Catecholamines and vasopressin during critical illness

The stress-related hormone norepinephrine induced upregulation of Nix, contributing to ECM protein expression

Organ fibrosis has been viewed as a major medical problem that leads to progressive dysfunction of the organ and eventually the death of patients. Stress-related hormone norepinephrine (NE) has been reported to exert fibrogenic actions in the injured organ. Nix plays a critical role in pressure overload-induced cardiac remodeling and heart failure through mediating cardiomyocyte apoptosis. However, cardiac remodeling also includes fibrosis. Whether Nix is involved in stress-induced fibrosis remains unclear. The present study was designed to determine the role of Nix in NE-induced NIH/3T3 fibroblasts. The results showed that Nix was upregulated and closely associated with cell proliferation, collagen and fibronectin expression in NIH/3T3 fibroblasts following NE treatment. Overexpression of Nix promoted collagen and fibronectin expression, whereas the suppression of Nix resulted in a strong reduction in collagen and fibronectin expression. Moreover, the increases in collagen and fibronectin expression induced by NE were successively increased when Nix was overexpressed and reduced when Nix was inhibited. Furthermore, we demonstrated that the PKC activation is responsible for the upregulation of Nix induced by NE. Inhibition of Nix expression with α-adrenoceptor antagonist, β-adrenoceptor antagonist or PKC inhibitor attenuated NE-induced collagen and fibronectin expression. Our data revealed that Nix is a novel mediator of NE-induced fibrosis. Thus, it would provide a new insight into the development of effective preventative measures and therapies of tissue fibrosis.

Management and Treatment Guidelines for Sepsis in Pediatric Patients

Sepsis remains one of the leading causes of morbidity and mortality in children despite improved understanding of the pathophysiology leading to better clinical management and survival. Recent studies have identified several areas that must be addressed by the clinician in order to continue to impact the morbidity and mortality associated with sepsis. In this review, we discuss the evidence in several of these areas including initial resuscitation, pathogen eradication, maintenance of oxygen delivery, and directed modifiers of the inflammatory response. Our overall goal is to provide the bedside clinician with an updated systematic approach to treat sepsis in children.

The Relationship between Blood Lactate and Survival following the Use of Adrenaline in the Treatment of Septic Shock

This prospective observational study evaluates the relationship between adrenaline, lactate and intensive care unit survival in septic shock. Forty patients requiring adrenaline therapy for a first episode of septic shock acquired >24 hours after admission to the intensive care unit had blood lactate levels measured two-hourly over a 24-hour period. Adrenaline therapy was escalated until target mean arterial pressure was reached. The lactate index was calculated as the ratio of maximum lactate increase to the adrenaline increase. Lactate increased from 2.3 to 2.9 mmol.l-1 (P=0.024) and the mean adrenaline increase was 0.14 μg.kg-1.minute-1. Peak lactate correlated with peak adrenaline (rho=0.34, P=0.032). Lactate index was the only independent predictor of survival after controlling for age and Acute Physiological and Chronic Health Evaluation II score (odds ratio 1.14, 95% confidence interval 1.03 to 1.26, P=0.009). A high lactate following adrenaline administration may be a beneficial and appropriate response.

Physiology of the vasopressin receptors

This review article summarizes the structure, signalling pathways, and tissue distribution of the vasopressin receptors, V1 vascular, V2 renal, V3 pituitary, and oxytocin receptors, as well as the P2 class of purinoceptors. The physiological effects of vasopressin on its receptors are described. The future direction with regard to the role of the V1a receptor in circulatory shock states is discussed; further studies with V1a receptor agonists are warranted to further develop treatment strategies to reduce mortality in life threatening diseases like septic shock.

Glucose metabolism and catecholamines

Until now, catecholamines were the drugs of choice to treat hypotension during shock states. Catecholamines, however, also have marked metabolic effects, particularly on glucose metabolism, and the degree of this metabolic response is directly related to the beta2-adrenoceptor activity of the individual compound used. Under physiologic conditions, infusing catecholamine is associated with enhanced rates of aerobic glycolysis (resulting in adenosine triphosphate production), glucose release (both from glycogenolysis and gluconeogenesis), and inhibition of insulin-mediated glycogenesis. Consequently, hyperglycemia and hyperlactatemia are the hallmarks of this metabolic response. Under pathophysiologic conditions, the metabolic effects of catecholamines are less predictable because of changes in receptor affinity and density and in drug kinetics and the metabolic capacity of the major gluconeogenic organs, both resulting from the disease per se and the ongoing treatment. It is also well-established that shock states are characterized by a hypermetabolic condition with insulin resistance and increased oxygen demands, which coincide with both compromised tissue microcirculatory perfusion and mitochondrial dysfunction. This, in turn, causes impaired glucose utilization and may lead to inadequate glucose supply and, ultimately, metabolic failure. Based on the landmark studies on intensive insulin use, a crucial role is currently attributed to glucose homeostasis. This article reviews the effects of the various catecholamines on glucose utilization, both under physiologic conditions, as well as during shock states. Because, to date (to our knowledge), no patient data are available, results from relevant animal experiments are discussed. In addition, potential strategies are outlined to influence the catecholamine-induced effects on glucose homeostasis.