Maya Keplinger

A prospective interventional study on the use of extracorporeal photopheresis in patients with bronchiolitis obliterans syndrome after lung transplantation

BACKGROUND The aim of this prospective study was to evaluate the efficacy and safety of extracorporeal photopheresis (ECP) in patients with bronchiolitis obliterans syndrome (BOS) after lung transplantation and to identify factors predicting treatment response. METHODS The study was performed at a single center and consisted of a cohort of 1,012 lung transplant recipients (November 1989-June 2010). A total of 194 patients developed BOS after a mean of 1,293 ± 1,008 days (range, 99-4,949 days) and received established treatment, and 51 patients received additional ECP. RESULTS Thirty-one (61%) of the ECP-treated patients responded to the therapy and showed sustained stabilization (forced expiratory volume in 1 second range, -5% to 5% vs baseline at start of ECP) of lung function over 6 months. Responders to ECP showed significantly greater survival and less need for retransplantation (p = 0.001) than non-responders. Factors associated with an inferior treatment response were cystic fibrosis as underlying lung disease and a longer time between transplantation and development of BOS. No side effects were observed after ECP. Compared with BOS patients not treated with ECP, the ECP responders showed an improved graft survival (p = 0.05). CONCLUSIONS These results confirm and suggest that early use of ECP could be an effective adjunct treatment for patients who develop BOS after lung transplantation.

Cytomegalovirus Prevention in High-risk Lung Transplant Recipients: Comparison of 3- vs 12-Month Valganciclovir Therapy

BACKGROUND Cytomegalovirus (CMV) infections are common after lung transplantation (LuTx) and have an influence on acute rejection rates and chronic organ dysfunction. The objective of this study was to determine the incidence of CMV infections by comparing a prolonged valganciclovir prophylaxis with a standard regimen in high-risk LuTx recipients. METHODS A retrospective, single-center study was performed comparing two different CMV prophylactic regimens in high-risk LuTx recipients (D(+)/R(-)). The study population received either 3 months (Group A, 15 patients) or 12 months (Group B, 17 patients) of oral valganciclovir 900 mg/day in combination with CMV hyperimmune globulin in four doses (Days 1, 7, 14 and 21 post-transplant). RESULTS CMV viremia was noted in 11 of 15 patients in Group A (75%) and 5 of 17 in Group B (33%) (p < 0.05) at 6 months after valganciclovir cessation. The incidence of symptomatic CMV disease/syndrome was 6 of 15 (44%) in Group A and 2 of 17 in Group B (13%) (p < 0.05). Histologically proven acute rejection episodes of ISHLT Grade > or =A2 were found in 4 patients in Group A and in 1 patient in Group B within the first year (p = 0.14). CONCLUSIONS A 12-month CMV prophylaxis with oral valganciclovir is effective in significantly reducing CMV viremia and CMV disease/syndrome in high-risk lung transplant recipients. In addition, a reduction in acute and recurrent rejection episodes was observed, possibly due to less CMV viremia and subsequent immunomodulatory effects.

Lung transplantation in children and young adults: a 20-year single-centre experience

Lung transplantation in adults is an accepted therapeutic option, whereas there is ongoing debate on its positive impact on survival in children. We report our experience of the first 20 yrs of paediatric lung transplantation at a single centre in Austria. Patient survival, organ survival and freedom from bronchiolitis obliterans were estimated by Kaplan–Meier curves. Pre- and post-transplant parameters were assessed and their influence on patient and organ survival evaluated by univariate tests and stepwise multivariate analyses. A total of 55 transplantations were performed in 43 patients. 1- and 5-yr patient survival rates were 72.1% and 60.6%, respectively, and 52.6% of patients were found to be free from bronchiolitis obliterans syndrome at 5 yrs post-transplant. Analysing different eras of transplantation suggests an improvement over the years with a 5-yr survival rate of 70.6% in the second decade. A positive effect of pre-transplant diabetes mellitus and immunosuppression was found with the newer drug tacrolimus, and a negative effect of pre-transplant in-hospital admission was reported. A high rate of successful re-transplantation prolonged total patient survival.

A pharmacodynamic evaluation of dexmedetomidine as an additive drug to ropivacaine for peripheral nerve blockade: A randomised, triple-blind, controlled study in volunteers.

BACKGROUND Previous data have indicated the efficacy of dexmedetomidine as an additive to peripheral regional anaesthesia. There are no pharmacodynamic data regarding the addition of dexmedetomidine to local anaesthetics for perineural administration. OBJECTIVE The objective of this study is to assess the dose-dependency of dexmedetomidine when injected with ropivacaine for peripheral nerve blockade. DESIGN A randomised, triple-blind, controlled study in volunteers. SETTING Department of Clinical Pharmacology, Medical University of Vienna. PARTICIPANTS Twenty-four volunteers. INTERVENTIONS All volunteers received an ulnar nerve block with 22.5 mg ropivacaine alone (R), or mixed with 50 (RD50), 100 (RD100) or 150 &mgr;g (RD150) dexmedetomidine. MAIN OUTCOME MEASURES The primary outcome was the duration of complete sensory block to pinprick and time to complete recovery of pinprick. Secondary outcomes included block success and onset time, motor block, haemodynamic parameters and sedation level. RESULTS There was a significant dose-dependent (P < 0.0001) increase in the mean duration (SD) of sensory block with dexmedetomidine: R: 8.7 (1.5) h, RD50: 16.4 (4.0) h, RD100: 20.4 (2.8) h and group RD150: 21.2 (1.7) h. Sedation was also enhanced in a dose-dependent (P < 0.001) manner. Two volunteers each receiving 150 &mgr;g dexmedetomidine had postblock paraesthesia for 72 h. CONCLUSION Dexmedetomidine mixed with ropivacaine produces a dose-dependent prolongation of sensory block and clinically relevant dose-dependent sedation. Dexmedetomidine 100 &mgr;g may represent a balance between efficacy and sedation.

Effective local anaesthetic volumes for sciatic nerve blockade: a clinical evaluation of the ED99

Previous results in volunteers have indicated the effective dose in 99% of subjects (ED99) of local anaesthetic volume to be 0.10 ml.mm−2 of cross‐sectional nerve area for sciatic nerve blockade. The objective of this prospective, randomised, double‐blind study was to investigate the ED99 of local anaesthetic for ultrasound‐guided sciatic nerve blockade in patients undergoing foot surgery, according to Dixons up‐and‐down method and probit analysis. A starting volume of 0.20 ml local anaesthetic per mm2 cross‐sectional nerve area was used. If surgical anaesthesia was judged to be adequate, the volume of local anaesthetic for the next case was reduced by 0.02 ml.mm−2, until the first block failed. Thereafter, the volume of local anaesthetic was increased by 0.02 ml.mm−2. The ED99 volume of local anaesthetic for ultrasound‐guided sciatic nerve blockade was calculated to be 0.15 ml.mm−2 cross‐sectional nerve area, which is higher than the previously evaluated ED99 volume in volunteers.

Lumbar neuraxial anatomical changes throughout pregnancy: a longitudinal study using serial ultrasound scans.

This observational study was designed to investigate the anatomical changes of the lumbar spine over the course of pregnancy using serial ultrasound scans. We performed paramedian scans on 58 women at the L2–3, L3–4 and L4–5 levels; these were done at four periods of 11+0–13+6, 19+0–23+0, 28+0–32+0 and 38+0–40+0 weeks gestation. At each intervertebral level, the length of the interlaminar space, length of the visible intervertebral posterior dura and depth of the posterior dura mater from the skin were measured. The length of the interlaminar space and length of the visible intervertebral posterior dura mater were longer, and the depth of the posterior dura mater was shallower, with ascending spinal interspace. The depth of the posterior dura mater increased during pregnancy, although it plateaued between the third and fourth measurement periods. The other spinal measurements were not affected by gestation. These findings indicate that the L2–3 level is the most appropriate puncture site for epidural anaesthesia in pregnant women. Our results ought to be embraced as a departure point towards developing neuraxial insertion techniques guided or aided by ultrasound.

Awake caudals and epidurals should be used more frequently in neonates and infants.

The current literature provides fundamental insights regarding the neurotoxic potency of various general anesthetic drugs in neonates and small infants. Therefore, considerations to minimize the use of general anesthetic drugs in this age group are required. The use of caudal and epidural anesthesia under sedation is one possibility to minimize the use of general anesthetic drugs. A large number of surgical procedures can be managed with this anesthetic concept. Training, practical hand skills, good infrastructure, a well‐defined indication, and a team approach including the entire operation room staff are the major prerequisites to implement these techniques in the daily clinical practice. This review article discusses all present aspects and possible future evolutions of caudal and epidural anesthesia under sedation.

Feasibility and pharmacokinetics of caudal blockade in children and adolescents with 30-50 kg of body weight.

Caudal blockade, although an important technique of pediatric regional anesthesia, is rarely used in children heavier than 30 kg. This reservation is due to anatomical concerns and lack of pharmacokinetic data. We therefore set out to evaluate, in pediatric patients weighing 30−50 kg, the feasibility of ultrasound‐guided caudal blockade and the pharmacokinetics of caudally administered ropivacaine.

Forced-Air Warming During Pediatric Surgery: A Randomized Comparison of a Compressible with a Noncompressible Warming System.

BACKGROUND:Perioperative hypothermia is a common problem, challenging the anesthesiologist and influencing patient outcome. Efficient and safe perioperative active warming is therefore paramount; yet, it can be particularly challenging in pediatric patients. Forced-air warming technology is the most widespread patient-warming option, with most forced-air warming systems consisting of a forced-air blower connected to a compressible, double layer plastic and/or a paper blanket with air holes on the patient side. We compared an alternative, forced-air, noncompressible, under-body patient-warming mattress (Baby/Kleinkinddecke of MoeckWarmingSystems, Moeck und Moeck GmbH; group MM) with a standard, compressible warming mattress system (Pediatric Underbody, Bair Hugger, 3M; group BH). METHODS:The study included 80 patients aged <2 years, scheduled for elective surgery. After a preoperative core temperature measurement, the patients were placed on the randomized mattress in the operation theater and 4 temperature probes were applied rectally and to the patients’ skin. The warming devices were turned on as soon as possible to the level for pediatric patients as recommended by the manufacturer (MM = 40°C, BH = 43°C). RESULTS:There was a distinct difference of temperature slope between the 2 groups: core temperatures of patients in the group MM remained stable and mean of the core temperature of patients in the group BH increased significantly (difference: +1.48°C/h; 95% confidence interval, 0.82–2.15°C/h; P = 0.0001). The need for temperature downregulation occurred more often in the BH group, with 22 vs 7 incidences (RR, 3.14; 95% confidence interval, 1.52–6.52; P = 0.0006). Skin temperatures were all lower in the MM group. Perioperatively, no side effects related to a warming device were observed in any group. CONCLUSIONS:Both devices are feasible choices for active pediatric patient warming, with the compressible mattress system being better suited to increase core temperature. The use of lower pediatric forced-air temperature settings, as recommended by the manufacturer, in the noncompressible mattress group resulted in more stable core temperature conditions, with fewer forced-air temperature adjustments necessary to avoid hyperthermia.

Supraclavicular ultrasound-guided catheterization of the brachiocephalic vein in infants and children: A retrospective analysis

Objective/Background: Ultrasound (US) facilitates central venous catheter (CVC) placement in children. A new supraclavicular approach using the brachiocephalic vein (BCV) for US-guided CVC placement in very small children has been recently described. In 2012, we changed our departmental standard and used the left BCV as preferred puncture site during CVC placement. In our retrospective analysis, we compared US-guided cannulation of the BCV with other puncture sites (control). Design/Materials and Methods: We performed a retrospective analysis of all CVC cannulations from October 2012 to October 2013 in our department. For cannulation of the BCV, the in-plane technique was used to guide the needle into the target vein. Results: We performed CVC cannulations in 106 children (age 1-day to 18 years). In 29 patients, the weight was <4.5 kg. CVC placement was successful in all patients. The left BCV could be used in 81.1% of all cases. In a Poisson regression model of punctures regressed by age, weight or group (left BCV vs. control), age, weight or the cannulation site did not influence the number of punctures. In a logistic regression model of complications (yes vs. no) regressed by the group (left brachiocephalic vs. control) an odds ratio of 0.15 was observed (95% confidence interval 0.03-0.72, P likelihood ratio test = 0.007). Conclusion: US-guided puncture of the left BCV is a safe method of CVC placement in children. The use of the left BCV was associated with a high success rate in our retrospective analysis.