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Dobson GP, Letson HL, Morris JL. Revolution in sepsis: a symptoms-based to a systems-based approach? J Biomed Sci 2024; 31:57. [PMID: 38811967 PMCID: PMC11138085 DOI: 10.1186/s12929-024-01043-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
Severe infection and sepsis are medical emergencies. High morbidity and mortality are linked to CNS dysfunction, excessive inflammation, immune compromise, coagulopathy and multiple organ dysfunction. Males appear to have a higher risk of mortality than females. Currently, there are few or no effective drug therapies to protect the brain, maintain the blood brain barrier, resolve excessive inflammation and reduce secondary injury in other vital organs. We propose a major reason for lack of progress is a consequence of the treat-as-you-go, single-nodal target approach, rather than a more integrated, systems-based approach. A new revolution is required to better understand how the body responds to an infection, identify new markers to detect its progression and discover new system-acting drugs to treat it. In this review, we present a brief history of sepsis followed by its pathophysiology from a systems' perspective and future opportunities. We argue that targeting the body's early immune-driven CNS-response may improve patient outcomes. If the barrage of PAMPs and DAMPs can be reduced early, we propose the multiple CNS-organ circuits (or axes) will be preserved and secondary injury will be reduced. We have been developing a systems-based, small-volume, fluid therapy comprising adenosine, lidocaine and magnesium (ALM) to treat sepsis and endotoxemia. Our early studies indicate that ALM therapy shifts the CNS from sympathetic to parasympathetic dominance, maintains cardiovascular-endothelial glycocalyx coupling, reduces inflammation, corrects coagulopathy, and maintains tissue O2 supply. Future research will investigate the potential translation to humans.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Sepsis and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia.
| | - Hayley L Letson
- Heart, Sepsis and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia
| | - Jodie L Morris
- Heart, Sepsis and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia
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Abdelrehim AB, Mohsen FM, Haredi MA, Abdel Hameed Z, Ibrahim WH. PROGNOSTIC VALUE OF LOW-DOSE ADRENOCORTICOTROPIC HORMONE TEST IN CRITICALLY ILL PATIENTS. Shock 2023; 59:871-876. [PMID: 37011042 DOI: 10.1097/shk.0000000000002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
ABSTRACT Background: Previous trials evaluated the incidence of critical illness-related corticosteroid insufficiency (CIRCI) using 250 μg adrenocorticotropic hormone (ACTH). However, this supraphysiological dose could result in false-positive levels. We aimed to determine the incidence of CIRCI in septic patients using a 1 μg ACTH stress test. Methods: We conducted a prospective cohort study on 39 patients with septic shock. Critical illness-related corticosteroid insufficiency was defined as a Δ max cortisol <9 μg/dL after 1 μg ACTH stress test. The primary outcome of the study was death. Secondary outcomes included days of vasopressors, days of mechanical ventilation (MV), amount of fluid per day, the incidence of acute kidney injury (AKI), and days of intensive care unit (ICU) stay. Results: The incidence of CIRCI in our cohort was 43.6% using 1 μg ACTH. There were no significant differences between groups in terms of ICU scores, laboratory investigations, vasopressors, MV days, amount of fluid per day, and the ICU stay ( P = > 0.05). The CIRCI group had lower median survival and survival probability rates (5 days and 48.4%, respectively) compared with the non-CIRCI group (7 days and 49.5%, respectively). In addition, the CIRCI group had a shorter time to develop AKI and a higher probability of developing AKI (4 days and 44.6%, respectively) in comparison with the non-CIRCI group (6 days and 45.57%, respectively). Conclusion: We concluded that the CIRCI group had a lower mean survival rate and a higher incidence of AKI. We recommend the use of 1 μg ACTH test in septic shock patients to identify this subgroup of patients.
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Affiliation(s)
| | - Fatma M Mohsen
- Department of Internal Medicine, Critical Care Unit, Assiut University Hospital, Egypt
| | - Mostafa A Haredi
- Department of Internal Medicine, Endocrinology Unit, Assiut University Hospital, Egypt
| | | | - Walaa Hosny Ibrahim
- Department of Internal Medicine, Nephrology Unit, Assiut University Hospital, Egypt
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Luteolin improves vasoconstriction function and survival of septic mice via AMPK/NF-κB pathway. Heliyon 2023; 9:e13330. [PMID: 36816271 PMCID: PMC9932738 DOI: 10.1016/j.heliyon.2023.e13330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/19/2022] [Accepted: 01/26/2023] [Indexed: 02/01/2023] Open
Abstract
Septic shock, the leading cause of death in sepsis, is related to vasoconstriction dysfunction. To investigate the effects of Luteolin (LTL), a flavonoid polyphenol compound, on vasoconstriction dysfunction in septic mice and the underlying mechanism, cecal ligation and puncture (CLP) surgery was performed on wild-type C57BL/6 mice to induce septic shock. Mice were intraperitoneally injected with 0.2 mg/kg LTL within 10 min after CLP surgery with or without 20 mg/kg Compound C (AMPK inhibitor) (CC) 1 h before CLP surgery, and re-administrated every 12 h. The survival rate, systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and mean arterial pressure (MAP) were explored. After the mice were sacrificed, the vasoconstriction function, inflammatory indicators, and possible regulatory signaling pathways were examined. Our data showed that CLP decreased the survival rate, SAP, DAP, MAP, vasoconstriction function, and expression of ADRA1A and p-AMPK/AMPK, as well as increased the mRNA expression of inflammatory cytokines and iNOS, the serum levels of inflammatory cytokines, and the levels of iNOS, p-p65/p65, and p-IκBα/IκBα in aortas (P < 0.05), which could be reversed by LTL treatment (P < 0.05). However, inhibition of AMPK could abolish the protective effects of LTL (P < 0.05). In conclusion, our study manifested that LTL could prevent vasoconstriction dysfunction and increase survival of septic mice via activating AMPK, which suggested that LTL could be a novel therapeutic option for patients with sepsis.
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Jahandideh F, Panahi S, Noble RMN, Gragasin FS, Khadaroo RG, Macala KF, Bourque SL. Characterization of Systemic and Regional Hemodynamics and Vascular Dysfunction in Mice with Fecal Induced Peritonitis. Biomedicines 2022; 10:biomedicines10020470. [PMID: 35203689 PMCID: PMC8962278 DOI: 10.3390/biomedicines10020470] [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: 01/11/2022] [Revised: 02/08/2022] [Accepted: 02/16/2022] [Indexed: 01/09/2023] Open
Abstract
Sepsis is associated with circulatory dysfunction contributing to disturbed blood flow and organ injury. Decreased organ perfusion in sepsis is attributed, in part, to the loss of vasoregulatory mechanisms. Identifying which vascular beds are most susceptible to dysfunction is important for monitoring the recovery of organ function and guiding interventions. This study aimed to investigate the development of vascular dysfunction as sepsis progressed to septic shock. Anesthetized C57Bl/6 mice were instrumented with a fiberoptic pressure sensor in the carotid artery for blood pressure measurements. In subgroups of mice, regional blood flow measurements were taken by positioning a perivascular flow probe around either the left carotid, left renal, or superior mesenteric arteries. Hemodynamic parameters and their responsiveness to bolus doses of vasoactive drugs were recorded prior to and continuously after injection of fecal slurry (1.3 mg/g body weight) for 4 h. Fecal slurry-induced peritonitis reduced mean arterial pressure (62.7 ± 2.4 mmHg vs. 37.5 ± 3.2 mmHg in vehicle and septic mice, respectively), impaired cardiac function, and eventually reduced organ blood flow (71.9%, 66.8%, and 65.1% in the superior mesenteric, renal, and carotid arteries, respectively). The mesenteric vasculature exhibited dysregulation before the renal and carotid arteries, and this underlying dysfunction preceded the blood pressure decline and impaired organ blood flow.
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Affiliation(s)
- Forough Jahandideh
- Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada; (F.J.); (S.P.); (F.S.G.); (K.F.M.)
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, AB T6G 1C9, Canada;
| | - Sareh Panahi
- Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada; (F.J.); (S.P.); (F.S.G.); (K.F.M.)
| | - Ronan M. N. Noble
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, AB T6G 1C9, Canada;
- Department of Pediatrics, University of Alberta, Edmonton, AB T6G 2G3, Canada
| | - Ferrante S. Gragasin
- Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada; (F.J.); (S.P.); (F.S.G.); (K.F.M.)
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, AB T6G 1C9, Canada;
| | - Rachel G. Khadaroo
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada;
- Department of Surgery, University of Alberta, Edmonton, AB T6G 2G3, Canada
| | - Kimberly F. Macala
- Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada; (F.J.); (S.P.); (F.S.G.); (K.F.M.)
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, AB T6G 1C9, Canada;
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada;
| | - Stephane L. Bourque
- Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada; (F.J.); (S.P.); (F.S.G.); (K.F.M.)
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, AB T6G 1C9, Canada;
- Department of Pediatrics, University of Alberta, Edmonton, AB T6G 2G3, Canada
- Department of Pharmacology, University of Alberta, Edmonton, AB T6G 2G3, Canada
- Correspondence: ; Tel.: +1-780-492-6000
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Kanjo A, Molnar Z, Zádori N, Gede N, Erőss B, Szakó L, Kiss T, Márton Z, Malbrain MLNG, Szuldrzynski K, Szrama J, Kusza K, Kogelmann K, Hegyi P. Dosing of Extracorporeal Cytokine Removal In Septic Shock (DECRISS): protocol of a prospective, randomised, adaptive, multicentre clinical trial. BMJ Open 2021; 11:e050464. [PMID: 34446497 PMCID: PMC8395301 DOI: 10.1136/bmjopen-2021-050464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Sepsis and septic shock have mortality rates between 20% and 50%. In sepsis, the immune response becomes dysregulated, which leads to an imbalance between proinflammatory and anti-inflammatory mediators. When standard therapeutic measures fail to improve patients' condition, additional therapeutic alternatives are applied to reduce morbidity and mortality. One of the most recent alternatives is extracorporeal cytokine adsorption with a device called CytoSorb. This study aims to compare the efficacy of standard medical therapy and continuous extracorporeal cytokine removal with CytoSorb therapy in patients with early refractory septic shock. Furthermore, we compare the dosing of CytoSorb adsorber device changed every 12 or 24 hours. METHODS AND ANALYSIS It is a prospective, randomised, controlled, open-label, international, multicentre, phase III study. Patients fulfilling the inclusion criteria will be randomly assigned to receive standard medical therapy (group A) or-in addition to standard treatment-CytoSorb therapy. CytoSorb treatment will be continuous and last for at least 24 hours, CytoSorb adsorber device will be changed every 12 (group B) or 24 hours (group C). Our primary outcome is shock reversal (no further need or a reduced (≤10% of the maximum dose) vasopressor requirement for 3 hours) and time to shock reversal (number of hours elapsed from the start of the treatment to shock reversal).Based on sample size calculation, 135 patients (1:1:1) will need to be enrolled in the study. A predefined interim analysis will be performed after reaching 50% of the planned sample size, therefore, the corrected level of significance (p value) will be 0.0294. ETHICS AND DISSEMINATION Ethics approval was obtained from the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (OGYÉI/65049/2020). Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04742764; Pre-results.
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Affiliation(s)
- Anna Kanjo
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Heim Pál National Paediatric Institute, Budapest, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Zsolt Molnar
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
- Chair and Department of Anaesthesiology and Intensive Therapy and Pain Treatment, Poznan University for Medical Sciences, Poznan, Poland
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Noémi Zádori
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Department of Anaesthesiology and Intensive Care, Medical School, University of Pécs, Pécs, Hungary
| | - Noémi Gede
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Lajos Szakó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Tamás Kiss
- Department of Anaesthesiology and Intensive Care, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Márton
- 1st Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Manu L N G Malbrain
- International Fluid Academy, Lovenjoel, Belgium
- Faculty of Engineering, Department of Electronics and Informatics, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Medical Department, CMO, AZ Jan Palfijn Hospital, Ghent, Belgium
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Konstanty Szuldrzynski
- Department of Anaesthesiology and Intensive Care, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
- Chair of Anatomy, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Szrama
- Chair and Department of Anaesthesiology and Intensive Therapy and Pain Treatment, Poznan University for Medical Sciences, Poznan, Poland
| | - Krzysztof Kusza
- Chair and Department of Anaesthesiology and Intensive Therapy and Pain Treatment, Poznan University for Medical Sciences, Poznan, Poland
| | - Klaus Kogelmann
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Emden, Emden, Germany
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Zhou X, Pan W, Chen B, Xu Z, Pan J. Predictive performance of dynamic arterial elastance for arterial pressure response to fluid expansion in mechanically ventilated hypotensive adults: a systematic review and meta-analysis of observational studies. Ann Intensive Care 2021; 11:119. [PMID: 34331607 PMCID: PMC8325731 DOI: 10.1186/s13613-021-00909-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/22/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Dynamic arterial elastance (Eadyn) has been extensively considered as a functional parameter of arterial load. However, conflicting evidence has been obtained on the ability of Eadyn to predict mean arterial pressure (MAP) changes after fluid expansion. This meta-analysis sought to assess the predictive performance of Eadyn for the MAP response to fluid expansion in mechanically ventilated hypotensive patients. METHODS We systematically searched electronic databases through November 28, 2020, to retrieve studies that evaluated the association between Eadyn and fluid expansion-induced MAP increases in mechanically ventilated hypotensive adults. Given the diverse threshold value of Eadyn among the studies, we only reported the area under the hierarchical summary receiver operating characteristic curve (AUHSROC) as the primary measure of diagnostic accuracy. RESULTS Eight observational studies that included 323 patients with 361 fluid expansions met the eligibility criteria. The results showed that Eadyn was a good predictor of MAP increases in response to fluid expansion, with an AUHSROC of 0.92 [95% confidence interval (CI) 0.89 to 0.94]. Six studies reported the cut-off value of Eadyn, which ranged from 0.65 to 0.89. The cut-off value of Eadyn was nearly conically symmetrical, most data were centred between 0.7 and 0.8, and the mean and median values were 0.77 and 0.75, respectively. The subgroup analyses indicated that the AUHSROC was slightly higher in the intensive care unit (ICU) patients (0.96; 95% CI 0.94 to 0.98) but lower in the surgical patients in the operating room (0.72; 95% CI 0.67 to 0.75). The results indicated that the fluid type and measurement technique might not affect the diagnostic accuracy of Eadyn. Moreover, the AUHSROC for the sensitivity analysis of prospective studies was comparable to that in the primary analysis. CONCLUSIONS Eadyn exhibits good performance for predicting MAP increases in response to fluid expansion in mechanically ventilated hypotensive adults, especially in the ICU setting.
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Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Weihao Pan
- Department of Emergency, Ningbo Yinzhou No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Bixin Chen
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Zhaojun Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Jianneng Pan
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China. .,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China.
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Young TL. A narrative review of paracetamol-induced hypotension: Keeping the patient safe. Nurs Open 2021; 9:1589-1601. [PMID: 34102027 PMCID: PMC8994964 DOI: 10.1002/nop2.943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/01/2021] [Accepted: 04/28/2021] [Indexed: 12/21/2022] Open
Abstract
Aim To understand the prevalence and epidemiology of paracetamol‐induced hypotension and clinical implications for contemporaneous practice. Design Narrative review. Methods In May and June 2020, an open‐date literature search of English publications indexed in ProQuest, PubMed, and EBSCO was conducted with the search terms ‘acetaminophen’ and ‘hypotension’ and related search combinations (‘paracetamol’, ‘propacetamol’, ‘low blood pressure’, ‘fever’, ‘sepsis’, and ‘shock’) to identify peer‐reviewed publications of blood pressure changes after paracetamol administration in humans. Results A pattern of blood pressure reduction following the administration of paracetamol is demonstrated in the 27 studies included in this review. Haemodynamic intervention often followed persistent blood pressure reduction, and was greatest in febrile critically ill patients who received parenteral paracetamol.
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Affiliation(s)
- Tricia L Young
- Australia and Bairnsdale Regional Health Service, University of New England, Armadale, VIC, Australia
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Pecchiari M, Pontikis K, Alevrakis E, Vasileiadis I, Kompoti M, Koutsoukou A. Cardiovascular Responses During Sepsis. Compr Physiol 2021; 11:1605-1652. [PMID: 33792902 DOI: 10.1002/cphy.c190044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sepsis is the life-threatening organ dysfunction arising from a dysregulated host response to infection. Although the specific mechanisms leading to organ dysfunction are still debated, impaired tissue oxygenation appears to play a major role, and concomitant hemodynamic alterations are invariably present. The hemodynamic phenotype of affected individuals is highly variable for reasons that have been partially elucidated. Indeed, each patient's circulatory condition is shaped by the complex interplay between the medical history, the volemic status, the interval from disease onset, the pathogen, the site of infection, and the attempted resuscitation. Moreover, the same hemodynamic pattern can be generated by different combinations of various pathophysiological processes, so the presence of a given hemodynamic pattern cannot be directly related to a unique cluster of alterations. Research based on endotoxin administration to healthy volunteers and animal models compensate, to an extent, for the scarcity of clinical studies on the evolution of sepsis hemodynamics. Their results, however, cannot be directly extrapolated to the clinical setting, due to fundamental differences between the septic patient, the healthy volunteer, and the experimental model. Numerous microcirculatory derangements might exist in the septic host, even in the presence of a preserved macrocirculation. This dissociation between the macro- and the microcirculation might account for the limited success of therapeutic interventions targeting typical hemodynamic parameters, such as arterial and cardiac filling pressures, and cardiac output. Finally, physiological studies point to an early contribution of cardiac dysfunction to the septic phenotype, however, our defective diagnostic tools preclude its clinical recognition. © 2021 American Physiological Society. Compr Physiol 11:1605-1652, 2021.
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Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Konstantinos Pontikis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Emmanouil Alevrakis
- 4th Department of Pulmonary Medicine, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Ioannis Vasileiadis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Maria Kompoti
- Intensive Care Unit, Thriassio General Hospital of Eleusis, Magoula, Greece
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
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Velasco R, Gomez B, Torre M, Benito J, Mintegi S. A positive nitrite test was an independent risk factor for invasive bacterial infections in infants under 90 days of age with fever without source. Acta Paediatr 2020; 109:2316-2323. [PMID: 32061143 DOI: 10.1111/apa.15230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/01/2020] [Accepted: 02/13/2020] [Indexed: 12/13/2022]
Abstract
AIM This study analysed the association between a positive nitrite dipstick test and an invasive bacterial infection (IBI) in infants younger than 90 days of age with fever without source (FWS). METHODS We performed a secondary analysis of data from a prospective multicentre study of infants up to 90 days of age with FWS undergoing care in 19 paediatric EDs between October 2011 and September 2013. Invasive bacterial infection was defined as a positive blood or cerebrospinal fluid culture. RESULTS The dipstick urinalysis was positive for nitrite or leucocyte esterase in 766 (22.5%) of the 3401 infants we studied, and 270 (35.2%) had a dipstick test that was just positive for nitrite. Overall, 107 were diagnosed with an IBI (3.1%). The IBI prevalence was 2.2% among patients with a normal urine dipstick, 4.4% if they had positive leucocyte esterase test results, 8.3% where the nitrite test was positive and 10.6% when both tests were positive. After multivariate analysis, a positive nitrite test remained an independent risk factor for IBI (odds ratio 2.7, 95% confidence interval 1.4-4.9). CONCLUSION In infants under 90 days of age with FWS, a positive nitrite urine dipstick test was an independent risk factor for IBI.
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Affiliation(s)
- Roberto Velasco
- Pediatric Emergency Department Rio Hortega Universitary Hospital Valladolid Spain
| | - Borja Gomez
- Pediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao Spain
| | - Mercedes Torre
- Pediatric Emergency Department Niño Jesús University Hospital Madrid Spain
| | - Javier Benito
- Pediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao Spain
| | - Santiago Mintegi
- Pediatric Emergency Department Biocruces Bizkaia Health Research Institute Hospital Universitario Cruces University of the Basque Country UPV/EHU Bilbao Spain
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10
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Tubeimoside I improves survival of mice in sepsis by inhibiting inducible nitric oxide synthase expression. Biomed Pharmacother 2020; 126:110083. [DOI: 10.1016/j.biopha.2020.110083] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/05/2020] [Accepted: 03/05/2020] [Indexed: 12/12/2022] Open
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Bottasso E. Toward the Existence of a Sympathetic Neuroplasticity Adaptive Mechanism Influencing the Immune Response. A Hypothetical View-Part II. Front Endocrinol (Lausanne) 2019; 10:633. [PMID: 31620088 PMCID: PMC6760024 DOI: 10.3389/fendo.2019.00633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/30/2019] [Indexed: 01/16/2023] Open
Abstract
In the preceding work, a hypothesis on the existence of a specific neural plasticity program from sympathetic fibers innervating secondary lymphoid organs was introduced. This proposed adaptive mechanism would involve segmental retraction and degeneration of noradrenergic terminals during the immune system (IS) activation followed by regeneration once the IS returns to the steady-state. Starting from such view, this second part presents clinical and experimental evidence allowing to envision that this sympathetic neural plasticity mechanism is also operative on inflamed non-lymphoid peripheral tissues. Importantly, the sympathetic nervous system regulates most of the physiological bodily functions, ranging from cardiovascular, respiratory and gastro-intestinal functions to endocrine and metabolic ones, among others. Thus, it seems sensible to think that compensatory programs should be put into place during inflammation in non-lymphoid tissues as well, to avoid the possible detrimental consequences of a sympathetic blockade. Nevertheless, in many pathological scenarios like severe sepsis, chronic inflammatory diseases, or maladaptive immune responses, such compensatory programs against noradrenergic transmission impairment would fail to develop. This would lead to a manifest sympathetic dysfunction in the above-mentioned settings, partly accounting for their underlying pathophysiological basis; which is also discussed. The physiological/teleological significance for the whole neural plasticity process is postulated, as well.
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Affiliation(s)
- Emanuel Bottasso
- Departments of Pathology and Physiology, Faculty of Medicine, Centro de Altos Estudios en Ciencias Humanas y de la Salud, Universidad Abierta Interamericana, Rosario, Argentina
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Pascual-Ramirez J, Koutrouvelis A. The nitric oxide pathway antagonists in septic shock: Meta-analysis of controlled clinical trials. J Crit Care 2019; 51:34-38. [DOI: 10.1016/j.jcrc.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/09/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
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Transcriptional Suppression of CPI-17 Gene Expression in Vascular Smooth Muscle Cells by Tumor Necrosis Factor, Krüppel-Like Factor 4, and Sp1 Is Associated with Lipopolysaccharide-Induced Vascular Hypocontractility, Hypotension, and Mortality. Mol Cell Biol 2019; 39:MCB.00070-19. [PMID: 30936247 PMCID: PMC6517596 DOI: 10.1128/mcb.00070-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/22/2019] [Indexed: 12/15/2022] Open
Abstract
Vasodilatory shock in sepsis is caused by the failure of the vasculature to respond to vasopressors, which results in hypotension, multiorgan failure, and ultimately patient death. Recently, it was reported that CPI-17, a key player in the regulation of smooth muscle contraction, was downregulated by lipopolysaccharide (LPS) in mesenteric arteries concordant with vascular hypocontractilty. Vasodilatory shock in sepsis is caused by the failure of the vasculature to respond to vasopressors, which results in hypotension, multiorgan failure, and ultimately patient death. Recently, it was reported that CPI-17, a key player in the regulation of smooth muscle contraction, was downregulated by lipopolysaccharide (LPS) in mesenteric arteries concordant with vascular hypocontractilty. While Sp1 has been shown to activate CPI-17 transcription, it is unknown whether Sp1 is involved in LPS-induced smooth muscle CPI-17 downregulation. Here we report that tumor necrosis factor (TNF) was critical for LPS-induced smooth muscle CPI-17 downregulation. Mechanistically, we identified two GC boxes as a key TNF response element in the CPI-17 promoter and demonstrated that KLF4 was upregulated by TNF, competed with Sp1 for the binding to the GC boxes in the CPI-17 promoter, and repressed CPI-17 transcription through histone deacetylases (HDACs). Moreover, genetic deletion of TNF or pharmacological inhibition of HDACs protected mice from LPS-induced smooth muscle CPI-17 downregulation, vascular hypocontractility, hypotension, and mortality. In summary, these data provide a novel mechanism of the transcriptional control of CPI-17 in vascular smooth muscle cells under inflammatory conditions and suggest a new potential therapeutic strategy for the treatment of vasodilatory shock in sepsis.
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Saramago EA, Borges GS, Singolani-Jr CG, Nogueira JE, Soriano RN, Cárnio EC, Branco LGS. Molecular hydrogen potentiates hypothermia and prevents hypotension and fever in LPS-induced systemic inflammation. Brain Behav Immun 2019; 75:119-128. [PMID: 30261305 DOI: 10.1016/j.bbi.2018.09.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/21/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022] Open
Abstract
Molecular hydrogen (H2) exerts anti-oxidative, anti-apoptotic, and anti-inflammatory effects. Here we tested the hypothesis that H2 modulates cardiovascular, inflammatory, and thermoregulatory changes in systemic inflammation (SI) induced by lipopolysaccharide (LPS) at different doses (0.1 or 1.5 mg/kg, intravenously, to induce mild or severe SI) in male Wistar rats (250-300 g). LPS or saline was injected immediately before the beginning of 360-minute inhalation of H2 (2% H2, 21% O2, balanced with nitrogen) or room air (21% O2, balanced with nitrogen). Deep body temperature (Tb) was measured by dataloggers pre-implanted in the peritoneal cavity. H2 caused no change in cardiovascular, inflammatory parameters, and Tb of control rats (treated with saline). During mild SI, H2 reduced plasma surges of proinflammatory cytokines (TNF-α and IL-6) while caused an increase in plasma IL-10 (anti-inflammatory cytokine) and prevented fever. During severe SI, H2 potentiated hypothermia, and prevented fever and hypotension, which coincided with reduced plasma nitric oxide (NO) production. Moreover, H2 caused a reduction in surges of proinflammatory cytokines (plasma TNF-α and IL-1β) and prostaglandin E2 [(PGE2), in plasma and hypothalamus], and an increase in plasma IL-10. These data are consistent with the notion that H2 blunts fever in mild SI, and during severe SI potentiates hypothermia, prevents hypotension reducing plasma NO production, and exerts anti-inflammatory effects strong enough to prevent fever by altering febrigenic signaling and ultimately down-modulating hypothalamic PGE2 production.
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Affiliation(s)
- Eduardo A Saramago
- Medical School of Ribeirão Preto, 14049-900, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Gabriela S Borges
- Medical School of Ribeirão Preto, 14049-900, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Carlitos G Singolani-Jr
- Medical School of Ribeirão Preto, 14049-900, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Jonatas E Nogueira
- Medical School of Ribeirão Preto, 14049-900, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; School of Physical Education and Sports of Ribeirao Preto, 14030-680, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Renato N Soriano
- Division of Physiology and Biophysics, Department of Basic Life Sciences, 35010-177, Federal University of Juiz de Fora, Governador Valadares, Minas Gerais, Brazil
| | - Evelin C Cárnio
- Nursing School of Ribeirão Preto, 14040-902, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Luiz G S Branco
- Dental School of Ribeirão Preto, 14040-904, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
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Barcella M, Bollen Pinto B, Braga D, D'Avila F, Tagliaferri F, Cazalis MA, Monneret G, Herpain A, Bendjelid K, Barlassina C. Identification of a transcriptome profile associated with improvement of organ function in septic shock patients after early supportive therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:312. [PMID: 30463588 PMCID: PMC6249814 DOI: 10.1186/s13054-018-2242-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 10/16/2018] [Indexed: 12/24/2022]
Abstract
Background Septic shock is the most severe complication of sepsis and this syndrome is associated with high mortality. Treatment of septic shock remains largely supportive of hemodynamics and tissue perfusion. Early changes in organ function assessed by the Sequential Organ Function Assessment (SOFA) score are highly predictive of the outcome. However, the individual patient’s response to supportive therapy is very heterogeneous, and the mechanisms underlying this variable response remain elusive. The aim of the study was to investigate the transcriptome of whole blood in septic shock patients with different responses to early supportive hemodynamic therapy assessed by changes in SOFA scores within the first 48 h from intensive care unit (ICU) admission. Methods We performed whole blood RNA sequencing in 31 patients: 17 classified as responders (R) and 14 as non-responders (NR). Gene expression was investigated at ICU admission (time point 1, or T1), comparing R with NR [padj < 0.01; Benjamini–Hochberg (BH)] and over time from T1 to T2 (48 h later) in R and NR independently (paired analysis, padj < 0.01; BH). Then the differences in gene expression trends over time were evaluated (Mann–Whitney, P <0.01). To identify enriched biological processes, we performed an over-representation analysis based on a right-sided hypergeometric test with Bonferroni step-down as multiple testing correction (padj < 0.05). Results At ICU admission, we did not identify differentially expressed genes (DEGs) between the two groups. In the transition from T1 to T2, the activation of genes involved in T cell–mediated immunity, granulocyte and natural killer (NK) cell functions, and pathogen lipid clearance was noted in the R group. Genes involved in acute inflammation were downregulated in both groups. Conclusions Within the limits of a small sample size, our results could suggest that early activation of genes of the adaptive immune response is associated with an improvement in organ function. Electronic supplementary material The online version of this article (10.1186/s13054-018-2242-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matteo Barcella
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Via Rudini 8, 20142, Milan, Italy.,Fondazione Filarete, Viale Ortles 22/4, 20139, Milan, Italy
| | - Bernardo Bollen Pinto
- Department of Anaesthesia, Pharmacology and Intensive Care, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, 1205, Switzerland
| | - Daniele Braga
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Via Rudini 8, 20142, Milan, Italy.,Fondazione Filarete, Viale Ortles 22/4, 20139, Milan, Italy
| | - Francesca D'Avila
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Via Rudini 8, 20142, Milan, Italy.,Fondazione Filarete, Viale Ortles 22/4, 20139, Milan, Italy
| | - Federico Tagliaferri
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Via Rudini 8, 20142, Milan, Italy.,Fondazione Filarete, Viale Ortles 22/4, 20139, Milan, Italy
| | - Marie-Angelique Cazalis
- Laboratoire Commun de Recherche HCL-bioMérieux, Hôpital Edouard Herriot, 376 Chemin de l'Orme, 6928 Marcy-l'Etoile, Lyon, France
| | - Guillaume Monneret
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Laboratoire d'Immunologie, 5 Place d'Arsonval, 69437, Lyon cedex 03, France
| | - Antoine Herpain
- Department of Intensive Care, Hospital Erasme, Hospital, Université Libre de Bruxelles, Route de Lennik 808, Brussels, 1070, Belgium
| | - Karim Bendjelid
- Department of Anaesthesia, Pharmacology and Intensive Care, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, 1205, Switzerland
| | - Cristina Barlassina
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Via Rudini 8, 20142, Milan, Italy. .,Fondazione Filarete, Viale Ortles 22/4, 20139, Milan, Italy.
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Björck V, Påhlman LI, Törnebrant J, Bodelsson M. Streptococcal M1 protein induces hyporesponsiveness and cytokine release from human arteries in a fibrinogen-dependent manner: a translational study. Scand J Trauma Resusc Emerg Med 2018; 26:61. [PMID: 30041663 PMCID: PMC6057097 DOI: 10.1186/s13049-018-0530-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Streptococcus pyogenes is a Gram positive bacterial species commonly involved in sepsis. Invasive strains express virulence factors such as the M1 protein. M1 protein forms complexes with fibrinogen leading to a cytokine storm in plasma contributing to the development of septic shock and organ failure. In experimental animals M1 protein causes vascular nitric oxide production and hyporesponsiveness to pressors, but it is not known whether it affects the human vascular wall. METHODS Human omental arteries obtained during surgery were incubated in vitro with M1 protein or lipopolysaccharide (LPS) as positive control, with or without plasma. After 48 h, contractile response to noradrenaline was measured, and levels of nitrite/nitrate and the cytokines interleukin (IL)-1β, IL-6, IL-8, IL-10, and tumor necrosis factor (TNF)-α in the incubation medium were measured. A second set of arteries were incubated with or without main components of plasma (immunoglobulin G, albumin or fibrinogen), in the presence of M1 protein followed by cytokine measurement. RESULTS Artery segments incubated with M1 protein and plasma contracted weaker in response to noradrenaline, and levels of IL-6 and IL-8 were significantly higher compared to after incubation with M1 protein alone. Incubation with M1 protein and fibrinogen resulted in elevated levels of IL-6 and IL-8, while incubation with M1 protein and albumin or immunoglobulin G did not affect the levels. Neither any of the other cytokines nor nitrite/nitrate was detected in the medium in any of the incubation conditions. CONCLUSIONS The study shows that M1 protein of Streptococcus pyogenes has a direct effect on the human vascular wall in the presence of plasma, demonstrated both as a diminished contractile response to noradrenaline and increased cytokine production. The effect of plasma was attributed to fibrinogen. The findings suggest that M1 protein contributes to the development of septic shock through impairment of the contractility of the vascular wall.
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Affiliation(s)
- Viveka Björck
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Anaesthesiology and intensive care, SE-221 85, Lund, Sweden
| | - Lisa I Påhlman
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Infection medicine, SE-221 85, Lund, Sweden
| | - Johan Törnebrant
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Anaesthesiology and intensive care, SE-221 85, Lund, Sweden
| | - Mikael Bodelsson
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Anaesthesiology and intensive care, SE-221 85, Lund, Sweden.
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Neuroendocrine Derangements in Early Septic Shock: Pharmacotherapy for Relative Adrenal and Vasopressin Insufficiency. Shock 2018; 48:284-293. [PMID: 28296657 DOI: 10.1097/shk.0000000000000864] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Septic shock is a leading cause of mortality in intensive care units throughout the world. While this disease state represents a highly complex pathophysiology involving numerous organ systems, the early approach to care includes adequate hemodynamic support traditionally achieved via infusions of vasoactive medications after adequate fluid resuscitation. Relative adrenal and vasopressin deficiencies are a common feature of septic shock that contribute to impaired hemodynamics. Hydrocortisone and vasopressin are endocrine system hormone analogues that target the acute neuroendocrine imbalance associated with septic shock. This clinically focused annotated review describes the pathophysiological mechanisms behind their use and explores the potential clinical roles of early administration and synergy when combined.
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Sharawy N, Mahrous R, Whynot S, George R, Lehmann C. Clinical relevance of early sublingual microcirculation monitoring in septic shock patients. Clin Hemorheol Microcirc 2018; 68:347-359. [DOI: 10.3233/ch-170244] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nivin Sharawy
- Department of Anaesthesia, Surgical Intensive Care Trauma Center, Faculty of Medicine, Cairo University, Cairo, Egypt
- Department of Physiology, Faculty of Medicine, Cairo University, Cairo, Egypt
- Department of Anaesthesia, Pain Management and Perioperative Medicine’s, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Reham Mahrous
- Department of Anaesthesia, Surgical Intensive Care Trauma Center, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sara Whynot
- Department of Anaesthesia, Pain Management and Perioperative Medicine’s, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Ronald George
- Department of Anaesthesia, Pain Management and Perioperative Medicine’s, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Christian Lehmann
- Department of Anaesthesia, Pain Management and Perioperative Medicine’s, Faculty of Medicine, Dalhousie University, Halifax, Canada
- Department of Pharmacology, Faculty of Medicine, Dalhousie University, Halifax, Canada
- Department of Immunology, Faculty of Medicine, Dalhousie University, Halifax, Canada
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Holm J, Szabó Z, Alehagen U, Lindahl TL, Cederholm I. Copeptin Release in Cardiac Surgery–A New Biomarker to Identify Risk Patients? J Cardiothorac Vasc Anesth 2018; 32:245-250. [DOI: 10.1053/j.jvca.2017.06.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Indexed: 12/20/2022]
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Abstract
Fluids during resuscitation from shock increase mean systemic pressure and venous return. The pressure gradient for venous return must increase. Mean systemic pressure is the amount of vascular space in unstressed and stressed volume, mostly unstressed. Shock states can decrease mean systemic pressure by increasing unstressed volume, decreasing total blood volume, or decreasing the pressure gradient for venous return. Crystalloids across bodily spaces restore normal volume, whereas colloids remain in the intravascular space. Electrolyte content of fluids matters and excess chloride impairs renal blood flow. Albumin seems to be more effective at restoring blood volume in severe sepsis, but not in other conditions.
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Burgdorff AM, Bucher M, Schumann J. Vasoplegia in patients with sepsis and septic shock: pathways and mechanisms. J Int Med Res 2018; 46:1303-1310. [PMID: 29332515 PMCID: PMC6091823 DOI: 10.1177/0300060517743836] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Sepsis is one of the most frequent causes of death among patients in intensive care units. Many therapeutic strategies have been assessed without the desired success rates. A key risk factor for death is hypotension due to vasodilatation with vascular hyposensitivity. However, the pathways underlying this process remain unclear. Endotoxemia induces inflammatory mediators, and this is followed by vasoplegia and decreased cardiac contractility. Although inhibition of these mediators diminishes mortality rates in animal models, this phenomenon has not been confirmed in humans. Downregulation of vasoconstrictive receptors such as angiotensin receptors, adrenergic and vasopressin receptors is seen in sepsis, which is associated with a hyporesponsiveness to vasoconstrictive mediators. Animal studies have verified that receptor downregulation is linked to the above-mentioned inflammatory mediators. Anti-inflammatory therapy with glucocorticoids reportedly improves responsiveness to catecholamines with higher survival in rats, although this has not been shown to be clinically significant in humans. Hence, there is an urgent need for in-depth studies investigating the underlying mechanisms of vasoplegia to allow for development of effective therapeutic strategies for the treatment of sepsis.
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Affiliation(s)
- A-M Burgdorff
- Department of Anesthesiology and Surgical Intensive Care, University Hospital Halle (Saale), Halle (Saale), Germany
| | - M Bucher
- Department of Anesthesiology and Surgical Intensive Care, University Hospital Halle (Saale), Halle (Saale), Germany
| | - J Schumann
- Department of Anesthesiology and Surgical Intensive Care, University Hospital Halle (Saale), Halle (Saale), Germany
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Effects of SPAK on vascular reactivity and nitric oxide production in endotoxemic mice. Eur J Pharmacol 2017; 814:248-254. [PMID: 28864211 DOI: 10.1016/j.ejphar.2017.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/21/2017] [Accepted: 08/28/2017] [Indexed: 11/20/2022]
Abstract
Vasoplegia impedes therapeutic interventions to restore vascular tone, leading to severe hypotension, poor tissue perfusion, and multiple organ failure in septic shock. High levels of circulating nitric oxide (NO) play a crucial role in endotoxin-induced vascular hyporeactivity. Proinflammatory cytokines have been implicated in the induction of inducible NO synthase and overproduction of NO. Anti-inflammatory therapy can diminish NO formation and improve vascular hyporeactivity in septic shock. STE20/SPS1-realted proline/alanine-rich kinase (SPAK) has been reported to activate mitogen-activated protein kinase and contribute to intestinal inflammation. Thus, we evaluated the roles of SPAK in NO production and vascular hyporeactivity in endotoxemic animals. Male wild-type and SPAK deficiency mice were intraperitoneally administered vehicle or Escherichia coli lipopolysaccharide (LPS, 50mg/kg). The changes of systolic blood pressure and plasma nitrate and nitrite levels were measured during the experimental period. Thoracic aortas were exercised to assess vascular reactivity and SPAK expression. In the present study, mice in endotoxin model showed severe hypotension and hyporeactivity to serotonin, phenylephrine (PE), and acetylcholine in the aortic rings. Phosphorylated SPAK expression in the aorta and NO levels in the plasma were also increased in animals with endotoxic shock. However, deletion of SPAK not only reduced the elevation of NO levels but also improved vascular hyporeactivity to serotonin and PE in endotoxemic mice. Taken together, SPAK could be involved in the NO overproduction and vascular hyporesponsiveness to vasoconstrictors in endotoxic shock. Thus, inhibition of SPAK could be useful in the prevention of endotoxin-induced vascular hyporeactivity.
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Bhattacharjee S, Soni KD, Maitra S, Baidya DK. Levosimendan does not provide mortality benefit over dobutamine in adult patients with septic shock: A meta-analysis of randomized controlled trials. J Clin Anesth 2017; 39:67-72. [PMID: 28494911 DOI: 10.1016/j.jclinane.2017.03.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/11/2017] [Accepted: 03/04/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Despite of advancement in intensive care medicine, sepsis and septic shock carry a high mortality. Levosimendan, an inodilator, may be promising for septic shock patients with myocardial dysfunction; however, firm evidence is lacking. In this meta- analysis of randomized controlled trials, levosimendan has been compared with dobutamine in adult patients with sepsis and septic shock. DESIGN Meta-analysis of randomized controlled trial. SETTING Intensive-care unit. PARTICIPANTS Adult septic shock patients. INTERVENTION Adult septic shock patients received dobutamine or levosimendan. MAIN OUTCOME MEASURE Mortality at longest follow-up, blood lactate level, cardiac index and noradrenaline requirement. RESULTS Data from 7 randomized trials have been included in this meta-analysis. Levosimendan has no benefit in terms of mortality at longest follow up in comparison to dobutamine (Odds ratio 0.77, 95% CI 0.45, 132; p=0.34) and length of ICU stay (MD -4.7days, 95% CI -10.3, 0.9days, p=0.10). Patients received levosimendan had less blood lactate level (standardized mean difference -0.95; 95% CI -1.64, -0.27; p=0.006) and higher cardiac index (mean difference 0.44; 95% CI 0.17, 0.71; p=0.001). Noradrenaline requirements are similar in both the groups. CONCLUSION There is no evidence that levosimendan is superior to dobutamine in adult patients with sepsis and septic shock. Further large randomized trials are necessary in this area.
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Affiliation(s)
- Sulagna Bhattacharjee
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil D Soni
- Department of Trauma Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India.
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Uludag MO, Ozdemir ED, Bal NB, Han S, Dayanir H, Babacan A, Emel Usanm S, Demirel-Yi E. Effects of Ozone Treatment in Endotoxin Induced Shock Model in Rats. INT J PHARMACOL 2017. [DOI: 10.3923/ijp.2017.166.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Hawiger J, Veach RA, Zienkiewicz J. New paradigms in sepsis: from prevention to protection of failing microcirculation. J Thromb Haemost 2015; 13:1743-56. [PMID: 26190521 PMCID: PMC5014149 DOI: 10.1111/jth.13061] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 07/06/2015] [Indexed: 12/24/2022]
Abstract
Sepsis, also known as septicemia, is one of the 10 leading causes of death worldwide. The rising tide of sepsis due to bacterial, fungal and viral infections cannot be stemmed by current antimicrobial therapies and supportive measures. New paradigms for the mechanism and resolution of sepsis and consequences for sepsis survivors are emerging. Consistent with Benjamin Franklin's dictum 'an ounce of prevention is worth a pound of cure', sepsis can be prevented by vaccinations against pneumococci and meningococci. Recently, the NIH NHLBI Panel redefined sepsis as 'severe endothelial dysfunction syndrome in response to intravascular and extravascular infections causing reversible or irreversible injury to the microcirculation responsible for multiple organ failure'. Microvascular endothelial injury underlies sepsis-associated hypotension, edema, disseminated intravascular coagulation, acute respiratory distress syndrome and acute kidney injury. Microbial genome products trigger 'genome wars' in sepsis that reprogram the human genome and culminate in a 'genomic storm' in blood and vascular cells. Sepsis can be averted experimentally by endothelial cytoprotection through targeting nuclear signaling that mediates inflammation and deranged metabolism. Endothelial 'rheostats' (e.g. inhibitors of NF-κB, A20 protein, CRADD/RAIDD protein and microRNAs) regulate endothelial signaling. Physiologic 'extinguishers' (e.g. suppressor of cytokine signaling 3) can be replenished through intracellular protein therapy. Lipid mediators (e.g. resolvin D1) hasten sepsis resolution. As sepsis cases rose from 387 330 in 1996 to 1.1 million in 2011, and are estimated to reach 2 million by 2020 in the US, mortality due to sepsis approaches that of heart attacks and exceeds deaths from stroke. More preventive vaccines and therapeutic measures are urgently needed.
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Affiliation(s)
- J Hawiger
- Immunotherapy Program at Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Medicine Division of Allergy Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - R A Veach
- Immunotherapy Program at Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Medicine Division of Allergy Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - J Zienkiewicz
- Immunotherapy Program at Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Medicine Division of Allergy Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
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Guo L, Tian S, Chen Y, Mao Y, Cui S, Hu A, Zhang J, Xia SL, Su Y, Du J, Block ER, Wang XL, Cui Z. CAT-1 as a novel CAM stabilizes endothelial integrity and mediates the protective actions of l-Arg via a NO-independent mechanism. J Mol Cell Cardiol 2015; 87:180-91. [DOI: 10.1016/j.yjmcc.2015.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/10/2015] [Accepted: 08/12/2015] [Indexed: 12/21/2022]
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Sharawy N, Lehmann C. New directions for sepsis and septic shock research. J Surg Res 2014; 194:520-527. [PMID: 25596653 DOI: 10.1016/j.jss.2014.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/19/2014] [Accepted: 12/04/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Septic shock is a frequent complication in intensive care unit that can result in multiple organ failure and death. In addition, recent data suggested that severe sepsis and septic shock represent an economic burden. Therefore, septic shock is an important public health problem. METHOD In this review, we will focus on the recent evidences concerning the stages of septic shock, the complex macrocirculation and microcirculation relationship, and the importance of those evidences for future resuscitation goals and therapeutic strategies during late septic shock. RESULT Recently, two stages of septic shock are suggested. In early stage, hypovolemia is the main contributing factor. During this stage, macrocirculatory and microcirculatory changes run parallel, and fluid resuscitation seems to be effective in restoring the hemodynamic parameters. Late stage of septic shock is characterized by complex microcirculation and macrocirculation relationship. CONCLUSIONS Although early goal-directed therapy is a stepwise approach in the treatment of septic shock, tissue perfusion remains an important factor that contributes to septic shock outcome. Because appropriate monitoring of tissue perfusion is a matter of debt, the ideal therapeutic strategy remains a controversial issue that needs further investigations.
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Affiliation(s)
- Nivin Sharawy
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Christian Lehmann
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
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de Montmollin E, Annane D. Year in review 2013: Critical Care--sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:578. [PMID: 25673430 PMCID: PMC4331148 DOI: 10.1186/s13054-014-0578-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review presents key publications from the research field of sepsis published in Critical Care and other relevant journals during 2013. The results of these experimental studies and clinical trials are discussed in the context of current scientific and clinical background. The discussion highlights and summarises articles on four main topics: sepsis pathogenesis, diagnostic and prognostic biomarkers, potential new therapies, and epidemiologic and outcome studies.
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