Current projects in the Department of Thoracic Anaesthesiology

​Knud Jepsen, MD 
Bleeding and transfusion
Together with “Bloodmanager”, supported by the TRYG foundation, and in cooperation with the bloodbank, the research focus areas of the Heart Centre are thrombelastography and bleeding mechanisms. Most recently, a quality assurance project was carried out, implementing thrombelastography and new transfusion guidance in the post-operative phase after heart surgery. 

The project has helped reduce the use of blood products by 40% and optimise the use of erythrocytes, fresh frozen plasma and thrombocytes. This will form the basis for a future transfusion algorithm for treatment of patients at the Department of Thoracic Anaesthesiology.

Transfusion-medicinal projects are also planned, aimed at child heart surgery patients in intensive care and transfusion-medicinal projects during patients’ surgical treatment. This aims at establishing algorithms involving thrombelastography. 

The department is interested in setting up networks at international level on transfusion-medicinal aspects of heart surgery patients - adults as well as children. 

 
Vibeke Jørgensen, MD and 
Jens Christian Nilsson, MD 
PPC trial resumé
During cardiac surgery with cardiopulmonal bypass (CPB) the normal pulsatile flow and oxygenation is altered for a limited period of time. Perfusion pressures may vary and the optimal relation between flow and pressure level for sufficient oxygenation of different organs is not known, and furthermore difficult to monitor. 

Reduction in kidney function is observed in 20% of patients treated with CPB, and 20% of these will need dialysis. Reduced kidney function has been shown to be an independent predictor of an adverse outcome after cardiac surgery.

In this trial the effect of perfusion pressure during CPB on postoperative kidney function will be investigated. After informed consent 30 patients planned for CABG and valve operation will be randomized to perfusion pressure > 60 mm Hg (obtained with nor-epinephrine infusion) during CPB, or no intervention. 

Markers of cellular kidney damage, auto regulation and oxygenation are obtained through a kidney vein catheter and global markers of oxygenation and flow are measured with a pulmonary artery catheter, both intra- and post operatively. Kidney function is measured by Cr-EDTA clearance before and after surgery. 


Vibeke Jørgensen, MD and 
Jens Christian Nilsson, MD 
Renal flow and oxygenation 
Monitoring of renal flow and metabolic state during surgery and postoperative intensive care is technically difficult, and global parameters may not reflect regional impairment in oxygenation and metabolism. 

Renal oxygenation, lactate production and markers of renal cell damage can in this trial be compared to global parameters and urine production at several time points peri-operatively. In this way the sensitivity of standard monitoring of renal function in detecting impaired renal cellular metabolism can be investigated.


​Kim Wildgaard, MD
Classic thoracic surgery – pain study
The Department of Thoracic Anaesthesiology is participating in a series of trials concerning persistent pain states after thoracic surgery (post thoracotomy pain syndrome or PTPS). 

The trials look at epidemiology of persistent pain after thoracotomy and video-assisted thoracic surgery (VATS) as well as a number of possible interventions.

Since a major theory within chronification involves reduction of acute pain, the trial series also consist of trials with a multimodal analgesic approach to acute pain.

Studies on PTPS and chronification of pain are a joint-venture between surgeons, anaesthesiologists and the Department of Surgical Pathophysiology. Some studies also involve other centres.

So far the projects have resulted in the following publications:
  • Wildgaard K, Ravn J, Kehlet H: Chronic post-thoracotomy pain - a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg 36:170-180, 2009
  • Wildgaard K, Iversen M, Kehlet H: Chronic pain after lung transplantation: a nationwide study. Clin J Pain 26:217-222, 2010

 
Lisbeth Rosengaard Bredahl, MD and 
Marianne Kjaer Jensen, MD 
Fast-track anesthesia 
The development of cardiac surgery in the last century, with the introduction of the latest and in some cases minimally invasive techniques, the increasing age and comorbidity of patients, and growing cost pressures  place new and increasing demands on perioperative management in cardiac anesthesia. 

Early extubation after cardiac surgery is now possible due to the advances in anesthetic techniques, drugs, surgery and extracorporeal circulation techniques. The definition of early extubation is most commonly postoperative intubation time of less than 6 hours. This is proved and safe.

Inspired by the Leipzig Fast-track Protocol (FTP) we have implemented the protocol adjusted to our local techniques.Our protocol is anesthesia with sevofluran and ultiva as a supplement to our standard anesthesia protocol (sp).After an introduction period, our preliminary results are promising and we now plan to implement the protocol for suitable patients.

Cheng DCH, Karski J, Peniston C, at al. Morbidity outcome in early versus conventional tracheal extubation after coronary bypass grafting
A prospective randomised controlled trail. J Thorac Cadiovasc Surg 1996; 112: 755-64.

 
Cheng DCH 
Fast-track cardiac surgery pathways
Early extubation, process of care, and costs containment. Anesthesiology 1998; 88: 1429-33.

 
Cheng DCH, Wall C, Djaiani G, et al. Randomized assessment of resource use in fast-track cardiac surgery 1 year after hospital discharge
Anesthesiology 2003; 98: 651-7. 

 
Häntschel D, Fassl J, Scholz M, Sommer M, Funkat AK, Wittmann M, Ender J.  Leipzig fast-track protocol for cardio-anesthesia: Effective, safe and economical.
Anaesthesist. 2009 Apr;58(4):379-86. German.


​Ender J, Borger MA, Scholz M, Funkat AK, Anwar N, Sommer M, Mohr FW, Fassl J.  Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept.
Anesthesiology. 2008 Jul;109(1):61-6

 
Ender J, Lindner J, Haentschel D et al. Fast-track Cardiac Anesthesia in the Elderly: Poster.


​Jens Højberg, MD
GLP-1 infusion for normoglycaemia in intensive care patients
​Inspired by the great work by Van den Berghe showing that especially patients in a post-operative intensive care setting could benefit from strict regulation of their blood glucose level, and also greatly inspired by the work of both my wife P. Hoejberg and her colleague F. Knop, showing that GLP-1 only induces lowering of the blood glucose at levels above 5 mM and that GLP-1 treatment over time normalizes insulin sensitivity, my supervisor K. Moller and I designed a study with the primary aim to show that GLP-1 infusion can be used as a safer alternative to insulin infusion in order to normalize the blood glucose levels in critically ill patients admitted to an intensive care unit. 

Interested professionals will know that GLP-1 not only induces increased insulin sensitivity to glucose but also acts as an inotropic agent by channels so far not known. This led us to think that we will see a reduced need for other inotropic agents in patients being treated with GLP-1 infusion. Also peripheral nerves have been shown to benefit from GLP-1 and we will measure the degree of critical illness polyneuropathy in the population being treated. 

On the downside GLP-1 is suspected to reduce the pace of ventricular emptying, an effect that might contra-indicate its use on intensive care patients. This side effect will be tested for by several means, hoping to show the insignificance of this side effect. Finally the effect on the overall glucose/insulin metabolism will be tested by repeated hyperinsulinaemic euglycaemic clamping on these patients. 

The study will be initiated by a dose-response study and will continue with a double-blinded-randomized, clinically controlled trial with GLP-1 and supplemental insulin infusion on the one hand and placebo and insulin infusion on the other hand. 

The above study has been launched in parallel to another study using healthy subjects getting GLP-1 to regulate glucose metabolism under simultaneously TNF-α infusion in order to induce a hyperglycemic state caused by the systemic inflammatory response syndrome. This study is intended to give more basic physiologic knowledge of the pathophysiologic effect of sepsis-induced hyperglycaemia.

 
Lars Willy Andersen, MD,
MSci
Main research area in inflammatory response (endotoximia) in connection with paediatric and adult cardiopulmonary bypass and severe sepsis and septic shock. In Sweden an endotoxin adsorber has been developed to reduce the amount of endotoxins in blood. 

This adsorber is being used increasingly worldwide as adjunctive thearapy in septic patients and patients undergoing cardiopulmonary bypass and ECMO-treatment. The inflammatory research is at the moment focused on endotoxin adsorption strategies in connection with severe sepsis, septic shock, hypothermia and cardiac arrest in centres at Rigshospitalet and worldwide.​


Responsible editor