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Tamme K, Acosta S, Biloslavo A, Björck M, Casian D, Damaskos D, Forbes A, Kase K, Kisand K, Lakbar I, Mihnovitš V, Murruste M, Mändul M, Nuzzo A, Padar M, Starkopf J, Visconti D, Reintam Blaser A. Biomarkers In Prediction of Acute Mesenteric Ischaemia: a prospective multicentre study (BIPAMI study): a study protocol. BMC Surg 2024; 24:201. [PMID: 38961419 PMCID: PMC11221143 DOI: 10.1186/s12893-024-02491-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Acute mesenteric ischaemia (AMI) is a life-threatening disease where early diagnosis is critical to avoid morbidity and mortality from extensive irreversible bowel necrosis. Appropriate prediction of presence of bowel necrosis is currently not available but would help to choose the optimal method of treatment. The study aims to identify combinations of biomarkers that can reliably identify AMI and distinguish between potentially reversible and irreversible bowel ischaemia. METHODS This is a prospective multicentre study. Adult patients with clinical suspicion of AMI (n = 250) will be included. Blood will be sampled on admission, at and after interventions, or during the first 48 h of suspicion of AMI if no intervention undertaken. Samples will be collected and the following serum or plasma biomarkers measured at Tartu University Hospital laboratory: intestinal fatty acid-binding protein (I-FABP), alpha-glutathione S-transferase (Alpha- GST), interleukin 6 (IL-6), procalcitonin (PCT), ischaemia-modified albumin (IMA), D-lactate, D-dimer, signal peptide-CUB-EGF domain-containing protein 1 (SCUBE-1) and lipopolysaccharide-binding protein (LBP). Additionally, more common laboratory markers will be measured in routine clinical practice at study sites. Diagnosis of AMI will be confirmed by computed tomography angiography, surgery, endoscopy or autopsy. Student's t or Wilcoxon rank tests will be used for comparisons between transmural vs. suspected (but not confirmed) AMI (comparison A), confirmed AMI of any stage vs suspected AMI (comparison B) and non-transmural AMI vs transmural AMI (comparison C). Optimal cut-off values for each comparison will be identified based on the AUROC analysis and likelihood ratios calculated. Positive likelihood ratio > 10 (> 5) and negative likelihood ratio < 0.1 (< 0.2) indicate high (moderate) diagnostic accuracy, respectively. All biomarkers with at least moderate accuracy will be entered as binary covariates (using the best cutoffs) into the multivariable stepwise regression analysis to identify the best combination of biomarkers for all comparisons separately. The best models for each comparison will be used to construct a practical score to distinguish between no AMI, non-transmural AMI and transmural AMI. DISCUSSION As a result of this study, we aim to propose a score including set of biomarkers that can be used for diagnosis and decision-making in patients with suspected AMI. TRIAL REGISTRATION NCT06212921 (Registration Date 19-01-2024).
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Affiliation(s)
- Kadri Tamme
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
- Tartu University Hospital, Tartu, Estonia.
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Alan Biloslavo
- General Surgery Department, Cattinara University Hospital, Trieste, Italy
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Dumitru Casian
- Department of General Surgery Nr. 3, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Moldova
- Vascular Surgery Clinic, Institute of Emergency Medicine, Chisinau, Moldova
| | - Dimitrios Damaskos
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Karri Kase
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Kalle Kisand
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Ines Lakbar
- Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, University of Montpellier, Montpellier, France
| | - Vladislav Mihnovitš
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Marko Murruste
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Merli Mändul
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Alexandre Nuzzo
- Department of Gastroenterology, IBD and Intestinal Failure, Intestinal Stroke Center, AP-HP. Nord, Beaujon Hospital, Paris Cité University, Paris, France
| | | | - Joel Starkopf
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | | | - Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
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Zarnescu NO, Dumitrascu I, Zarnescu EC, Costea R. Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review. Diagnostics (Basel) 2022; 13:diagnostics13010001. [PMID: 36611293 PMCID: PMC9818265 DOI: 10.3390/diagnostics13010001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Abdominal compartment syndrome (ACS) represents a severe complication of acute pancreatitis (AP), resulting from an acute and sustained increase in abdominal pressure >20 mmHg, in association with new organ dysfunction. The harmful effect of high intra-abdominal pressure on regional and global perfusion results in significant multiple organ failure and is associated with increased morbidity and mortality. There are several deleterious consequences of elevated intra-abdominal pressure on end-organ function, including respiratory, cardiovascular, gastrointestinal, neurologic, and renal effects. It is estimated that about 15% of patients with severe AP develop intra-abdominal hypertension or ACS, with a mortality rate around 50%. The treatment of abdominal compartment syndrome in acute pancreatitis begins with medical intervention and percutaneous drainage, where possible. Abdominal compartment syndrome unresponsive to conservatory treatment requires immediate surgical decompression, along with vacuum-assisted closure therapy techniques, followed by early abdominal fascia closure.
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Affiliation(s)
- Narcis Octavian Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
- Correspondence: (N.O.Z.); (E.C.Z.); Tel.: +40-723-592-483 (N.O.Z.); +40-748-412-341 (E.C.Z.)
| | - Ioana Dumitrascu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Eugenia Claudia Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
- Correspondence: (N.O.Z.); (E.C.Z.); Tel.: +40-723-592-483 (N.O.Z.); +40-748-412-341 (E.C.Z.)
| | - Radu Costea
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
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Morphological Assessment and Biomarkers of Low-Grade, Chronic Intestinal Inflammation in Production Animals. Animals (Basel) 2022; 12:ani12213036. [PMID: 36359160 PMCID: PMC9654368 DOI: 10.3390/ani12213036] [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: 09/26/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022] Open
Abstract
Simple Summary Production animals are continuously exposed to environmental and dietary factors that might induce a state of low-grade, chronic intestinal inflammation. This condition compromises the productive performance and well-fare of these animals, requiring studies to understand what causes it and to develop control strategies. An intestinal inflammatory process is generally associated with alterations in the structure and functionality of its wall, resulting in the release of cellular components into the blood and/or feces. These components can act as biomarkers, i.e., they are measured to identify and quantify an inflammatory process without requiring invasive methods. In this review we discuss the mechanisms of low-grade inflammation, its effects on animal production and sustainability, and the identification of biomarkers that could provide early diagnosis of this process and support studies of useful interventional strategies. Abstract The complex interaction between the intestinal mucosa, the gut microbiota, and the diet balances the host physiological homeostasis and is fundamental for the maximal genetic potential of production animals. However, factors such as chemical and physical characteristics of the diet and/or environmental stressors can continuously affect this balance, potentially inducing a state of chronic low-grade inflammation in the gut, where inflammatory parameters are present and demanding energy, but not in enough intensity to provoke clinical manifestations. It’s vital to expand the understanding of inflammation dynamics and of how they compromise the function activity and microscopic morphology of the intestinal mucosa. These morphometric alterations are associated with the release of structural and functional cellular components into the feces and the blood stream creating measurable biomarkers to track this condition. Moreover, the identification of novel, immunometabolic biomarkers can provide dynamic and predictors of low-grade chronic inflammation, but also provide indicators of successful nutritional or feed additive intervention strategies. The objective of this paper is to review the mechanisms of low-grade inflammation, its effects on animal production and sustainability, and the biomarkers that could provide early diagnosis of this process and support studies of useful interventional strategies.
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Teng J, Xiang L, Long H, Gao C, Lei L, Zhang Y. The Serum Citrulline and D-Lactate are Associated with Gastrointestinal Dysfunction and Failure in Critically Ill Patients. Int J Gen Med 2021; 14:4125-4134. [PMID: 34377012 PMCID: PMC8349205 DOI: 10.2147/ijgm.s305209] [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: 02/03/2021] [Accepted: 05/18/2021] [Indexed: 12/12/2022] Open
Abstract
Objective This study attempted to screen and combine effective biomarkers to analyse the association between these biomarkers and gastrointestinal failure (GIF) in critically ill patients. Methods A total of 110 critically ill patients with acute gastrointestinal injury (AGI) admitted to ICU were enrolled. The AGI grade was determined by the AGI classification proposed by ESICM. There were 67 patients in gastrointestinal dysfunction (GID) group (AGI grade II), 43 patients in GIF group (AGI grade III–IV), and 41 healthy adults in healthy control (HC) group. APACHE II and SOFA score were used to evaluate the disease severity. Peripheral blood samples of patients were collected within 24 hours of admission to the ICU (prior-treatment) and after the conventional medication therapy for 7 consecutive days (post-treatment). Citrulline serum level was detected by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method, and D-lactate and lipopolysaccharide (LPS) serum levels were measured by ELISA. Pearson correlation, logistic regression, and ROC curve analysis were used. Results Patients with GID or GIF had lower serum level of citrulline, while higher levels of D-lactate and LPS than HC. Compared with GID patients, serum level of citrulline was reduced, while D-lactate and LPS were elevated in GIF patients. Correlation analysis displayed that serum levels of citrulline, D-lactate, and LPS were associated with the APACHE II and SOFA score in patients with GID or GIF. Logistics regression analysis showed that citrulline and D-lactate were risk for both GID and GIF. ROC curve analysis exhibited that combination of citrulline and D-lactate had relatively high value to distinguish GID from HC, GIF from GID, and GIF from HC. Conclusion Serum citrulline and D-lactate were associated with severity of GIF, combination of citrulline and D-lactate improved the diagnostic efficacy to identify GIF in critically ill patients.
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Affiliation(s)
- Jin Teng
- Department of Cadre Health, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu City, Sichuan Province, 610072, People's Republic of China
| | - Lu Xiang
- Department of Geriatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu City, Sichuan Province, 610072, People's Republic of China
| | - Huaicong Long
- Department of Geriatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu City, Sichuan Province, 610072, People's Republic of China
| | - Caiping Gao
- Department of Digestive Internal Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu City, Sichuan Province, 610072, People's Republic of China
| | - Lei Lei
- Department of Digestive Internal Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu City, Sichuan Province, 610072, People's Republic of China
| | - Yinghui Zhang
- Department of Digestive Internal Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu City, Sichuan Province, 610072, People's Republic of China
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Park Y, Ryu B, Ki SJ, McCracken B, Pennington A, Ward KR, Liang X, Kurabayashi K. Few-Layer MoS 2 Photodetector Arrays for Ultrasensitive On-Chip Enzymatic Colorimetric Analysis. ACS NANO 2021; 15:7722-7734. [PMID: 33825460 DOI: 10.1021/acsnano.1c01394] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Enzymatic colorimetric analysis of metabolites provides signatures of energy conversion and biosynthesis associated with disease onsets and progressions. Miniaturized photodetectors based on emerging two-dimensional transition metal dichalcogenides (TMDCs) promise to advance point-of-care diagnosis employing highly sensitive enzymatic colorimetric detection. Reducing diagnosis costs requires a batched multisample assay. The construction of few-layer TMDC photodetector arrays with consistent performance is imperative to realize optical signal detection for a miniature batched multisample enzymatic colorimetric assay. However, few studies have promoted an optical reader with TMDC photodetector arrays for on-chip operation. Here, we constructed 4 × 4 pixel arrays of miniaturized molybdenum disulfide (MoS2) photodetectors and integrated them with microfluidic enzyme reaction chambers to create an optoelectronic biosensor chip device. The fabricated device allowed us to achieve arrayed on-chip enzymatic colorimetric detection of d-lactate, a blood biomarker signifying the bacterial translocation from the intestine, with a limit of detection that is 1000-fold smaller than the clinical baseline, a 10 min assay time, high selectivity, and reasonably small variability across the entire arrays. The enzyme (Ez)/MoS2 optoelectronic biosensor unit consistently detected d-lactate in clinically important biofluids, such as saliva, urine, plasma, and serum of swine and humans with a wide detection range (10-3-103 μg/mL). Furthermore, the biosensor enabled us to show that high serum d-lactate levels are associated with the symptoms of systemic infection and inflammation. The lensless, optical waveguide-free device architecture should readily facilitate development of a monolithically integrated hand-held module for timely, cost-effective diagnosis of metabolic disorders in near-patient settings.
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Affiliation(s)
- Younggeun Park
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Byunghoon Ryu
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Seung Jun Ki
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Brendan McCracken
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Amanda Pennington
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Kevin R Ward
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan 48109, United States
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109, United States
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Xiaogan Liang
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Katsuo Kurabayashi
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan 48109, United States
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan 48109, United States
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Effect of Electroacupuncture at Zusanli (ST36) on Sepsis Induced by Cecal Ligation Puncture and Its Relevance to Spleen. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:1914031. [PMID: 33082818 PMCID: PMC7563055 DOI: 10.1155/2020/1914031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/18/2020] [Accepted: 09/23/2020] [Indexed: 12/29/2022]
Abstract
Background Acupuncture at Zusanli (ST36), Quchi (LI11), and Tianshu (ST25) is commonly used in septic patients by traditional Chinese physicians. The protective effect of acupuncture at ST36 on the intestinal barrier is associated with Cholinergic Anti-Inflammatory Pathway (CAIP). However, its detailed mechanism and whether acupuncture at LI11 and ST25 have similar effects to ST36 remain unclear. Aim To explore the effects of electroacupuncture (EA) at ST36, LI11, and ST25 on septic rats and investigate the role of the spleen in the treatment of EA at ST36. Methods A septic rat model caused by cecal ligation and puncture (CLP) and a postsplenectomy (SPX) CLP rat model were established. Rats were divided into nine groups depending on different treatments. Serum levels of TNF-α, IL-10, D-lactic acidosis (D-LA), double amine oxidase (DAO), and T-lymphocyte subgroup level in intestinal lymph nodes were compared. Results EA could not improve the 2-day survival of CLP rats. For CLP rats, EA at ST36 and LI11 significantly decreased the levels of TNF-α, IL-10, DAO, and D-LA in serum and normalized intestinal T-cell immunity. For SPX CLP rats, EA at ST36 failed to reduce serum concentrations of TNF-α, IL-10, and D-LA but increased the values of CD3+CD4+/CD3+CD8+ cells and Treg/Th17 cells. Conclusions EA at ST36 and LI11, respectively, could alleviate inflammation reaction, protect the intestinal barrier, and maintain intestinal T-cell function in septic rats. Spleen participated in the protective effect of EA at ST36 in sepsis.
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Strang SG, Habes QLM, Van der Hoven B, Tuinebreijer WE, Verhofstad MHJ, Pickkers P, Van Lieshout EMM, Van Waes OJF. Intestinal fatty acid binding protein as a predictor for intra-abdominal pressure-related complications in patients admitted to the intensive care unit; a prospective cohort study (I-Fabulous study). J Crit Care 2020; 63:211-217. [PMID: 32980233 DOI: 10.1016/j.jcrc.2020.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/24/2020] [Accepted: 08/30/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Critically ill patients are at risk for intra-abdominal hypertension (IAH) and related complications such as organ failure, abdominal compartment syndrome (ACS), and death. This study aimed to determine the value of urinary and serum intestinal fatty acid binding protein (I-FABP) levels as early marker for IAH-associated complications. METHODS A prospective observational study was conducted in two academic institutional mixed medical-surgical ICUs in the Netherlands. Adult patients admitted to the ICU with two or more risk factors for IAH (198) were included. Urinary and serum I-FABP and intra-abdominal pressure (IAP) were measured every six hours during 72 h. RESULTS Fifteen (8%) patients developed ACS and 74 (37%) developed new organ failure. I-FABP and IAP were positively correlated. Patients who developed ACS had higher median baseline levels of urinary I-FABP (235(P25-P75 85-1747)μg/g creat) than patients with IAH who did not develop ACS (87(P25-P75 33-246)μg/g, p = 0.037). With an odds ratio of 1.00, neither urinary nor serum I-FABP indicated increased risk for developing new organ failure or ACS. CONCLUSIONS A relevant diagnostic value of I-FABP levels for identifying individual patients at risk for intra-abdominal pressure related complications could not be demonstrated.
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Affiliation(s)
- Steven G Strang
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Quirine L M Habes
- Department of Intensive Care Medicine, Radboudumc, Nijmegen, the Netherlands
| | - Ben Van der Hoven
- Department of Intensive Care Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Wim E Tuinebreijer
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboudumc, Nijmegen, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Oscar J F Van Waes
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Gugliucci A, Caccavello R. Optimized sensitive and inexpensive method to measure D-lactate as a surrogate marker of methylglyoxal fluxes in metabolically relevant contexts. Methods 2020; 203:5-9. [DOI: 10.1016/j.ymeth.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022] Open
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Venn EC, Barnes AJ, Hansen RJ, Boscan PL, Twedt DC, Sullivan LA. Serum D-lactate concentrations in dogs with parvoviral enteritis. J Vet Intern Med 2020; 34:691-699. [PMID: 31919893 PMCID: PMC7096611 DOI: 10.1111/jvim.15688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 12/11/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Dogs infected with canine parvovirus (CPV) have compromised intestinal epithelial barrier integrity. Production of D-lactate by enteric bacteria may directly reflect disease severity or contribute to metabolic acid-base status in these dogs. HYPOTHESIS Serum D-lactate concentration will be increased in CPV dogs compared to healthy controls and correlate with markers of disease severity and acid-base status. ANIMALS Dogs with CPV undergoing treatment (n = 40) and healthy control dogs (n = 9). METHODS Prospective observational study. Dogs with CPV had a baseline and daily CBC, venous blood gas with serum electrolyte concentrations, composite clinical severity score, and serum D-lactate concentration performed. A single serum D-lactate measurement was obtained from healthy control dogs. RESULTS The CPV dogs had a higher D-lactate concentration (mean ± SD) of 469 ± 173 μM compared to controls, 306 ± 45 μM (P < .001). There was no difference in baseline D-lactate concentrations for CPV survivors (474 ± 28 μM), versus nonsurvivors (424 ± 116 μM; P = .70). D-lactate concentration decreased over the first 4 days of treatment (-9.6 μM/d; P = .46). Dogs hospitalized for <4 days had lower baseline D-lactate concentrations compared to those hospitalized ≥4 days (400 ± 178 μM versus 520 ± 152 μM; P = .03). No sustained correlation over time between serum D-lactate concentration and clinical severity score or recorded acid-base results. CONCLUSIONS AND CLINICAL IMPORTANCE Serum D-lactate concentrations are higher in dogs with CPV compared to healthy controls but do not appear to be clinically relevant. No relationship identified between serum D-lactate concentrations and markers of CPV disease severity, acid-base status, or outcome.
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Affiliation(s)
- Emilee C Venn
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - Alex J Barnes
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - Ryan J Hansen
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - Pedro L Boscan
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - David C Twedt
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - Lauren A Sullivan
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
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Evaluation and Management of Abdominal Compartment Syndrome in the Emergency Department. J Emerg Med 2019; 58:43-53. [PMID: 31753758 DOI: 10.1016/j.jemermed.2019.09.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/25/2019] [Accepted: 09/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Abdominal compartment syndrome is a potentially deadly condition that can be missed in the emergency department setting. OBJECTIVE The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of abdominal compartment syndrome with a focus on emergency clinicians. DISCUSSION Abdominal compartment syndrome is caused by excessive pressure within the abdominal compartment due to diminished abdominal wall compliance, increased intraluminal contents, increased abdominal contents, or capillary leak/fluid resuscitation. History and physical examination are insufficient in isolation, and the gold standard is intra-abdominal pressure measurement. Abdominal compartment syndrome is defined as an intra-abdominal pressure >20 mm Hg with evidence of end-organ injury. Management involves increasing abdominal wall compliance (e.g., analgesia, sedation, and neuromuscular blocking agents), evacuating gastrointestinal contents (e.g., nasogastric tubes, rectal tubes, and prokinetic agents), avoiding excessive fluid resuscitation, draining intraperitoneal contents (e.g., percutaneous drain), and decompressive laparotomy in select cases. Patients are critically ill and often require admission to a critical care unit. CONCLUSIONS Abdominal compartment syndrome is an increasingly recognized condition with the potential for significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.
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11
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Asrani VM, Brown A, Huang W, Bissett I, Windsor JA. Gastrointestinal Dysfunction in Critical Illness: A Review of Scoring Tools. JPEN J Parenter Enteral Nutr 2019; 44:182-196. [PMID: 31350771 DOI: 10.1002/jpen.1679] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/27/2019] [Accepted: 06/28/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Varsha M. Asrani
- Department of Surgery School of Medicine Faculty of Medical and Health Sciences, University of Auckland Auckland New Zealand
- Department of Nutrition and Dietetics Auckland City Hospital Auckland New Zealand
| | - Annabelle Brown
- Discipline of Nutrition and Dietetics Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
| | - Wei Huang
- Department of Integrated Traditional Chinese and Western Medicine Sichuan Provincial Pancreatitis Centre West China Hospital of Sichuan University Chengdu China
| | - Ian Bissett
- Department of Surgery School of Medicine Faculty of Medical and Health Sciences, University of Auckland Auckland New Zealand
- Department of General Surgery Auckland City Hospital Auckland New Zealand
| | - John A. Windsor
- Department of Surgery School of Medicine Faculty of Medical and Health Sciences, University of Auckland Auckland New Zealand
- Department of General Surgery Auckland City Hospital Auckland New Zealand
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Schlegel M, Körner A, Kaussen T, Knausberg U, Gerber C, Hansmann G, Jónasdóttir HS, Giera M, Mirakaj V. Inhibition of neogenin fosters resolution of inflammation and tissue regeneration. J Clin Invest 2018; 128:4711-4726. [PMID: 30222138 DOI: 10.1172/jci96259] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 07/26/2018] [Indexed: 12/14/2022] Open
Abstract
The resolution of inflammation is an active process that is coordinated by endogenous mediators. Previous studies have demonstrated the immunomodulatory properties of the axonal guidance proteins in the initial phase of acute inflammation. We hypothesized that the neuronal guidance protein neogenin (Neo1) modulates mechanisms of inflammation resolution. In murine peritonitis, Neo1 deficiency (Neo1-/-) resulted in higher efficacies in reducing neutrophil migration into injury sites, increasing neutrophil apoptosis, actuating PMN phagocytosis, and increasing the endogenous biosynthesis of specialized proresolving mediators, such as lipoxin A4, maresin-1, and protectin DX. Neo1 expression was limited to Neo1-expressing Ly6Chi monocytes, and Neo1 deficiency induced monocyte polarization toward an antiinflammatory and proresolving phenotype. Signaling network analysis revealed that Neo1-/- monocytes mediate their immunomodulatory effects specifically by activating the PI3K/AKT pathway and suppressing the TGF-β pathway. In a cohort of 59 critically ill, intensive care unit (ICU) pediatric patients, we found a strong correlation between Neo1 blood plasma levels and abdominal compartment syndrome, Pediatric Risk of Mortality III (PRISM-III) score, and ICU length of stay and mortality. Together, these findings identify a crucial role for Neo1 in regulating tissue regeneration and resolution of inflammation, and determined Neo1 to be a predictor of morbidity and mortality in critically ill children affected by clinical inflammation.
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Affiliation(s)
- Martin Schlegel
- Department of Anesthesiology and Intensive Care Medicine, Molecular Intensive Care Medicine, University Hospital Tübingen, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Andreas Körner
- Department of Anesthesiology and Intensive Care Medicine, Molecular Intensive Care Medicine, University Hospital Tübingen, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Torsten Kaussen
- Department of Pediatric Cardiology and Critical Care, Pulmonary Vascular Research Center, Hannover Medical School, Hannover, Germany
| | - Urs Knausberg
- Department of Anesthesiology and Intensive Care Medicine, Molecular Intensive Care Medicine, University Hospital Tübingen, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Carmen Gerber
- Department of Anesthesiology and Intensive Care Medicine, Molecular Intensive Care Medicine, University Hospital Tübingen, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Pulmonary Vascular Research Center, Hannover Medical School, Hannover, Germany
| | - Hulda Soffia Jónasdóttir
- Center for Proteomics and Metabolomics, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Martin Giera
- Center for Proteomics and Metabolomics, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Valbona Mirakaj
- Department of Anesthesiology and Intensive Care Medicine, Molecular Intensive Care Medicine, University Hospital Tübingen, Eberhard-Karls University Tübingen, Tübingen, Germany
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13
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Párraga Ros E, Correa-Martín L, Sánchez-Margallo FM, Candanosa-Aranda IE, Malbrain MLNG, Wise R, Latorre R, López Albors O, Castellanos G. Intestinal histopathological changes in a porcine model of pneumoperitoneum-induced intra-abdominal hypertension. Surg Endosc 2018; 32:3989-4002. [PMID: 29777353 DOI: 10.1007/s00464-018-6142-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/06/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Low splanchnic perfusion is an immediate effect of pneumoperitoneum-induced intra-abdominal hypertension (IAH). Anatomical structure results in the intestinal mucosa being the area most sensitive to hypoperfusion. The relationship between intestinal injury and clinical parameters of tissue perfusion [abdominal perfusion pressure (APP), gastric intramucosal pH (pHi) and lactic acid (Lc)] has not been previously studied. This study aimed to monitorize intestinal pathogenesis through sequential ileal biopsies and to measure APP, pHi, and Lc levels at different pneumoperitoneum-induced intra-abdominal pressures (20, 30, and 40 mmHg) to evaluate the potential relationships between them. MATERIALS AND METHODS Fifty pigs were divided into four groups; a control group (C) and three experimental groups with different pneumoperitoneum-induced levels [20 mmHg (G20), 30 mmHg (G30), and 40 mmHg (G40)], that were maintained for 3 and 5 h. APP, pHi, and Lc were measured and ileal biopsies taken laparoscopically every 30 min. The mucosal damage was graded using the standardized Park's Score and animals were classified as injured (I+) or uninjured (I-). RESULTS Different histopathological lesions were observed in groups G20, G30, and G40 but no damage observed in group C. A 33.3% of animals in G20 and G30 were I+ after 3 h, while 93.3% were injured in G40. After 5 h, histopathological lesions were no longer seen in some animals in G20 and only 10% were I+. Conversely, in G30 I+ pigs increased to 80% while those in G40 remained at 93.3% I+. The I+ animals had significantly lower APP and pHi than those I-. Lc was the clinical parameter that showed the earliest differences, with significantly higher figures in I+ animals. CONCLUSIONS The evolution of intestinal injuries from pneumoperitoneum-induced IAH depends on the degree of IAP. These damages may be associated with decreases in APP and pHi, and increases in Lc.
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Affiliation(s)
- Ester Párraga Ros
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, 30100, Murcia, Spain.
| | - Laura Correa-Martín
- Laparoscopy Department, Jesús Usón Minimally Invasive Surgery Centre (JUMISC), Cáceres, Spain
| | | | - Irma Eugenia Candanosa-Aranda
- Highlands Teaching and Research Farm (CEIEPAA), Faculty of Veterinary Medicine, National Autonomous University of México, Querétaro, Mexico
| | - Manu L N G Malbrain
- Medical and Surgical ICU and High Care Burn Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg/St-Erasmus, Lange Beeldekensstraat 267, 2060, Antwerp, Belgium
| | - Robert Wise
- Pietermaritzburg Metropolitan Department of Anaesthetics, Critical Care and Pain Management, Pietermaritzburg, South Africa.,Clinical Unit, Critical Care, Edendale Hospital, Pietermaritzburg, South Africa.,Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Rafael Latorre
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, 30100, Murcia, Spain
| | - Octavio López Albors
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, 30100, Murcia, Spain
| | - Gregorio Castellanos
- Department of General Surgery, Virgen de la Arrixaca General University Hospital, Murcia, Spain
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14
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Richards C, Ishihara K, Grayson C, Lustik M, Yheulon C. Serum lactate predicts resource utilization, but not surgical need, in the emergency department. J Surg Res 2018; 226:89-93. [PMID: 29661294 DOI: 10.1016/j.jss.2018.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/29/2017] [Accepted: 01/12/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Serum lactate is frequently tested in the emergency department (ED) setting to diagnose visceral ischemia and as a marker of end-organ perfusion. It is highly nonspecific, and levels can be affected by both kidney and liver function. In this retrospective chart review, we aim to demonstrate that serum lactate is overused in the ED setting and predicts resource utilization but not the need for surgical intervention. METHODS ED records with a chief complaint of "abdominal pain" were queried for the preceding 12 mo. We excluded pregnant patients, patients aged less than 18 years, and patients for whom a blood count and chemistry were not obtained. Vital signs, laboratory values, resource utilization, and outcome of the visit were obtained. Logistic regression models were developed to correct for confounding associations. RESULTS A total of 1003 records were obtained initially with 753 patients (75%) included in the study. Serum lactate was drawn in 118 patients (15%) and was elevated in 19 patients (16% of those drawn). Utilization of computed tomography imaging was associated with lactate utilization (P < 0.001). Patients in whom lactate was drawn were more likely to have a general surgery consult (51% versus 34%, P < 0.001) and to be admitted to the hospital (P < 0.001). CONCLUSIONS The use of serum lactate in the workup of patients with abdominal pain should be targeted at patients who have signs of sepsis and based on the index of suspicion for specific disease processes such as mesenteric ischemia.
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Affiliation(s)
- Carly Richards
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii.
| | - Kelli Ishihara
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii
| | - Cary Grayson
- Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii
| | - Michael Lustik
- Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, Hawaii
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15
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Time-course evaluation of intestinal structural disorders in a porcine model of intra-abdominal hypertension by mechanical intestinal obstruction. PLoS One 2018; 13:e0191420. [PMID: 29357386 PMCID: PMC5777654 DOI: 10.1371/journal.pone.0191420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/04/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND A mechanical intestinal obstruction (MIO) can generate intraabdominal hypertension (IAH) that is life threatening. The intestines are very sensitive to IAH since the low splanchnic perfusion causes intestinal hypoxia, local acidosis and bacterial translocations. This may lead to acute intestinal distress syndrome (AIDS). The identification of intestinal injuries during IAH and its correlation with clinical parameters as the abdominal perfusion pressure (APP), the gastric intramucosal pH (pHi) and lactic acid (Lc) are still unknown. This study aimed to evaluate the sequence of intestinal histopathological findings in an MIO model and to analyze potential relationships with parameters currently used in clinical practice (APP, pHi and Lc). MATERIAL AND METHODS Twenty pigs were divided into three groups: a control group (n = 5) and two experimental groups with 20 mmHg (G1, n = 10) and 30 mmHg (G2, n = 5) of IAH by MIO. The pressures were maintained for 3 hours, except in 5 animals in G1 where it was maintained for 5 hours. The APP, pHi and LA were recorded and biopsies of the terminal ileum were taken every 30 minutes in all groups. The intestinal damage was graded according to the Park Score. RESULTS Intestinal injuries were found in 42.9% of pigs in the experimental groups. The lesions were independent of the level and duration of IAH. Although APP and pHi were slightly lower in injured animals (I +) of G1 and G2, there were no significant differences among those uninjured (I-). Lc was significantly increased in all I+ pigs from the onset of IAH. CONCLUSION The IAH by MIO causes intestinal lesions from the first 30 minutes with concurrent decreases in APP and pHi and increases in Lc. Lc could be the best clinical parameter related to intestinal damages with a clear difference between I + and I- animals.
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16
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Smit M, Buddingh KT, Bosma B, Nieuwenhuijs VB, Hofker HS, Zijlstra JG. Abdominal Compartment Syndrome and Intra-abdominal Ischemia in Patients with Severe Acute Pancreatitis. World J Surg 2017; 40:1454-61. [PMID: 26830909 PMCID: PMC4868862 DOI: 10.1007/s00268-015-3388-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Introduction Severe acute pancreatitis may be complicated by intra-abdominal hypertension (IAH), abdominal compartment syndrome (ACS), and intestinal ischemia. The aim of this retrospective study is to describe the incidence, treatment, and outcome of patients with severe acute pancreatitis and ACS, in particular the occurrence of intestinal ischemia. Methods The medical records of all patients admitted with severe acute pancreatitis admitted to the ICU of a tertiary referral center were reviewed. The criteria proposed by the World Society of the Abdominal Compartment Syndrome (WSACS) were used to determine whether patients had IAH or ACS. Results Fifty-nine patients with severe acute pancreatitis were identified. Intra-abdominal pressure (IAP) measurements were performed in 29 patients (49.2 %). IAH was present in all patients (29/29). ACS developed in 13/29 (44.8 %) patients. Ten patients with ACS underwent decompressive laparotomy. A large proportion of patients with ACS had intra-abdominal ischemia upon laparotomy: 8/13 (61.5 %). Mortality was high in both the ACS group and the IAH group. Conclusion This study confirms that ACS is common in severe acute pancreatitis. Intra-abdominal ischemia occurs in a large proportion of patients with ACS. Swift surgical intervention may be indicated when conservative measures fail in patients with ACS. National and international guidelines need to be updated so that routine IAP measurements become standard of care for patients with severe acute pancreatitis in the ICU.
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Affiliation(s)
- M Smit
- Department of Critical Care (BA 49), University Medical Center Groningen, University of Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands.
| | - K T Buddingh
- Department of Critical Care (BA 49), University Medical Center Groningen, University of Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - B Bosma
- Department of Critical Care (BA 49), University Medical Center Groningen, University of Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - V B Nieuwenhuijs
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - H S Hofker
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J G Zijlstra
- Department of Critical Care (BA 49), University Medical Center Groningen, University of Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands
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17
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Abstract
PURPOSE OF REVIEW The current review summarizes different aspects of assessment of gastrointestinal function and provides a practical approach to management of adult patients with gastrointestinal dysfunction in the ICU. RECENT FINDINGS Different ways to define gastrointestinal failure have been used in the past. Recently, the term 'acute gastrointestinal injury (AGI)' has been proposed to specifically describe gastrointestinal dysfunction as a part of multiple organ dysfunction syndrome. Possible pathophysiological mechanisms and different aspects in assessment of gastrointestinal function in adult ICU patients are presented. Currently, there is no single marker that could reliably describe gastrointestinal dysfunction. Therefore, monitoring and management is still based on complex assessment of different gastrointestinal symptoms and feeding intolerance, even though this approach includes a large amount of subjectivity. The possible role of biomarkers (citrulline, enterohormones, etc.) and additional parameters like intra-abdominal pressure remains to be clarified. SUMMARY Defining gastrointestinal failure remains challenging but broad consensus needs to be reached and disseminated soon to allow conduct of interventional studies. A systematic approach to management of gastrointestinal problems is recommended.
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18
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Hecker A, Hecker B, Hecker M, Riedel JG, Weigand MA, Padberg W. Acute abdominal compartment syndrome: current diagnostic and therapeutic options. Langenbecks Arch Surg 2015; 401:15-24. [PMID: 26518567 DOI: 10.1007/s00423-015-1353-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/22/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND If untreated, the abdominal compartment syndrome (ACS) has a mortality of nearly 100 %. Thus, its early recognition is of major importance for daily rounds on surgical intensive care units. Intraabdominal hypertension (IAH) is a poorly recognized entity, which occurs if intraabdominal pressure arises >12 mmHg. Measurement of the intravesical pressure is the gold standard to diagnose IAH, which can be detected in about one fourth of surgical intensive care patients. PURPOSE The aim of this manuscript is to outline the current diagnostic and therapeutic options for IAH and ACS. While diagnosis of IAH and ACS strongly depends on clinical experience, new diagnostic markers could play an important role in the future. Therapy of IAH/ACS consists of five treatment "columns": intraluminal evacuation, intraabdominal evacuation, improvement of abdominal wall compliance, fluid management, and improved organ perfusion. If conservative therapy fails, emergency laparotomy is the most effective therapeutic approach to achieve abdominal decompression. Thereafter, patients with an open abdomen require intensive care and are permanently threatened by the quadrangle of fluid loss, muscle proteolysis, heat loss, and an impaired immune function. As a consequence, complication rate dramatically increases after 8 days of open abdomen therapy. CONCLUSION Despite many efforts, the mortality of patients with ACS remains unacceptably high. Permanent clinical education and surgical trials will be necessary to improve the outcome of our critically ill surgical patients.
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Affiliation(s)
- A Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.
| | - B Hecker
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Hecker
- Medical Clinic II, Pulmonary and Critical Care Medicine, University Hospital of Giessen, Giessen, Germany
| | - J G Riedel
- Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - M A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - W Padberg
- Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
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