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Plaschke K, Do TQM, Uhle F, Brenner T, Weigand MA, Kopitz J. Ablation of the Right Cardiac Vagus Nerve Reduces Acetylcholine Content without Changing the Inflammatory Response during Endotoxemia. Int J Mol Sci 2018; 19:ijms19020442. [PMID: 29389905 PMCID: PMC5855664 DOI: 10.3390/ijms19020442] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/23/2018] [Accepted: 01/26/2018] [Indexed: 02/06/2023] Open
Abstract
Acetylcholine is the main transmitter of the parasympathetic vagus nerve. According to the cholinergic anti-inflammatory pathway (CAP) concept, acetylcholine has been shown to be important for signal transmission within the immune system and also for a variety of other functions throughout the organism. The spleen is thought to play an important role in regulating the CAP. In contrast, the existence of a “non-neuronal cardiac cholinergic system” that influences cardiac innervation during inflammation has been hypothesized, with recent publications introducing the heart instead of the spleen as a possible interface between the immune and nervous systems. To prove this hypothesis, we investigated whether selectively disrupting vagal stimulation of the right ventricle plays an important role in rat CAP regulation during endotoxemia. We performed a selective resection of the right cardiac branch of the Nervus vagus (VGX) with a corresponding sham resection in vehicle-injected and endotoxemic rats. Rats were injected with lipopolysaccharide (LPS, 1 mg/kg body weight, intravenously) and observed for 4 h. Intraoperative blood gas analysis was performed, and hemodynamic parameters were assessed using a left ventricular pressure-volume catheter. Rat hearts and blood were collected, and the expression and concentration of proinflammatory cytokines using quantitative reverse transcription polymerase chain reaction and enzyme-linked immunosorbent assay were measured, respectively. Four hours after injection, LPS induced a marked deterioration in rat blood gas parameters such as pH value, potassium, base excess, glucose, and lactate. The mean arterial blood pressure and the end-diastolic volume had decreased significantly. Further, significant increases in blood cholinesterases and in proinflammatory (IL-1β, IL-6, TNF-α) cytokine concentration and gene expression were obtained. Right cardiac vagus nerve resection (VGX) led to a marked decrease in heart acetylcholine concentration and an increase in cardiac acetylcholinesterase activity. Without LPS, VGX changed rat hemodynamic parameters, including heart frequency, cardiac output, and end-diastolic volume. In contrast, VGX during endotoxemia did not significantly change the concentration and expression of proinflammatory cytokines in the heart. In conclusion we demonstrate that right cardiac vagal innervation regulates cardiac acetylcholine content but neither improves nor worsens systemic inflammation.
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Affiliation(s)
- Konstanze Plaschke
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany.
| | - Thuc Quyen Monica Do
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany.
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany.
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany.
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany.
| | - Jürgen Kopitz
- Department of Pathology, Heidelberg University Hospital, Im Neuenheimer Feld 224, D-69120 Heidelberg, Germany.
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Zimmermann JB, Pinder N, Bruckner T, Lehmann M, Motsch J, Brenner T, Hoppe-Tichy T, Swoboda S, Weigand MA, Hofer S. Adjunctive use of physostigmine salicylate (Anticholium®) in perioperative sepsis and septic shock: study protocol for a randomized, double-blind, placebo-controlled, monocentric trial (Anticholium® per Se). Trials 2017; 18:530. [PMID: 29126416 PMCID: PMC5681758 DOI: 10.1186/s13063-017-2231-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 10/05/2017] [Indexed: 11/24/2022] Open
Abstract
Background Severe sepsis and septic shock remain a major challenge, even in modern intensive care. In Germany, about 68,000 patients die annually because of septic diseases, characterized by a complex systemic inflammatory response. Causal treatment of the underlying infection is essential for successful management of sepsis, but the course can be positively influenced by supportive and adjuvant measures. The cholinergic anti-inflammatory pathway (CAP) represents a new approach to adjunctive therapy of septic diseases and can be pharmacologically activated by the acetylcholinesterase inhibitor physostigmine (Anticholium®). Promising effects can be found in several in vitro and in vivo models of sepsis, such as a reduction in pro-inflammatory cytokines and improved survival. Methods Anticholium® per Se is a randomized, double-blind, placebo-controlled, monocentric trial to assess whether the CAP can be transferred from bench to bedside. In this pilot study, 20 patients with perioperative sepsis and septic shock as a result of intra-abdominal infection are enrolled. According to randomization, participants are treated with physostigmine salicylate (verum group) or 0.9% sodium chloride (placebo group) for up to 5 days. The mean Sequential Organ Failure Assessment (SOFA) score during treatment and subsequent intensive care of up to 14 days is used as surrogate outcome (primary endpoint). Secondary outcome measures include 30- and 90-day mortality. An embedded pharmacokinetics and pharmacodynamics study investigates plasma concentrations of physostigmine and its metabolite eseroline. Further analyses will contribute to our understanding of the role of various cytokines in the pathophysiology of human sepsis. A computer-generated list is used for block randomization. Discussion This randomized, controlled, monocentric trial investigates for the first time the adjunctive use of physostigmine (Anticholium®) in patients with perioperative sepsis and septic shock and may be a pivotal step toward the clinical use in this indication. Trial registration EudraCT Number: 2012-001650-26 (entered 14 August 2012), ClinicalTrials.gov identifier: NCT03013322 (registered on 1 Jan 2017). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2231-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johannes B Zimmermann
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Nadine Pinder
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,Pharmacy Department, University Hospital Heidelberg, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Marsilius-Arkaden, Tower West, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Monika Lehmann
- Coordination Centre for Clinical Trials, University Hospital Heidelberg, Marsilius-Arkaden, Tower West, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Johann Motsch
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Torsten Hoppe-Tichy
- Pharmacy Department, University Hospital Heidelberg, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Stefanie Swoboda
- Pharmacy Department, University Hospital Heidelberg, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Stefan Hofer
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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Lichtenstern C, Herold C, Mieth M, Brenner T, Decker S, Busch CJ, Hofer S, Zimmermann S, Weigand MA, Bernhard M. Relevance of Candida and other mycoses for morbidity and mortality in severe sepsis and septic shock due to peritonitis. Mycoses 2015; 58:399-407. [PMID: 26010584 DOI: 10.1111/myc.12331] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/02/2015] [Accepted: 04/06/2015] [Indexed: 12/29/2022]
Abstract
This single-centre retrospective cohort study evaluated the incidence and outcome of mycoses in critical ill patients (n = 283) with sepsis due to peritonitis. Overall mortality was 41.3%, and the 28-day mortality was 29.3%. Fungal pathogens were found in 51.9%. The common first location was the respiratory tract (66.6%), followed by the abdominal site (19.7%). Candida colonisation was found in 64.6%, and invasive Candida infection in 34.0%. Identified fungi were Candida spp. in 98.6% and Aspergillus spp. in 6.1%. Patients with fungal pathogens showed a higher rate of postoperative peritonitis, APACHE II and tracheotomy. In comparison to patients without fungal pathogens, these patients showed a longer duration on mechanical ventilation, and a higher overall mortality. Patients with Candida-positive swabs from abdominal sites had more fascia dehiscence and anastomosis leakage. Seventy-two patients (48.9%) received antifungal therapy, 26 patients were treated empirically. Antifungal therapy was not associated with a decrease in mortality. Age and renal replacement therapy were associated with mortality. In conclusion, fungi are common pathogens in critically ill patients with peritonitis, and detection of fungi is associated with an increase in overall mortality. Particularly, Candida-positive abdominal swabs are associated with an increase in morbidity. However, we were not able to demonstrate a survival benefit for antifungal therapy in peritonitis patients.
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Affiliation(s)
| | - Christina Herold
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Decker
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Cornelius J Busch
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Hofer
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Zimmermann
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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Crandall M. Evaluating the effect of previous splenectomy on outcomes from intra-abdominal sepsis. J Surg Res 2010; 171:78-9. [PMID: 21131006 DOI: 10.1016/j.jss.2010.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 10/22/2010] [Accepted: 10/26/2010] [Indexed: 11/16/2022]
Affiliation(s)
- Marie Crandall
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair, Suite 650, Chicago, IL 60611, USA.
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