Impairment of cognitive function in different domains early after lung transplantation

In this prospective observational pilot study patients with the diagnosis of end-stage lung disease and listed for lung transplantation underwent a cognitive function test battery before and after lung transplantation to investigate postoperative cognitive function in three domains (visual and verbal memory, executive functioning, concentration/speed of processing). Additionally we investigated intraoperative risk factors for postoperative cognitive dysfunction. In total, 24 patients were included in this pilot study. The incidence of postoperative cognitive dysfunction was 58.3%. In the cognitive dysfunction group, the domains executive functioning and concentration/attention were significantly impaired whereas memory was not affected. Patients with cognitive impairment had a significantly longer ICU stay. The strongest independent risk factor for the development of cognitive dysfunction was operation time. No influence of cerebral oxygen desaturations on cognitive dysfunction was found. This might have important implications for early psychological rehabilitation strategies in this high-risk patient collective

Hydroxyethyl starch 130/0.4 and its impact on perioperative outcome: a propensity score matched controlled observation study

BACKGROUND Adverse effects of hydroxyethyl starches (HESs) have been verified in patients suffering from sepsis or kidney disease, but not in surgical patients at large. The investigation aimed to determine whether the use of HES 130/0.4 was associated with the incidence of acute postinterventional adverse events compared to Ringer's acetate alone in a perioperative setting. METHODS This propensity score matched, controlled observational study was performed in a single-centre university hospital. The perioperative data of 9085 patients were analyzed. Group matching was based on 13 categories including demographic data, type of procedure, and 5 preexisting comorbidities. Duration of procedure and intraoperative transfusion requirements were integrated in the matching process to reduce selection and indication bias. The primary outcome was incidence of postoperative kidney failure. Secondary outcomes were in-hospital mortality, fluid requirements, blood loss, hemodynamic stability, and the need for postoperative intensive care unit (ICU) treatment. RESULTS The administration of HES 130/0.4 was not associated with an increased frequency of postoperative kidney failure. In-hospital mortality (Ringer's acetate: 2.58%; HES 130/0.4: 2.68%) and the need for ICU care (Ringer's acetate: 30.5%; HES 130/0.4: 34.3%) did not differ significantly between groups. Significant intergroup differences were observed for mean blood loss (Ringer's acetate: 406 ± 821 mL; HES 130/0.4: 867 ± 1275 mL; P < .001) and median length of hospital stay (Ringer's acetate: 10.5 (5/17) days; HES 130/0.4: 12.0 (8/19) days; P < .001). CONCLUSIONS An association between intraoperative HES therapy and postoperative kidney failure was not observed in a mixed cohort of elective surgical patients. In addition, HES 130/0.4 was not associated with an increased morbidity or the need for ICU therapy in this propensity score matched study

No Differences in Renal Function between Balanced 6% Hydroxyethyl Starch (130/0.4) and 5% Albumin for Volume Replacement Therapy in Patients Undergoing Cystectomy: a Randomized Controlled Trial

BACKGROUND The use of artificial colloids has declined in critical care, whereas they are still used in perioperative medicine. Little is known about the nephrotoxic potential in noncritically ill patients during routine surgery. The objective of this trial was to evaluate the influences of albumin 5% and balanced hydroxyethyl starch 6% (130/0.4) on renal function and kidney injury. METHODS One hundred urologic patients undergoing elective cystectomy were randomly assigned for this prospective, single-blinded, controlled study with two parallel groups to receive either albumin 5% or balanced hydroxyethyl starch 6% (130/0.4) as the only perioperative colloid. The primary endpoint was the ratio of serum cystatin C between the last visit at day 90 and the first preoperative visit. Secondary endpoints were estimated glomerular filtration rate and serum neutrophil gelatinase-associated lipocalin until the third postoperative day and risk, injury, failure, loss, and end-stage renal disease criteria at postoperative days 3 and 90. RESULTS The median cystatin C ratio was 1.11 (interquartile range, 1.01 to 1.23) in the albumin and 1.08 (interquartile range, 1.00 to 1.20) in the hydroxyethyl starch group (median difference = 0.03; 95% CI, -0.09 to 0.08; P = 0.165). Also, there were no significant differences concerning serum cystatin C concentrations; estimated glomerular filtration rate; risk, injury, failure, loss, and end-stage renal disease criteria; and neutrophil gelatinase-associated lipocalin. Infusion requirements, transfusion rates, and perioperative hemodynamics were similar in both groups. CONCLUSIONS With respect to renal function and kidney injury, this study indicates that albumin 5% and balanced hydroxyethyl starch 6% have comparable safety profiles in noncritically ill patients undergoing major surgery

The impact of phosphate-balanced crystalloid infusion on acid-base homeostasis (PALANCE study): study protocol for a randomized controlled trial

Background: This study aims to investigate the effects of a modified, balanced crystalloid including phosphate in a perioperative setting in order to maintain a stable electrolyte and acid-base homeostasis in the patient. Methods/design: This is a single-centre, open-label, randomized controlled trial involving two parallel groups of female patients comparing a perioperative infusion regime with sodium glycerophosphate and Jonosteril (R) (treatment group) or Jonosteril (R) (comparator) alone. The primary endpoint is to maintain a stable concentration of weak acids [A(-)] according to the Stewart approach of acid-base balance. Secondary endpoints are measurement of serum phosphate levels, other acid-base parameters such as the strong ion difference (SID), the onset and severity of postoperative nausea and vomiting (PONV), electrolyte levels and their excretion in the urine, monitoring of renal function and glycocalyx components, haemodynamics, amounts of catecholamines and other vasopressors used and the safety of the infusion regime. Discussion: Perioperative fluid replacement with the use of currently available crystalloid preparations still fail to maintain a stable acid-base balance and experts agree that common balanced solutions are still not ideal. This study aims to investigate the effectivity and safety of a new crystalloid solution by adding sodium glycerophosphate to a standardized crystalloid preparation in order to maintain a balanced perioperative acid-base homeostasis

Changes of hemodynamic and cerebral oxygenation after exercise in normobaric and hypobaric hypoxia: associations with acute mountain sickness

Objective: Normobaric (NH) and hypobaric hypoxia (HH) are associated with acute mountain sickness (AMS) and cognitive dysfunction. Only few variables, like heart-rate-variability, are correlated with AMS. However, prediction of AMS remains difficult. We therefore designed an expedition-study with healthy volunteers in NH/HH to investigate additional non-invasive hemodynamic variables associated with AMS.Methods: Eleven healthy subjects were examined in NH (FiO(2) 13.1%;equivalent of 3.883m a.s.l;duration 4h) and HH (3.883ma.s.l.;duration 24h) before and after an exercise of 120min. Changes in parameters of electrical cardiometry (cardiac index (CI), left-ventricular ejection time (LVET), stroke volume (SV), index of contractility (ICON)), near-infrared spectroscopy (cerebral oxygenation, rScO(2)), Lake-Louise-Score (LLS) and cognitive function tests were assessed. One-Way-ANOVA, Wilcoxon matched-pairs test, Spearman's-correlation-analysis and Student's t-test were performed.Results: HH increased heart rate (HR), mean arterial pressure (MAP) and CI and decreased LVET, SV and ICON, whereas NH increased HR and decreased LVET. In both NH and HH cerebral oxygenation decreased and LLS increased significantly. After 24h in HH, 6 of 11 subjects (54.6%) developed AMS. LLS remained increased until 24h in HH, whereas cognitive function remained unaltered. In HH, HR and LLS were inversely correlated (r=-0.692;p<0.05). More importantly, the rScO2-decrease after exercise in NH significantly correlated with LLS after 24h in HH (r=-0.971;p<0.01) and rScO2 correlated significantly with HR (r=0.802;p<0.01), CI (r=0.682;p<0.05) and SV (r=0.709;p<0.05) after exercise in HH.Conclusion: sBoth acute NH and HH altered hemodynamic and cerebral oxygenation and induced AMS. Subjects, who adapted their CI had higher rScO2 and lower LLS. Furthermore, rScO2 after exercise under normobaric conditions was associated with AMS at high altitudes

Reply to Sarridou et al.

&lt;jats:title&gt;Abstract&lt;/jats:title&gt;&lt;jats:p&gt;The Ötztal Nappe in the Eastern Alps is a thrust sheet of Variscan metamorphic basement rocks and their Mesozoic sediment cover. It has been argued that the main part of the Ötztal Nappe and its southeastern part, the Texel Complex, belong to two different Austroalpine nappe systems and are separated by a major tectonic contact. Different locations have been proposed for this boundary. We use microprobe mapping of garnet and structural field geology to test the hypothesis of such a tectonic separation. The Pre-Mesozoic rocks in the area include several lithotectonic units: Ötztal Complex s.str., Texel Complex, Laas Complex, Schneeberg Complex, and Schneeberg Frame Zone. With the exception of the Schneeberg Complex which contains only single-phased (Eoalpine, i.e. Late Cretaceous) garnet, all these units have two-phased garnet with Variscan cores and Eoalpine rims. The Schneeberg Complex represents Paleozoic sediments with only low-grade (sub-garnet-grade) Variscan metamorphism which was thrust over the other units and their Mesozoic cover (Brenner Mesozoic) during an early stage of the Eoalpine orogeny, before the peak of Eoalpine metamorphism and garnet growth. Folding of the thrust later modified the structural setting so that the Schneeberg Thrust was locally inverted and the Schneeberg Complex came to lie under the Ötztal Complex s.str. The hypothesized Ötztal/Texel boundaries of earlier authors either cut across undisturbed lithological layering or are unsupported by any structural evidence. Our results support the existence of one coherent Ötztal Nappe, including the Texel Complex, and showing a southeastward increase of Eoalpine metamorphism which resulted from southeastward subduction.&lt;/jats:p&gt

Perioperative Management of Severe Acquired Coagulopathy in Patients with Left Ventricular Assist Device—a Literature Review and Expert Recommendations

Purpose of This Review The implantation of a left ventricular assist device (LVAD) is associated with high hemorrhage-related re-exploration rates. Improved management of coagulopathy may improve patient outcome. The optimal management of acquired coagulopathy in LVAD patients needing urgent non-cardiac surgery needs to be defined. We aim to review risk factors for perioperative bleeding and diagnosis and management of LVAD-associated coagulopathy and to provide expert recommendations for clinical practice. Recent Findings In patients undergoing LVAD implantation, the severity of coagulopathy is directly related to the severity of the cardiac failure. The evidence from current literature for optimal management of acquired coagulopathy during and after LVAD implantation is sparse. The traditional transfusion strategy of replacing coagulation factors with fresh frozen plasma involves the risk of transfusion-associated circulatory overload. Current recommendations for targeted replacement of coagulation factors with 4-factor prothrombin concentrate and fibrinogen concentrate in cardiac surgery may be translated in this special setting. Summary The targeted, point-of-care use of concentrated coagulation factors may improve treatment of severe acquired coagulopathy during LVAD implantation and in LVAD patients needing urgent non-cardiac surgery

Perioperative management of severe acquired coagulopathy in patients with left ventricular assist device

$\textbf {Purpose of This Review}$ The implantation of a left ventricular assist device (LVAD) is associated with high hemorrhage-related re-exploration rates. Improved management of coagulopathy may improve patient outcome. The optimal management of acquired coagulopathy in LVAD patients needing urgent non-cardiac surgery needs to be defined. We aim to review risk factors for perioperative bleeding and diagnosis and management of LVAD-associated coagulopathy and to provide expert recommendations for clinical practice. $\textbf {Recent Findings}$ In patients undergoing LVAD implantation, the severity of coagulopathy is directly related to the severity of the cardiac failure. The evidence from current literature for optimal management of acquired coagulopathy during and after LVAD implantation is sparse. The traditional transfusion strategy of replacing coagulation factors with fresh frozen plasma involves the risk of transfusion-associated circulatory overload. Current recommendations for targeted replacement of coagulation factors with 4-factor prothrombin concentrate and fibrinogen concentrate in cardiac surgery may be translated in this special setting. $\bf Summary$ The targeted, point-of-care use of concentrated coagulation factors may improve treatment of severe acquired coagulopathy during LVAD implantation and in LVAD patients needing urgent non-cardiac surgery