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  • Weiler, Norbert  (17)
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  • 1
    Language: English
    In: Critical care (London, England), 2011, Vol.15(1), pp.R8
    Description: To accomplish early enteral feeding in the critically ill patient a new transnasal endoscopic approach to the placement of postpyloric feeding tubes by intensive care physicians was evaluated. This was a prospective cohort study in 27 critically ill patients subjected to transnasal endoscopy and intubation of the pylorus. Attending intensive care physicians were trained in the handling of the new endoscope for transnasal gastroenteroscopy for two days. A jejunal feeding tube was advanced via the instrument channel and the correct position assessed by contrast radiography. The primary outcome measure was successful postpyloric placement of the tube. Secondary outcome measures were time needed for the placement, complications such as bleeding and formation of loops, and the score of the placement difficulty graded from 1 (easy) to 4 (difficult). Data are given as mean values and standard deviation. Out of 34 attempted jejunal tube placements, 28 tubes (82%) were placed correctly in the jejunum. The duration of the procedure was 28 ± 12 minutes. The difficulty of the tube placement was judged as follows: grade 1: 17 patients, grade 2: 8 patients, grade 3: 7 patients, grade 4: 2 patients. In three cases, the tube position was incorrect, and in another three cases, the procedure had to be aborted. In one patient bleeding occurred that required no further treatment. Fast and reliable transnasal insertion of postpyloric feeding tubes can be accomplished by trained intensive care physicians at the bedside using the presented procedure. This new technique may facilitate early initiation of enteral feeding in intensive care patients.
    Keywords: Critical Care ; Point-of-Care Systems -- Methods ; Enteral Nutrition -- Instrumentation ; Intubation, Gastrointestinal -- Methods ; Medical Staff, Hospital -- Education
    E-ISSN: 1466-609X
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  • 2
    Language: English
    In: Critical Care, Jan 17, 2011, Vol.15, p.R22
    Description: Introduction Continuous cardiac output monitoring is used for early detection of hemodynamic instability and guidance of therapy in critically ill patients. Recently, the accuracy of pulse contour-derived cardiac output (PCCO) has been questioned in different clinical situations. In this study, we examined agreement between PCCO and transcardiopulmonary thermodilution cardiac output (CO.sub.TCP ) in critically ill patients, with special emphasis on norepinephrine (NE) administration and the time interval between calibrations. Methods This prospective, observational study was performed with a sample of 73 patients (mean age, 63 [+ -] 13 years) requiring invasive hemodynamic monitoring on a non-cardiac surgery intensive care unit. PCCO was recorded immediately before calibration by CO.sub.TCP . Bland-Altman analysis was performed on data subsets comparing agreement between PCCO and CO.sub.TCP according to NE dosage and the time interval between calibrations up to 24 hours. Further, central artery stiffness was calculated on the basis of the pulse pressure to stroke volume relationship. Results A total of 330 data pairs were analyzed. For all data pairs, the mean CO.sub.TCP ([+ -]SD) was 8.2 [+ -] 2.0 L/min. PCCO had a mean bias of 0.16 L/min with limits of agreement of -2.81 to 3.15 L/min (percentage error, 38%) when compared to CO.sub.TCP . Whereas the bias between PCCO and CO.sub.TCP was not significantly different between NE dosage categories or categories of time elapsed between calibrations, interchangeability (percentage error [less than]30%) between methods was present only in the high NE dosage subgroup ([greater than or equal to]0.1 [mu]g/kg/min), as the percentage errors were 40%, 47% and 28% in the no NE, NE [less than] 0.1 and NE [greater than or equal to] 0.1 [mu]g/kg/min subgroups, respectively. PCCO was not interchangeable with CO.sub.TCP in subgroups of different calibration intervals. The high NE dosage group showed significantly increased central artery stiffness. Conclusions This study shows that NE dosage, but not the time interval between calibrations, has an impact on the agreement between PCCO and CO.sub.TCP . Only in the measurements with high NE dosage (representing the minority of measurements) was PCCO interchangeable with CO.sub.TCP .
    Keywords: Cardiac Output -- Health Aspects ; Cardiac Output -- Measurement ; Critically Ill Persons -- Care And Treatment ; Norepinephrine -- Dosage And Administration ; Norepinephrine -- Complications And Side Effects
    ISSN: 1364-8535
    Source: Cengage Learning, Inc.
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  • 3
    Language: English
    In: Critical Care, Jan 17, 2011, Vol.15, p.R22
    Description: Introduction Continuous cardiac output monitoring is used for early detection of hemodynamic instability and guidance of therapy in critically ill patients. Recently, the accuracy of pulse contour-derived cardiac output (PCCO) has been questioned in different clinical situations. In this study, we examined agreement between PCCO and transcardiopulmonary thermodilution cardiac output (CO.sub.TCP ) in critically ill patients, with special emphasis on norepinephrine (NE) administration and the time interval between calibrations. Methods This prospective, observational study was performed with a sample of 73 patients (mean age, 63 [+ -] 13 years) requiring invasive hemodynamic monitoring on a non-cardiac surgery intensive care unit. PCCO was recorded immediately before calibration by CO.sub.TCP . Bland-Altman analysis was performed on data subsets comparing agreement between PCCO and CO.sub.TCP according to NE dosage and the time interval between calibrations up to 24 hours. Further, central artery stiffness was calculated on the basis of the pulse pressure to stroke volume relationship. Results A total of 330 data pairs were analyzed. For all data pairs, the mean CO.sub.TCP ([+ -]SD) was 8.2 [+ -] 2.0 L/min. PCCO had a mean bias of 0.16 L/min with limits of agreement of -2.81 to 3.15 L/min (percentage error, 38%) when compared to CO.sub.TCP . Whereas the bias between PCCO and CO.sub.TCP was not significantly different between NE dosage categories or categories of time elapsed between calibrations, interchangeability (percentage error [less than]30%) between methods was present only in the high NE dosage subgroup ([greater than or equal to]0.1 [mu]g/kg/min), as the percentage errors were 40%, 47% and 28% in the no NE, NE [less than] 0.1 and NE [greater than or equal to] 0.1 [mu]g/kg/min subgroups, respectively. PCCO was not interchangeable with CO.sub.TCP in subgroups of different calibration intervals. The high NE dosage group showed significantly increased central artery stiffness. Conclusions This study shows that NE dosage, but not the time interval between calibrations, has an impact on the agreement between PCCO and CO.sub.TCP . Only in the measurements with high NE dosage (representing the minority of measurements) was PCCO interchangeable with CO.sub.TCP .
    Keywords: Cardiac Output -- Health Aspects ; Cardiac Output -- Measurement ; Critically Ill Persons -- Care And Treatment ; Norepinephrine -- Dosage And Administration ; Norepinephrine -- Complications And Side Effects
    ISSN: 1364-8535
    Source: Cengage Learning, Inc.
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  • 4
    In: PLoS ONE, 2015, Vol.10(3)
    Description: Background The application of hydroxyethyl starch (HES) for volume resuscitation is controversially discussed and clinical studies have suggested adverse effects of HES substitution, leading to increased patient mortality. Although, the intestine is of high clinical relevance and plays a crucial role in sepsis and inflammation, information about the effects of HES on intestinal function and barrier integrity is very scarce. We therefore evaluated the effects of clinically relevant concentrations of HES on intestinal function and barrier integrity employing an isolated perfused model of the mouse small intestine. Methods An isolated perfused model of the mouse small intestine was established and intestines were vascularly perfused with a modified Krebs-Henseleit buffer containing 3% Albumin (N=7) or 3% HES (130/0.4; N=7). Intestinal metabolic function (galactose uptake, lactate-to-pyruvate ratio), edema formation (wet-to-dry weight ratio), morphology (histological and electron microscopical analysis), fluid shifts within the vascular, lymphatic and luminal compartments, as well as endothelial and epithelial barrier permeability (FITC-dextran translocation) were evaluated in both groups. Results Compared to the Albumin group, HES perfusion did not significantly change the wet-to-dry weight ratio and lactate-to-pyruvate ratio. However, perfusing the small intestine with 3% HES resulted in a significant loss of vascular fluid (p〈0.01), an increased fluid accumulation in the intestinal lumen (p〈0.001), an enhanced translocation of FITC-dextran from the vascular to the luminal compartment (p〈0.001) and a significantly impaired intestinal galactose uptake (p〈0.001). Morphologically, these findings were associated with an aggregation of intracellular vacuoles within the intestinal epithelial cells and enlarged intercellular spaces. Conclusion A vascular perfusion with 3% HES impairs the endothelial and epithelial barrier integrity as well as metabolic function of the small intestine.
    Keywords: Research Article
    E-ISSN: 1932-6203
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  • 5
    Language: English
    In: Critical care (London, England), 2011, Vol.15(1), pp.R22
    Description: Continuous cardiac output monitoring is used for early detection of hemodynamic instability and guidance of therapy in critically ill patients. Recently, the accuracy of pulse contour-derived cardiac output (PCCO) has been questioned in different clinical situations. In this study, we examined agreement between PCCO and transcardiopulmonary thermodilution cardiac output (COTCP) in critically ill patients, with special emphasis on norepinephrine (NE) administration and the time interval between calibrations. This prospective, observational study was performed with a sample of 73 patients (mean age, 63 ± 13 years) requiring invasive hemodynamic monitoring on a non-cardiac surgery intensive care unit. PCCO was recorded immediately before calibration by COTCP. Bland-Altman analysis was performed on data subsets comparing agreement between PCCO and COTCP according to NE dosage and the time interval between calibrations up to 24 hours. Further, central artery stiffness was calculated on the basis of the pulse pressure to stroke volume relationship. A total of 330 data pairs were analyzed. For all data pairs, the mean COTCP (±SD) was 8.2 ± 2.0 L/min. PCCO had a mean bias of 0.16 L/min with limits of agreement of -2.81 to 3.15 L/min (percentage error, 38%) when compared to COTCP. Whereas the bias between PCCO and COTCP was not significantly different between NE dosage categories or categories of time elapsed between calibrations, interchangeability (percentage error 〈30%) between methods was present only in the high NE dosage subgroup (≥0.1 μg/kg/min), as the percentage errors were 40%, 47% and 28% in the no NE, NE 〈 0.1 and NE ≥ 0.1 μg/kg/min subgroups, respectively. PCCO was not interchangeable with COTCP in subgroups of different calibration intervals. The high NE dosage group showed significantly increased central artery stiffness. This study shows that NE dosage, but not the time interval between calibrations, has an impact on the agreement between PCCO and COTCP. Only in the measurements with high NE dosage (representing the minority of measurements) was PCCO interchangeable with COTCP.
    Keywords: Cardiac Output -- Drug Effects ; Critical Care -- Methods ; Norepinephrine -- Pharmacology ; Vasoconstrictor Agents -- Pharmacology
    ISSN: 13648535
    E-ISSN: 1466-609X
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  • 6
    Language: English
    In: Intensive Care Medicine, 2003, Vol.29(10), pp.1656-1665
    Description: Byline: Matthias David (1), Norbert Weiler (2), Wolfgang Heinrichs (1), Markus Neumann (1), Thilo Joost (1), Klaus Markstaller (1), Balthasar Eberle (1) Keywords: Adult respiratory distress syndrome; High-frequency oscillatory ventilation; Respiratory therapy; Ventilator-associated lung injury; Human Abstract: Objective This study examined whether ARDS patients in whom predefined ventilator settings fail to maintain oxygenation and CO.sub.2 removal can be safely transitioned to high-frequency oscillatory ventilation (HFOV), and whether HFOV use is efficacious. Design and setting Prospective observational study in the 14-bed intensive care unit of a university hospital. Patients and participants 42 patients with ARDS (APACHE II score 28 (IQR 24--37) and ventilation time prior HFOV 3.0 days (0.7--9.1). Measurements and results Gas exchange parameters and ventilator data were recorded before and during HFOV treatment (-12 h, -6 h, baseline, 10 min, 1 h, 6 h, 12 h, 24 h). Primary endpoints included: (a) [P.sub.a]O.sub.2/FIO.sub.2 ratio 24 h after start of HFOV treatment or the last point of measurement if HFOV ended within the first 24 h (b) HFOV-related complications. Post hoc analysis assessed the relationship between outcome and the response to HFOV, and between outcome and time of mechanical ventilation prior to HFOV. At baseline the median [P.sub.a]O.sub.2/FIO.sub.2 ratio was 95 (IQR 62--129) after 24 h of HFOV the [P.sub.a]O.sub.2/FIO.sub.2 ratio had increased significantly to 165 (88--225) only one patient developed a unilateral pneumothorax. Of the 42 patients 18 (43%) had died by day 30. Subset analyses showed a significantly higher 30-day mortality rate in patients with at least 3 days of mechanical ventilation prior to HFOV (64%) and in patients without oxygenation improvement after 24 h on HFOV (71%). Conclusions HFOV is an effective and safe method to ventilate ARDS patients. Failure to improve oxygenation within 24 h of HFOV is associated with high mortality. Author Affiliation: (1) Department of Anesthesiology, Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany (2) Department of Anesthesiology and Intensive Care Medicine, Christian Albrecht University, Schwanenweg 21, 24105, Kiel, Germany Article History: Received Date: 27/08/2002 Accepted Date: 03/06/2003 Online Date: 25/07/2003 Article note: An editorial regarding this article can be found in the same issue http://dx.doi.org/10.1007/s00134-003-1939-z
    Keywords: Adult respiratory distress syndrome ; High-frequency oscillatory ventilation ; Respiratory therapy ; Ventilator-associated lung injury ; Human
    ISSN: 0342-4642
    E-ISSN: 1432-1238
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  • 7
    Language: English
    In: PloS one, 2015, Vol.10(4), pp.e0127136
    Description: The application of hydroxyethyl starch (HES) for volume resuscitation is controversially discussed and clinical studies have suggested adverse effects of HES substitution, leading to increased patient mortality. Although, the intestine is of high clinical relevance and plays a crucial role in sepsis and inflammation, information about the effects of HES on intestinal function and barrier integrity is very scarce. We therefore evaluated the effects of clinically relevant concentrations of HES on intestinal function and barrier integrity employing an isolated perfused model of the mouse small intestine. An isolated perfused model of the mouse small intestine was established and intestines were vascularly perfused with a modified Krebs-Henseleit buffer containing 3% Albumin (N=7) or 3% HES (130/0.4; N=7). Intestinal metabolic function (galactose uptake, lactate-topyruvate ratio), edema formation (wet-to-dry weight ratio), morphology (histological and electron microscopical analysis), fluid shifts within the vascular, lymphatic and luminal compartments, as well as endothelial and epithelial barrier permeability (FITC-dextran translocation) were evaluated in both groups. Compared to the Albumin group, HES perfusion did not significantly change the wet-to-dry weight ratio and lactate-to-pyruvate ratio. However, perfusing the small intestine with 3% HES resulted in a significant loss of vascular fluid (p〈0.01), an increased fluid accumulation in the intestinal lumen (p〈0.001), an enhanced translocation of FITC-dextran from the vascular to the luminal compartment (p〈0.001) and a significantly impaired intestinal galactose uptake (p〈0.001). Morphologically, these findings were associated with an aggregation of intracellular vacuoles within the intestinal epithelial cells and enlarged intercellular spaces. A vascular perfusion with 3% HES impairs the endothelial and epithelial barrier integrity as well as metabolic function of the small intestine.
    Keywords: Endothelium, Vascular -- Drug Effects ; Hydroxyethyl Starch Derivatives -- Adverse Effects ; Intestine, Small -- Drug Effects
    E-ISSN: 1932-6203
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  • 8
    Language: English
    In: JAMA, 01 November 2016, Vol.316(17), pp.1775-1785
    Description: Adjunctive hydrocortisone therapy is suggested by the Surviving Sepsis Campaign in refractory septic shock only. The efficacy of hydrocortisone in patients with severe sepsis without shock remains controversial. To determine whether hydrocortisone therapy in patients with severe sepsis prevents the development of septic shock. Double-blind, randomized clinical trial conducted from January 13, 2009, to August 27, 2013, with a follow-up of 180 days until February 23, 2014. The trial was performed in 34 intermediate or intensive care units of university and community hospitals in Germany, and it included 380 adult patients with severe sepsis who were not in septic shock. Patients were randomly allocated 1:1 either to receive a continuous infusion of 200 mg of hydrocortisone for 5 days followed by dose tapering until day 11 (n = 190) or to receive placebo (n = 190). The primary outcome was development of septic shock within 14 days. Secondary outcomes were time until septic shock, mortality in the intensive care unit or hospital, survival up to 180 days, and assessment of secondary infections, weaning failure, muscle weakness, and hyperglycemia (blood glucose level 〉150 mg/dL [to convert to millimoles per liter, multiply by 0.0555]). The intention-to-treat population consisted of 353 patients (64.9% male; mean [SD] age, 65.0 [14.4] years). Septic shock occurred in 36 of 170 patients (21.2%) in the hydrocortisone group and 39 of 170 patients (22.9%) in the placebo group (difference, -1.8%; 95% CI, -10.7% to 7.2%; P = .70). No significant differences were observed between the hydrocortisone and placebo groups for time until septic shock; mortality in the intensive care unit or in the hospital; or mortality at 28 days (15 of 171 patients [8.8%] vs 14 of 170 patients [8.2%], respectively; difference, 0.5%; 95% CI, -5.6% to 6.7%; P = .86), 90 days (34 of 171 patients [19.9%] vs 28 of 168 patients [16.7%]; difference, 3.2%; 95% CI, -5.1% to 11.4%; P = .44), and 180 days (45 of 168 patients [26.8%] vs 37 of 167 patients [22.2%], respectively; difference, 4.6%; 95% CI, -4.6% to 13.7%; P = .32). In the hydrocortisone vs placebo groups, 21.5% vs 16.9% had secondary infections, 8.6% vs 8.5% had weaning failure, 30.7% vs 23.8% had muscle weakness, and 90.9% vs 81.5% had hyperglycemia. Among adults with severe sepsis not in septic shock, use of hydrocortisone compared with placebo did not reduce the risk of septic shock within 14 days. These findings do not support the use of hydrocortisone in these patients. clinicaltrials.gov Identifier: NCT00670254.
    Keywords: Anti-Inflammatory Agents -- Administration & Dosage ; Hydrocortisone -- Administration & Dosage ; Sepsis -- Complications ; Shock, Septic -- Prevention & Control
    ISSN: 00987484
    E-ISSN: 1538-3598
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  • 9
    Language: English
    In: Respirology (Carlton, Vic.), April 2011, Vol.16(3), pp.523-31
    Description: Reliable assessment of regional lung ventilation and good reproducibility of electrical impedance tomography (EIT) data are the prerequisites for the future application of EIT in a clinical setting. The aims of our study were to determine (i) the reproducibility of repeated EIT measurements and (ii) the effect of the studied transverse chest plane on ventilation distribution in different postures. Ten healthy adult subjects were studied in three postures on two separate days. EIT and spirometric data were obtained during tidal breathing and slow vital capacity (VC) manoeuvres. EIT data were acquired in two chest planes at 13 scans/s. Reproducibility of EIT findings was assessed by Bland-Altman analysis and Pearson correlation in 16 regions of interest in each plane. Regional ventilation distribution during tidal breathing and deep expiration was determined as fractional ventilation in four quadrants of the studied chest cross-sections. Our study showed a good reproducibility of EIT measurements repeated after an average time interval of 8 days. Global tidal volumes and VCs determined by spirometry on separate days were not significantly different. Regional ventilation in chest quadrants assessed by EIT was also unaffected. Posture exerted a significant effect on ventilation distribution among the chest quadrants during spontaneous breathing and deep expiration in both planes. The spatial distribution patterns in the two planes were not identical. We conclude that regional EIT ventilation findings are reproducible and recommend that the EIT examination location on the chest is carefully chosen especially during repeated measurements and follow-up.
    Keywords: Posture -- Physiology ; Pulmonary Ventilation -- Physiology
    ISSN: 13237799
    E-ISSN: 1440-1843
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  • 10
    Language: English
    In: Journal of translational medicine, 27 February 2016, Vol.14, pp.60
    Description: Volume resuscitation with hydroxyethyl starch (HES) is controversially discussed and we recently showed that HES perfusion impairs endothelial and epithelial intestinal barrier integrity. Here we investigated whether Albumin containing HES solutions are superior to HES alone in maintaining intestinal barrier function. An isolated perfused model of the mouse small intestine was used to investigate the effects of: (i) 3 % Albumin (Alb), (ii) 3 % HES or (iii) 1.5 % HES/1.5 % Albumin (HES/Alb). Intestinal morphology, cell damage, metabolic functions, fluid shifts and endothelial/epithelial barrier permeability were evaluated. Potentially involved signaling mechanisms (Erk1/2, Akt and Stat5 phosphorylation) were screened. HES induced histomorphological damage (p 〈 0.01 vs. Alb), by trend elevated the amount of luminal intestinal fatty acid binding protein and reduced galactose uptake (p 〈 0.001 vs. Alb). Luminal and lymphatic flow rates were increased (p 〈 0.001 vs. Alb), while vascular flow was decreased (p 〈 0.001 vs. Alb) during HES perfusion. HES also increased the vascular to luminal FITC-dextran transfer (p 〈 0.001 vs. Alb), pointing towards a fluid shift from the vascular to the luminal and lymphatic compartments during HES perfusion. Addition of Alb (HES/Alb) reversed all adverse effects of HES (p 〈 0.05 vs. HES), restored barrier integrity (p 〈 0.05 vs. HES) and improved metabolic function of the intestine (p 〈 0.001 vs. HES; p 〈 0.05 vs. Alb). Mechanistically, HES/Alb perfusion resulted in an increased phosphorylation of Erk1/2 and Akt kinases (p 〈 0.001 vs. HES), while Stat5 remained unchanged. Albumin supplementation abrogates the adverse effects of HES in the intestine and underlying mechanism may function via phosphorylation of Erk1/2 and Akt. Albumin containing HES solutions are superior to HES alone and may improve the suitability of HES in the clinic.
    Keywords: Albumins -- Pharmacology ; Hydroxyethyl Starch Derivatives -- Adverse Effects ; Intestinal Mucosa -- Metabolism ; Intestines -- Pathology
    E-ISSN: 1479-5876
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