the mean duration of treatment was 11.3 +/- 4.2 days. INTERVENTIONS: 1 g of sucralfate suspension intragastrically six times daily. MEASUREMENTS AND MAIN RESULTS: Baseline plasma aluminum concentrations were determined at the beginning of the study. Patients received 1 g of sucralfate suspension given intragastrically six times daily via a nasogastric tube. Daily plasma aluminum concentration was measured 3 hrs after the morning dose of sucralfate. The urine aluminum excretion rate was determined from the 24-hr urine samples. Determinations of plasma and urine aluminum concentrations were carried out by flameless atomic absorption spectrophotometry. Renal function was compromised in eight patients (maximum plasma creatinine concentration 2.7 mg/dL [238.7 mumol/L]; normal value < 1.4 mg/dL [< 123.8 mumol/L]). Mean daily plasma aluminum concentration varied between 7.5 +/- 1.6 micrograms/L (278 +/- 59.3 nmol/L) and 21.1 +/- 7.1 micrograms/L (782 +/- 263.1 nmol/L) (normal value < 10 micrograms/L [< 371 nmol/L]). The 24-hr urine aluminum excretion rate varied between 25.7 +/- 18.1 and 53.4 +/- 87.2 micrograms/L (952.4 +/- 671 and 1979 +/- 3232 nmol/L) (normal value < 12.2 micrograms/L [< 452 nmol/L]). Aluminum accumulation did not occur in any of the patients. CONCLUSIONS: The administration of 6 g of sucralfate daily in long-term mechanically ventilated surgical patients did not result in an increase in the plasma aluminum concentration. Sucralfate can be administered safely for a period of at least 2 wks, even in critically ill patients with impaired renal function.

Adult↗
PubMed1994

Oropharyngeal decontamination with gentamicin for long-term ventilated patients on stress ulcer prophylaxis with sucralfate?

The incidence of nosocomial pneumonia in long-term ventilated patients has been reduced by stress ulcer prophylaxis with sucralfate. In a double-blind trial we studied whether gentamicin administered topically to the oropharynx (OPG) had additional clinical benefits in these patients. 67 critically ill adult patients fulfilled entry criteria for > or = 5 days on ventilation. The OPG group received 40 mg gentamicin, the control group received 5% dextrose topically administered to the oropharynx 4 times a day. During OPG, pharyngeal colonization rate (21 vs 44%) and tracheal secretion colonization rate (12 vs 41%) were significantly lower than during placebo (p < 0.05). Despite these differences nosocomial pneumonia rate (3 vs 12%), duration of mechanical ventilation [15.8 +/- 11.1 vs 19.9 +/- 37.5 days (means +/- SD)] and mortality (27 vs 41%) were not significantly affected by OPG. Moreover, 13 of 15 bacteria (87%) that occurred during OPG were resistant to gentamicin. Despite its reduction of bacterial colonization rates of pharyngeal and tracheal secretions, OPG did not seem to offer additional clinical benefits in long-term mechanically ventilated patients on stress ulcer prophylaxis with sucralfate.

Administration, Topical↗
PubMed1993

Critical care pharmacotherapy. A review.

During recent years, research in critical care medicine has focused on the role of the gastrointestinal tract in the pathogenesis of multiple organ failure and nosocomial infection, and on preventive measures. Gram-negative bacterial overgrowth of the oropharynx and stomach has been proved to be a cause of nosocomial pneumonia. Topical application of antibiotics into the oropharynx and stomach, and preservation of gastric acidity have been shown to be effective prophylaxis in ventilated patients. Recent studies have demonstrated that gastric alkalinisation is no longer necessary for the prevention of stress ulcer bleeding in critically ill patients. Tissue hypoxaemia, not gastric acidity, is the underlying pathomechanism of stress ulcer bleeding. In experimental investigations, pirenzepine and sucralfate improved gastric mucosal oxygen supply. Both compounds effectively prevent bleeding without increasing gastric pH. In mechanically ventilated patients, significantly lower rates of pneumonia occur with both of these drugs compared with antacids or histamine H2-receptor antagonists. Topical antibiotics (selective digestive decontamination) are most effective in patients with alkaline gastric juice, but of only marginal clinical relevance in those with acidic gastric contents. Isoflurane, propofol and clonidine have been recently investigated for sedation of ventilated patients. Isoflurane may lead to fluoride accumulation after more than 1 day. Propofol dosage has to be increased more often after 4 to 7 days, leading to fat overload and significantly increased costs. Clonidine was highly effective in patients with 'sympathetic overshoot', e.g. those experiencing alcohol or opioid withdrawal. Wound infections are an important problem in burn patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Critical Care↗
PubMed1993

Inotropic support of the critically ill patient. A review of the agents.

Intensive care patients often require inotropic support to stabilise circulation and to optimise oxygen supply. In this context, the catecholamines norepinephrine (noradrenaline), epinephrine (adrenaline), dopamine and dobutamine are still the mainstay of therapy. They provide, to different extents, a variety of adrenoceptor-mediated actions comprising vasoconstriction (via alpha-receptors) as well as vasodilatation (via beta 1-receptors), and an increase in cardiac output by enhancing inotropy and heart rate (again via beta 1-receptors). Because of their favourable pharmacokinetic profile (plasma half-lives of about 2 minutes) their actions can easily be controlled. Combinations of different catecholamines with each other or with other drugs such as phosphodiesterase inhibitors or nitrates lead to a broad spectrum of possible haemodynamic actions. However, the use of catecholamines is limited by side effects like tachycardia, hypertension and disturbances of organ perfusion caused by vasoconstriction. Furthermore, as a result of receptor downregulation during long term therapy, the efficacy of catecholamine treatment decreases. These shortfalls stimulated the search for alternatives to catecholamine treatment. Among these, phosphodiesterase inhibitors (e.g. enoximone and amrinone) appear to be the most promising drugs which have been introduced into acute clinical practice up to now. They act via inhibition of the phosphodiesterase isoenzyme III, leading to higher intracellular calcium levels by increasing cyclic adenosine monophosphate (cAMP) levels. These agents improve cardiac performance by enhancing contractility, reducing left ventricular afterload and improve diastolic relaxation. In cases of failing catecholamine therapy due to receptor downregulation, treatment with phosphodiesterase inhibitors may still be effective since their action is not receptor-mediated. Inhibition of the phosphodiesterase enzyme in vascular smooth muscle leads to vasodilatation. Therefore, in low cardiac output states combined with increased total peripheral or pulmonary vascular resistance, phosphodiesterase inhibitor therapy is particularly effective. Depending on the dosage and the speed of intravenous administration, the use of phosphodiesterase inhibitors sometimes results in pronounced decrease of blood pressure which may require vasopressor therapy. Other drugs including histamine H2-agonists are currently under investigation. Their value in the treatment of intensive care patients has still to be evaluated.

Cardiotonic Agents↗