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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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Legrand M, Oufella HA, De Backer D, Duranteau J, Leone M, Levy B, Rossignol P, Vicaut E, Dépret F. The I-MICRO trial, Ilomedin for treatment of septic shock with persistent microperfusion defects: a double-blind, randomized controlled trial-study protocol for a randomized controlled trial. Trials 2020; 21:601. [PMID: 32611377 PMCID: PMC7329442 DOI: 10.1186/s13063-020-04549-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/22/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Septic shock remains a significant cause of death in critically ill patients. During septic shock, some patients will retain microcirculatory disorders despite optimal hemodynamic support (i.e., fluid resuscitation, vasopressors, inotropes). Alterations in the microcirculation are a key pathophysiological factor of organ dysfunction and death in septic shock patients. Ilomedin is a prostacyclin analog with vasodilatory effect and anti-thrombotic properties (i.e., inhibition of platelet aggregation) preferentially at the microcirculatory level. We hypothesize that early utilization of intravenous Ilomedin in septic shock patients with clinical persistence of microperfusion disorders would improve the recovery of organ dysfunction. METHODS The I-MICRO trial is a multicenter, prospective, randomized, double-blinded, placebo-controlled study. We plan to recruit 236 adult patients with septic shock and persistent microcirculatory disorders (i.e., skin mottling or increased capillary refill time) despite hemodynamic support. Participants will be randomized to receive a 48-h intravenous infusion of either Ilomedin or placebo starting at the earliest 6 h and later 24 h after septic shock. The primary outcome will be the change (delta) of sequential organ failure assessment (SOFA) score between randomization and day 7. Secondary outcomes will include mean SOFA score during the first 7 days after randomization, mortality at day 28 post-randomization, number of ventilation-free survival days in the 28 days post-randomization, number of renal replacement therapy-free survival days in the 28 days post-randomization, number of vasopressor-free survival days in the 28 days post-randomization, and mottling score at day 1 after randomization. DISCUSSION The trial aims to provide evidence on the efficacy and safety of Ilomedin in patients with septic shock and persistent microcirculatory disorders. TRIAL REGISTRATION NCT NCT03788837 . Registered on 28 December 2018.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesiology, Critical Care Medicine and Burn Unit, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, 75010, Paris, France.
- INSERM UMR-S942, Institut National de la Santé et de la Recherche Médicale (INSERM), Lariboisière Hospital and INI-CRCT Network, Paris, France.
- Univ Paris Diderot, F-75475, Paris, France.
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 500 Parnassus Avenue MUE416, Box 0648, San Francisco, CA, 94143, USA.
| | - Hafid Ait Oufella
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de Réanimation Médicale, 75571, Paris Cedex 12, France
- Sorbonne Université, Université Pierre-et-Marie Curie, Paris 6, France
| | - Daniel De Backer
- Intensive Care Department, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Duranteau
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, Université Paris Sud XI, Le Kremlin Bicêtre, France
| | - Marc Leone
- Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation, Hôpital Nord, Marseille, France
| | - Bruno Levy
- Service de Réanimation Médicale, Centre Hospitalo-Universitaire de Nancy, F-54511, Vandœuvre-Lès-Nancy, France
- Université de Lorraine, F-54000, Nancy, France
| | - Patrick Rossignol
- Centre d'Investigation Clinique Plurithématique Pierre Drouin-INSERM CHU de Nancy, Nancy, France
- FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) Network, Université de Lorraine, Nancy, France
| | - Eric Vicaut
- APHP, Department of Biostatistics, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, Paris, France
| | - François Dépret
- Department of Anaesthesiology, Critical Care Medicine and Burn Unit, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, 75010, Paris, France
- INSERM UMR-S942, Institut National de la Santé et de la Recherche Médicale (INSERM), Lariboisière Hospital and INI-CRCT Network, Paris, France
- Univ Paris Diderot, F-75475, Paris, France
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Ramackers W, Friedrich L, Tiede A, Bergmann S, Schuettler W, Schuerholz T, Mengel M, Goudeva L, Ganser A, Klempnauer J, Piepenbrock S, Winkler M. Effects of pharmacological intervention on coagulopathy and organ function in xenoperfused kidneys. Xenotransplantation 2008; 15:46-55. [PMID: 18333913 DOI: 10.1111/j.1399-3089.2008.00443.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Following pig to primate kidney transplantation, xenogenic activation of the coagulation (XAC) system of the recipient eventually leading to organ dysfunction and disseminated intravascular coagulation (DIC) can be observed. METHODS Using an ex-vivo perfusion circuit based on low-dose heparin-mediated anticoagulation and exogenous complement inhibition by C1- Inhibitor (C1-Inh), we have analysed XAC following contact of human blood with porcine endothelium. Porcine kidneys (n = 23) were recovered following in situ cold perfusion with histidine-tryptophan-ketoglutarate (HTK) solution and were connected to a perfusion circuit utilizing freshly drawn pooled human AB blood. RESULTS Kidney survival during organ perfusion with human blood, CI-Inh, heparin but without any further pharmacological intervention was 126 +/- 78 min. XAC was observed with significantly elevated levels of D-dimer and thrombin antithrombin complexes (TAT). Pharmacological intervention with nitroprusside and prostacycline resulted in increased organ survival (220 +/- 28 min and 180 +/- 85 min respectively) but failed to inhibit XAC. In contrast, addition of activated protein C (APC) significantly reduced the increase in D-dimer and TAT and prolonged organ survival to 240 min (+/-0). On histology, no remarkable signs of XAC were observed. CONCLUSIONS We conclude that exogenous APC is able to reduce XAC in this ex vivo perfusion model.
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Affiliation(s)
- Wolf Ramackers
- Klinik für Sllgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, 30625 Hannover, Germany
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Zardi EM, Dobrina A, Amoroso A, Afeltra A. Prostacyclin in liver disease: a potential therapeutic option. Expert Opin Biol Ther 2007; 7:785-90. [PMID: 17555364 DOI: 10.1517/14712598.7.6.785] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Complex molecular and cellular mechanisms are involved in the initiation and progression of hepatic fibrosis. Recent studies have shown that hepatic stellate cells, endothelin, cytokines and prostacyclin play crucial roles in this pathology. Prostacyclin exerts vasorelaxant, antioxidant and antifibrotic properties that prevent the development of fibrosis and cirrhosis in liver diseases. In this editorial, the authors discuss some of the molecular and cellular mechanisms involved in the initiation and progression of liver fibrosis and the role played by prostacyclin in counteracting it. At the moment, however, only limited information is available from clinical studies demonstrating the effectiveness of prostacyclin in liver diseases and this makes it difficult to draw any conclusions; further efforts are necessary to verify whether prostacyclin, alone or in combination with other drugs, may be a valid therapeutic option in liver diseases.
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Slofstra SH, ten Cate H, Spek CA. Signal transduction induced by activated protein C: no role in protection against sepsis? Trends Mol Med 2006; 12:374-81. [PMID: 16820322 DOI: 10.1016/j.molmed.2006.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 05/24/2006] [Accepted: 06/20/2006] [Indexed: 11/15/2022]
Abstract
The anticoagulant activated protein C (APC) is historically known as a risk factor for venous thrombosis. However, after the positive results of the protein C worldwide evaluation in severe sepsis (PROWESS) trial, which showed that APC was the first drug that considerably reduced sepsis-related mortality, APC is considered a pleiotropic protein with both anticoagulant and anti-inflammatory properties. In addition, in vitro studies have suggested that APC-induced intracellular signal transduction is a potential mechanism by which APC might be protective against sepsis. Recently, however, the efficacy of APC in sepsis has been argued, and also the extent to which the signal transduction capacity of APC contributes to its pro-survival effects is debated. Here, we review the role of APC in the body natural defense against sepsis and discuss the mechanism by which APC might act at a cellular level.
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Affiliation(s)
- Sjoukje H Slofstra
- Center for Experimental and Molecular Medicine, Academic Medical Center, 1105 AZ Amsterdam, the Netherlands
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Lima A, Bakker J. Noninvasive monitoring of peripheral perfusion. Intensive Care Med 2005; 31:1316-26. [PMID: 16170543 DOI: 10.1007/s00134-005-2790-2] [Citation(s) in RCA: 235] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2005] [Accepted: 08/04/2005] [Indexed: 12/14/2022]
Abstract
BACKGROUND Early hemodynamic assessment of global parameters in critically ill patients fails to provide adequate information on tissue perfusion. It requires invasive monitoring and may represent a late intervention initiated mainly in the intensive care unit. Noninvasive monitoring of peripheral perfusion can be a complementary approach that allows very early application throughout the hospital. In addition, as peripheral tissues are sensitive to alterations in perfusion, monitoring of the periphery could be an early marker of tissue hypoperfusion. This review discusses noninvasive methods for monitoring perfusion in peripheral tissues based on clinical signs, body temperature gradient, optical monitoring, transcutaneous oximetry, and sublingual capnometry. DISCUSSION Clinical signs of poor peripheral perfusion consist of a cold, pale, clammy, and mottled skin, associated with an increase in capillary refill time. The temperature gradients peripheral-to-ambient, central-to-peripheral and forearm-to-fingertip skin are validated methods to estimate dynamic variations in skin blood flow. Commonly used optical methods for peripheral monitoring are perfusion index, near-infrared spectroscopy, laser Doppler flowmetry and orthogonal polarization spectroscopy. Continuous noninvasive transcutaneous measurement of oxygen and carbon dioxide tensions can be used to estimate cutaneous blood flow. Sublingual capnometry is a noninvasive alternative for gastric tonometry.
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Affiliation(s)
- Alexandre Lima
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Sakr Y, Dubois MJ, De Backer D, Creteur J, Vincent JL. Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med 2004; 32:1825-31. [PMID: 15343008 DOI: 10.1097/01.ccm.0000138558.16257.3f] [Citation(s) in RCA: 812] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize the time course of microcirculatory alterations and their relation to outcome in patients with septic shock. DESIGN Prospective, observational study. SETTING Thirty-one-bed, medico-surgical intensive care unit in a university hospital. PATIENTS Forty-nine patients with septic shock. INTERVENTIONS The sublingual microcirculation was investigated with an orthogonal polarization spectral imaging device on the day of onset of septic shock (baseline) and each day until resolution of shock. MEASUREMENTS AND MAIN RESULTS Five sequences of 20 secs each were recorded and analyzed off-line by a semiquantitative method. Data were analyzed with nonparametric tests and presented as median (25th-75th percentiles). Three patients died after the resolution of shock from unrelated causes and were excluded. Of the other 46 patients, 26 survived and 20 died: 13 due to unresolving shock and seven due to persistent multiple organ failure after resolution of shock. At the onset of shock, survivors and nonsurvivors had similar vascular density (5.6 [4.7-7.0] vs. 6.2 [5.4-7.0]/mL; p = nonsignificant) and percentage of perfused small vessels (65.0 [53.1-68.9] vs. 58.4 [47.5-69.1]%; p = nonsignificant). Small vessel perfusion improved over time in survivors (analysis of variance, p <.05 between survivors and nonsurvivors) but not in nonsurvivors. Despite similar hemodynamic and oxygenation profiles and use of vasopressors at the end of shock, patients dying after the resolution of shock in multiple organ failure had a lower percentage of perfused small vessels than survivors (57.4 [46.6-64.9] vs. 79.3 [67.2-83.2]%; p =.02). CONCLUSIONS Microcirculatory alterations improve rapidly in septic shock survivors but not in patients dying with multiple organ failure, regardless of whether shock has resolved.
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Affiliation(s)
- Yasser Sakr
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium
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Tadros T, Traber DL, Herndon DN. Opposite effects of prostacyclin on hepatic blood flow and oxygen consumption after burn and sepsis. Ann Surg 2004; 239:67-74. [PMID: 14685102 PMCID: PMC1356194 DOI: 10.1097/01.sla.0000103073.65311.c8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Burn and sepsis are associated with hepatic ischemia and reperfusion injury. This study examines the hypothesis that postburn treatment with the vasodilator prostacyclin would be beneficial for hepatic perfusion and oxygenation. METHODS Female pigs (n = 18, 20-25 kg) underwent laparotomy, during which ultrasonic flow probes were placed on the portal vein and the common hepatic artery. Catheters were inserted in the superior mesenteric and left hepatic veins. After 5 days, all animals were anesthetized and 12 of them received 40% total body surface area third-degree burn; 100 microg/kg Escherichia coli lipopolysaccharide (LPS) was intravenously administered 18 hours postburn. Burned animals were randomized to receive a constant infusion of iloprost (20 ng/kg per minute) or an equivalent amount of carrier solution (normal saline). All animals were studied for 42 hours. RESULTS Burn caused a 2.5-fold increase in hepatic arterial vascular resistance (HAVR) and a 39% decrease in hepatic arterial blood flow (HABF). Postburn administration of iloprost did not improve the hepatic arterial hemodynamics (1.8-fold increase in HAVR and 38% decrease in HABF). Post-LPS, HABF was significantly reduced to 22% of baseline and HAVR was 15-fold increased (P < 0.05 vs. baseline, ANOVA). In contrast, iloprost-treated animals did not show hepatic arterial vasoconstriction, as both HABF and HAVR remained baseline values during the endotoxic phase (P < 0.05 vs. nontreated group, ANOVA). Postburn iloprost treatment yielded a significant improvement in post-LPS portal venous blood flow (PVBF, 79% of baseline vs. 45% of baseline in nontreated animals, P < 0.05, ANOVA). Portal venous pressure showed 16% and 56% increases after burn and endotoxin, respectively. Portal hypertension did not occur in iloprost-treated animals, as portal venous pressure remained within baseline range (P < 0.05 vs. nontreated group, ANOVA). Burn and endotoxemia resulted in a significant decrease of hepatic oxygen delivery (hDO2, 63% and 12% of baseline, respectively) and hepatic oxygen consumption (hVO2, 61% and 21% of baseline, respectively). Only during the postburn endotoxic phase, iloprost improved hDO2 and hVO2 (140% and 79%, respectively; P < 0.05 vs. nontreated group, ANOVA). CONCLUSIONS Postburn prostacyclin treatment appears to have no beneficial effects on hepatic perfusion early postburn. However, during the late postburn endotoxic phase, prostacyclin seems to significantly improve hepatic total blood flow and oxygenation. In addition, prostacyclin treatment attenuated burn- and endotoxin-induced portal hypertension.
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Affiliation(s)
- Tamer Tadros
- Shriners Burns Institute and the University of Texas Medical Branch, Galveston, TX, USA.
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