1
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Datzmann T, Münz F, Hoffmann A, Moehrke E, Binzenhöfer M, Gröger M, Kapapa T, Mathieu R, Mayer S, Zink F, Gässler H, Wolfschmitt EM, Hogg M, Merz T, Calzia E, Radermacher P, Messerer DAC. An exploratory study investigating the effect of targeted hyperoxemia in a randomized controlled trial in a long-term resuscitated model of combined acute subdural hematoma and hemorrhagic shock in cardiovascular healthy pigs. Front Immunol 2023; 14:1123196. [PMID: 37114041 PMCID: PMC10126345 DOI: 10.3389/fimmu.2023.1123196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
Severe physical injuries and associated traumatic brain injury and/or hemorrhagic shock (HS) remain leading causes of death worldwide, aggravated by accompanying extensive inflammation. Retrospective clinical data indicated an association between mild hyperoxemia and improved survival and outcome. However, corresponding prospective clinical data, including long-term resuscutation, are scarce. Therefore, the present study explored the effect of mild hyperoxemia for 24 hours in a prospective randomized controlled trial in a long-term resuscitated model of combined acute subdural hematoma (ASDH) and HS. ASDH was induced by injecting 0.1 ml × kg-1 autologous blood into the subdural space and HS was triggered by passive removal of blood. After 2 hours, the animals received full resuscitation, including retransfusion of the shed blood and vasopressor support. During the first 24 hours, the animals underwent targeted hyperoxemia (PaO2 = 200 - 250 mmHg) or normoxemia (PaO2 = 80 - 120 mmHg) with a total observation period of 55 hours after the initiation of ASDH and HS. Survival, cardiocirculatory stability, and demand for vasopressor support were comparable between both groups. Likewise, humoral markers of brain injury and systemic inflammation were similar. Multimodal brain monitoring, including microdialysis and partial pressure of O2 in brain tissue, did not show significant differences either, despite a significantly better outcome regarding the modified Glasgow Coma Scale 24 hours after shock that favors hyperoxemia. In summary, the present study reports no deleterious and few beneficial effects of mild targeted hyperoxemia in a clinically relevant model of ASDH and HS with long-term resuscitation in otherwise healthy pigs. Further beneficial effects on neurological function were probably missed due to the high mortality in both experimental groups. The present study remains exploratory due to the unavailability of an a priori power calculation resulting from the lack of necessary data.
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Affiliation(s)
- Thomas Datzmann
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Franziska Münz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Andrea Hoffmann
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Elena Moehrke
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Martha Binzenhöfer
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Michael Gröger
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Thomas Kapapa
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - René Mathieu
- Department of Neurosurgery, German Federal Armed Forces Hospital Ulm, Ulm, Germany
| | - Simon Mayer
- Department of Neurosurgery, German Federal Armed Forces Hospital Ulm, Ulm, Germany
| | - Fabian Zink
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Holger Gässler
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, German Armed Forces Hospital Ulm, Ulm, Germany
| | - Eva-Maria Wolfschmitt
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Melanie Hogg
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Enrico Calzia
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - David Alexander Christian Messerer
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander University Erlangen-Nuremberg, University Hospital Erlangen, Erlangen, Germany
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Hu RT, Lankadeva YR, Yanase F, Osawa EA, Evans RG, Bellomo R. Continuous bladder urinary oxygen tension as a new tool to monitor medullary oxygenation in the critically ill. Crit Care 2022; 26:389. [PMID: 36527088 PMCID: PMC9758873 DOI: 10.1186/s13054-022-04230-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022] Open
Abstract
Acute kidney injury (AKI) is common in the critically ill. Inadequate renal medullary tissue oxygenation has been linked to its pathogenesis. Moreover, renal medullary tissue hypoxia can be detected before biochemical evidence of AKI in large mammalian models of critical illness. This justifies medullary hypoxia as a pathophysiological biomarker for early detection of impending AKI, thereby providing an opportunity to avert its evolution. Evidence from both animal and human studies supports the view that non-invasively measured bladder urinary oxygen tension (PuO2) can provide a reliable estimate of renal medullary tissue oxygen tension (tPO2), which can only be measured invasively. Furthermore, therapies that modify medullary tPO2 produce corresponding changes in bladder PuO2. Clinical studies have shown that bladder PuO2 correlates with cardiac output, and that it increases in response to elevated cardiopulmonary bypass (CPB) flow and mean arterial pressure. Clinical observational studies in patients undergoing cardiac surgery involving CPB have shown that bladder PuO2 has prognostic value for subsequent AKI. Thus, continuous bladder PuO2 holds promise as a new clinical tool for monitoring the adequacy of renal medullary oxygenation, with its implications for the recognition and prevention of medullary hypoxia and thus AKI.
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Affiliation(s)
- Raymond T. Hu
- grid.410678.c0000 0000 9374 3516Department of Anaesthesia, Austin Health, Heidelberg, VIC Australia ,grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia
| | - Yugeesh R. Lankadeva
- grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia ,grid.1008.90000 0001 2179 088XPre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC Australia
| | - Fumitake Yanase
- grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Heidelberg, Australia
| | - Eduardo A. Osawa
- Cardiology Intensive Care Unit, DF Star Hospital, Brasília, Brazil ,grid.472984.4D’Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
| | - Roger G. Evans
- grid.1008.90000 0001 2179 088XPre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC Australia ,grid.1002.30000 0004 1936 7857Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, VIC Australia
| | - Rinaldo Bellomo
- grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC Australia ,grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Heidelberg, Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia ,grid.416153.40000 0004 0624 1200Department of Intensive Care, Royal Melbourne Hospital, Parkville, Australia
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3
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Datzmann T, Messerer DAC, Münz F, Hoffmann A, Gröger M, Mathieu R, Mayer S, Gässler H, Zink F, McCook O, Merz T, Scheuerle A, Wolfschmitt EM, Thebrath T, Zuech S, Calzia E, Asfar P, Radermacher P, Kapapa T. The effect of targeted hyperoxemia in a randomized controlled trial employing a long-term resuscitated, model of combined acute subdural hematoma and hemorrhagic shock in swine with coronary artery disease: An exploratory, hypothesis-generating study. Front Med (Lausanne) 2022; 9:971882. [PMID: 36072939 PMCID: PMC9442904 DOI: 10.3389/fmed.2022.971882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/04/2022] [Indexed: 11/24/2022] Open
Abstract
Controversial evidence is available regarding suitable targets for the arterial O2 tension (PaO2) after traumatic brain injury and/or hemorrhagic shock (HS). We previously demonstrated that hyperoxia during resuscitation from hemorrhagic shock attenuated cardiac injury and renal dysfunction in swine with coronary artery disease. Therefore, this study investigated the impact of targeted hyperoxemia in a long-term, resuscitated model of combined acute subdural hematoma (ASDH)-induced brain injury and HS. The prospective randomized, controlled, resuscitated animal investigation consisted of 15 adult pigs. Combined ASDH plus HS was induced by injection of 0.1 ml/kg autologous blood into the subdural space followed by controlled passive removal of blood. Two hours later, resuscitation was initiated comprising re-transfusion of shed blood, fluids, continuous i.v. noradrenaline, and either hyperoxemia (target PaO2 200 – 250 mmHg) or normoxemia (target PaO2 80 – 120 mmHg) during the first 24 h of the total of 54 h of intensive care. Systemic hemodynamics, intracranial and cerebral perfusion pressures, parameters of brain microdialysis and blood biomarkers of brain injury did not significantly differ between the two groups. According to the experimental protocol, PaO2 was significantly higher in the hyperoxemia group at the end of the intervention period, i.e., at 24 h of resuscitation, which coincided with a higher brain tissue PO2. The latter persisted until the end of observation period. While neurological function as assessed using the veterinary Modified Glasgow Coma Score progressively deteriorated in the control group, it remained unaffected in the hyperoxemia animals, however, without significant intergroup difference. Survival times did not significantly differ in the hyperoxemia and control groups either. Despite being associated with higher brain tissue PO2 levels, which were sustained beyond the intervention period, targeted hyperoxemia exerted neither significantly beneficial nor deleterious effects after combined ASDH and HS in swine with pre-existing coronary artery disease. The unavailability of a power calculation and, thus, the limited number of animals included, are the limitations of the study.
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Affiliation(s)
- Thomas Datzmann
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Germany
- *Correspondence: Thomas Datzmann,
| | - David Alexander Christian Messerer
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Germany
- Transfusionsmedizinische und Hämostaseologische Abteilung, Universitätsklinikum Erlangen und Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Franziska Münz
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Germany
| | - Andrea Hoffmann
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Michael Gröger
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - René Mathieu
- Klinik fuür Neurochirurgie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Simon Mayer
- Klinik fuür Neurochirurgie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Holger Gässler
- Klinik fuür Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Fabian Zink
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Oscar McCook
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Tamara Merz
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Germany
| | - Angelika Scheuerle
- Sektion Neuropathologie, Institut für Pathologie, Universitätsklinikum Ulm, Ulm, Germany
| | - Eva-Maria Wolfschmitt
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Timo Thebrath
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Stefan Zuech
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Enrico Calzia
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Pierre Asfar
- Département de Médecine Intensive – Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire, Angers, France
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Thomas Kapapa
- Klinik für Neurochirurgie, Universitätsklinikum Ulm, Ulm, Germany
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Chabaud S, Pellerin È, Caneparo C, Ringuette‑goulet C, Pouliot F, Bolduc S. Bladder cancer cell lines adapt their aggressiveness profile to oxygen tension. Oncol Lett 2022; 24:220. [PMID: 35720486 PMCID: PMC9178683 DOI: 10.3892/ol.2022.13341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/05/2021] [Indexed: 11/21/2022] Open
Abstract
During the process of tumor growth, cancer cells will be subjected to intermittent hypoxia. This results from the delay in the development of the vascular network in relation to the proliferation of cancer cells. The hypoxic nature of a tumor has been demonstrated as a negative factor for patient survival. To evaluate the impact of hypoxia on the survival and migration properties of low and high-grade bladder cancer cell lines, two low-grade (MGHU-3 and SW-780) and two high-grade (SW-1710 and T24) bladder cancer cell lines were cultured in normoxic (20% O2) or hypoxic atmospheric conditions (2% O2). The response of bladder cancer cell lines to hypoxic atmospheric cell culture conditions was examined under several parameters, including epithelial-mesenchymal transition, doubling time and metabolic activities, thrombospondin-1 expression, whole Matrix Metallo-Proteinase activity, migration and resistance to oxidative stress. The low-grade cell line response to hypoxia was heterogeneous even if it tended to adopt a more aggressive profile. Hypoxia enhanced migration and pro-survival properties of MGHU-3 cells, whereas these features were reduced for the SW-780 cell line cultured under low oxygen tension. The responses of tested high-grade cell lines were more homogeneous and tended to adopt a less aggressive profile. Hypoxia drastically changed some of the bladder cancer cell line properties, for example matrix metalloproteinases expression for all cancer cells but also switch in glycolytic metabolism of low grade cancer cells. Overall, studying bladder cancer cells in hypoxic environments are relevant for the translation from in vitro findings to in vivo context.
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Affiliation(s)
- Stéphane Chabaud
- Centre de Recherche en Organogénèse Expérimentale (Experimental Organogenesis Research Center)/LOEX, Regenerative Medicine Division, CHU de Québec‑Laval University Research Center, Enfant‑Jésus Hospital, Quebec, QC G1J 1Z4, Canada
| | - Ève Pellerin
- Centre de Recherche en Organogénèse Expérimentale (Experimental Organogenesis Research Center)/LOEX, Regenerative Medicine Division, CHU de Québec‑Laval University Research Center, Enfant‑Jésus Hospital, Quebec, QC G1J 1Z4, Canada
| | - Christophe Caneparo
- Centre de Recherche en Organogénèse Expérimentale (Experimental Organogenesis Research Center)/LOEX, Regenerative Medicine Division, CHU de Québec‑Laval University Research Center, Enfant‑Jésus Hospital, Quebec, QC G1J 1Z4, Canada
| | - Cassandra Ringuette‑goulet
- Centre de Recherche en Organogénèse Expérimentale (Experimental Organogenesis Research Center)/LOEX, Regenerative Medicine Division, CHU de Québec‑Laval University Research Center, Enfant‑Jésus Hospital, Quebec, QC G1J 1Z4, Canada
| | - Frédéric Pouliot
- Department of Surgery, Faculty of Medicine, Laval University, Quebec, QC G1V 4G2, Canada
| | - Stéphane Bolduc
- Centre de Recherche en Organogénèse Expérimentale (Experimental Organogenesis Research Center)/LOEX, Regenerative Medicine Division, CHU de Québec‑Laval University Research Center, Enfant‑Jésus Hospital, Quebec, QC G1J 1Z4, Canada
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5
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Singer M, Young PJ, Laffey JG, Asfar P, Taccone FS, Skrifvars MB, Meyhoff CS, Radermacher P. Dangers of hyperoxia. Crit Care 2021; 25:440. [PMID: 34924022 PMCID: PMC8686263 DOI: 10.1186/s13054-021-03815-y] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/04/2021] [Indexed: 01/27/2023] Open
Abstract
Oxygen (O2) toxicity remains a concern, particularly to the lung. This is mainly related to excessive production of reactive oxygen species (ROS). Supplemental O2, i.e. inspiratory O2 concentrations (FIO2) > 0.21 may cause hyperoxaemia (i.e. arterial (a) PO2 > 100 mmHg) and, subsequently, hyperoxia (increased tissue O2 concentration), thereby enhancing ROS formation. Here, we review the pathophysiology of O2 toxicity and the potential harms of supplemental O2 in various ICU conditions. The current evidence base suggests that PaO2 > 300 mmHg (40 kPa) should be avoided, but it remains uncertain whether there is an "optimal level" which may vary for given clinical conditions. Since even moderately supra-physiological PaO2 may be associated with deleterious side effects, it seems advisable at present to titrate O2 to maintain PaO2 within the normal range, avoiding both hypoxaemia and excess hyperoxaemia.
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Affiliation(s)
- Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Paul J Young
- Medical Research Institute of New Zealand, and Intensive Care Unit, Wellington Hospital, Wellington, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Department of Critical Care Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, and School of Medicine, National University of Ireland, Galway, Ireland
| | - Pierre Asfar
- Département de Médecine Intensive - Réanimation Et Médecine Hyperbare, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081, Ulm, Germany.
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6
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Demiselle J, Calzia E, Hartmann C, Messerer DAC, Asfar P, Radermacher P, Datzmann T. Target arterial PO 2 according to the underlying pathology: a mini-review of the available data in mechanically ventilated patients. Ann Intensive Care 2021; 11:88. [PMID: 34076802 PMCID: PMC8170650 DOI: 10.1186/s13613-021-00872-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/10/2021] [Indexed: 12/15/2022] Open
Abstract
There is an ongoing discussion whether hyperoxia, i.e. ventilation with high inspiratory O2 concentrations (FIO2), and the consecutive hyperoxaemia, i.e. supraphysiological arterial O2 tensions (PaO2), have a place during the acute management of circulatory shock. This concept is based on experimental evidence that hyperoxaemia may contribute to the compensation of the imbalance between O2 supply and requirements. However, despite still being common practice, its use is limited due to possible oxygen toxicity resulting from the increased formation of reactive oxygen species (ROS) limits, especially under conditions of ischaemia/reperfusion. Several studies have reported that there is a U-shaped relation between PaO2 and mortality/morbidity in ICU patients. Interestingly, these mostly retrospective studies found that the lowest mortality coincided with PaO2 ~ 150 mmHg during the first 24 h of ICU stay, i.e. supraphysiological PaO2 levels. Most of the recent large-scale retrospective analyses studied general ICU populations, but there are major differences according to the underlying pathology studied as well as whether medical or surgical patients are concerned. Therefore, as far as possible from the data reported, we focus on the need of mechanical ventilation as well as the distinction between the absence or presence of circulatory shock. There seems to be no ideal target PaO2 except for avoiding prolonged exposure (> 24 h) to either hypoxaemia (PaO2 < 55-60 mmHg) or supraphysiological (PaO2 > 100 mmHg). Moreover, the need for mechanical ventilation, absence or presence of circulatory shock and/or the aetiology of tissue dysoxia, i.e. whether it is mainly due to impaired macro- and/or microcirculatory O2 transport and/or disturbed cellular O2 utilization, may determine whether any degree of hyperoxaemia causes deleterious side effects.
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Affiliation(s)
- Julien Demiselle
- Service de Médecine Intensive - Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, 1, place de l′Hôpital, F–67091, Strasbourg, Cedex, France
| | - Enrico Calzia
- Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081 Ulm, Germany
| | - Clair Hartmann
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - David Alexander Christian Messerer
- Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081 Ulm, Germany
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Pierre Asfar
- Service de Médecine Intensive - Réanimation Et Médecine Hyperbare, Centre Hospitalier Universitaire D’Angers, 4 rue Larrey - 49 933, Angers Cedex 9, France
| | - Peter Radermacher
- Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081 Ulm, Germany
| | - Thomas Datzmann
- Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081 Ulm, Germany
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Anastasova S, Spehar‐Délèze A, Kwasnicki RM, Yang G, Vadgama P. Electrochemical Monitoring of Subcutaneous Tissue pO
2
Fluctuations during Exercise Using a Semi‐implantable Needle Electrode. ELECTROANAL 2020. [DOI: 10.1002/elan.202060242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Salzitsa Anastasova
- Institute of Global Health and Innovation Hamlyn Centre Imperial College of Science, Technology & Medicine London W2 1NY UK
- Queen Mary, University of London Mile End Road London E1 4NS UK QMUL
| | | | - Richard Mark Kwasnicki
- Institute of Global Health and Innovation Hamlyn Centre Imperial College of Science, Technology & Medicine London W2 1NY UK
| | - Guang‐Zhong Yang
- Institute of Global Health and Innovation Hamlyn Centre Imperial College of Science, Technology & Medicine London W2 1NY UK
- Institute of Medical Robotics Shanghai Jiao Tong University Shanghai 200040 China
| | - Pankaj Vadgama
- Queen Mary, University of London Mile End Road London E1 4NS UK QMUL
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8
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Merz T, Denoix N, Huber-Lang M, Singer M, Radermacher P, McCook O. Microcirculation vs. Mitochondria-What to Target? Front Med (Lausanne) 2020; 7:416. [PMID: 32903633 PMCID: PMC7438707 DOI: 10.3389/fmed.2020.00416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/29/2020] [Indexed: 01/02/2023] Open
Abstract
Circulatory shock is associated with marked disturbances of the macro- and microcirculation and flow heterogeneities. Furthermore, a lack of tissue adenosine trisphosphate (ATP) and mitochondrial dysfunction are directly associated with organ failure and poor patient outcome. While it remains unclear if microcirculation-targeted resuscitation strategies can even abolish shock-induced flow heterogeneity, mitochondrial dysfunction and subsequently diminished ATP production could still lead to organ dysfunction and failure even if microcirculatory function is restored or maintained. Preserved mitochondrial function is clearly associated with better patient outcome. This review elucidates the role of the microcirculation and mitochondria during circulatory shock and patient management and will give a viewpoint on the advantages and disadvantages of tailoring resuscitation to microvascular or mitochondrial targets.
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Affiliation(s)
- Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Nicole Denoix
- Clinic for Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, Ulm, Germany
| | - Markus Huber-Lang
- Institute for Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Mervyn Singer
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, United Kingdom
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
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9
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Parker T, Brealey D, Dyson A, Singer M. Optimising organ perfusion in the high-risk surgical and critical care patient: a narrative review. Br J Anaesth 2019; 123:170-176. [PMID: 31054772 DOI: 10.1016/j.bja.2019.03.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/18/2019] [Accepted: 03/12/2019] [Indexed: 12/18/2022] Open
Abstract
Maintenance or prompt restoration of an oxygen supply sufficient to facilitate adequate cellular metabolism is fundamental in maintaining organ function. This is particularly relevant when metabolic needs change markedly, for example in response to major surgery or critical illness. The consequences of inadequate tissue oxygenation include wound and anastomotic breakdown, organ dysfunction, and death. However, our ability to identify those at risk and to promptly recognise and correct tissue hypoperfusion is limited. Reliance is placed upon surrogate markers of tissue oxygenation such as arterial blood pressure and serum lactate that are insensitive to early organ compromise. Advances in oxygen sensing technology will facilitate monitoring in various organ beds and allow more precise titration of therapies to physiologically relevant endpoints. Clinical trials will be needed to evaluate any impact on outcomes, however accurate on-line monitoring of the adequacy of tissue oxygenation offers the promise of a paradigm shift in resuscitation and perioperative practice. This narrative review examines current evidence for goal-directed therapy in the optimisation of organ perfusion in high-risk surgical and critically ill patients, and offers arguments to support the potential utility of tissue oxygen monitoring.
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Affiliation(s)
- Thomas Parker
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Alex Dyson
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK.
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Abstract
Hyperoxia (ventilation with FIO2 = 1.0) has vasoconstrictor properties, in particular in the coronary vascular bed, and, hence, may promote cardiac dysfunction. However, we previously showed that hyperoxia attenuated myocardial injury during resuscitation from hemorrhage in swine with coronary artery disease. Therefore, we tested the hypothesis whether hyperoxia would also mitigate myocardial injury and improve heart function in the absence of chronic cardiovascular comorbidity.After 3 h of hemorrhage (removal of 30% of the calculated blood volume and subsequent titration of mean arterial pressure to 40 mm Hg) 19 anesthetized, mechanically ventilated, and instrumented pigs received FIO2 = 0.3(control) or hyperoxia(FIO2 = 1.0) during the first 24 h. Before, at the end of and every 12 h after shock, hemodynamics, blood gases, metabolism, cytokines, and cardiac function (pulmonary artery thermodilution, left ventricular pressure-conductance catheterization) were recorded. At 48 h, cardiac tissue was harvested for western blotting, immunohistochemistry, and mitochondrial respiration.Except for higher left ventricular end-diastolic pressures at 24 h (hyperoxia 21 (17;24), control 17 (15;18) mm Hg; P = 0.046), hyperoxia affected neither left ventricular function cardiac injury (max. Troponin I at 12 h: hyperoxia:9 (6;23), control:17 (11;24) ng mL; P = 0.395), nor plasma cytokines (except for interleukin-1β: hyperoxia 10 (10;10) and 10 (10;10)/control 14 (10;22), 12 (10;15) pg mL, P = 0.023 and 0.021 at 12 and 24 h, respectively), oxidation and nitrosative stress, and mitochondrial respiration. However, hyperoxia decreased cardiac tissue three-nitrotyrosine formation (P < 0.001) and inducible nitric oxide synthase expression (P = 0.016). Ultimately, survival did not differ significantly either.In conclusion, in contrast to our previous study in swine with coronary artery disease, hyperoxia did not beneficially affect cardiac function or tissue injury in healthy swine, but was devoid of deleterious side effects.
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Demiselle J, Wepler M, Hartmann C, Radermacher P, Schortgen F, Meziani F, Singer M, Seegers V, Asfar P. Hyperoxia toxicity in septic shock patients according to the Sepsis-3 criteria: a post hoc analysis of the HYPER2S trial. Ann Intensive Care 2018; 8:90. [PMID: 30225670 PMCID: PMC6141409 DOI: 10.1186/s13613-018-0435-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/03/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Criteria for the Sepsis-3 definition of septic shock include vasopressor treatment to maintain a mean arterial pressure > 65 mmHg and a lactate concentration > 2 mmol/L. The impact of hyperoxia in patients with septic shock using these criteria is unknown. METHODS A post hoc analysis was performed of the HYPER2S trial assessing hyperoxia versus normoxia in septic patients requiring vasopressor therapy, in whom a plasma lactate value was available at study inclusion. Mortality was compared between patients fulfilling the Sepsis-3 septic shock criteria and patients requiring vasopressors for hypotension only (i.e., with lactate ≤ 2 mmol/L). RESULTS Of the 434 patients enrolled, 397 had available data for lactate at inclusion. 230 had lactate > 2 mmol/L and 167 ≤ 2 mmol/L. Among patients with lactate > 2 mmol/L, 108 and 122 were "hyperoxia"- and "normoxia"-treated, respectively. Patients with lactate > 2 mmol/L had significantly less COPD more cirrhosis and required surgery more frequently. They also had higher illness severity (SOFA 10.6 ± 2.8 vs. 9.5 ± 2.5, p = 0.0001), required more renal replacement therapy (RRT), and received vasopressor and mechanical ventilation for longer time. Mortality rate at day 28 was higher in the "hyperoxia"-treated patients with lactate > 2 mmol/L as compared to "normoxia"-treated patients (57.4% vs. 44.3%, p = 0.054), despite similar RRT requirements as well as vasopressor and mechanical ventilation-free days. A multivariate analysis showed an independent association between hyperoxia and mortality at day 28 and 90. In patients with lactate ≤ 2 mmol/L, hyperoxia had no effect on mortality nor on other outcomes. CONCLUSIONS Our results suggest that hyperoxia may be associated with a higher mortality rate in patients with septic shock using the Sepsis-3 criteria, but not in patients with hypotension alone.
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Affiliation(s)
- Julien Demiselle
- Médecine Intensive et Réanimation, Médecine Hyperbare, Centre Hospitalier Universitaire, 4, Rue Larrey, 49933, Angers Cedex 9, France.,LUNAM Université, Université d'Angers, Angers, France
| | - Martin Wepler
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081, Ulm, Germany.,Klinik für Anästhesiologie, Abteilung Klinische Anästhesiologie, Universitätsklinikum, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Clair Hartmann
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081, Ulm, Germany.,Klinik für Anästhesiologie, Abteilung Klinische Anästhesiologie, Universitätsklinikum, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081, Ulm, Germany.
| | - Frédérique Schortgen
- Service de Réanimation Adulte, Centre Hospitalier Intercommunal de Créteil, 40, Avenue de Verdun, 94010, Créteil Cedex, France
| | - Ferhat Meziani
- Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), Strasbourg, France.,INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Valérie Seegers
- Médecine Intensive et Réanimation, Médecine Hyperbare, Centre Hospitalier Universitaire, 4, Rue Larrey, 49933, Angers Cedex 9, France
| | - Pierre Asfar
- Médecine Intensive et Réanimation, Médecine Hyperbare, Centre Hospitalier Universitaire, 4, Rue Larrey, 49933, Angers Cedex 9, France.,LUNAM Université, Université d'Angers, Angers, France
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13
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Karlsson M, Ehinger JK, Piel S, Sjövall F, Henriksnäs J, Höglund U, Hansson MJ, Elmér E. Changes in energy metabolism due to acute rotenone-induced mitochondrial complex I dysfunction – An in vivo large animal model. Mitochondrion 2016; 31:56-62. [DOI: 10.1016/j.mito.2016.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 10/06/2016] [Accepted: 10/13/2016] [Indexed: 12/30/2022]
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Effects of Hyperoxia and Mild Therapeutic Hypothermia During Resuscitation From Porcine Hemorrhagic Shock. Crit Care Med 2016; 44:e264-77. [PMID: 26588829 DOI: 10.1097/ccm.0000000000001412] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Hemorrhagic shock-induced tissue hypoxia induces hyperinflammation, ultimately causing multiple organ failure. Hyperoxia and hypothermia can attenuate tissue hypoxia due to increased oxygen supply and decreased demand, respectively. Therefore, we tested the hypothesis whether mild therapeutic hypothermia and hyperoxia would attenuate postshock hyperinflammation and thereby organ dysfunction. DESIGN Prospective, controlled, randomized study. SETTING University animal research laboratory. SUBJECTS Thirty-six Bretoncelles-Meishan-Willebrand pigs of either gender. INTERVENTIONS After 4 hours of hemorrhagic shock (removal of 30% of the blood volume, subsequent titration of mean arterial pressure at 35 mm Hg), anesthetized and instrumented pigs were randomly assigned to "control" (standard resuscitation: retransfusion of shed blood, fluid resuscitation, norepinephrine titrated to maintain mean arterial pressure at preshock values, mechanical ventilation titrated to maintain arterial oxygen saturation > 90%), "hyperoxia" (standard resuscitation, but FIO2, 1.0), "hypothermia" (standard resuscitation, but core temperature 34°C), or "combi" (hyperoxia plus hypothermia) (n = 9 each). MEASUREMENTS AND MAIN RESULTS Before, immediately at the end of and 12 and 22 hours after hemorrhagic shock, we measured hemodynamics, blood gases, acid-base status, metabolism, organ function, cytokine production, and coagulation. Postmortem kidney specimen were taken for histological evaluation, immunohistochemistry (nitrotyrosine, cystathionine γ-lyase, activated caspase-3, and extravascular albumin), and immunoblotting (nuclear factor-κB, hypoxia-inducible factor-1α, heme oxygenase-1, inducible nitric oxide synthase, B-cell lymphoma-extra large, and protein expression of the endogenous nuclear factor-κB inhibitor). Although hyperoxia alone attenuated the postshock hyperinflammation and thereby tended to improve visceral organ function, hypothermia and combi treatment had no beneficial effect. CONCLUSIONS During resuscitation from near-lethal hemorrhagic shock, hyperoxia attenuated hyperinflammation, and thereby showed a favorable trend toward improved organ function. The lacking efficacy of hypothermia was most likely due to more pronounced barrier dysfunction with vascular leakage-induced circulatory failure.
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De Santis V, Singer M. Tissue oxygen tension monitoring of organ perfusion: rationale, methodologies, and literature review. Br J Anaesth 2015. [PMID: 26198717 DOI: 10.1093/bja/aev162] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Tissue oxygen tension is the partial pressure of oxygen within the interstitial space of an organ bed. As it represents the balance between local oxygen delivery and consumption at any given time, it offers a ready monitoring capability to assess the adequacy of tissue perfusion relative to local demands. This review covers the various methodologies used to measure tissue oxygen tension, describes the underlying physiological and pathophysiological principles, and summarizes human and laboratory data published to date.
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Affiliation(s)
- V De Santis
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
| | - M Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
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Kemmler J, Bindl R, McCook O, Wagner F, Gröger M, Wagner K, Scheuerle A, Radermacher P, Ignatius A. Exposure to 100% Oxygen Abolishes the Impairment of Fracture Healing after Thoracic Trauma. PLoS One 2015; 10:e0131194. [PMID: 26147725 PMCID: PMC4492600 DOI: 10.1371/journal.pone.0131194] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 05/30/2015] [Indexed: 12/22/2022] Open
Abstract
In polytrauma patients a thoracic trauma is one of the most critical injuries and an important trigger of post-traumatic inflammation. About 50% of patients with thoracic trauma are additionally affected by bone fractures. The risk for fracture malunion is considerably increased in such patients, the pathomechanisms being poorly understood. Thoracic trauma causes regional alveolar hypoxia and, subsequently, hypoxemia, which in turn triggers local and systemic inflammation. Therefore, we aimed to unravel the role of oxygen in impaired bone regeneration after thoracic trauma. We hypothesized that short-term breathing of 100% oxygen in the early post-traumatic phase ameliorates inflammation and improves bone regeneration. Mice underwent a femur osteotomy alone or combined with blunt chest trauma 100% oxygen was administered immediately after trauma for two separate 3 hour intervals. Arterial blood gas tensions, microcirculatory perfusion and oxygenation were assessed at 3, 9 and 24 hours after injury. Inflammatory cytokines and markers of oxidative/nitrosative stress were measured in plasma, lung and fracture hematoma. Bone healing was assessed on day 7, 14 and 21. Thoracic trauma induced pulmonary and systemic inflammation and impaired bone healing. Short-term exposure to 100% oxygen in the acute post-traumatic phase significantly attenuated systemic and local inflammatory responses and improved fracture healing without provoking toxic side effects, suggesting that hyperoxia could induce anti-inflammatory and pro-regenerative effects after severe injury. These results suggest that breathing of 100% oxygen in the acute post-traumatic phase might reduce the risk of poorly healing fractures in severely injured patients.
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Affiliation(s)
- Julia Kemmler
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research, University of Ulm, Ulm, Germany
| | - Ronny Bindl
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research, University of Ulm, Ulm, Germany
| | - Oscar McCook
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Florian Wagner
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Michael Gröger
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Katja Wagner
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | | | - Peter Radermacher
- Institute of Pathophysiological Anaesthesiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Anita Ignatius
- Institute of Orthopaedic Research and Biomechanics, Center of Musculoskeletal Research, University of Ulm, Ulm, Germany
- * E-mail:
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Ekbal NJ, Dyson A, Black C, Singer M. Monitoring tissue perfusion, oxygenation, and metabolism in critically ill patients. Chest 2013; 143:1799-1808. [PMID: 23732592 DOI: 10.1378/chest.12-1849] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Alterations in oxygen transport and use are integral to the development of multiple organ failure; therefore, the ultimate goal of resuscitation is to restore effective tissue oxygenation and cellular metabolism. Hemodynamic monitoring is the cornerstone of management to promptly identify and appropriately manage (impending) organ dysfunction. Prospective randomized trials have confirmed outcome benefit when preemptive or early treatment is directed toward maintaining or restoring adequate tissue perfusion. However, treatment end points remain controversial, in large part because of current difficulties in determining what constitutes "optimal." Information gained from global whole-body monitoring may not detect regional organ perfusion abnormalities until they are well advanced. Conversely, the ideal "canary" organ that is readily accessible for monitoring, yet offers an early and sensitive indicator of tissue "unwellness," remains to be firmly identified. This review describes techniques available for real-time monitoring of tissue perfusion and metabolism and highlights novel developments that may complement or even supersede current tools.
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Affiliation(s)
- Nasirul J Ekbal
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, England
| | - Alex Dyson
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, England
| | - Claire Black
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, England
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, England.
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Year in review in Intensive Care Medicine 2012: I. Neurology and neurointensive care, epidemiology and nephrology, biomarkers and inflammation, nutrition, experimentals. Intensive Care Med 2012; 39:232-46. [PMID: 23248038 PMCID: PMC3569582 DOI: 10.1007/s00134-012-2774-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 11/29/2012] [Indexed: 01/06/2023]
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