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Krinsley JS, Fisher M. The diabetes paradox: diabetes is not independently associated with mortality in critically ill patients. Hosp Pract (1995) 2014; 40:31-5. [PMID: 22615076 DOI: 10.3810/hp.2012.04.967] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intensive monitoring of blood glucose levels and treatment of hyperglycemia in critically ill patients has become a standard of care over the past decade. Although diabetes is associated with a large burden of illness in outpatients, the "diabetes paradox" suggests that in patients admitted to intensive care units, the presence of diabetes as a comorbidity is not independently associated with increased risk of mortality. This review article 1) describes prospective trial and observational cohort literature addressing this issue, 2) addresses the potential mechanisms underlying the diabetes paradox, and 3) discusses implications for patient care and future research.
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Affiliation(s)
- James S Krinsley
- Director of Critical Care, Stamford Hospital, Stamford, CT; Clinical Professor of Medicine, Columbia University College of Physicians and Surgeons, New York, NY.
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Xiang L, Lu S, Mittwede PN, Clemmer JS, Husband GW, Hester RL. β(2)-Adrenoreceptor blockade improves early posttrauma hyperglycemia and pulmonary injury in obese rats. Am J Physiol Heart Circ Physiol 2014; 307:H621-7. [PMID: 24929860 DOI: 10.1152/ajpheart.00208.2014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Early hyperglycemia after trauma increases morbidity and mortality. Insulin is widely used to control posttrauma glucose, but this treatment increases the risk of hypoglycemia. We tested a novel method for early posttrauma hyperglycemia control by suppressing hepatic glycogenolysis via β2-adrenoreceptor blockade [ICI-118551 (ICI)]. We have shown that, after severe trauma, obese Zucker (OZ) rats, similar to obese patients, exhibit increased acute lung injury compared with lean Zucker (LZ) rats. We hypothesized that OZ rats exhibit a greater increase in early posttrauma glucose compared with LZ rats, with the increased posttrauma hyperglycemia suppressed by ICI treatment. Orthopedic trauma was applied to both hindlimbs in LZ and OZ rats. Fasting plasma glucose was then monitored for 6 h with or without ICI (0.2 mg·kg(-1)·h(-1) iv.) treatment. One day after trauma, plasma IL-6 levels, lung neutrophil numbers, myeloperoxidase (MPO) activity, and wet-to-dry weight ratios were measured. Trauma induced rapid hepatic glycogenolysis, as evidenced by decreased liver glycogen levels, and this was inhibited by ICI treatment. Compared with LZ rats, OZ rats exhibited higher posttrauma glucose, IL-6, lung neutrophil infiltration, and MPO activity. Lung wet-to-dry weight ratios were increased in OZ rats but not in LZ rats. ICI treatment reduced the early hyperglycemia, lung neutrophil retention, MPO activity, and wet-to-dry weight ratio in OZ rats to levels comparable with those seen in LZ rats, with no effect on blood pressure or heart rate. These results demonstrate that β2-adrenoreceptor blockade effectively reduces the early posttrauma hyperglycemia, which is associated with decreased lung injury in OZ rats.
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Affiliation(s)
- Lusha Xiang
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Silu Lu
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Peter N Mittwede
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - John S Clemmer
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Graham W Husband
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Robert L Hester
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
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Pathophysiology and biomarkers of acute respiratory distress syndrome. J Intensive Care 2014; 2:32. [PMID: 25520844 PMCID: PMC4267590 DOI: 10.1186/2052-0492-2-32] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/24/2014] [Indexed: 01/28/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is defined as an acute-onset, progressive, hypoxic condition with radiographic bilateral lung infiltration, which develops after several diseases or injuries, and is not derived from hydrostatic pulmonary edema. One specific pathological finding of ARDS is diffuse alveolar damage. In 2012, in an effort to increase diagnostic specificity, a revised definition of ARDS was published in JAMA. However, no new parameters or biomarkers were adopted by the revised definition. Discriminating between ARDS and other similar diseases is critically important; however, only a few biomarkers are currently available for diagnostic purposes. Furthermore, predicting the severity, response to therapy, or outcome of the illness is also important for developing treatment strategies for each patient. However, the PaO2/FIO2 ratio is currently the sole clinical parameter used for this purpose. In parallel with progress in understanding the pathophysiology of ARDS, various humoral factors induced by inflammation and molecules derived from activated cells or injured tissues have been shown as potential biomarkers that may be applied in clinical practice. In this review, the current understanding of the basic pathophysiology of ARDS and associated candidate biomarkers will be discussed.
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Gu WJ, Wan YD, Tie HT, Kan QC, Sun TW. Risk of acute lung injury/acute respiratory distress syndrome in critically ill adult patients with pre-existing diabetes: a meta-analysis. PLoS One 2014; 9:e90426. [PMID: 24587357 PMCID: PMC3937384 DOI: 10.1371/journal.pone.0090426] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 01/30/2014] [Indexed: 12/29/2022] Open
Abstract
Background The impact of pre-existing diabetes on the development of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) in critically ill patients remains unclear. We performed a meta-analysis of cohort studies to evaluate the risk of ALI/ARDS in critically ill patients with and without pre-existing diabetes. Materials and Methods We searched PubMed and Embase from the inception to September 2013 for cohort studies assessing the effect of pre-existing diabetes on ALI/ARDS occurrence. Pooled odds ratio (OR) with 95% confidence interval (CI) was calculated using random- or fixed-effect models when appropriate. Results Seven cohort studies with a total of 12,794 participants and 2,937 cases of pre-existing diabetes, and 2,457 cases of ALI/ARDS were included in the meta-analysis. A fixed-effects model meta-analysis showed that pre-existing diabetes was associated with a reduced risk of ALI/ARDS (OR 0.66; 95% CI, 0.55–0.80; p<0.001), with low heterogeneity among the studies (I2 = 18.9%; p = 0.286). However, the asymmetric funnel plot and Egger's test (p = 0.007) suggested publication bias may exist. Conclusions Our meta-analysis suggests that pre-existing diabetes was associated with a decreased risk of ALI/ARDS in critically ill adult patients. However, the result should be interpreted with caution because of the potential bias and confounding in the included studies.
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Affiliation(s)
- Wan-Jie Gu
- Department of Anaesthesiology, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
- Department of Integrated Intensive Care Unit, the First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - You-Dong Wan
- Department of Integrated Intensive Care Unit, the First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Hong-Tao Tie
- The First College of Clinical Medicine, the First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Quan-Cheng Kan
- Pharmaceutical Department, the First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Tong-Wen Sun
- Department of Integrated Intensive Care Unit, the First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
- * E-mail:
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Diabetes and acute respiratory distress syndrome: can we finally believe the epidemiology? Crit Care Med 2014; 41:2822-3. [PMID: 24275394 DOI: 10.1097/ccm.0b013e31829cb06b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVES Diabetes has been associated with decreased development of acute respiratory distress syndrome in some, but not all, previous studies. Therefore, we examined the relationship between diabetes and development of acute respiratory distress syndrome and whether this association was modified by type of diabetes, etiology of acute respiratory distress syndrome, diabetes medications, or other potential confounders. DESIGN Observational prospective multicenter study. SETTING Four adult ICUs at two tertiary academic medical centers. PATIENTS Three thousand eight hundred sixty critically ill patients at risk for acute respiratory distress syndrome from sepsis, pneumonia, trauma, aspiration, or massive transfusion. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Diabetes history was present in 25.8% of patients. Diabetes was associated with lower rates of developing acute respiratory distress syndrome on univariate (odds ratio, 0.79; 95% CI, 0.66-0.94) and multivariate analysis (adjusted odds ratio, 0.76; 95% CI, 0.61-0.95). After including diabetes medications into the model, diabetes remained protective (adjusted odds ratio, 0.75; 95% CI, 0.59-0.94). Diabetes was associated with decreased development of acute respiratory distress syndrome both in the subgroup of patients with sepsis (adjusted odds ratio, 0.77; 95% CI, 0.61-0.97) and patients with noninfectious etiologies (adjusted odds ratio, 0.30; 95% CI, 0.10-0.90). The protective effect of diabetes on acute respiratory distress syndrome development is not clearly restricted to either type 1 (adjusted odds ratio, 0.50; 95% CI, 0.26-0.99; p = 0.046) or type 2 (adjusted odds ratio, 0.77; 95% CI, 0.60-1.00; p = 0.050) diabetes. Among patients in whom acute respiratory distress syndrome developed, diabetes was not associated with 60-day mortality on univariate (odds ratio, 1.11; 95% CI, 0.80-1.52) or multivariate analysis (adjusted odds ratio, 0.81; 95% CI, 0.56-1.18). CONCLUSIONS Diabetes is associated with a lower rate of acute respiratory distress syndrome development, and this relationship remained after adjusting for clinical differences between diabetics and nondiabetics, such as obesity, acute hyperglycemia, and diabetes-associated medications. In addition, this association was present for type 1 and 2 diabetics and in all subgroups of at-risk patients.
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Wang G, Han D, Zhang Y, Xie X, Wu Y, Li S, Li M. A novel hypothesis: up-regulation of HO-1 by activation of PPARγ inhibits HMGB1-RAGE signaling pathway and ameliorates the development of ALI/ARDS. J Thorac Dis 2013; 5:706-10. [PMID: 24255785 DOI: 10.3978/j.issn.2072-1439.2013.08.69] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 08/27/2013] [Indexed: 01/11/2023]
Abstract
Suppression of inflammation in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) by activation of peroxisome proliferator-activated receptor (PPAR)-γ has been well demonstrated in animal model studies. However, the molecular mechanisms underlying this effect remain largely unknown. The induction of heme oxygenase-1 (HO-1) exerts antioxidant, anti-apoptotic, and immunomodulatory functions in various situations. Recent studies have indicated that activation of PPARγ induces expression of HO-1, suggesting that HO-1 is a downstream target of PPARγ. Meanwhile, study has shown that activation of PPARγ ameliorates inflammatory response of cells by inhibiting high mobility group box 1 (HMGB1) release. In pulmonary system, binding of HMGB1 to its receptor for advanced glycation end-products (RAGE) triggers the production of pro-inflammatory cytokines, chemokines, adhesion molecules and reactive oxygen species, promoting the development of ALI/ARDS. Based on the recent findings that induction of HO-1 protects tissues and cells from extracellular stress by reducing HMGB1 production, we propose the hypothesis that HO-1 may mediate the protective effects of PPARγ on inhibition of HMGB1-RAGE signaling pathway to attenuate the development of ALI/ARDS.
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Affiliation(s)
- Guizuo Wang
- Department of Respiratory Medicine, the Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710004, People's Republic of China
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Singla A, Turner P, Pendurthi MK, Agrawal V, Modrykamien A. Effect of type II diabetes mellitus on outcomes in patients with acute respiratory distress syndrome. J Crit Care 2013; 29:66-9. [PMID: 24331945 DOI: 10.1016/j.jcrc.2013.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 09/09/2013] [Accepted: 10/04/2013] [Indexed: 01/04/2023]
Abstract
PURPOSE The acute respiratory distress syndrome (ARDS) is a life-threatening condition, whereas the presence of diabetes has been shown to be protective in its development. We undertook this study to assess the association of type II diabetes mellitus with clinical outcomes in patients with ARDS. MATERIALS AND METHODS We retrospectively examined the medical records of consecutive series of patients with ARDS requiring mechanical ventilation from January 2008 to March 2011. Patients with type I diabetes were excluded from the study. Clinical outcomes such as ventilator-free days, mortality, length of stay in the hospital and intensive care unit (ICU), and reintubations were compared based on the presence of diabetes. Multivariate regression model was used to find if the presence of type II diabetes mellitus predicts ventilator-free days at day 28. RESULTS Two hundred forty-nine patients with ARDS were admitted to the ICU during the study period. Fifty (20%) subjects had type II diabetes mellitus. Differences in ventilator-free days, in-hospital mortality, reintubation rate, and length of stay in the hospital or ICU were not statistically significant between diabetic and nondiabetic patients with ARDS. Acute Physiologic and Chronic Health Evaluation II, ICU specialty, use of vasopressors, and the need for reintubation were predictors of ventilator-free days at day 28. The presence of type II diabetes mellitus and its adjustment by body mass index did not show association with ventilator-free days at day 28. CONCLUSIONS The presence of type II diabetes mellitus is not associated with clinical outcomes in ARDS, even when its presence is adjusted by body mass index.
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Affiliation(s)
- Abhishek Singla
- Department of Internal Medicine, Creighton University Medical Center, Omaha, NE, USA
| | - Paul Turner
- Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE, USA
| | | | - Vrinda Agrawal
- Division of Endocrinology, Baylor College of Medicine, Houston, TX, USA
| | - Ariel Modrykamien
- Intensive Care Unit and Respiratory Care Services, Pulmonary, Sleep and Critical Care Medicine Division, Creighton University School of Medicine, Omaha, NE, USA.
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Jian MY, Alexeyev MF, Wolkowicz PE, Zmijewski JW, Creighton JR. Metformin-stimulated AMPK-α1 promotes microvascular repair in acute lung injury. Am J Physiol Lung Cell Mol Physiol 2013; 305:L844-55. [PMID: 24097562 DOI: 10.1152/ajplung.00173.2013] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute lung injury secondary to sepsis is a leading cause of mortality in sepsis-related death. Present therapies are not effective in reversing endothelial cell dysfunction, which plays a key role in increased vascular permeability and compromised lung function. AMP-activated protein kinase (AMPK) is a molecular sensor important for detection and mediation of cellular adaptations to vascular disruptive stimuli. In this study, we sought to determine the role of AMPK in resolving increased endothelial permeability in the sepsis-injured lung. AMPK function was determined in vivo using a rat model of endotoxin-induced lung injury, ex vivo using the isolated lung, and in vitro using cultured rat pulmonary microvascular endothelial cells (PMVECs). AMPK stimulation using N1-(α-d-ribofuranosyl)-5-aminoimidizole-4-carboxamide or metformin decreased the LPS-induced increase in permeability, as determined by filtration coefficient (Kf) measurements, and resolved edema as indicated by decreased wet-to-dry ratios. The role of AMPK in the endothelial response to LPS was determined by shRNA designed to decrease expression of the AMPK-α1 isoform in capillary endothelial cells. Permeability, wounding, and barrier resistance assays using PMVECs identified AMPK-α1 as the molecule responsible for the beneficial effects of AMPK in the lung. Our findings provide novel evidence for AMPK-α1 as a vascular repair mechanism important in the pulmonary response to sepsis and identify a role for metformin treatment in the management of capillary injury.
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Affiliation(s)
- Ming-Yuan Jian
- Dept. of Anesthesiology, BMR II, 901 19 St., S. Birmingham, AL 35294.
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Developing prevention model of acute lung injury: Validity of lung injury prediction score and risk panel. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013. [DOI: 10.1016/j.ejcdt.2013.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
OBJECTIVE The objective of this study was to analyze the association between candidate gene polymorphisms and susceptibility to acute respiratory distress syndrome (ARDS) in patients with severe sepsis. METHODS Patients older than 18 years admitted to the intensive care unit (ICU) with the diagnosis of severe sepsis were prospectively included. A blood sample was drawn on the first day of ICU admission, and DNA was extracted. We genotyped the insertion/deletion polymorphism of the angiotensin-converting enzyme (ACE) gene (polymerase chain reaction) and the following single-nucleotide polymorphisms (TaqMan SNP genotyping assay): tumor necrosis factor α -376 G/A, -308 G/A, and -238 G/A; interleukin 8 -251 T/A; pre-B cell colony-enhancing factor -1001 G/T; and vascular endothelial growth factor +405 C/G and +936 C/T. Polymorphisms were selected based on reports on their association with ARDS. Variables associated in univariate analysis (P < 0.1) with the diagnosis of ARDS were included in a multiple logistic regression analysis. RESULTS We studied 149 patients, of whom 35 presented ARDS. Variables included in the maximal multivariate model were male sex, chronic alcoholism, use of ACE inhibitors or angiotensin-receptor blockers, Simplified Acute Physiology Score II score, serum glucose concentration at ICU admission, and the presence of the allele D of the ACE gene. After adjustment for those variables, the presence of the allele D of the ACE gene (odds ratio, 4.75; 95% confidence interval, 1.02-22.20; P = 0.048) was significantly associated with the diagnosis of ARDS. CONCLUSION The presence of the allele D of the ACE gene is associated with ARDS in patients with severe sepsis.
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Cooke CR, Watkins TR. Variation in the incidence and timing of acute lung injury: the role of race. Chest 2013; 143:881-882. [PMID: 23546474 DOI: 10.1378/chest.12-2683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.
| | - Timothy R Watkins
- Research Institute, Puget Sound Blood Center, Seattle, WA; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA
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Fan W, Nakazawa K, Abe S, Inoue M, Kitagawa M, Nagahara N, Makita K. Inhaled aerosolized insulin ameliorates hyperglycemia-induced inflammatory responses in the lungs in an experimental model of acute lung injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R83. [PMID: 23622115 PMCID: PMC4057452 DOI: 10.1186/cc12697] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 04/28/2013] [Indexed: 01/04/2023]
Abstract
Introduction Previous studies have shown that patients with diabetes mellitus appear to have a lower prevalence of acute lung injury. We assumed that insulin prescribed to patients with diabetes has an anti-inflammatory property and pulmonary administration of insulin might exert beneficial effects much more than intravenous administration. Methods Twenty-eight mechanically ventilated rabbits underwent lung injury by saline lavage, and then the animals were allocated into a normoglycemia group (NG), a hyperglycemia group (HG), an HG treated with intravenous insulin (HG-VI) group or an HG treated with aerosolized insulin (HG-AI) group with continuous infusion of different fluid solutions and treatments: normal saline, 50% glucose, 50% glucose with intravenous insulin, or 50% glucose with inhaled aerosolized insulin, respectively. After four hours of treatment, the lungs and heart were excised en bloc, and then high-mobility group B1 concentration in bronchoalveolar lavage fluid, interleukin-8 and toll-like receptor 4 mRNA expression in bronchoalveolar lavage fluid cells, and lung myeloperoxidase activity were measured. Results Treatment with both aerosolized insulin and intravenous insulin attenuated toll-like receptor 4 mRNA expressions in the bronchoalveolar lavage fluid cells. Interleukin-8 and toll-like receptor 4 mRNA expression was significantly lower in the HG-AI group than in the HG-IV group. The lung myeloperoxidase activity in the normal healthy group showed significantly lower levels compared to the NG group but not different compared to those of the HG, HG-VI and HG-AI groups. Conclusions The results suggest that insulin attenuates inflammatory responses in the lungs augmented by hyperglycemia in acute lung injury and the insulin's efficacy may be better when administered by aerosol.
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Christiansen CF, Johansen MB, Christensen S, O'Brien JM, Tønnesen E, Sørensen HT. Type 2 diabetes and 1-year mortality in intensive care unit patients. Eur J Clin Invest 2013; 43:238-47. [PMID: 23240763 DOI: 10.1111/eci.12036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/24/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Data on the prognostic impact of diabetes and diabetic complications in intensive care unit (ICU) patients are limited and inconsistent. We, therefore, examined mortality in ICU patients with type 2 diabetes with and without pre-existing heart and kidney diseases compared with nondiabetic patients. DESIGN We conducted this population-based cohort study in Northern Denmark during 2005-2011. We included all ICU patients aged 40 years or older from the 17 ICUs in the area and identified type 2 diabetes by either a filled prescription for an antidiabetic drug, a previous diagnosis of diabetes, or an elevated glycosylated haemoglobin level. Diabetic patients were disaggregated according to pre-existing diagnoses of heart disease (myocardial infarction or heart failure) and kidney disease. We estimated 1-year mortality by the Kaplan-Meier method and hazard ratios of death (HRs) during follow-up using Cox regression, controlling for confounding factors and stratified by relevant subgroups. RESULTS Among 45 018 ICU patients, 7219 (16·0%) had type 2 diabetes. Overall, 1-year mortality was 36·0% in ICU patients with type 2 diabetes, rising to 54·6% in patients with pre-existing heart and kidney diseases, compared with 29·1% in nondiabetic patients. Comparing diabetic with nondiabetic patients, the adjusted 0- to 30-day HR was 1·20 (95% confidence interval (CI): 1·13-1·26) and 1·19 (95% CI: 1·10-1·28) during the 31- to 365-day follow-up period. Pre-existing kidney disease further increased the impact of diabetes, while heart disease alone had no such effect. CONCLUSIONS ICU patients with type 2 diabetes had higher 1-year mortality compared with nondiabetic ICU patients, particularly those with pre-existing kidney disease.
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Hung CH, Chang CN, Chen YW, Chen YC, Tzeng JI, Wang JJ. Cardiopulmonary Profile in Streptozotocin-Induced Type 1 Diabetic Rats during Systemic Endotoxemia. J Diabetes Res 2013; 2013:494179. [PMID: 23671873 PMCID: PMC3647548 DOI: 10.1155/2013/494179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 12/16/2012] [Indexed: 11/18/2022] Open
Abstract
This study was designed to determine the severity of cardiopulmonary dysfunction during systemic endotoxemia in type 1 diabetes. Thirty-two adult male Wistar rats were randomly assigned to a control group or to a group treated with streptozotocin (STZ) to create an animal model of type 1 diabetes. Survival time and cardiovascular parameters were continually monitored in urethane anaesthetized animals receiving intravenous infusion of endotoxin (lipopolysaccharide (LPS)) or saline. We also determined arterial blood gases, lung injury, and tumor necrosis factor-alpha (TNF- α ) levels in serum and bronchoalveolar lavage fluid. Before LPS administration, the mean arterial pressure in STZ rats was significantly higher than that in normal rats. After LPS injection, the heart rate drop significantly in STZ rats than that in the control group. Also, the increased levels of TNF- α in serum and lavage fluid after LPS treatment were significantly higher in STZ rats than those in normal rats. Survival time in STZ rats was shorter than that in normal rats after LPS application. Albumin content, wet/dry weight ratio of lung, and lung injury were indistinguishable between STZ and normal rats. These results indicate that the cardiopulmonary change which occurs during LPS-induced endotoxemia is minor in STZ-induced diabetic rats.
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Affiliation(s)
- Ching-Hsia Hung
- Department of Physical Therapy, National Cheng Kung University, Tainan 701, Taiwan
| | - Che-Ning Chang
- Department of Physical Therapy, National Cheng Kung University, Tainan 701, Taiwan
| | - Yu-Wen Chen
- Department of Physical Therapy, China Medical University, Taichung 404, Taiwan
- *Yu-Wen Chen:
| | - Yu-Chung Chen
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, Cheng Hsin Rehabilitation Medical Center, Taipei 112, Taiwan
| | - Jann-Inn Tzeng
- Department of Food Sciences and Technology, Chia Nan University of Pharmacy and Sciences, Tainan 717, Taiwan
- Department of Anesthesiology, Chi-Mei Medical Center, Tainan 710, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi-Mei Medical Centre, Tainan 710, Taiwan
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Hung CH, Tzeng JI, Chang CN, Chen YW, Cho CY, Wang JJ. Treadmill exercise preconditioning attenuates lung damage caused by systemic endotoxemia in type 1 diabetic rats. J Diabetes Res 2013; 2013:527090. [PMID: 24392457 PMCID: PMC3872431 DOI: 10.1155/2013/527090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 11/25/2013] [Accepted: 11/26/2013] [Indexed: 11/17/2022] Open
Abstract
Endotoxemia induces a series of inflammatory responses that may result in lung injury. However, heat shock protein72 (HSP72) has the potential to protect the lungs from damage. The objective of this study was to determine whether prior exercise conditioning could increase the expression of HSP72 in the lungs and attenuate lung damage in diabetic rats receiving lipopolysaccharide (LPS). Streptozotocin was used to induce diabetes in adult male Wistar rats. Rats were randomly assigned to sedentary or exercise groups. Rats in the exercise condition ran on a treadmill 5 days/week, 30-60 min/day, with an intensity of 1.0 mile/hour over a 3-week period. Rats received an intravenous infusion of LPS after 24 hrs from the last training session. Elevated lavage tumor necrosis factor-alpha (TNF- α ) level in response to LPS was more marked in diabetic rats. HSP72 expression in lungs was significantly increased after exercise conditioning, but less pronounced in diabetic rats. After administration of LPS, exercised rats displayed higher survival rate as well as decreased lavage TNF- α level and lung edema in comparison to sedentary rats. Our findings suggest that exercise conditioning could attenuate the occurrence of inflammatory responses and lung damage, thereby reducing mortality rate in diabetic rats during endotoxemia.
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Affiliation(s)
- Ching-Hsia Hung
- Department of Physical Therapy, National Cheng Kung University, Tainan 701, Taiwan
| | - Jann-Inn Tzeng
- Department of Food Sciences and Technology, Chia Nan University of Pharmacy and Sciences, Jen-Te, Tainan 717, Taiwan
- Department of Anesthesiology, Chi-Mei Medical Center, Yong Kang, Tainan 710, Taiwan
| | - Che-Ning Chang
- Department of Physical Therapy, National Cheng Kung University, Tainan 701, Taiwan
| | - Yu-Wen Chen
- Department of Physical Therapy, China Medical University, Taichung 404, Taiwan
- *Yu-Wen Chen:
| | - Chia-Ying Cho
- Department of Physical Therapy, National Cheng Kung University, Tainan 701, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi-Mei Medical Centre, Tainan 710, Taiwan
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Dixon DL, Mayne GC, Griggs KM, De Pasquale CG, Bersten AD. Chronic elevation of pulmonary microvascular pressure in chronic heart failure reduces bi-directional pulmonary fluid flux. Eur J Heart Fail 2012; 15:368-75. [PMID: 23248216 DOI: 10.1093/eurjhf/hfs201] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Chronic heart failure leads to pulmonary vascular remodelling and thickening of the alveolar-capillary barrier. We examined whether this protective effect may slow resolution of pulmonary oedema consistent with decreased bi-directional fluid flux. METHODS AND RESULTS Seven weeks following left coronary artery ligation, we measured both fluid flux during an acute rise in left atrial pressure (n = 29) and intrinsic alveolar fluid clearance (n = 45) in the isolated rat lung. Chronic elevation of pulmonary microvascular pressure prevented pulmonary oedema and decreased lung compliance when left atrial pressure was raised to 20 cmH2O, and was associated with reduced expression of endothelial aquaporin 1 (P = 0.03). However, no other changes were found in mediators of fluid flux or cellular fluid channels. In isolated rat lungs, chronic LV dysfunction (LV end-diastolic pressure and infarct circumference) was also inversely related to alveolar fluid clearance (P ≤ 0.001). The rate of pulmonary oedema reabsorption was estimated by plasma volume expansion in eight patients with a previous clinical history of chronic heart failure and eight without, who presented with acute pulmonary oedema. Plasma volume expansion was reduced at 24 h in those with chronic heart failure (P = 0.03). CONCLUSIONS Chronic elevation of pulmonary microvascular pressure in CHF leads to decreased intrinsic bi-directional fluid flux at the alveolar-capillary barrier. This adaptive response defends against alveolar flooding, but may delay resolution of alveolar oedema.
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Affiliation(s)
- Dani-Louise Dixon
- Intensive and Critical Care Unit, Flinders Medical Centre, and Department of Critical Care Medicine, Flinders University, Adelaide, Australia.
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Koslowski R, Kasper M, Schaal K, Knels L, Lange M, Bernhard W. Surfactant metabolism and anti-oxidative capacity in hyperoxic neonatal rat lungs: effects of keratinocyte growth factor on gene expression in vivo. Histochem Cell Biol 2012; 139:461-72. [DOI: 10.1007/s00418-012-1038-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2012] [Indexed: 01/10/2023]
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Elie-Turenne MC, Hou PC, Mitani A, Barry JM, Kao EY, Cohen JE, Frendl G, Gajic O, Gentile NT. Lung injury prediction score for the emergency department: first step towards prevention in patients at risk. Int J Emerg Med 2012; 5:33. [PMID: 22943391 PMCID: PMC3598475 DOI: 10.1186/1865-1380-5-33] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 08/14/2012] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Early identification of patients at risk of developing acute lung injury (ALI) is critical for potential preventive strategies. We aimed to derive and validate an acute lung injury prediction score (EDLIPS) in a multicenter sample of emergency department (ED) patients. METHODS We performed a subgroup analysis of 4,361 ED patients enrolled in the previously reported multicenter observational study. ED risk factors and conditions associated with subsequent ALI development were identified and included in the EDLIPS model. Scores were derived and validated using logistic regression analyses. The model was assessed with the area under the receiver-operating curve (AUC) and compared to the original LIPS model (derived from a population of elective high-risk surgical and ED patients) and the Acute Physiology and Chronic Health Evaluation (APACHE II) score. RESULTS The incidence of ALI was 7.0% (303/4361). EDLIPS discriminated patients who developed ALI from those who did not with an AUC of 0.78 (95% CI 0.75, 0.82), better than the APACHE II AUC 0.70 (p ≤ 0.001) and similar to the original LIPS score AUC 0.80 (p = 0.07). At an EDLIPS cutoff of 5 (range -0.5, 15) positive and negative likelihood ratios (95% CI) for ALI development were 2.74 (2.43, 3.07) and 0.39 (0.30, 0.49), respectively, with a sensitivity 0.72(0.64, 0.78), specificity 0.74 (0.72, 0.76), and positive and negative predictive value of 0.18 (0.15, 0.21) and 0.97 (0.96, 0.98). CONCLUSION EDLIPS may help identify patients at risk for ALI development early in the course of their ED presentation. This novel model may detect at-risk patients for treatment optimization and identify potential patients for ALI prevention trials.
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Affiliation(s)
- Marie-Carmelle Elie-Turenne
- Department of Emergency Medicine, University of Florida College of Medicine, PO Box 100186, 1329 SW 16th Street, Gainesville, FL 32610, USA
- Emergency Department, Shands University of Florida Medical Center, Gainesville, FL, USA
| | - Peter C Hou
- Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
- Division of Burn, Trauma, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA, USA
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Department of Emergency Medicine & Division of Burn, Trauma, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Neville House 312-B, Boston, MA 02115, USA
| | - Aya Mitani
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Stanford Hospitals and Clinincs, 300 Pasteur Drive, Room: S102, MC: 5110, Stanford, CA 94305, USA
| | - Jonathan M Barry
- Division of Burn, Trauma, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA, USA
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
| | - Erica Y Kao
- Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
- F. Edward Hebert School of Medicine, Uniform Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4712, USA
| | - Jason E Cohen
- Department of Emergency Medicine, Albany Medical Center, Albany, NY, USA
- Albany Medical College, Albany, NY, USA
- Albany Medical Center Emergency Medicine Group, 47 New Scotland Avenue, MC 139, Albany, NY 12208, USA
| | - Gyorgy Frendl
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Department of Emergency Medicine & Division of Burn, Trauma, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Neville House 312-B, Boston, MA 02115, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Anesthesiology Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Ognjen Gajic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA
- Mayo Medical School, Rochester, MA, USA
- Mayo Clinic, Pulmonary and Critical Care Medicine, Old Marian Hall, Second Floor, Room 115, 200 First St. SW, Rochester, MN 5590, USA
| | - Nina T Gentile
- Department of Emergency Medicine, Temple School of Medicine, Philadelphia, PA, USA
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Tsaknis G, Siempos II, Kopterides P, Maniatis NA, Magkou C, Kardara M, Panoutsou S, Kotanidou A, Roussos C, Armaganidis A. Metformin attenuates ventilator-induced lung injury. Crit Care 2012; 16:R134. [PMID: 22827994 PMCID: PMC3580719 DOI: 10.1186/cc11439] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 06/01/2012] [Accepted: 07/24/2012] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Diabetic patients may develop acute lung injury less often than non-diabetics; a fact that could be partially ascribed to the usage of antidiabetic drugs, including metformin. Metformin exhibits pleiotropic properties which make it potentially beneficial against lung injury. We hypothesized that pretreatment with metformin preserves alveolar capillary permeability and, thus, prevents ventilator-induced lung injury. METHODS Twenty-four rabbits were randomly assigned to pretreatment with metformin (250 mg/Kg body weight/day per os) or no medication for two days. Explanted lungs were perfused at constant flow rate (300 mL/min) and ventilated with injurious (peak airway pressure 23 cmH₂O, tidal volume ≈17 mL/Kg) or protective (peak airway pressure 11 cmH₂O, tidal volume ≈7 mL/Kg) settings for 1 hour. Alveolar capillary permeability was assessed by ultrafiltration coefficient, total protein concentration in bronchoalveolar lavage fluid (BALF) and angiotensin-converting enzyme (ACE) activity in BALF. RESULTS High-pressure ventilation of the ex-vivo lung preparation resulted in increased microvascular permeability, edema formation and microhemorrhage compared to protective ventilation. Compared to no medication, pretreatment with metformin was associated with a 2.9-fold reduction in ultrafiltration coefficient, a 2.5-fold reduction in pulmonary edema formation, lower protein concentration in BALF, lower ACE activity in BALF, and fewer histological lesions upon challenge of the lung preparation with injurious ventilation. In contrast, no differences regarding pulmonary artery pressure and BALF total cell number were noted. Administration of metformin did not impact on outcomes of lungs subjected to protective ventilation. CONCLUSIONS Pretreatment with metformin preserves alveolar capillary permeability and, thus, decreases the severity of ventilator-induced lung injury in this model.
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Affiliation(s)
- George Tsaknis
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Ilias I Siempos
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Petros Kopterides
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Nikolaos A Maniatis
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Christina Magkou
- Department of Histopathology, Evangelismos Hospital, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Matina Kardara
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Stefania Panoutsou
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Anastasia Kotanidou
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- First Department of Critical Care and Pulmonary Services, "Evangelismos" Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Charis Roussos
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- First Department of Critical Care and Pulmonary Services, "Evangelismos" Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Apostolos Armaganidis
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
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Effects of anesthetic regimes on inflammatory responses in a rat model of acute lung injury. Intensive Care Med 2012; 38:1548-55. [PMID: 22711173 DOI: 10.1007/s00134-012-2610-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 05/17/2012] [Indexed: 12/30/2022]
Abstract
PURPOSE Gamma-aminobutyric acid (GABA) is the major inhibitory neurotransmitter through activation of GABA receptors. Volatile anesthetics activate type-A (GABA(A)) receptors resulting in inhibition of synaptic transmission. Lung epithelial cells have been recently found to express GABA(A) receptors that exert anti-inflammatory properties. We hypothesized that the volatile anesthetic sevoflurane (SEVO) attenuates lung inflammation through activation of lung epithelial GABA(A) receptors. METHODS Sprague-Dawley rats were anesthetized with SEVO or ketamine/xylazine (KX). Acute lung inflammation was induced by intratracheal instillation of endotoxin, followed by mechanical ventilation for 4 h at a tidal volume of 15 mL/kg without positive end-expiratory pressure (two-hit lung injury model). To examine the specific effects of GABA, healthy human lung epithelial cells (BEAS-2B) were challenged with endotoxin in the presence and absence of GABA with and without addition of the GABA(A) receptor antagonist picrotoxin. RESULTS Anesthesia with SEVO improved oxygenation and reduced pulmonary cytokine responses compared to KX. This phenomenon was associated with increased expression of the π subunit of GABA(A) receptors and glutamic acid decarboxylase (GAD). The endotoxin-induced cytokine release from BEAS-2B cells was attenuated by the treatment with GABA, which was reversed by the administration of picrotoxin. CONCLUSION Anesthesia with SEVO suppresses pulmonary inflammation and thus protects the lung from the two-hit injury. The anti-inflammatory effect of SEVO is likely due to activation of pulmonary GABA(A) signaling pathways.
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Sunahara KKS, Martins JO. Alveolar macrophages in diabetes: friends or foes? J Leukoc Biol 2012; 91:871-6. [DOI: 10.1189/jlb.0911488] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Koh GCKW, Vlaar APJ, Hofstra JJ, de Jong HK, van Nierop S, Peacock SJ, Wiersinga WJ, Schultz MJ, Juffermans NP. In the critically ill patient, diabetes predicts mortality independent of statin therapy but is not associated with acute lung injury: a cohort study. Crit Care Med 2012; 40:1835-43. [PMID: 22488007 PMCID: PMC3379571 DOI: 10.1097/ccm.0b013e31824e1696] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Patients with diabetes mellitus form 23%-30% of published cohorts of critically ill patients. Conflicting published evidence links diabetes mellitus to both higher and lower mortality. Other cohort studies suggest that diabetes mellitus protects against acute lung injury. We hypothesized that diabetes mellitus is an independent risk factor for mortality. We further hypothesized that diabetes mellitus is a risk factor for cardiac overload and not for acute lung injury. DESIGN Retrospective cohort study. SETTING The intensive care unit of a tertiary referral hospital. PATIENTS From November 1, 2004, to October 1, 2007, a cohort of patients admitted ≥48 hrs to the intensive care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 2,013 patients, 317 had diabetes mellitus. Ninety-day mortality was higher in the diabetes mellitus patients compared to patients without diabetes mellitus (hazard ratio 1.53, 95% confidence interval 1.29-1.80). This association strengthened after adjusting for confounders and for medication (hazard ratio 1.53, 95% confidence interval 1.07-2.17).We found no association between diabetes mellitus and acute lung injury (relative risk ratio 1.01, 95% confidence interval 0.78-1.32; adjusted relative risk ratio 0.99, 95% confidence interval 0.75-1.31), but diabetes mellitus was a risk factor for cardiac overload (relative risk ratio 1.91, 95% confidence interval 1.30-2.81; adjusted relative risk ratio 1.45, 95% confidence interval 0.97-2.18). Statins were associated with both a reduced risk of mortality (hazard ratio 0.74, 95% confidence interval 0.63-0.87; adjusted hazard ratio 0.53, 95% confidence interval 0.44-0.64) and a decreased risk of developing acute lung injury (relative risk ratio 0.71, 95% confidence interval 0.56-0.89; adjusted relative risk ratio 0.61, 95% confidence interval 0.47-0.79). CONCLUSIONS Diabetes mellitus is an independent risk factor for mortality in critically ill patients and failure to adjust for statins underestimates the size of this association. Diabetes mellitus is not associated with acute lung injury but is associated with cardiac overload. A diagnosis of cardiac overload excludes a diagnosis of acute lung injury. Investigators who do not account for cardiac overload as a competing alternative outcome may therefore falsely conclude that diabetes mellitus protects from acute lung injury.
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Abstract
Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are distinctly modern clinical entities. Recent epidemiologic research has taken advantage of large cohorts in efforts to better describe these highly lethal syndromes with a focus on differentiation of clinically meaningful subtypes and early prediction in an effort to improve treatment and prevention. This article identifies the most significant studies and systematic reviews of recent years, defining the incidence, mortality, risk and prognostic factors, and etiologic classes of ARDS/ALI.
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Affiliation(s)
- Ross Blank
- Division of Critical Care, Department of Anesthesiology, University of Michigan Health System, 1500 East Medical Center Drive, SPC 5861, Ann Arbor, MI 48109-5861, USA.
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Abstract
BACKGROUND Acute lung injury (ALI) is a serious postoperative complication with limited treatment options. A preoperative risk-prediction model would assist clinicians and scientists interested in ALI. The objective of this investigation was to develop a surgical lung injury prediction (SLIP) model to predict risk of postoperative ALI based on readily available preoperative risk factors. METHODS Secondary analysis of a prospective cohort investigation including adult patients undergoing high-risk surgery. Preoperative risk factors for postoperative ALI were identified and evaluated for inclusion in the SLIP model. Multivariate logistic regression was used to develop the model. Model performance was assessed with the area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test. RESULTS Out of 4,366 patients, 113 (2.6%) developed early postoperative ALI. Predictors of postoperative ALI in multivariate analysis that were maintained in the final SLIP model included high-risk cardiac, vascular, or thoracic surgery, diabetes mellitus, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and alcohol abuse. The SLIP score distinguished patients who developed early postoperative ALI from those who did not with an area under the receiver operating characteristic curve (95% CI) of 0.82 (0.78-0.86). The model was well calibrated (Hosmer-Lemeshow, P = 0.55). Internal validation using 10-fold cross-validation noted minimal loss of diagnostic accuracy with a mean ± SD area under the receiver operating characteristic curve of 0.79 ± 0.08. CONCLUSIONS Using readily available preoperative risk factors, we developed the SLIP scoring system to predict risk of early postoperative ALI.
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Moss M, Standiford TJ. Leptin in fibroproliferative acute respiratory distress syndrome: not just a satiety factor. Am J Respir Crit Care Med 2011; 183:1443-4. [PMID: 21642251 DOI: 10.1164/rccm.201102-0286ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Di Naso FC, Forgiarini Junior LA, Forgiarini LF, Porawski M, Dias AS, Marroni NAP. Aminoguanidine reduces oxidative stress and structural lung changes in experimental diabetes mellitus. J Bras Pneumol 2011; 36:485-9. [PMID: 20835596 DOI: 10.1590/s1806-37132010000400014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 04/22/2010] [Indexed: 11/21/2022] Open
Abstract
We evaluated the effect of aminoguanidine on pulmonary oxidative stress and lung structure in an experimental model of diabetes mellitus. Thiobarbituric acid reactive substances (TBARS), histology and arterial blood gases were evaluated in animals with diabetes mellitus (DM group), animals with diabetes mellitus treated with aminoguanidine (DM+AG group), and controls. The TBARS levels were significantly higher in the DM group than in the control and DM+AG groups (2.90 ± 1.12 vs. 1.62 ± 0.28 and 1.68 ± 0.04 nmol/mg protein, respectively), as was PaCO2 when compared with that of the control group (49.2 ± 1.65 vs. 38.12 ± 4.85 mmHg), and PaO2 was significantly higher in the control group (104.5 ± 6.3 vs. 16.30 ± 69.48 and 97.05 ± 14.02 mmHg, respectively). In this experimental model of diabetes mellitus, aminoguanidine reduced oxidative stress, structural tissue alterations, and gas exchange.
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Affiliation(s)
- Fabio Cangeri Di Naso
- Programa de Pós-Graduação em Ciências Biológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
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Alsara A, Warner DO, Li G, Herasevich V, Gajic O, Kor DJ. Derivation and validation of automated electronic search strategies to identify pertinent risk factors for postoperative acute lung injury. Mayo Clin Proc 2011; 86:382-8. [PMID: 21531881 PMCID: PMC3084640 DOI: 10.4065/mcp.2010.0802] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To develop and validate time-efficient automated electronic search strategies for identifying preoperative risk factors for postoperative acute lung injury. PATIENTS AND METHODS This secondary analysis of a prospective cohort study included 249 patients undergoing high-risk surgery between November 1, 2005, and August 31, 2006. Two independent data-extraction strategies were compared. The first strategy used a manual review of medical records and the second a Web-based query-building tool. Web-based searches were derived and refined in a derivation cohort of 83 patients and subsequently validated in an independent cohort of 166 patients. Agreement between the 2 search strategies was assessed with percent agreement and Cohen κ statistics. RESULTS Cohen κ statistics ranged from 0.34 (95% confidence interval, 0.00-0.86) for amiodarone to 0.85 for cirrhosis (95% confidence interval, 0.57-1.00). Agreement between manual and automated electronic data extraction was almost complete for 3 variables (diabetes mellitus, cirrhosis, H(2)-receptor antagonists), substantial for 3 (chronic obstructive pulmonary disease, proton pump inhibitors, statins), moderate for gastroesophageal reflux disease, and fair for 2 variables (restrictive lung disease and amiodarone). Automated electronic queries outperformed manual data collection in terms of sensitivities (median, 100% [range, 77%-100%] vs median, 87% [range, 0%-100%]). The specificities were uniformly high (≥ 96%) for both search strategies. CONCLUSION Automated electronic query building is an iterative process that ultimately results in accurate, highly efficient data extraction. These strategies may be useful for both clinicians and researchers when determining the risk of time-sensitive conditions such as postoperative acute lung injury.
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Affiliation(s)
| | | | | | | | | | - Daryl J. Kor
- Individual reprints of this article are not available. Address correspondence to Daryl J. Kor, MD, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Yang Y, Salam ZHA, Ong BC, Yang KS. Respiratory dysfunction in patients with sepsis: protective effect of diabetes mellitus. Am J Crit Care 2011; 20:e41-7. [PMID: 21362712 DOI: 10.4037/ajcc2011391] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Sepsis is a common complication in patients with diabetes mellitus. In a Western population, risk of respiratory dysfunction was lower in diabetic patients with sepsis. OBJECTIVE To compare organ dysfunction, particularly respiratory dysfunction, between sepsis patients with and without diabetes mellitus in an Asian population. METHOD Hospital discharge data were collected for the period 2004 through 2008. Patients with sepsis, diabetes mellitus, and organ dysfunction were identified by using the International Statistical Classification of Diseases and Related Health Problems, 9th Revision, Australian Modification codes. RESULTS Of the 383 238 patients hospitalized during the 5 years, 2943 of the 9221 who had sepsis also had diabetes (31.9%).The most common organ dysfunctions in patients with sepsis were renal (31.5%), cardiovascular (19.2%), and respiratory (10.9%). Among patients with sepsis, respiratory dysfunction was less likely in patients with diabetes (9.4%) than in those without (11.6%; P = .002), but renal dysfunction was more likely in patients with diabetes (46.5%) than in those without (24.4%; P < .001). However, only 27.6% of patients with diabetes had a respiratory source of sepsis compared with 33.4% in patients without diabetes (P < .001). Among patients with sepsis, diabetes mellitus was a significant and independent predictor of respiratory dysfunction (odds ratio, 0.80; 95% confidence interval, 0.66-0.98) after adjustments for age, sex, ethnicity, admission to intensive care, number of comorbid conditions, and other infection sources. CONCLUSION Among an Asian population, respiratory dysfunction in patients with sepsis is less likely to develop in those with diabetes than in those without diabetes.
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Affiliation(s)
- Yong Yang
- Yong Yang is an epidemiologist, Kok Soong Yang is the head of the epidemiology department, and Biauw Chi Ongis the director of clinical governance at Singapore General Hospital, Singapore. Zakir-Hussain Abdul Salam is a lecturer at the National University of Singapore
| | - Zakir-Hussain Abdul Salam
- Yong Yang is an epidemiologist, Kok Soong Yang is the head of the epidemiology department, and Biauw Chi Ongis the director of clinical governance at Singapore General Hospital, Singapore. Zakir-Hussain Abdul Salam is a lecturer at the National University of Singapore
| | - Biauw Chi Ong
- Yong Yang is an epidemiologist, Kok Soong Yang is the head of the epidemiology department, and Biauw Chi Ongis the director of clinical governance at Singapore General Hospital, Singapore. Zakir-Hussain Abdul Salam is a lecturer at the National University of Singapore
| | - Kok Soong Yang
- Yong Yang is an epidemiologist, Kok Soong Yang is the head of the epidemiology department, and Biauw Chi Ongis the director of clinical governance at Singapore General Hospital, Singapore. Zakir-Hussain Abdul Salam is a lecturer at the National University of Singapore
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Jain M, Budinger GRS, Lo A, Urich D, Rivera SE, Ghosh AK, Gonzalez A, Chiarella SE, Marks K, Donnelly HK, Soberanes S, Varga J, Radigan KA, Chandel NS, Mutlu GM. Leptin promotes fibroproliferative acute respiratory distress syndrome by inhibiting peroxisome proliferator-activated receptor-γ. Am J Respir Crit Care Med 2011; 183:1490-8. [PMID: 21317313 DOI: 10.1164/rccm.201009-1409oc] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Diabetic patients have a lower incidence of acute respiratory distress syndrome (ARDS), and those who develop ARDS are less likely to die. The mechanisms that underlie this protection are unknown. OBJECTIVES To determine whether leptin resistance, a feature of diabetes, prevents fibroproliferation after lung injury. METHODS We examined lung injury and fibroproliferation after the intratracheal instillation of bleomycin in wild-type and leptin-resistant (db/db) diabetic mice. We examined the effect of leptin on transforming growth factor (TGF)-β(1)-mediated transcription in primary normal human lung fibroblasts. Bronchoalveolar lavage fluid (BAL) samples from patients with ARDS and ventilated control subjects were obtained for measurement of leptin and active TGF-β(1) levels. MEASUREMENTS AND MAIN RESULTS Diabetic mice (db/db) were resistant to lung fibrosis. The db/db mice had higher levels of peroxisome proliferator-activated receptor-γ (PPARγ), an inhibitor of the transcriptional response to TGF-β(1), a cytokine critical in the pathogenesis of fibroproliferative ARDS. In normal human lung fibroblasts, leptin augmented the transcription of profibrotic genes in response to TGF-β(1) through a mechanism that required PPARγ. In patients with ARDS, BAL leptin levels were elevated and correlated with TGF-β(1) levels. Overall, there was no significant relationship between BAL leptin levels and clinical outcomes; however, in nonobese patients, higher BAL leptin levels were associated with fewer intensive care unit- and ventilator-free days and higher mortality. CONCLUSIONS Leptin signaling is required for bleomycin-induced lung fibrosis. Leptin augments TGF-β(1) signaling in lung fibroblasts by inhibiting PPARγ. These findings provide a mechanism for the observed protection against ARDS observed in diabetic patients.
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Affiliation(s)
- Manu Jain
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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Acute Lung Injury in the ICU: Focus on Prevention. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2011 2011. [DOI: 10.1007/978-3-642-18081-1_11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Inhaled aerosolized insulin: a "topical" anti-inflammatory treatment for acute lung injury and respiratory distress syndrome? Inflammation 2010; 33:315-9. [PMID: 20186475 DOI: 10.1007/s10753-010-9187-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute lung injury (ALI) and the more severe acute respiratory distress syndrome (ARDS) are forms of pulmonary edema that result from robust local and systemic inflammatory states, such as sepsis. The morbidity and mortality associated with ALI and ARDS are significant and the treatment of these conditions presents a formidable challenge. Controlling hyperglycemia with insulin is a core component of patient management in the critically ill. Insulin treatment also exerts beneficial metabolic effects beyond glucose control, as well as non-metabolic effects, in insulin-resistant states. For instance, insulin inhibits NF-kappaB--dependent synthesis of pro-inflammatory factors and attenuates production of ROS. Indeed, intravenous administration of insulin ameliorates pulmonary injury and dysfunction in the LPS model of ALI. Most recently, an inhalable insulin formulation was shown to effectively reduce glucose concentrations with minimal impact on long-term pulmonary function. We propose that administering inhalable insulin to hyperglycemic ALI/ARDS patients could directly reduce alveolar inflammation while reducing circulating glucose levels.
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Sen S, Sen S, Sentürk E, Kuman NK. Postresectional lung injury in thoracic surgery pre and intraoperative risk factors: a retrospective clinical study of a hundred forty-three cases. J Cardiothorac Surg 2010; 5:62. [PMID: 20716368 PMCID: PMC2936288 DOI: 10.1186/1749-8090-5-62] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2010] [Accepted: 08/17/2010] [Indexed: 02/02/2023] Open
Abstract
Introduction Acute respiratory dysfunction syndrome (ARDS), defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, is a major cause of morbidity and mortality after pulmonary resection. The aim of the study was to determine the pre and intraoperative factors associated with ARDS after pulmonary resection retrospectively. Methods Patients undergoing elective pulmonary resection at Adnan Menderes University Medical Faculty Thoracic Surgery Department from January 2005 to February 2010 were included in this retrospective study. The authors collected data on demographics, relevant co-morbidities, the American Society of Anesthesiologists (ASA) Physical Status classification score, pulmonary function tests, type of operation, duration of surgery and intraoperative fluid administration (fluid therapy and blood products). The primary outcome measure was postoperative ARDS, defined as the need for continuation of mechanical ventilation for greater than 48-hours postoperatively or the need for reinstitution of mechanical ventilation after extubation. Statistical analysis was performed with Fisher exact test for categorical variables and logistic regression analysis for continuous variables. Results Of one hundred forty-three pulmonary resection patients, 11 (7.5%) developed postoperative ARDS. Alcohol abuse (p = 0.01, OR = 39.6), ASA score (p = 0.001, OR: 1257.3), resection type (p = 0.032, OR = 28.6) and fresh frozen plasma (FFP)(p = 0.027, OR = 1.4) were the factors found to be statistically significant. Conclusion In the light of the current study, lung injury after lung resection has a high mortality. Preoperative and postoperative risk factor were significant predictors of postoperative lung injury.
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Affiliation(s)
- Serdar Sen
- Department of Thoracic Surgery, Medical Faculty, Adnan Menderes University, Aydin, Turkey.
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Sheu CC, Gong MN, Zhai R, Chen F, Bajwa EK, Clardy PF, Gallagher DC, Thompson BT, Christiani DC. Clinical characteristics and outcomes of sepsis-related vs non-sepsis-related ARDS. Chest 2010; 138:559-67. [PMID: 20507948 DOI: 10.1378/chest.09-2933] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND ARDS may occur after either septic or nonseptic injuries. Sepsis is the major cause of ARDS, but little is known about the differences between sepsis-related and non-sepsis-related ARDS. METHODS A total of 2,786 patients with ARDS-predisposing conditions were enrolled consecutively into a prospective cohort, of which 736 patients developed ARDS. We defined sepsis-related ARDS as ARDS developing in patients with sepsis and non-sepsis-related ARDS as ARDS developing after nonseptic injuries, such as trauma, aspiration, and multiple transfusions. Patients with both septic and nonseptic risks were excluded from analysis. RESULTS Compared with patients with non-sepsis-related ARDS (n = 62), patients with sepsis-related ARDS (n = 524) were more likely to be women and to have diabetes, less likely to have preceding surgery, and had longer pre-ICU hospital stays and higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (median, 78 vs 65, P < .0001). There were no differences in lung injury score, blood pH, Pao(2)/Fio(2) ratio, and Paco(2) on ARDS diagnosis. However, patients with sepsis-related ARDS had significantly lower Pao(2)/Fio(2) ratios than patients with non-sepsis-related ARDS patients on ARDS day 3 (P = .018), day 7 (P = .004), and day 14 (P = .004) (repeated-measures analysis, P = .011). Compared with patients with non-sepsis-related ARDS, those with sepsis-related had a higher 60-day mortality (38.2% vs 22.6%; P = .016), a lower successful extubation rate (53.6% vs 72.6%; P = .005), and fewer ICU-free days (P = .0001) and ventilator-free days (P = .003). In multivariate analysis, age, APACHE III score, liver cirrhosis, metastatic cancer, admission serum bilirubin and glucose levels, and treatment with activated protein C were independently associated with 60-day ARDS mortality. After adjustment, sepsis-related ARDS was no longer associated with higher 60-day mortality (hazard ratio, 1.26; 95% CI, 0.71-2.22). CONCLUSION Sepsis-related ARDS has a higher overall disease severity, poorer recovery from lung injury, lower successful extubation rate, and higher mortality than non-sepsis-related ARDS. Worse clinical outcomes in sepsis-related ARDS appear to be driven by disease severity and comorbidities.
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Affiliation(s)
- Chau-Chyun Sheu
- Department of Environmental Health, Harvard School of Public Health, Boston, MA 02115, USA
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Acute lung injury in children: importance of host factors. Crit Care Med 2010; 38:350. [PMID: 20023513 DOI: 10.1097/ccm.0b013e3181c30e82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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