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Lim J, Litton E, Robinson H, Das Gupta M. Characteristics and outcomes of patients treated with airway pressure release ventilation for acute respiratory distress syndrome: A retrospective observational study. J Crit Care 2016; 34:154-9. [PMID: 27020770 DOI: 10.1016/j.jcrc.2016.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/25/2016] [Accepted: 03/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal mode of ventilation in acute respiratory distress syndrome (ARDS) remains uncertain. Airway pressure release ventilation (APRV) is a recognized treatment for mechanically-ventilated patients with severe hypoxaemia. However, contemporary data on its role as a rescue modality in ARDS is lacking. The goal of this study was to describe the clinical and physiological effects of APRV in patients with established ARDS. METHODS This retrospective observational study was performed in a 23-bed adult intensive care unit in a tertiary extracorporeal membrane oxygenation (ECMO) referral centre. Patients with ARDS based on Berlin criteria were included through a prospectively-collected APRV database. Patients receiving APRV for less than six hours were excluded. RESULTS Fifty patients fulfilled the eligibility criteria. Prior to APRV initiation, median Murray Lung Injury Score was 3.5 (interquartile range (IQR) 2.5-3.9) and PaO2/FiO2 was 99mmHg (IQR 73-137). PaO2/FiO2 significantly improved within twenty-four hours post-APRV initiation (ANOVA F(1, 27)=24.34, P<.005). Two patients (4%) required intercostal catheter insertion for barotrauma. Only one patient (2%) required ECMO after APRV initiation, despite a majority (68%) fulfilling previously established criteria for ECMO at baseline. Hospital mortality rate was 38%. CONCLUSIONS In patients with ARDS-related refractory hypoxaemia treated with APRV, an early and sustained improvement in oxygenation, low incidence of clinically significant barotrauma and progression to ECMO was observed. The safety and efficacy of APRV requires further consideration.
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Affiliation(s)
- Jolene Lim
- Medical student, Royal Perth Hospital, Perth, Western Australia
| | - Edward Litton
- Staff Specialist Intensive Care Medicine, Intensive Care Unit, Royal Perth Hospital, Perth, Western Australia; Clinical Senior Lecturer, School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia.
| | - Hayley Robinson
- Senior Registrar Intensive Care Medicine, Intensive Care Unit, Royal Perth Hospital, Western Australia
| | - Mike Das Gupta
- Senior Clinical Respiratory Technician, Intensive Care Unit, Royal Perth Hospital, Perth, Western Australia
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Hutchings S, Naumann DN, Harris T, Wendon J, Midwinter MJ. Observational study of the effects of traumatic injury, haemorrhagic shock and resuscitation on the microcirculation: a protocol for the MICROSHOCK study. BMJ Open 2016; 6:e010893. [PMID: 26944694 PMCID: PMC4785297 DOI: 10.1136/bmjopen-2015-010893] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION The microcirculation is the physiological site of oxygen and substrate exchange. Its effectiveness during circulatory shock is vital for the perfusion of tissues, and has a bearing on subsequent organ function and prognosis. Microcirculatory dysfunction following traumatic haemorrhagic shock (THS) has been understudied compared with other pathologies such as sepsis. The aim of the MICROSHOCK study is to investigate changes seen in the microcirculation of patients following THS, and to assess its response to resuscitation. A greater understanding of the behaviour and mechanisms of microcirculatory dysfunction in this context may direct future avenues of goal-directed resuscitation for these patients. METHODS AND ANALYSIS This multicentre prospective longitudinal observational study includes patients who present as an emergency with THS. Microcirculatory parameters are recorded using sublingual incident dark field microscopy alongside measurements of global flow (oesophageal Doppler and transthoracic echocardiography). Patients are enrolled into the study as soon as feasible after they arrive in hospital, and then at subsequent daily time points. Blood samples are taken for investigation into the mechanisms of microcirculatory dysfunction. Sequential Organ Failure Assessment scores will be analysed with microcirculatory parameters to determine whether they correlate with greater fidelity than more conventional, global circulatory parameters. ETHICS AND DISSEMINATION Research Ethics Committee approval has been granted for this study (Reference: 14/YH/0078). Owing to the nature of THS, capacity for informed consent will be absent on patient enrolment. This will be addressed according to the Mental Health Capacity Act 2005. The physician in charge of the patient's care (nominated consultee) may consent on behalf of the patient. Consent will also be sought from a personal consultee (close relative or friend). After capacity is regained, the participant will be asked for their consent. Results will be submitted for publication in peer-reviewed journal format and presented at relevant academic meetings. TRIAL REGISTRATION NUMBER NCT02111109; Pre-results.
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Affiliation(s)
- Sam Hutchings
- Kings College Hospital, Denmark Hill, London, UK
- Kings College London, London, UK
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - David N Naumann
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
- University of Birmingham, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Tim Harris
- Barts Health NHS Trust and Queen Mary University of London, London, UK
| | - Julia Wendon
- Kings College Hospital, Denmark Hill, London, UK
- Kings College London, London, UK
| | - Mark J Midwinter
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
- University of Birmingham, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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de Bruin AFJ, Kornmann VNN, van der Sloot K, van Vugt JL, Gosselink MP, Smits A, Van Ramshorst B, Boerma EC, Noordzij PG, Boerma D, van Iterson M. Sidestream dark field imaging of the serosal microcirculation during gastrointestinal surgery. Colorectal Dis 2016; 18:O103-10. [PMID: 26725570 DOI: 10.1111/codi.13250] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 11/02/2015] [Indexed: 01/06/2023]
Abstract
AIM The study aimed to describe the serosal microcirculation of the human bowel using sidestream dark field imaging, a microscopic technique using polarized light to visualize erythrocytes through capillaries. We also compared its feasibility to the current practice of sublingual microcirculatory assessment. METHOD In 17 patients sidestream dark field measurements were performed during gastrointestinal surgery. Microcirculatory parameters like microvascular flow index (MFI), proportion of perfused vessels (PPV), perfused vessel density (PVD) and total vessel density (TVD) were determined for every patient, sublingually and on the bowel serosa. RESULTS Sixty measurements were done on the bowel of which eight (13%) were excluded, five owing to too much bowel peristalsis and three because of pressure artefacts. Image stability was in favour of sublingual measurements [pixel loss per image, bowel 145 (95% CI 126-164) vs sublingual 55 (95% CI 41-68); P < 0.001] and time to acquire a stable image [bowel 96 s (95% CI 63-129) vs. sublingual 46 s (95% CI 29-64); P = 0.013]. No difference in the MFI was observed [bowel 2.9 (interquartile range 2.87-2.95) vs sublingual 3.0 (interquartile range 2.91-3.0); P = 0.081]. There was a difference in the PPV [bowel 95% (95% CI 94-96) vs sublingual 97% (95% CI 97-99); P < 0.001], PVD [bowel 12.9 mm/mm2 (95% CI 11.1-14.8) vs sublingual 17.4 mm/mm2 (95% CI 15.6-19.1); P = 0.003] and the TVD [bowel 13.6 mm/mm2 (95% CI 11.6-15.6) vs sublingual 17.7 mm/mm2 (95% CI 16.0-19.4); P = 0.008]. CONCLUSION Sidestream dark field imaging is a very promising technique for bowel microcirculatory visualization and assessment. It is comparable to sublingual assessment and the analysis produces a similar outcome with slightly differing anatomical features.
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Affiliation(s)
- A F J de Bruin
- Department of Anesthesiology, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - V N N Kornmann
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - K van der Sloot
- Department of Anesthesiology, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - J L van Vugt
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M P Gosselink
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - A Smits
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - B Van Ramshorst
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - E C Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - P G Noordzij
- Department of Anesthesiology, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - D Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M van Iterson
- Department of Anesthesiology, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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June KJ, Choi E. Infection Control of Hospital Nurses: Cases of Middle East Respiratory Syndrome. ACTA ACUST UNITED AC 2016. [DOI: 10.5807/kjohn.2016.25.1.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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ARDS: what experimental models have taught us. Intensive Care Med 2016; 42:806-810. [PMID: 26928038 DOI: 10.1007/s00134-016-4268-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 02/09/2016] [Indexed: 10/22/2022]
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Shears M, Alhazzani W, Marshall JC, Muscedere J, Hall R, English SW, Dodek PM, Lauzier F, Kanji S, Duffett M, Barletta J, Alshahrani M, Arabi Y, Deane A, Cook DJ. Stress ulcer prophylaxis in critical illness: a Canadian survey. Can J Anaesth 2016; 63:718-24. [DOI: 10.1007/s12630-016-0612-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 01/18/2016] [Accepted: 02/04/2016] [Indexed: 01/31/2023] Open
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Zhang G, Wang Q, Zhou Q, Wang R, Xu M, Wang H, Wang L, Wilcox CS, Liu R, Lai EY. Protective Effect of Tempol on Acute Kidney Injury Through PI3K/Akt/Nrf2 Signaling Pathway. Kidney Blood Press Res 2016; 41:129-138. [PMID: 26894882 PMCID: PMC4841277 DOI: 10.1159/000443414] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Tempol is a protective antioxidant against ischemic injury in many animal models. The molecular mechanisms are not well understood. Nuclear factor erythroid 2-related factor (Nrf2) is a master transcription factor during oxidative stress, which is enhanced by activation of protein kinase C (PKC) pathway. Another factor, tubular epithelial apoptosis, is mediated by activation of phosphoinositide 3-kinase (PI3K)/protein kinase B (PKB, Akt) signaling pathway during renal ischemic injury. We tested the hypothesis that tempol activates PKC or PI3K/Akt/Nrf2 pathways to transcribe many genes that coordinate endogenous antioxidant defense. METHODS The right renal pedicle was clamped for 45 minutes and the left kidney was removed to study renal ischemia/reperfusion (I/R) injury in C57BL/6 mice. The response was assessed from serum parameters, renal morphology and renal expression of PKC, phosphorylated-PKC (p-PKC), Nrf2, heme oxygenase-1 (HO-1), Akt, phosphorylated-Akt (p-Akt), pro-caspase-3 and cleaved caspase-3 in groups of sham and I/R mice given vehicle, or tempol (50 or 100 mg/kg, intraperitoneal injection). RESULTS The serum malondialdehyde (MDA, marker of reactive oxygen species) doubled and the BUN and creatinine increased 5- to 10-fold after I/R injury. Tempol (50 or 100 mg/kg) prevented the increases in MDA but only tempol (50 mg/kg) lessened the increases in BUN and creatinine and moderated the acute tubular necrosis. I/R did not change expression of PKC or p-PKC but reduced renal expression of Nrf2, p-Akt, HO-1 and pro-caspase-3 and increased cleaved caspase-3. Tempol (50 mg/kg) prevented these changes produced by I/R whereas tempol (100 mg/kg) had lesser or inconsistent effects. CONCLUSION Tempol (50 mg/kg) prevents lipid peroxidation and attenuates renal damage after I/R injury. The beneficial pathway apparently is not dependent on upregulation or phosphorylation of PKC, at lower tempol doses, does implicate upregulation of Akt with expression of Nrf2 that could account for the increase in the antioxidant gene HO-1 and a reduction in the cleavage of the cellular damage marker pro-caspase-3.
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Affiliation(s)
- Gensheng Zhang
- Department of Physiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Journal of Clinical Monitoring and Computing 2015 end of year summary: tissue oxygenation and microcirculation. J Clin Monit Comput 2016; 30:141-6. [PMID: 26897032 PMCID: PMC4792340 DOI: 10.1007/s10877-016-9846-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 02/14/2016] [Indexed: 12/29/2022]
Abstract
Last year we started this series of end of year summaries of papers published in the 2014 issues of the Journal Of Clinical Monitoring And Computing with a review on near infrared spectroscopy (Scheeren et al. in J Clin Monit Comput 29(2):217-220, 2015). This year we will broaden the scope and include papers published in the field of tissue oxygenation and microcirculation, or a combination of both entities. We present some promising new technologies that might enable a deeper insight into the (patho)physiology of certain diseases such as sepsis, but also in healthy volunteers. These may help researchers and clinicians to evaluate both tissue oxygenation and microcirculation beyond macro-hemodynamic measurements usually available at the bedside.
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Michard F. Hemodynamic monitoring in the era of digital health. Ann Intensive Care 2016; 6:15. [PMID: 26885656 PMCID: PMC4757593 DOI: 10.1186/s13613-016-0119-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 02/08/2016] [Indexed: 01/20/2023] Open
Abstract
Digital innovations are changing medicine, and hemodynamic monitoring will not be an exception. Five to ten years from now, we can envision a world where clinicians will learn hemodynamics with simulators and serious games, will monitor patients with wearable or implantable sensors in the hospital and after discharge, will use medical devices able to communicate and integrate the historical, clinical, physiologic and biological information necessary to predict adverse events, propose the most rationale therapy and ensure it is delivered properly. Considerable intellectual and financial investments are currently made to ensure some of these new ideas and products soon become a reality.
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6360
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A guide to human in vivo microcirculatory flow image analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:35. [PMID: 26861691 PMCID: PMC4748457 DOI: 10.1186/s13054-016-1213-9] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Various noninvasive microscopic camera technologies have been used to visualize the sublingual microcirculation in patients. We describe a comprehensive approach to bedside in vivo sublingual microcirculation video image capture and analysis techniques in the human clinical setting. We present a user perspective and guide suitable for clinical researchers and developers interested in the capture and analysis of sublingual microcirculatory flow videos. We review basic differences in the cameras, optics, light sources, operation, and digital image capture. We describe common techniques for image acquisition and discuss aspects of video data management, including data transfer, metadata, and database design and utilization to facilitate the image analysis pipeline. We outline image analysis techniques and reporting including video preprocessing and image quality evaluation. Finally, we propose a framework for future directions in the field of microcirculatory flow videomicroscopy acquisition and analysis. Although automated scoring systems have not been sufficiently robust for widespread clinical or research use to date, we discuss promising innovations that are driving new development.
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6361
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Focus on infection and sepsis in intensive care patients. Intensive Care Med 2016; 42:491-493. [PMID: 26862017 DOI: 10.1007/s00134-016-4234-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 01/18/2016] [Indexed: 11/27/2022]
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Sims CR, Nguyen TC, Mayeux PR. Could Biomarkers Direct Therapy for the Septic Patient? J Pharmacol Exp Ther 2016; 357:228-39. [PMID: 26857961 DOI: 10.1124/jpet.115.230797] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/05/2016] [Indexed: 01/25/2023] Open
Abstract
Sepsis is a serious medical condition caused by a severe systemic inflammatory response to a bacterial, fungal, or viral infection that most commonly affects neonates and the elderly. Advances in understanding the pathophysiology of sepsis have resulted in guidelines for care that have helped reduce the risk of dying from sepsis for both children and older adults. Still, over the past three decades, a large number of clinical trials have been undertaken to evaluate pharmacological agents for sepsis. Unfortunately, all of these trials have failed, with the use of some agents even shown to be harmful. One key issue in these trials was the heterogeneity of the patient population that participated. What has emerged is the need to target therapeutic interventions to the specific patient's underlying pathophysiological processes, rather than looking for a universal therapy that would be effective in a "typical" septic patient, who does not exist. This review supports the concept that identification of the right biomarkers that can direct therapy and provide timely feedback on its effectiveness will enable critical care physicians to decrease mortality of patients with sepsis and improve the quality of life of survivors.
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Affiliation(s)
- Clark R Sims
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas (C.R.S., P.R.M.); and Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas (T.C.N.)
| | - Trung C Nguyen
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas (C.R.S., P.R.M.); and Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas (T.C.N.)
| | - Philip R Mayeux
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas (C.R.S., P.R.M.); and Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas (T.C.N.)
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Method Based on the β-Lactamase PenPC Fluorescent Labeled for β-Lactam Antibiotic Quantification in Human Plasma. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4307987. [PMID: 26904674 PMCID: PMC4745914 DOI: 10.1155/2016/4307987] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/31/2015] [Accepted: 01/03/2016] [Indexed: 11/17/2022]
Abstract
Recently, Wong et al. have successfully developed a fluorescent biosensor based on the PenPC β-lactamase which changes its intrinsic fluorescence in presence of β-lactam antibiotics (BLAs). Here, we studied systematically this correlation among the fluorescence change of the biosensor and the concentration of different BLAs aimed at developing a novel method for estimating the concentration of a wide range of BLAs. This method showed high precision and specificity and very low interference from clinically relevant samples. We were able to monitor the pharmacokinetics of meropenem in healthy volunteers as well as in an ill animal model too, indicating that the implemented method could be suitable for clinical practice.
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Ince C, Mik EG. Microcirculatory and mitochondrial hypoxia in sepsis, shock, and resuscitation. J Appl Physiol (1985) 2016; 120:226-35. [DOI: 10.1152/japplphysiol.00298.2015] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/05/2015] [Indexed: 12/23/2022] Open
Abstract
After shock, persistent oxygen extraction deficit despite the apparent adequate recovery of systemic hemodynamic and oxygen-derived variables has been a source of uncertainty and controversy. Dysfunction of oxygen transport pathways during intensive care underlies the sequelae that lead to organ failure, and the limitations of techniques used to measure tissue oxygenation in vivo have contributed to the lack of progress in this area. Novel techniques have provided detailed quantitative insight into the determinants of microcirculatory and mitochondrial oxygenation. These techniques, which are based on the oxygen-dependent quenching of phosphorescence or delayed luminescence are briefly reviewed. The application of these techniques to animal models of shock and resuscitation revealed the heterogeneous nature of oxygen distributions and the alterations in oxygen distribution in the microcirculation and in mitochondria. These studies identified functional shunting in the microcirculation as an underlying cause of oxygen extraction deficit observed in states of shock and resuscitation. The translation of these concepts to the bedside has been enabled by our development and clinical introduction of hand-held microscopy. This tool facilitates the direct observation of the microcirculation and its alterations at the bedside under the conditions of shock and resuscitation. Studies identified loss of coherence between the macrocirculation and the microcirculation, in which resuscitation successfully restored systemic circulation but did not alleviate microcirculatory perfusion alterations. Various mechanisms responsible for these alterations underlie the loss of hemodynamic coherence during unsuccessful resuscitation procedures. Therapeutic resolution of persistent heterogeneous microcirculatory alterations is expected to improve outcomes in critically ill patients.
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Affiliation(s)
- Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam
- Department of Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Egbert G. Mik
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam
- Department of Anesthesiology, Erasmus MC, University Medical Center, Rotterdam; and
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Abstract
PURPOSE OF REVIEW In shock states, optimizing intravascular volume is crucial to promote an adequate oxygen delivery to the tissues. Our current practice in fluid management pivots on the Frank-Starling law of the heart, and the effects of fluids are measured according to the induced changes on stroke volume. The purpose of this review is to evaluate the boundaries of current macrohemodynamic approach to fluid administration, and to introduce the microcirculatory integration as a fundamental part of tissue perfusion monitoring. RECENT FINDINGS Macrocirculatory changes induced by volume expansion are not always coupled to proportional changes in microcirculatory perfusion. Loss of hemodynamic coherence limits the value of guiding fluid therapy according to macrohemodynamics, and highlights the importance of evaluating the ultimate target of volume administration, the microcirculation. SUMMARY Current approach to intravascular volume optimization is made from a macrohemodynamic perspective. However, several situations wherein macrocirculatory and microcirculatory coherence is lost have been described. Future clinical trials should explore the usefulness of integrating the microcirculatory evaluation in fluid optimization.
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Abstract
PURPOSE OF REVIEW To describe the harmful effects of intravenous fluids on kidney structure and function and summarize recent comparisons between different fluids and their effect on kidney outcome. RECENT FINDINGS Administration of intravenous fluids may contribute to the development and sustention of acute kidney injury. In excess, fluids cause kidney interstitial edema and venous congestion, which prevents renal blood flow and glomerular filtration rate. In contrast to balanced crystalloids, chloride-rich solutions impair renal blood flow via autoregulatory mechanisms. Synthetic colloids, such as hydroxyethyl starches, gelatins, and dextrans are potentially nephrotoxic because they can cause osmotic nephrosis, which, in susceptible patients, might precede permanent kidney damage. Albumin solutions appear well tolerated to use in septic patients, although their renal efficacy over balanced crystalloids is not established. In contrast, administration of albumin solutions to patients with decompensated liver failure effectively prevents and ameliorates hepatorenal syndrome. SUMMARY Being nephrotoxic, synthetic colloids should be avoided in patients with reduced renal reserve, such as in critically ill patients and in patients with preexisting renal dysfunction. Suggested adverse effects with chloride-rich solutions need confirmation from ongoing trials. Albumin solutions are well tolerated in patients with sepsis and/or liver failure and improve outcomes in the latter.
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Affiliation(s)
- Johan Mårtensson
- aDepartment of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia bSection of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden cAustralian and New Zealand Intensive Care Research Centre, School of Preventive Medicine and Public Health, Monash University, Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW A host of immune modulators are now available in clinical practice. The perioperative period is characterized by profound alterations in host immunity, which can result in poor outcomes, which include infection, cancer recurrence and organ failure. Manipulation of the perioperative immune response has the potential to improve outcomes. A complete understanding of the mechanisms and clinical consequences of altered immune function in this setting is therefore imperative. RECENT FINDINGS Recent in-vivo data have emerged which further our understanding of the interaction between tissue damage, immune modulation and clinical outcomes by utilizing novel laboratory techniques capable of monitoring single-cell immune signatures. Traditional gene expression assays have continued to demonstrate their utility and have been instrumental in defining the host response to perioperative allogeneic blood transfusion. These mechanistic studies are complemented by large clinical studies describing associations between anaesthetic modalities and immune-related outcomes. SUMMARY Laboratory techniques are now available that can monitor the perioperative immune response and could be further developed to introduce personalized care pathways. Consideration must also be given to anaesthesia techniques and perioperative treatments that, although not immediately harmful, may be associated with poor outcomes temporally distant from the treatment, secondary to induced immunosuppression.
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Schwingshackl A, Meduri GU. Rationale for Prolonged Glucocorticoid Use in Pediatric ARDS: What the Adults Can Teach Us. Front Pediatr 2016; 4:58. [PMID: 27379217 PMCID: PMC4906037 DOI: 10.3389/fped.2016.00058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/23/2016] [Indexed: 12/21/2022] Open
Abstract
Based on molecular mechanisms and physiologic data, a strong association has been established between dysregulated systemic inflammation and progression of acute respiratory distress syndrome (ARDS). In ARDS patients, glucocorticoid receptor-mediated downregulation of systemic inflammation is essential to restore homeostasis, decrease morbidity and improve survival and can be significantly enhanced with prolonged low-to-moderate dose glucocorticoid treatment. A large body of evidence supports a strong association between prolonged glucocorticoid treatment-induced downregulation of the inflammatory response and improvement in pulmonary and extrapulmonary physiology. The balance of the available data from eight controlled trials (n = 622) provides consistent strong level of evidence for improving patient-centered outcomes and hospital survival. The sizable increase in mechanical ventilation-free days (weighted mean difference, 6.48 days; CI 95% 2.57-10.38, p < 0.0001) and intensive care unit-free days (weighted mean difference, 7.7 days; 95% CI, 3.13-12.20, p < 0.0001) by day 28 is superior to any investigated intervention in ARDS. For treatment initiated before day 14 of ARDS, the increased in hospital survival (70 vs. 52%, OR 2.41, CI 95% 1.50-3.87, p = 0.0003) translates into a number needed to treat to save one life of 5.5. Importantly, prolonged glucocorticoid treatment is not associated with increased risk for nosocomial infections (22 vs. 27%, OR 0.61, CI 95% 0.35-1.04, p = 0.07). Treatment decisions involve a tradeoff between benefits and risks, as well as costs. This low-cost, highly effective therapy is familiar to every physician and has a low risk profile when secondary prevention measures are implemented.
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Affiliation(s)
- Andreas Schwingshackl
- Department of Pediatrics, Division of Critical Care Medicine, Mattel Children's Hospital at UCLA , Los Angeles, CA , USA
| | - Gianfranco Umberto Meduri
- Departments of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Memphis Veterans Affairs Medical Center , Memphis, TN , USA
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Liang Q, Liu H, Jiang Y, Xing H, Zhang T, Ai-hua Z. High-throughput metabolic profiling for discovering metabolic biomarkers of sepsis-induced acute lung injury. RSC Adv 2016. [DOI: 10.1039/c5ra25961d] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Sepsis-induced acute lung injury (ALI) remains a leading cause of death in intensive care units and early detection is very important. This work showed that metabolite phenotype profiling might be a useful tool for the effective diagnosis and further understanding of ALI.
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Affiliation(s)
- Qun Liang
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
| | - Han Liu
- Simon Fraser University (SFU)
- Burnaby
- Canada
| | - Yan Jiang
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
| | - Haitao Xing
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
| | - Tianyu Zhang
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
| | - Zhang Ai-hua
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
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6371
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Yonis H, Richard JC. Place du magnésium et de l’hélium dans la prise en charge de l’asthme aigu grave. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1146-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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6372
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Liang Q, Liu H, Xing H, Jiang Y, Zhang T, Zhang AH. High-resolution mass spectrometry for exploring metabolic signatures of sepsis-induced acute kidney injury. RSC Adv 2016. [DOI: 10.1039/c6ra01192f] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Sepsis is a commonly encountered scenario in an intensive care unit (ICU), and the kidney is one of the organs frequently affected.
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Affiliation(s)
- Qun Liang
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
| | - Han Liu
- Simon Fraser University (SFU)
- Burnaby
- Canada
| | - Haitao Xing
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
| | - Yan Jiang
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
| | - Tianyu Zhang
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
| | - Ai-Hua Zhang
- ICU Center
- First Affiliated Hospital
- School of Pharmacy
- Heilongjiang University of Chinese Medicine
- Harbin 150040
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Abstract
PURPOSE OF REVIEW Measurements of lung volumes allow evaluating the pathophysiogical severity of acute respiratory distress syndrome (ARDS) in terms of the degree of reduction in aerated lung volume, calculating strain, quantifying recruitment and/or hyperinflation, and gas volume distribution. We summarize the current techniques for lung volume assessment selected according to their possible usage in the ICU and discuss the recent findings obtained with implementation of these techniques in patients with ARDS. RECENT FINDINGS Computed tomography technique remains irreplaceable in terms of quantitative aeration of different lung regions, but the commonly used cut-offs for classification may be questioned with recent findings on nonpathological lungs. Monitoring end expiratory lung volume using nitrogen washout technique enhanced our understanding on lung volume change during positioning, pleural effusion drainage, intra-abdominal hypertension, and recruitment maneuver. Recent studies supported that tidal volume could not surrogate tidal strain, which needs measurement of functional residual capacity and which is correlated with pro-inflammatory lung response. SUMMARY Although lung volume measurements are still limited to research area of ARDS, recent progress in technology provides clinicians more opportunities to evaluate lung volumes noninvasively at the bedside and may facilitate individualization of ventilator settings based on the specific physiological understandings of a given patient.
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6374
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Marini JJ. Re-tooling critical care to become a better intensivist: something old and something new. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19 Suppl 3:S3. [PMID: 26728560 PMCID: PMC4699063 DOI: 10.1186/cc14721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Developments in recent years have placed powerful new tools of diagnosis, therapy, and communication at the disposal of medicine in general, and of critical care in particular. The art of healing requires not only technical proficiency, but also personal connection, multidisciplinary teamwork, and commitment to the venerable traditions of our profession. The latter often seem to be under assault by today's high-pressure, high-efficiency, and increasingly business-driven hospital environments. Re-tooling critical care for the future generations of caregivers requires something old--empathetic connection--as well as the exciting newer technologies of our science and practice.
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Ince C. Hemodynamic coherence and the rationale for monitoring the microcirculation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19 Suppl 3:S8. [PMID: 26729241 PMCID: PMC4699073 DOI: 10.1186/cc14726] [Citation(s) in RCA: 299] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This article presents a personal viewpoint of the shortcoming of conventional hemodynamic resuscitation procedures in achieving organ perfusion and tissue oxygenation following conditions of shock and cardiovascular compromise, and why it is important to monitor the microcirculation in such conditions. The article emphasizes that if resuscitation procedures are based on the correction of systemic variables, there must be coherence between the macrocirculation and microcirculation if systemic hemodynamic-driven resuscitation procedures are to be effective in correcting organ perfusion and oxygenation. However, in conditions of inflammation and infection, which often accompany states of shock, vascular regulation and compensatory mechanisms needed to sustain hemodynamic coherence are lost, and the regional circulation and microcirculation remain in shock. We identify four types of microcirculatory alterations underlying the loss of hemodynamic coherence: type 1, heterogeneous microcirculatory flow; type 2, reduced capillary density induced by hemodilution and anemia; type 3, microcirculatory flow reduction caused by vasoconstriction or tamponade; and type 4, tissue edema. These microcirculatory alterations can be observed at the bedside using direct visualization of the sublingual microcirculation with hand-held vital microscopes. Each of these alterations results in oxygen delivery limitation to the tissue cells despite the presence of normalized systemic hemodynamic variables. Based on these concepts, we propose how to optimize the volume of fluid to maximize the oxygen-carrying capacity of the microcirculation to transport oxygen to the tissues.
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6376
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Marini JJ, Gattinoni L, Ince C, Kozek-Langenecker S, Mehta RL, Pichard C, Westphal M, Wischmeyer P, Vincent JL. A few of our favorite unconfirmed ideas. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19 Suppl 3:S1. [PMID: 26728101 PMCID: PMC4699060 DOI: 10.1186/cc14719] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Medical practice is rooted in our dependence on the best available evidence from incremental scientific experimentation and rigorous clinical trials. Progress toward determining the true worth of ongoing practice or suggested innovations can be glacially slow when we insist on following the stepwise scientific pathway, and a prevailing but imperfect paradigm often proves difficult to challenge. Yet most experienced clinicians and clinical scientists harbor strong thoughts about how care could or should be improved, even if the existing evidence base is thin or lacking. One of our Future of Critical Care Medicine conference sessions encouraged sharing of novel ideas, each presented with what the speaker considers a defensible rationale. Our intent was to stimulate insightful thinking and free interchange, and perhaps to point in new directions toward lines of innovative theory and improved care of the critically ill. In what follows, a brief background outlines the rationale for each novel and deliberately provocative unconfirmed idea endorsed by the presenter.
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6377
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Wang W, Das A, Cole O, Chikhani M, Hardman JG, Bates DG. Computational simulation indicates that moderately high-frequency ventilation can allow safe reduction of tidal volumes and airway pressures in ARDS patients. Intensive Care Med Exp 2015; 3:33. [PMID: 26662814 PMCID: PMC4675773 DOI: 10.1186/s40635-015-0068-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A recent prospective trial using porcine models of severe acute respiratory distress syndrome (ARDS) indicated that positive-pressure ventilation delivered by a conventional intensive care ventilator at a moderately high frequency allows safe reduction of tidal volume below 6 ml/kg, leading to more protective ventilation. We aimed to explore whether these results would be replicated when implementing similar ventilation strategies in a high-fidelity computational simulator, tuned to match data on the responses of a number of human ARDS patients to different ventilator inputs. METHODS We evaluated three different strategies for managing the trade-off between increasing respiratory rate and reducing tidal volume while attempting to maintain the partial pressure of carbon dioxide in arterial blood (PaCO2) constant on a computational simulator configured with ARDS patient datasets. RESULTS For a fixed sequence of stepwise increases in the respiratory rate, corresponding decreases in tidal volume to keep the alveolar minute ventilation and inspiratory flow constant were calculated according to standard formulae. When applied on the simulator, however, these sequences of ventilator settings failed to maintain PaCO2 adequately in the virtual patients considered. In contrast, an approach based on combining numerical optimisation methods with computational simulation allowed a sequence of tidal volume reductions to be computed for each virtual patient that maintained PaCO2 levels while significantly reducing peak airway pressures and dynamic alveolar strain in all patients. CONCLUSIONS Our study supports the proposition that moderately high-frequency respiratory rates can allow more protective ventilation of ARDS patients and highlights the potential role of high-fidelity simulators in computing optimised and personalised ventilator settings for individual patients using this approach.
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Affiliation(s)
- Wenfei Wang
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK.
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK.
| | - Oanna Cole
- Anaesthesia & Critical Care Research Group, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - Marc Chikhani
- Anaesthesia & Critical Care Research Group, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - Jonathan G Hardman
- Anaesthesia & Critical Care Research Group, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK.
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Santini A, Protti A, Langer T, Comini B, Monti M, Sparacino CC, Dondossola D, Gattinoni L. Prone position ameliorates lung elastance and increases functional residual capacity independently from lung recruitment. Intensive Care Med Exp 2015; 3:55. [PMID: 26215819 PMCID: PMC4480350 DOI: 10.1186/s40635-015-0055-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prone position is used to recruit collapsed dependent lung regions during severe acute respiratory distress syndrome, improving lung elastance and lung gas content. We hypothesised that, in the absence of recruitment, prone position would not result in any improvement in lung mechanical properties or gas content compared to supine position. METHODS Ten healthy pigs under general anaesthesia and paralysis underwent a pressure-volume curve of the respiratory system, chest wall and lung in supine and prone positions; the respective elastances were measured. A lung computed tomography (CT) scan was performed in the two positions to compute gas content (i.e. functional residual capacity (FRC)) and the distribution of aeration. Recruitment was defined as a percentage change in non-aerated lung tissue compared to the total lung weight. RESULTS Non-aerated (recruitable) lung tissue was a small percentage of the total lung tissue weight in both positions (4 ± 3 vs 1 ± 1 %, supine vs prone, p = 0.004). Lung elastance decreased (20.5 ± 1.8 vs 15.5 ± 1.6 cmH2O/l, supine vs prone, p < 0.001) and functional residual capacity increased (380 ± 82 vs 459 ± 60 ml, supine vs prone, p = 0.025) in prone position; specific lung elastance did not change (7.0 ± 0.5 vs 6.5 ± 0.5 cmH2O, supine vs prone, p = 0.24). Lung recruitment was low (3 ± 2 %) and was not correlated to increases in functional residual capacity (R (2) 0.2, p = 0.19). A higher amount of well-aerated and a lower amount of poorly aerated lung tissue were found in prone position. CONCLUSIONS In healthy pigs, prone position ameliorates lung mechanical properties and increases functional residual capacity independently from lung recruitment, through a redistribution of lung aeration.
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Affiliation(s)
- Alessandro Santini
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Alessandro Protti
- />Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Thomas Langer
- />Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Beatrice Comini
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Massimo Monti
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Cristina Carin Sparacino
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Daniele Dondossola
- />Centro di Ricerche Chirurgiche Precliniche, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Luciano Gattinoni
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
- />Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico di Milano, Milan, Italy
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6379
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Fernandes C, Horn A, Lopes BF, Bull ES, Azeredo NF, Kanashiro MM, Borges FV, Bortoluzzi AJ, Szpoganicz B, Pires AB, Franco RW, Almeida JCDA, Maciel LL, Resende JA, Schenk G. Induction of apoptosis in leukemia cell lines by new copper(II) complexes containing naphthyl groups via interaction with death receptors. J Inorg Biochem 2015; 153:68-87. [DOI: 10.1016/j.jinorgbio.2015.09.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/10/2015] [Accepted: 09/30/2015] [Indexed: 11/26/2022]
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6380
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Hernandez G, Tapia P, Ospina-Tascón G, Bruhn A, Soto D, Alegría L, Jarufe N, Luengo C, Menchaca R, Meissner A, Vives MI, Bakker J. Dexmedetomidine ameliorates gut lactate production and impairment of exogenous lactate clearance in an endotoxic sheep model. Intensive Care Med Exp 2015. [PMCID: PMC4798568 DOI: 10.1186/2197-425x-3-s1-a414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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6381
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Abstract
BACKGROUND Acute hypoxaemia de novo or on a background of chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes. Mortality from acute respiratory distress syndrome, one of the main contributors to the need for mechanical ventilation for hypoxaemia, remains approximately 40%. Ventilation in the prone position may improve lung mechanics and gas exchange and could improve outcomes. OBJECTIVES The objectives of this review are (1) to ascertain whether prone ventilation offers a mortality advantage when compared with traditional supine or semi recumbent ventilation in patients with severe acute respiratory failure requiring conventional invasive artificial ventilation, and (2) to supplement previous systematic reviews on prone ventilation for hypoxaemic respiratory failure in an adult population. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to 31 January 2014), EMBASE (1980 to 31 January 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 31 January 2014) and Latin American Caribbean Health Sciences Literature (LILACS) (1992 to 31 January 2014) in Ovid MEDLINE for eligible randomized controlled trials. We also searched for studies by handsearching reference lists of relevant articles, by contacting colleagues and by handsearching published proceedings of relevant journals. We applied no language constraints, and we reran the searches in CENTRAL, MEDLINE, EMBASE, CINAHL and LILACS in June 2015. We added five new studies of potential interest to the list of "Studies awaiting classification" and will incorporate them into formal review findings during the review update. SELECTION CRITERIA We included randomized controlled trials (RCTs) that examined the effects of prone position versus supine/semi recumbent position during conventional mechanical ventilation in adult participants with acute hypoxaemia. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all trials identified by the search and assessed them for suitability, methods and quality. Two review authors extracted data, and three review authors reviewed the data extracted. We analysed data using Review Manager software and pooled included studies to determine the risk ratio (RR) for mortality and the risk ratio or mean difference (MD) for secondary outcomes; we also performed subgroup analyses and sensitivity analyses. MAIN RESULTS We identified nine relevant RCTs, which enrolled a total of 2165 participants (10 publications). All recruited participants suffered from disorders of lung function causing moderate to severe hypoxaemia and requiring mechanical ventilation, so they were fairly comparable, given the heterogeneity of specific disease diagnoses in intensive care. Risk of bias, although acceptable in the view of the review authors, was inevitable: Blinding of participants and carers to treatment allocation was not possible (face-up vs face-down).Primary analyses of short- and longer-term mortality pooled from six trials demonstrated an RR of 0.84 to 0.86 in favour of the prone position (PP), but findings were not statistically significant: In the short term, mortality for those ventilated prone was 33.4% (363/1086) and supine 38.3% (395/1031). This resulted in an RR of 0.84 (95% confidence interval (CI) 0.69 to 1.02) marginally in favour of PP. For longer-term mortality, results showed 41.7% (462/1107) for prone and 47.1% (490/1041) for supine positions, with an RR of 0.86 (95% CI 0.72 to 1.03). The quality of the evidence for both outcomes was rated as low as a result of important potential bias and serious inconsistency.Subgroup analyses for mortality identified three groups consistently favouring PP: those recruited within 48 hours of meeting entry criteria (five trials; 1024 participants showed an RR of 0.75 (95% CI 0.59 to 94)); those treated in the PP for 16 or more hours per day (five trials; 1005 participants showed an RR of 0.77 (95% CI 0.61 to 0.99)); and participants with more severe hypoxaemia at trial entry (six trials; 1108 participants showed an RR of 0.77 (95% CI 0.65 to 0.92)). The quality of the evidence for these outcomes was rated as moderate as a result of potentially important bias.Prone positioning appeared to influence adverse effects: Pressure sores (three trials; 366 participants) with an RR of 1.37 (95% CI 1.05 to 1.79) and tracheal tube obstruction with an RR of 1.78 (95% CI 1.22 to 2.60) were increased with prone ventilation. Reporting of arrhythmias was reduced with PP, with an RR of 0.64 (95% CI 0.47 to 0.87). AUTHORS' CONCLUSIONS We found no convincing evidence of benefit nor harm from universal application of PP in adults with hypoxaemia mechanically ventilated in intensive care units (ICUs). Three subgroups (early implementation of PP, prolonged adoption of PP and severe hypoxaemia at study entry) suggested that prone positioning may confer a statistically significant mortality advantage. Additional adequately powered studies would be required to confirm or refute these possibilities of subgroup benefit but are unlikely, given results of the most recent study and recommendations derived from several published subgroup analyses. Meta-analysis of individual patient data could be useful for further data exploration in this regard. Complications such as tracheal obstruction are increased with use of prone ventilation. Long-term mortality data (12 months and beyond), as well as functional, neuro-psychological and quality of life data, are required if future studies are to better inform the role of PP in the management of hypoxaemic respiratory failure in the ICU.
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Affiliation(s)
- Roxanna Bloomfield
- Intensive Care Unit and Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZN
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Tanaka S, Harrois A, Nicolaï C, Flores M, Hamada S, Vicaut E, Duranteau J. Qualitative real-time analysis by nurses of sublingual microcirculation in intensive care unit: the MICRONURSE study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:388. [PMID: 26542952 PMCID: PMC4635966 DOI: 10.1186/s13054-015-1106-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/17/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION We aimed to determine i) the feasibility of nurses taking bedside measurements of microcirculatory parameters in real time in intensive care patients; and ii) whether such measurements would be comparable to those obtained by the classical delayed semi quantitative analysis made by a physician. METHODS This prospective observational study was conducted in a university hospital and was approved by our local Institutional Review Board (IRB 00006477). After ICU admission and study inclusion, a set of measurements of macrocirculatory and microcirculatory parameters was taken by the nurse in charge of the patient every 4 h within the first 12 h after admission and before and after every hemodynamic therapeutic intervention. Seventy-four sublingual microvascular measurements were performed with incident dark field illumination (IDF) microscopy in 20 mechanically ventilated patients hospitalized in the ICU. RESULTS There were no significant differences between the microvascular flow index (MFI) taken in real time by the nurses and the delayed evaluation by the physician. In fact, the nurses' real-time measurement of MFI demonstrated good agreement with the physician's delayed measurement. The mean difference between the two MFIs was -0.15, SD = 0.28. The nurses' real-time MFI assessment showed 97 % sensitivity (95 % CI: 84-99 %) and 95 % specificity (95 % CI: 84-99 %) at detecting a MFI <2.5 obtained by a physician upon delayed semiquantitative measurement. Concerning the density, 81 % of the paramedical qualitative density measurements corresponded with the automatized total vessel density (TVD) measurements. The nurses' real-time TVD assessment showed 77 % sensitivity (95 % CI: 46-95 %) and 100 % specificity (95 % CI: 89-100 %) at detecting a TVD <8 mm/mm(2). CONCLUSION A real-time qualitative bedside evaluation of MFI by nurses showed good agreement with the conventional delayed analysis by physicians. The bedside evaluations of MFI and TVD were highly sensitive and specific for detecting impaired microvascular flow and low capillary density. These results suggest that this real-time technique could become part of ICU nurse routine surveillance and be implemented in algorithms for hemodynamic resuscitation in future clinical trials and regular practice. These results are an essential step to demonstrate whether these real-time measurements have a clinical impact in the management of ICU patients.
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Affiliation(s)
- Sébastien Tanaka
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France.
| | - Anatole Harrois
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France. .,Laboratoire d'Etude de la Microcirculation, "Bio-CANVAS: Biomarqueurs in CardiaNeuroVascular Diseases" UMRS 942, Paris, France.
| | - Camille Nicolaï
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France.
| | - Mélanie Flores
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France.
| | - Sophie Hamada
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France.
| | - Eric Vicaut
- Laboratoire d'Etude de la Microcirculation, "Bio-CANVAS: Biomarqueurs in CardiaNeuroVascular Diseases" UMRS 942, Paris, France.
| | - Jacques Duranteau
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France. .,Laboratoire d'Etude de la Microcirculation, "Bio-CANVAS: Biomarqueurs in CardiaNeuroVascular Diseases" UMRS 942, Paris, France. .,Department of Anesthesia and Intensive Care, Bicêtre Hospital, Hôpitaux universitaires Paris-Sud, Université Paris-Sud, Assistance Publique - Hôpitaux de Paris, 78, rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.
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6383
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Jabaudon M, Blondonnet R, Roszyk L, Bouvier D, Audard J, Clairefond G, Fournier M, Marceau G, Déchelotte P, Pereira B, Sapin V, Constantin JM. Soluble Receptor for Advanced Glycation End-Products Predicts Impaired Alveolar Fluid Clearance in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2015; 192:191-9. [PMID: 25932660 DOI: 10.1164/rccm.201501-0020oc] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RATIONALE Levels of the soluble form of the receptor for advanced glycation end-products (sRAGE) are elevated during acute respiratory distress syndrome (ARDS) and correlate with severity and prognosis. Alveolar fluid clearance (AFC) is necessary for the resolution of lung edema but is impaired in most patients with ARDS. No reliable marker of this process has been investigated to date. OBJECTIVES To verify whether sRAGE could predict AFC during ARDS. METHODS Anesthetized CD-1 mice underwent orotracheal instillation of hydrochloric acid. At specified time points, lung injury was assessed by analysis of blood gases, alveolar permeability, lung histology, AFC, and plasma/bronchoalveolar fluid measurements of proinflammatory cytokines and sRAGE. Plasma sRAGE and AFC rates were also prospectively assessed in 30 patients with ARDS. MEASUREMENTS AND MAIN RESULTS The rate of AFC was inversely correlated with sRAGE levels in the plasma and the bronchoalveolar fluid of acid-injured mice (Spearman's ρ = -0.73 and -0.69, respectively; P < 10(-3)), and plasma sRAGE correlated with AFC in patients with ARDS (Spearman's ρ = -0.59; P < 10(-3)). Similarly, sRAGE levels were significantly associated with lung injury severity, and decreased over time in mice, whereas AFC was restored and lung injury resolved. CONCLUSIONS Our results indicate that sRAGE levels could be a reliable predictor of impaired AFC during ARDS, and should stimulate further studies on the pathophysiologic implications of RAGE axis in the mechanisms leading to edema resolution. Clinical trial registered with www.clinicaltrials.gov (NCT 00811629).
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Affiliation(s)
- Matthieu Jabaudon
- 1 Intensive Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, Estaing University Hospital.,2 Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | - Raiko Blondonnet
- 1 Intensive Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, Estaing University Hospital.,2 Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | - Laurence Roszyk
- 3 Department of Medical Biochemistry and Molecular Biology.,2 Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | - Damien Bouvier
- 3 Department of Medical Biochemistry and Molecular Biology.,2 Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | - Jules Audard
- 1 Intensive Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, Estaing University Hospital
| | - Gael Clairefond
- 2 Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | | | - Geoffroy Marceau
- 3 Department of Medical Biochemistry and Molecular Biology.,2 Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | | | - Bruno Pereira
- 6 Department of Clinical Research and Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France; and
| | - Vincent Sapin
- 3 Department of Medical Biochemistry and Molecular Biology.,2 Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- 1 Intensive Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, Estaing University Hospital.,2 Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
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6384
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Understanding abdominal compartment syndrome. Intensive Care Med 2015; 42:1068-70. [PMID: 26459879 DOI: 10.1007/s00134-015-4089-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 10/04/2015] [Indexed: 10/22/2022]
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6385
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Lesur O. Myocardial impact and cardioprotective effects of apelin-13 and a c-terminal-modified analog during lps and clp experimental sepsis. Intensive Care Med Exp 2015. [PMCID: PMC4798084 DOI: 10.1186/2197-425x-3-s1-a436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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6386
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Blet A, Sadoune M, Polidano E, Merval R, Bernard C, Samuel JL, Mebazaa A. Hemodynamics effects of adrecizumab in sepsis rat. Intensive Care Med Exp 2015. [PMCID: PMC4797557 DOI: 10.1186/2197-425x-3-s1-a618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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6387
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Reiterer F, Sivieri E, Abbasi S. Evaluation of bedside pulmonary function in the neonate: From the past to the future. Pediatr Pulmonol 2015; 50:1039-50. [PMID: 26139200 DOI: 10.1002/ppul.23245] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/01/2015] [Accepted: 05/08/2015] [Indexed: 01/10/2023]
Abstract
Pulmonary function testing and monitoring plays an important role in the respiratory management of neonates. A noninvasive and complete bedside evaluation of the respiratory status is especially useful in critically ill neonates to assess disease severity and resolution and the response to pharmacological interventions as well as to guide mechanical respiratory support. Besides traditional tools to assess pulmonary gas exchage such as arterial or transcutaenous blood gas analysis, pulse oximetry, and capnography, additional valuable information about global lung function is provided through measurement of pulmonary mechanics and volumes. This has now been aided by commercially available computerized pulmonary function testing systems, respiratory monitors, and modern ventilators with integrated pulmonary function readouts. In an attempt to apply easy-to-use pulmonary function testing methods which do not interfere with the infant́s airflow, other tools have been developed such as respiratory inductance plethysmography, and more recently, electromagnetic and optoelectronic plethysmography, electrical impedance tomography, and electrical impedance segmentography. These alternative technologies allow not only global, but also regional and dynamic evaluations of lung ventilation. Although these methods have proven their usefulness for research applications, they are not yet broadly used in a routine clinical setting. This review will give a historical and clinical overview of different bedside methods to assess and monitor pulmonary function and evaluate the potential clinical usefulness of such methods with an outlook into future directions in neonatal respiratory diagnostics.
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Affiliation(s)
- F Reiterer
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Graz, Austria
| | - E Sivieri
- Section on Newborn Pediatrics, Pennsylvania Hospital, Philadelphia, Pennsylvania.,Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - S Abbasi
- Section on Newborn Pediatrics, Pennsylvania Hospital, Philadelphia, Pennsylvania.,Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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6388
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Impact of Chest Wall Modifications and Lung Injury on the Correspondence Between Airway and Transpulmonary Driving Pressures. Crit Care Med 2015; 43:e287-95. [PMID: 26186478 DOI: 10.1097/ccm.0000000000001036] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Recent interest has arisen in airway driving pressure (DP(AW)), the quotient of tidal volume (V(T)), and respiratory system compliance (C(RS)), which could serve as a direct and easily measured marker for ventilator-induced lung injury risk. We aimed to test the correspondence between DP(AW) and transpulmonary driving pressure (DP(TP))-the quotient of V(T) and lung compliance (C(L)), in response to intra-abdominal hypertension and changes in positive end-expiratory pressure during different models of lung pathology. DESIGN Well-controlled experimental setting that allowed reversible modification of chest wall compliance (C(CW)) in a variety of models of lung pathology. SETTING Large animal laboratory of a university-affiliated hospital. SUBJECTS Ten deeply anesthetized swine. INTERVENTIONS Application of intra-abdominal pressures of 0 and 20 cm H2O at positive end-expiratory pressure of 1 and 10 cm H2O, under volume-controlled mechanical ventilation in the settings of normal lungs (baseline), unilateral whole-lung atelectasis, and unilateral and bilateral lung injuries caused by saline lavage. MEASUREMENTS AND MAIN RESULTS Pulmonary mechanics including esophageal pressure and calculations of DP(AW), DP(TP), C(RS), C(L), and C(CW). When compared with normal intra-abdominal pressures, intra-abdominal hypertension increased DP(AW), during both "normal lung conditions" (p < 0.0001) and "unilateral atelectasis" (p = 0.0026). In contrast, DP(TP) remained virtually unaffected by changes in positive end-expiratory pressure or intra-abdominal pressures in both conditions. During unilateral lung injury, both DPA(W) and DP(TP) were increased by the presence of intra-abdominal hypertension (p < 0.0001 and p = 0.0222, respectively). During bilateral lung injury, intra-abdominal hypertension increased both DP(AW) (at positive end-expiratory pressure of 1 cm H2O, p < 0.0001; and at positive end-expiratory pressure of 10 cm H2O, p = 0.0091) and DP(TP) (at positive end-expiratory pressure of 1 cm H2O, p = 0.0510; and at positive end-expiratory pressure of 10 cm H2O, p = 0.0335). CONCLUSIONS Our data indicate that DP(AW) is influenced by reductions in chest wall compliance and by underlying lung properties. As with other measures of pulmonary mechanics that are based on unmodified P(AW), caution is advised in attempting to attribute hazard or safety to any specific absolute value of DP(AW).
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6389
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Ergin B, Bezemer R, Kandil A, Demirci-Tansel C, Ince C. TEMPOL has limited protective effects on renal oxygenation and hemodynamics but reduces kidney damage and inflammation in a rat model of renal ischemia/reperfusion by aortic clamping. J Clin Transl Res 2015; 1:1-13. [PMID: 30873445 PMCID: PMC6410622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 09/06/2015] [Accepted: 09/06/2015] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Renal ischemia-reperfusion (I/R) is a common clinical complication in critically ill patients that is associated with considerable morbidity and mortality. Renal I/R is a major cause of acute kidney injury (AKI) resulting from I/R-induced oxidative stress, sterile inflammation, and microcirculatory perfusion defects, which can be ameliorated with the superoxide scavenger TEMPOL. The most common cause of AKI in the clinical setting is aortic surgery with suprarenal aortic clamping. The protective effect of TEMPOL in aortic clamping-induced renal I/R has not been studied before. AIM To evaluate the protective effects of TEMPOL on oxidative stress, inflammation, tissue injury, and renal hemodynamics and oxygenation in a clinically representative rat model of I/R using aortic cross-clamping. METHODS Animals (N = 24) were either sham-operated or subjected to ischemia (30 min) and 90-min reperfusion, with or without TEMPOL treatment (15 min before ischemia and during entire reperfusion phase, 200 μmol/kg/h). Systemic and renal hemodynamics, renal oxygenation, and blood gas values were determined at 15 min and 90 min of reperfusion. At 90-min reperfusion, iNOS, inflammation (IL-6, MPO), oxidative stress (MDA), and tissue damage (NGAL, L-FABP) were determined in tissue biopsies. RESULTS TEMPOL administration at a cumulative dose of 400 μmol/kg conferred a protective effect on AKI in terms of reducing renal damage, inflammation, and iNOS activation. With respect to renal hemodynamics and oxygenation, TEMPOL only reduced renal vascular resistance to near-baseline levels at both reperfusion time points and partially ameliorated the I/R-induced drop microvascular partial tension of oxygen at 90 min reperfusion. Also, TEMPOL alleviated the I/R-induced metabolic acidosis. However, TEMPOL exerted no restorative effect in terms of the severely reduced mean arterial pressure, renal blood flow, and renal oxygen delivery and consumption. The renal oxygen extraction ratio remained unchanged during the 90-min reperfusion phase. Kidneys in all groups were anuric throughout the experiment. CONCLUSIONS This clinically representative renal I/R model, which entails both renal I/R and hind limb I/R as opposed to the standardly used renal I/R model that employs renal artery clamping, resulted in relatively moderate direct AKI. The damage was exacerbated by the perturbed systemic hemodynamics and metabolic acidosis as a result of the hind limb I/R. TEMPOL partially intervened in the factors that led to AKI as well as renal microvascular partial tension of oxygen and metabolic acidosis. However, more effective interventions should be devised for the mean arterial pressure drop (i.e., anuria) associated with aortic clamping and for restoring other critical renal hemodynamic and oxygenation parameters in order to improve post-I/R renal function. RELEVANCE FOR PATIENTS TEMPOL is a promising compound that has been shown to protect kidneys from I/R damage, which is relevant in kidney transplantation, pancreas transplantation, and aortic aneurysm repair in kidney transplant patients. This study suggests that intervening with TEMPOL is not sufficient to ensure optimal clinical outcome in patients that have undergone aortic clamping and that more effective interventions should be investigated.
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Affiliation(s)
- Bulent Ergin
- Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Rick Bezemer
- Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Asli Kandil
- Department of Biology, Faculty of Science, Istanbul University, Vezneciler, Istanbul, Turkey
| | - Cihan Demirci-Tansel
- Department of Biology, Faculty of Science, Istanbul University, Vezneciler, Istanbul, Turkey
| | - Can Ince
- Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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6390
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Sundar IK, Yao H, Sellix MT, Rahman I. Circadian molecular clock in lung pathophysiology. Am J Physiol Lung Cell Mol Physiol 2015; 309:L1056-75. [PMID: 26361874 DOI: 10.1152/ajplung.00152.2015] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/08/2015] [Indexed: 02/06/2023] Open
Abstract
Disrupted daily or circadian rhythms of lung function and inflammatory responses are common features of chronic airway diseases. At the molecular level these circadian rhythms depend on the activity of an autoregulatory feedback loop oscillator of clock gene transcription factors, including the BMAL1:CLOCK activator complex and the repressors PERIOD and CRYPTOCHROME. The key nuclear receptors and transcription factors REV-ERBα and RORα regulate Bmal1 expression and provide stability to the oscillator. Circadian clock dysfunction is implicated in both immune and inflammatory responses to environmental, inflammatory, and infectious agents. Molecular clock function is altered by exposomes, tobacco smoke, lipopolysaccharide, hyperoxia, allergens, bleomycin, as well as bacterial and viral infections. The deacetylase Sirtuin 1 (SIRT1) regulates the timing of the clock through acetylation of BMAL1 and PER2 and controls the clock-dependent functions, which can also be affected by environmental stressors. Environmental agents and redox modulation may alter the levels of REV-ERBα and RORα in lung tissue in association with a heightened DNA damage response, cellular senescence, and inflammation. A reciprocal relationship exists between the molecular clock and immune/inflammatory responses in the lungs. Molecular clock function in lung cells may be used as a biomarker of disease severity and exacerbations or for assessing the efficacy of chronotherapy for disease management. Here, we provide a comprehensive overview of clock-controlled cellular and molecular functions in the lungs and highlight the repercussions of clock disruption on the pathophysiology of chronic airway diseases and their exacerbations. Furthermore, we highlight the potential for the molecular clock as a novel chronopharmacological target for the management of lung pathophysiology.
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Affiliation(s)
- Isaac K Sundar
- Department of Environmental Medicine, Lung Biology and Disease Program, University of Rochester Medical Center, Rochester, New York; and
| | - Hongwei Yao
- Department of Environmental Medicine, Lung Biology and Disease Program, University of Rochester Medical Center, Rochester, New York; and
| | - Michael T Sellix
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Rochester Medical Center, Rochester, New York
| | - Irfan Rahman
- Department of Environmental Medicine, Lung Biology and Disease Program, University of Rochester Medical Center, Rochester, New York; and
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6391
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Zanier ER, Marchesi F, Ortolano F, Perego C, Arabian M, Zoerle T, Sammali E, Pischiutta F, De Simoni MG. Fractalkine Receptor Deficiency Is Associated with Early Protection but Late Worsening of Outcome following Brain Trauma in Mice. J Neurotrauma 2015; 33:1060-72. [PMID: 26180940 DOI: 10.1089/neu.2015.4041] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
An impaired ability to regulate microglia activation by fractalkine (CX3CL1) leads to microglia chronic sub-activation. How this condition affects outcome after acute brain injury is still debated, with studies showing contrasting results depending on the timing and the brain pathology. Here, we investigated the early and delayed consequences of fractalkine receptor (CX3CR1) deletion on neurological outcome and on the phenotypical features of the myeloid cells present in the lesions of mice with traumatic brain injury (TBI). Wild type (WT) and CX3CR1(-/-) C57Bl/6 mice were subjected to sham or controlled cortical impact brain injury. Outcome was assessed at 4 days and 5 weeks after TBI by neuroscore, neuronal count, and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining. Compared with WT mice, CX3CR1(-/-) TBI mice showed a significant reduction of sensorimotor deficits and lower cellular damage in the injured cortex 4 days post-TBI. Conversely, at 5 weeks, they showed a worsening of sensorimotor deficits and pericontusional cell death. Microglia (M) and macrophage (μ) activation and polarization were assessed by quantitative immunohistochemistry for CD11b, CD68, Ym1, and inducible nitric oxide synthase (iNOS)-markers of M/μ activation, phagocytosis, M2, and M1 phenotypes, respectively. Morphological analysis revealed a decreased area and perimeter of CD11b(+) cells in CX3CR1(-/-) mice at 4 days post-TBI, whereas, at 5 weeks, both parameters were significantly higher, compared with WT mice. At 4 days, CX3CR1(-/-) mice showed significantly decreased CD68 and iNOS immunoreactivity, while at 5 weeks post-injury, they showed a selective increase of iNOS. Gene expression on CD11b(+) sorted cells revealed an increase of interleukin 10 and insulin-like growth factor 1 (IGF1) at 1 day and a decrease of IGF1 4 days and 5 weeks post-TBI in CX3CR1(-/-), compared with WT mice. These data show an early protection followed by a chronic exacerbation of TBI outcome in the absence of CX3CR1. Thus, longitudinal effects of myeloid cell manipulation at different stages of pathology should be investigated to understand how and when their modulation may offer therapeutic chances.
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Affiliation(s)
- Elisa R Zanier
- 1 Department of Neuroscience, IRCCS-Istituto di Recerche Farmacologiche Mario Negri , Milan, Italy
| | - Federica Marchesi
- 1 Department of Neuroscience, IRCCS-Istituto di Recerche Farmacologiche Mario Negri , Milan, Italy
| | - Fabrizio Ortolano
- 2 Neuroscience ICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico , Milan, Italy
| | - Carlo Perego
- 1 Department of Neuroscience, IRCCS-Istituto di Recerche Farmacologiche Mario Negri , Milan, Italy
| | - Maedeh Arabian
- 1 Department of Neuroscience, IRCCS-Istituto di Recerche Farmacologiche Mario Negri , Milan, Italy .,3 Department of Physiology, Faculty of Medicine, Tehran University of Medical Science , Tehran, Iran
| | - Tommaso Zoerle
- 2 Neuroscience ICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico , Milan, Italy
| | - Eliana Sammali
- 1 Department of Neuroscience, IRCCS-Istituto di Recerche Farmacologiche Mario Negri , Milan, Italy .,4 Fondazione IRCCS Istituto Neurologico Carlo Besta , Milan, Italy
| | - Francesca Pischiutta
- 1 Department of Neuroscience, IRCCS-Istituto di Recerche Farmacologiche Mario Negri , Milan, Italy
| | - Maria-Grazia De Simoni
- 1 Department of Neuroscience, IRCCS-Istituto di Recerche Farmacologiche Mario Negri , Milan, Italy
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6392
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Schick MA, Baar W, Bruno RR, Wollborn J, Held C, Schneider R, Flemming S, Schlegel N, Roewer N, Neuhaus W, Wunder C. Balanced Hydroxyethylstarch (HES 130/0.4) Impairs Kidney Function In-Vivo without Inflammation. PLoS One 2015; 10:e0137247. [PMID: 26340751 PMCID: PMC4560431 DOI: 10.1371/journal.pone.0137247] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/14/2015] [Indexed: 01/04/2023] Open
Abstract
Volume therapy is a standard procedure in daily perioperative care, and there is an ongoing discussion about the benefits of colloid resuscitation with hydroxyethylstarch (HES). In sepsis HES should be avoided due to a higher risk for acute kidney injury (AKI). Results of the usage of HES in patients without sepsis are controversial. Therefore we conducted an animal study to evaluate the impact of 6% HES 130/0.4 on kidney integrity with sepsis or under healthy conditions Sepsis was induced by standardized Colon Ascendens Stent Peritonitis (sCASP). sCASP-group as well as control group (C) remained untreated for 24 h. After 18 h sCASP+HES group (sCASP+VOL) and control+HES (C+VOL) received 50 ml/KG balanced 6% HES (VOL) 130/0.4 over 6 h. After 24 h kidney function was measured via Inulin- and PAH-Clearance in re-anesthetized rats, and serum urea, creatinine (crea), cystatin C and Neutrophil gelatinase-associated lipocalin (NGAL) as well as histopathology were analysed. In vitro human proximal tubule cells (PTC) were cultured +/- lipopolysaccharid (LPS) and with 0.1-4.0% VOL. Cell viability was measured with XTT-, cell toxicity with LDH-test. sCASP induced severe septic AKI demonstrated divergent results regarding renal function by clearance or creatinine measure focusing on VOL. Soleley HES (C+VOL) deteriorated renal function without sCASP. Histopathology revealed significantly derangements in all HES groups compared to control. In vitro LPS did not worsen the HES induced reduction of cell viability in PTC cells. For the first time, we demonstrated, that application of 50 ml/KG 6% HES 130/0.4 over 6 hours induced AKI without inflammation in vivo. Severity of sCASP induced septic AKI might be no longer susceptible to the way of volume expansion.
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Affiliation(s)
- Martin Alexander Schick
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
- * E-mail:
| | - Wolfgang Baar
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Raphael Romano Bruno
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
| | - Jakob Wollborn
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Christopher Held
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Reinhard Schneider
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Sven Flemming
- Department of general, visceral, vascular and paediatric surgery (Department of Surgery I), University of Würzburg, Würzburg, Germany
| | - Nicolas Schlegel
- Department of general, visceral, vascular and paediatric surgery (Department of Surgery I), University of Würzburg, Würzburg, Germany
| | - Norbert Roewer
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
| | - Winfried Neuhaus
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
- Department of Medicinal Chemistry, University of Vienna, Vienna, Austria
- Institute of Medical Genetics, Medical University of Vienna, Vienna, Austria
| | - Christian Wunder
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
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6393
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Szabo PA, Anantha RV, Shaler CR, McCormick JK, Haeryfar SMM. CD1d- and MR1-Restricted T Cells in Sepsis. Front Immunol 2015; 6:401. [PMID: 26322041 PMCID: PMC4533011 DOI: 10.3389/fimmu.2015.00401] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/22/2015] [Indexed: 12/23/2022] Open
Abstract
Dysregulated immune responses to infection, such as those encountered in sepsis, can be catastrophic. Sepsis is typically triggered by an overwhelming systemic response to an infectious agent(s) and is associated with high morbidity and mortality even under optimal critical care. Recent studies have implicated unconventional, innate-like T lymphocytes, including CD1d- and MR1-restricted T cells as effectors and/or regulators of inflammatory responses during sepsis. These cell types are typified by invariant natural killer T (iNKT) cells, variant NKT (vNKT) cells, and mucosa-associated invariant T (MAIT) cells. iNKT and vNKT cells are CD1d-restricted, lipid-reactive cells with remarkable immunoregulatory properties. MAIT cells participate in antimicrobial defense, and are restricted by major histocompatibility complex-related protein 1 (MR1), which displays microbe-derived vitamin B metabolites. Importantly, NKT and MAIT cells are rapid and potent producers of immunomodulatory cytokines. Therefore, they may be considered attractive targets during the early hyperinflammatory phase of sepsis when immediate interventions are urgently needed, and also in later phases when adjuvant immunotherapies could potentially reverse the dangerous state of immunosuppression. We will highlight recent findings that point to the significance or the therapeutic potentials of NKT and MAIT cells in sepsis and will also discuss what lies ahead in research in this area.
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Affiliation(s)
- Peter A Szabo
- Department of Microbiology and Immunology, Western University , London, ON , Canada
| | - Ram V Anantha
- Department of Microbiology and Immunology, Western University , London, ON , Canada ; Division of General Surgery, Department of Medicine, Western University , London, ON , Canada
| | - Christopher R Shaler
- Department of Microbiology and Immunology, Western University , London, ON , Canada
| | - John K McCormick
- Department of Microbiology and Immunology, Western University , London, ON , Canada ; Centre for Human Immunology, Western University , London, ON , Canada ; Lawson Health Research Institute , London, ON , Canada
| | - S M Mansour Haeryfar
- Department of Microbiology and Immunology, Western University , London, ON , Canada ; Centre for Human Immunology, Western University , London, ON , Canada ; Lawson Health Research Institute , London, ON , Canada ; Division of Clinical Immunology and Allergy, Department of Medicine, Western University , London, ON , Canada
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6394
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Wagner K, Gröger M, McCook O, Scheuerle A, Asfar P, Stahl B, Huber-Lang M, Ignatius A, Jung B, Duechs M, Möller P, Georgieff M, Calzia E, Radermacher P, Wagner F. Blunt Chest Trauma in Mice after Cigarette Smoke-Exposure: Effects of Mechanical Ventilation with 100% O2. PLoS One 2015. [PMID: 26225825 PMCID: PMC4520521 DOI: 10.1371/journal.pone.0132810] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Cigarette smoking (CS) aggravates post-traumatic acute lung injury and increases ventilator-induced lung injury due to more severe tissue inflammation and apoptosis. Hyper-inflammation after chest trauma is due to the physical damage, the drop in alveolar PO2, and the consecutive hypoxemia and tissue hypoxia. Therefore, we tested the hypotheses that 1) CS exposure prior to blunt chest trauma causes more severe post-traumatic inflammation and thereby aggravates lung injury, and that 2) hyperoxia may attenuate this effect. Immediately after blast wave-induced blunt chest trauma, mice (n=32) with or without 3-4 weeks of CS exposure underwent 4 hours of pressure-controlled, thoraco-pulmonary compliance-titrated, lung-protective mechanical ventilation with air or 100 % O2. Hemodynamics, lung mechanics, gas exchange, and acid-base status were measured together with blood and tissue cytokine and chemokine concentrations, heme oxygenase-1 (HO-1), activated caspase-3, and hypoxia-inducible factor 1-α (HIF-1α) expression, nuclear factor-κB (NF-κB) activation, nitrotyrosine formation, purinergic receptor 2X4 (P2XR4) and 2X7 (P2XR7) expression, and histological scoring. CS exposure prior to chest trauma lead to higher pulmonary compliance and lower PaO2 and Horovitz-index, associated with increased tissue IL-18 and blood MCP-1 concentrations, a 2-4-fold higher inflammatory cell infiltration, and more pronounced alveolar membrane thickening. This effect coincided with increased activated caspase-3, nitrotyrosine, P2XR4, and P2XR7 expression, NF-κB activation, and reduced HIF-1α expression. Hyperoxia did not further affect lung mechanics, gas exchange, pulmonary and systemic cytokine and chemokine concentrations, or histological scoring, except for some patchy alveolar edema in CS exposed mice. However, hyperoxia attenuated tissue HIF-1α, nitrotyrosine, P2XR7, and P2XR4 expression, while it increased HO-1 formation in CS exposed mice. Overall, CS exposure aggravated post-traumatic inflammation, nitrosative stress and thereby organ dysfunction and injury; short-term, lung-protective, hyperoxic mechanical ventilation have no major beneficial effect despite attenuation of nitrosative stress, possibly due to compensation of by regional alveolar hypoxia and/or consecutive hypoxemia, resulting in down-regulation of HIF-1α expression.
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MESH Headings
- Acute Lung Injury/etiology
- Acute Lung Injury/physiopathology
- Acute Lung Injury/therapy
- Animals
- Disease Models, Animal
- Female
- Hyperoxia/complications
- Hyperoxia/pathology
- Hyperoxia/physiopathology
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Lung/pathology
- Lung/physiopathology
- Male
- Mice
- Mice, Inbred C57BL
- Oxidative Stress
- Pulmonary Disease, Chronic Obstructive/etiology
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Pulmonary Disease, Chronic Obstructive/therapy
- Reactive Nitrogen Species/metabolism
- Receptors, Purinergic P2X/metabolism
- Respiration, Artificial/adverse effects
- Smoking/adverse effects
- Thoracic Injuries/complications
- Thoracic Injuries/physiopathology
- Thoracic Injuries/therapy
- Wounds, Nonpenetrating/complications
- Wounds, Nonpenetrating/physiopathology
- Wounds, Nonpenetrating/therapy
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Affiliation(s)
- Katja Wagner
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
- Klinik für Anästhesiologie, Universitätsklinikum, Ulm, Germany
| | - Michael Gröger
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
| | - Oscar McCook
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
| | | | - Pierre Asfar
- Laboratoire HIFIH, UPRES EA 3859, PRES l’UNAM, IFR 132, CNRS UMR 6214, INSERM U1083, Université Angers, Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, Angers, France
| | - Bettina Stahl
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
| | - Markus Huber-Lang
- Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universitätsklinikum, Ulm, Germany
| | - Anita Ignatius
- Institut für Unfallchirurgische Forschung und Biomechanik, Universitätsklinikum, Ulm, Germany
| | - Birgit Jung
- Abteilung Respiratory Diseases Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach/Riss, Germany
| | - Matthias Duechs
- Abteilung Respiratory Diseases Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach/Riss, Germany
| | - Peter Möller
- Institut für Pathologie, Universitätsklinikum, Ulm, Germany
| | | | - Enrico Calzia
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
- * E-mail:
| | - Florian Wagner
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
- Klinik für Anästhesiologie, Universitätsklinikum, Ulm, Germany
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6395
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Abstract
Acute kidney injury (AKI) is a serious yet potentially reversible complication of sepsis. Several molecular mechanisms involved in the development of septic AKI have been identified. These mechanisms may be important targets in the development of future therapies. This review highlights the role of the innate immune response to sepsis and its downstream effects on kidney structure and function with special reference to the adaptive cellular response and glomerular hemodynamic changes. In addition, current evidence surrounding the management of patients with septic AKI is summarized. Finally, potential novel therapies for septic AKI are presented.
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Affiliation(s)
- Johan Mårtensson
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia; Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia; Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, School of Preventive Medicine and Public Health, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia.
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6396
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Wijnands KAP, Meesters DM, van Barneveld KWY, Visschers RGJ, Briedé JJ, Vandendriessche B, van Eijk HMH, Bessems BAFM, van den Hoven N, von Wintersdorff CJH, Brouckaert P, Bouvy ND, Lamers WH, Cauwels A, Poeze M. Citrulline Supplementation Improves Organ Perfusion and Arginine Availability under Conditions with Enhanced Arginase Activity. Nutrients 2015; 7:5217-38. [PMID: 26132994 PMCID: PMC4516994 DOI: 10.3390/nu7075217] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 05/15/2015] [Accepted: 06/18/2015] [Indexed: 01/10/2023] Open
Abstract
Enhanced arginase-induced arginine consumption is believed to play a key role in the pathogenesis of sickle cell disease-induced end organ failure. Enhancement of arginine availability with l-arginine supplementation exhibited less consistent results; however, l-citrulline, the precursor of l-arginine, may be a promising alternative. In this study, we determined the effects of l-citrulline compared to l-arginine supplementation on arginine-nitric oxide (NO) metabolism, arginine availability and microcirculation in a murine model with acutely-enhanced arginase activity. The effects were measured in six groups of mice (n = 8 each) injected intraperitoneally with sterile saline or arginase (1000 IE/mouse) with or without being separately injected with l-citrulline or l-arginine 1 h prior to assessment of the microcirculation with side stream dark-field (SDF)-imaging or in vivo NO-production with electron spin resonance (ESR) spectroscopy. Arginase injection caused a decrease in plasma and tissue arginine concentrations. l-arginine and l-citrulline supplementation both enhanced plasma and tissue arginine concentrations in arginase-injected mice. However, only the citrulline supplementation increased NO production and improved microcirculatory flow in arginase-injected mice. In conclusion, the present study provides for the first time in vivo experimental evidence that l-citrulline, and not l-arginine supplementation, improves the end organ microcirculation during conditions with acute arginase-induced arginine deficiency by increasing the NO concentration in tissues.
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Affiliation(s)
- Karolina A P Wijnands
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
| | - Dennis M Meesters
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
| | - Kevin W Y van Barneveld
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
| | - Ruben G J Visschers
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
| | - Jacob J Briedé
- Department of Toxicogenomics, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht 6200, The Netherlands.
| | - Benjamin Vandendriessche
- Department of Molecular Biomedical Research, VIB, Ghent B-9000, Belgium.
- Department of Biomedical Molecular Biology, Ghent University, Ghent B-9000, Belgium.
| | - Hans M H van Eijk
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
| | - Babs A F M Bessems
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
| | - Nadine van den Hoven
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
| | - Christian J H von Wintersdorff
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
| | - Peter Brouckaert
- Department of Molecular Biomedical Research, VIB, Ghent B-9000, Belgium.
- Department of Biomedical Molecular Biology, Ghent University, Ghent B-9000, Belgium.
| | - Nicole D Bouvy
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
| | - Wouter H Lamers
- Department of Anatomy & Embryology, Maastricht University Medical Center, Maastricht 6200, The Netherlands.
| | - Anje Cauwels
- Department of Molecular Biomedical Research, VIB, Ghent B-9000, Belgium.
- Department of Biomedical Molecular Biology, Ghent University, Ghent B-9000, Belgium.
| | - Martijn Poeze
- Department of Surgery, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands.
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6397
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Calaza KC, Kam JH, Hogg C, Jeffery G. Mitochondrial decline precedes phenotype development in the complement factor H mouse model of retinal degeneration but can be corrected by near infrared light. Neurobiol Aging 2015; 36:2869-76. [PMID: 26149919 DOI: 10.1016/j.neurobiolaging.2015.06.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 06/02/2015] [Accepted: 06/05/2015] [Indexed: 11/18/2022]
Abstract
Mitochondria produce adenosine triphosphate (ATP), critical for cellular metabolism. ATP declines with age, which is associated with inflammation. Here, we measure retinal and brain ATP in normal C57BL/6 and complement factor H knockout mice (Cfh(-/-)), which are proposed as a model of age-related macular degeneration. We show a significant premature 30% decline in retinal ATP in Cfh(-/-) mice and a subsequent shift in expression of a heat shock protein that is predominantly mitochondrial (Hsp60). Changes in Hsp60 are associated with stress and neuroprotection. We find no differences in brain ATP between C57BL/6 and Cfh(-/-) mice. Near infrared (NIR) increases ATP and reduces inflammation. ATP decline in Cfh(-/-) mice was corrected with NIR which also shifted Hsp60 labeling patterns. ATP decline in Cfh(-/-) mice occurs before inflammation becomes established and photoreceptor loss occurs and may relate to disease etiology. However, ATP levels were corrected with NIR. In summary, we provide evidence for a mitochondrial basis for this disease in mice and correct this with simple light exposure known to improve mitochondrial function.
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Affiliation(s)
- Karin C Calaza
- Program of Neurosciences, Institute of Biology, Federal Fluminense University, Rio de Janeiro, Brazil; Institute of Ophthalmology University College London, London, UK
| | - Jaimie Hoh Kam
- Institute of Ophthalmology University College London, London, UK
| | | | - Glen Jeffery
- Institute of Ophthalmology University College London, London, UK.
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6398
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A mathematical model approach quantifying patients' response to changes in mechanical ventilation: Evaluation in pressure support. J Crit Care 2015; 30:1008-15. [PMID: 26067844 DOI: 10.1016/j.jcrc.2015.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/30/2015] [Accepted: 05/12/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE This article evaluates how mathematical models of gas exchange, blood acid-base status, chemical respiratory drive, and muscle function can describe the respiratory response of spontaneously breathing patients to different levels of pressure support. METHODS The models were evaluated with data from 12 patients ventilated in pressure support ventilation. Models were tuned with clinical data (arterial blood gas measurement, ventilation, and respiratory gas fractions of O2 and CO2) to describe each patient at the clinical level of pressure support. Patients were ventilated up to 5 different pressure support levels, for 15 minutes at each level to achieve steady-state conditions. Model-simulated values of respiratory frequency (fR), arterial pH (pHa), and end-tidal CO2 (FeCO2) were compared to measured values at each pressure support level. RESULTS Model simulations compared well to measured data with Bland-Altman bias and limits of agreement of fR of 0.7 ± 2.2 per minute, pHa of -0.0007 ± 0.019, and FeCO2 of -0.001 ± 0.003. CONCLUSION The models describe patients' fR, pHa, and FeCO2 response to changes in pressure support with low bias and narrow limits of agreement.
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6399
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Besen BAMP, Gobatto ALN, Melro LMG, Maciel AT, Park M. Fluid and electrolyte overload in critically ill patients: An overview. World J Crit Care Med 2015; 4:116-129. [PMID: 25938027 PMCID: PMC4411563 DOI: 10.5492/wjccm.v4.i2.116] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/24/2014] [Accepted: 03/05/2015] [Indexed: 02/06/2023] Open
Abstract
Fluids are considered the cornerstone of therapy for many shock states, particularly states that are associated with relative or absolute hypovolemia. Fluids are also commonly used for many other purposes, such as renal protection from endogenous and exogenous substances, for the safe dilution of medications and as “maintenance” fluids. However, a large amount of evidence from the last decade has shown that fluids can have deleterious effects on several organ functions, both from excessive amounts of fluids and from their non-physiological electrolyte composition. Additionally, fluid prescription is more common in patients with systemic inflammatory response syndrome whose kidneys may have impaired mechanisms of electrolyte and free water excretion. These processes have been studied as separate entities (hypernatremia, hyperchloremic acidosis and progressive fluid accumulation) leading to worse outcomes in many clinical scenarios, including but not limited to acute kidney injury, worsening respiratory function, higher mortality and higher hospital and intensive care unit length-of-stays. In this review, we synthesize this evidence and describe this phenomenon as fluid and electrolyte overload with potentially deleterious effects. Finally, we propose a strategy to safely use fluids and thereafter wean patients from fluids, along with other caveats to be considered when dealing with fluids in the intensive care unit.
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6400
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Zolfaghari PS, Carré JE, Parker N, Curtin NA, Duchen MR, Singer M. Skeletal muscle dysfunction is associated with derangements in mitochondrial bioenergetics (but not UCP3) in a rodent model of sepsis. Am J Physiol Endocrinol Metab 2015; 308:E713-25. [PMID: 25714676 PMCID: PMC4420898 DOI: 10.1152/ajpendo.00562.2014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 02/18/2015] [Indexed: 12/31/2022]
Abstract
Muscle dysfunction is a common feature of severe sepsis and multiorgan failure. Recent evidence implicates bioenergetic dysfunction and oxidative damage as important underlying pathophysiological mechanisms. Increased abundance of uncoupling protein-3 (UCP3) in sepsis suggests increased mitochondrial proton leak, which may reduce mitochondrial coupling efficiency but limit reactive oxygen species (ROS) production. Using a murine model, we examined metabolic, cardiovascular, and skeletal muscle contractile changes following induction of peritoneal sepsis in wild-type and Ucp3(-/-) mice. Mitochondrial membrane potential (Δψm) was measured using two-photon microscopy in living diaphragm, and contractile function was measured in diaphragm muscle strips. The kinetic relationship between membrane potential and oxygen consumption was determined using a modular kinetic approach in isolated mitochondria. Sepsis was associated with significant whole body metabolic suppression, hypothermia, and cardiovascular dysfunction. Maximal force generation was reduced and fatigue accelerated in ex vivo diaphragm muscle strips from septic mice. Δψm was lower in the isolated diaphragm from septic mice despite normal substrate oxidation kinetics and proton leak in skeletal muscle mitochondria. Even though wild-type mice exhibited an absolute 26 ± 6% higher UCP3 protein abundance at 24 h, no differences were seen in whole animal or diaphragm physiology, nor in survival rates, between wild-type and Ucp3(-/-) mice. In conclusion, this murine sepsis model shows a hypometabolic phenotype with evidence of significant cardiovascular and muscle dysfunction. This was associated with lower Δψm and alterations in mitochondrial ATP turnover and the phosphorylation pathway. However, UCP3 does not play an important functional role, despite its upregulation.
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Affiliation(s)
- Parjam S Zolfaghari
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, United Kingdom; Department of Cell and Developmental Biology, University College London, London, United Kingdom
| | - Jane E Carré
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, United Kingdom
| | - Nadeene Parker
- Department of Cell and Developmental Biology, University College London, London, United Kingdom
| | - Nancy A Curtin
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Michael R Duchen
- Department of Cell and Developmental Biology, University College London, London, United Kingdom
| | - Mervyn Singer
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, United Kingdom
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