1
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Arynov A, Kaidarova D, Kabon B. Alternative blood transfusion triggers: a narrative review. BMC Anesthesiol 2024; 24:71. [PMID: 38395758 PMCID: PMC10885388 DOI: 10.1186/s12871-024-02447-3] [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: 09/13/2023] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Anemia, characterized by low hemoglobin levels, is a global public health concern. Anemia is an independent factor worsening outcomes in various patient groups. Blood transfusion has been the traditional treatment for anemia; its triggers, primarily based on hemoglobin levels; however, hemoglobin level is not always an ideal trigger for blood transfusion. Additionally, blood transfusion worsens clinical outcomes in certain patient groups. This narrative review explores alternative triggers for red blood cell transfusion and their physiological basis. MAIN TEXT The review delves into the physiology of oxygen transport and highlights the limitations of using hemoglobin levels alone as transfusion trigger. The main aim of blood transfusion is to optimize oxygen delivery, necessitating an individualized approach based on clinical signs of anemia and the balance between oxygen delivery and consumption, reflected by the oxygen extraction rate. The narrative review covers different alternative triggers. It presents insights into their diagnostic value and clinical applications, emphasizing the need for personalized transfusion strategies. CONCLUSION Anemia and blood transfusion are significant factors affecting patient outcomes. While restrictive transfusion strategies are widely recommended, they may not account for the nuances of specific patient populations. The search for alternative transfusion triggers is essential to tailor transfusion therapy effectively, especially in patients with comorbidities or unique clinical profiles. Investigating alternative triggers not only enhances patient care by identifying more precise indicators but also minimizes transfusion-related risks, optimizes blood product utilization, and ensures availability when needed. Personalized transfusion strategies based on alternative triggers hold the potential to improve outcomes in various clinical scenarios, addressing anemia's complex challenges in healthcare. Further research and evidence are needed to refine these alternative triggers and guide their implementation in clinical practice.
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Affiliation(s)
- Ardak Arynov
- Department of Anesthesiology and Intensive Care, Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan.
| | - Dilyara Kaidarova
- Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Medicine and Pain Medicine Medical, University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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2
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Cho DH, Thom SR, Son JW, Ko SM, Cha YS. Practical Recommendations for the Evaluation and Management of Cardiac Injury Due to Carbon Monoxide Poisoning. JACC. HEART FAILURE 2024:S2213-1779(24)00051-9. [PMID: 38385937 DOI: 10.1016/j.jchf.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 02/23/2024]
Abstract
Carbon monoxide (CO) is a relatively frequent cause of poisoning evaluated in emergency departments. The risk of neurologic injuries, such as cognitive, psychological, vestibular, and motor deficits, is 25% to 50%. However, the risk of cardiac injuries should also be considered. Among patients with CO poisoning, the mortality in patients with myocardial injury is approximately 3 times greater than that in patients without myocardial injury. In large-scale studies, up to 69.2% of patients with acute CO poisoning exhibiting elevated troponin I levels and no underlying cardiovascular illnesses had late gadolinium enhancement on cardiac magnetic resonance, suggesting covert CO-induced myocardial fibrosis. Myocardial damage can be evaluated using electrocardiography, echocardiography, computed tomography, and cardiac magnetic resonance. This paper offers recommendations for cardiac evaluations based on our collective experience of managing >2,000 cases of acute CO poisoning with supporting information taken from peer-reviewed published reports on CO poisoning.
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Affiliation(s)
- Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Stephen R Thom
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Sung Min Ko
- Department of Radiology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea; Research Institute of Hyperbaric Medicine and Science, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
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3
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Fischbach A, Wiegand SB, Zazzeron L, Traeger L, di Fenza R, Bagchi A, Farinelli WA, Franco W, Korupolu S, Arens J, Grassi L, Zadek F, Bloch DB, Rox Anderson R, Zapol WM. Veno-venous extracorporeal blood phototherapy increases the rate of carbon monoxide (CO) elimination in CO-poisoned pigs. Lasers Surg Med 2021; 54:256-267. [PMID: 34350599 DOI: 10.1002/lsm.23462] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Carbon monoxide (CO) inhalation is the leading cause of poison-related deaths in the United States. CO binds to hemoglobin (Hb), displaces oxygen, and reduces oxygen delivery to tissues. The optimal treatment for CO poisoning in patients with normal lung function is the administration of hyperbaric oxygen (HBO). However, hyperbaric chambers are only available in medical centers with specialized equipment, resulting in delayed therapy. Visible light dissociates CO from Hb with minimal effect on oxygen binding. In a previous study, we combined a membrane oxygenator with phototherapy at 623 nm to produce a "mini" photo-ECMO (extracorporeal membrane oxygenation) device, which improved CO elimination and survival in CO-poisoned rats. The objective of this study was to develop a larger photo-ECMO device ("maxi" photo-ECMO) and to test its ability to remove CO from a porcine model of CO poisoning. STUDY DESIGN/MATERIALS AND METHODS The "maxi" photo-ECMO device and the photo-ECMO system (six maxi photo-ECMO devices assembled in parallel), were tested in an in vitro circuit of CO poisoning. To assess the ability of the photo-ECMO device and the photo-ECMO system to remove CO from CO-poisoned blood in vitro, the half-life of COHb (COHb-t1/2 ), as well as the percent COHb reduction in a single blood pass through the device, were assessed. In the in vivo studies, we assessed the COHb-t1/2 in a CO-poisoned pig under three conditions: (1) While the pig breathed 100% oxygen through the endotracheal tube; (2) while the pig was connected to the photo-ECMO system with no light exposure; and (3) while the pig was connected to the photo-ECMO system, which was exposed to red light. RESULTS The photo-ECMO device was able to fully oxygenate the blood after a single pass through the device. Compared to ventilation with 100% oxygen alone, illumination with red light together with 100% oxygen was twice as efficient in removing CO from blood. Changes in gas flow rates did not alter CO elimination in one pass through the device. Increases in irradiance up to 214 mW/cm2 were associated with an increased rate of CO elimination. The photo-ECMO device was effective over a range of blood flow rates and with higher blood flow rates, more CO was eliminated. A photo-ECMO system composed of six photo-ECMO devices removed CO faster from CO-poisoned blood than a single photo-ECMO device. In a CO-poisoned pig, the photo-ECMO system increased the rate of CO elimination without significantly increasing the animal's body temperature or causing hemodynamic instability. CONCLUSION In this study, we developed a photo-ECMO system and demonstrated its ability to remove CO from CO-poisoned 45-kg pigs. Technical modifications of the photo-ECMO system, including the development of a compact, portable device, will permit treatment of patients with CO poisoning at the scene of their poisoning, during transit to a local emergency room, and in hospitals that lack HBO facilities.
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Affiliation(s)
- Anna Fischbach
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steffen B Wiegand
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Luca Zazzeron
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lisa Traeger
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raffaele di Fenza
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aranya Bagchi
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William A Farinelli
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Wellman Center for Photomedicine, Boston, Massachusetts, USA
| | - Walfre Franco
- Department of Biomedical Engineering, University of Massachusetts, Lowell, Massachusetts, USA
| | - Sandeep Korupolu
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Wellman Center for Photomedicine, Boston, Massachusetts, USA
| | - Jutta Arens
- Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, Twente, The Netherlands
| | - Luigi Grassi
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Francesco Zadek
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Donald B Bloch
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - R Rox Anderson
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Wellman Center for Photomedicine, Boston, Massachusetts, USA
| | - Warren M Zapol
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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4
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Huang CC, Chen TH, Ho CH, Chen YC, Hsu CC, Lin HJ, Wang JJ, Chang CP, Guo HR. Increased Risk of Congestive Heart Failure Following Carbon Monoxide Poisoning. Circ Heart Fail 2021; 14:e007267. [PMID: 33866825 DOI: 10.1161/circheartfailure.120.007267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Carbon monoxide poisoning (COP) is an important public health issue around the world. It may increase the risk of myocardial injury, but the association between COP and congestive heart failure (CHF) remains unclear. We conducted a study incorporating data from epidemiological and animal studies to clarify this issue. METHODS Using the National Health Insurance Database of Taiwan, we identified patients with COP diagnosed between 1999 and 2012 and compared them with patients without COP (non-COP cohort) matched by age and the index date at a 1:3 ratio. The comparison for the risk of CHF between the COP and non-COP cohorts was made using Cox proportional hazards regression. We also established a rat model to evaluate cardiac function using echocardiography and studied the pathological changes following COP. RESULTS The 20 942 patients in the COP cohort had a higher risk for CHF than the 62 826 members in the non-COP cohort after adjusting for sex and underlying comorbidities (adjusted hazard ratio, 2.01 [95% CI, 1.74-2.32]). The increased risk of CHF persisted even after 2 years of follow-up (adjusted hazard ratio, 1.85 [95% CI, 1.55-2.21]). In the animal model, COP led to a decreased left ventricular ejection fraction on echocardiography and damage to cardiac cells with remarkable fibrotic changes. CONCLUSIONS Our epidemiological data showed an increased risk of CHF was associated with COP, which was supported by the animal study. We suggest close follow-up of cardiac function for patients with COP to facilitate early intervention and further studies to identify other long-term effects that have not been reported in the literature.
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Affiliation(s)
- Chien-Cheng Huang
- Department of Emergency Medicine (C.-C. Huang, C.-C. Hsu, H.-J.L.), Chi Mei Medical Center, Tainan, Taiwan.,Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan (C.-C. Huang, T.-H.C., H.-R.G.).,Department of Senior Services (C.-C. Huang), Southern Taiwan University of Science and Technology, Tainan
| | - Tzu-Hao Chen
- Department of Medical Research (T.-H.C., C.-H.H., Y.-C.C., J.-J.W., C.-P.C.), Chi Mei Medical Center, Tainan, Taiwan.,Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan (C.-C. Huang, T.-H.C., H.-R.G.)
| | - Chung-Han Ho
- Department of Medical Research (T.-H.C., C.-H.H., Y.-C.C., J.-J.W., C.-P.C.), Chi Mei Medical Center, Tainan, Taiwan.,Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan (C.-H.H.)
| | - Yi-Chen Chen
- Department of Medical Research (T.-H.C., C.-H.H., Y.-C.C., J.-J.W., C.-P.C.), Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine (C.-C. Huang, C.-C. Hsu, H.-J.L.), Chi Mei Medical Center, Tainan, Taiwan.,Department of Biotechnology (C.-C. Hsu), Southern Taiwan University of Science and Technology, Tainan
| | - Hung-Jung Lin
- Department of Emergency Medicine (C.-C. Huang, C.-C. Hsu, H.-J.L.), Chi Mei Medical Center, Tainan, Taiwan.,Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan (H.-J.L.)
| | - Jhi-Joung Wang
- Department of Medical Research (T.-H.C., C.-H.H., Y.-C.C., J.-J.W., C.-P.C.), Chi Mei Medical Center, Tainan, Taiwan.,Allied AI Biomed Center (J.-J.W.), Southern Taiwan University of Science and Technology, Tainan
| | - Ching-Ping Chang
- Department of Medical Research (T.-H.C., C.-H.H., Y.-C.C., J.-J.W., C.-P.C.), Chi Mei Medical Center, Tainan, Taiwan
| | - How-Ran Guo
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan (C.-C. Huang, T.-H.C., H.-R.G.).,Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan (H.-R.G.).,Occupational Safety, Health and Medicine Research Center, National Cheng Kung University, Tainan Taiwan (H.-R.G.)
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5
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Rose JJ, Bocian KA, Xu Q, Wang L, DeMartino AW, Chen X, Corey CG, Guimarães DA, Azarov I, Huang XN, Tong Q, Guo L, Nouraie M, McTiernan CF, O'Donnell CP, Tejero J, Shiva S, Gladwin MT. A neuroglobin-based high-affinity ligand trap reverses carbon monoxide-induced mitochondrial poisoning. J Biol Chem 2020; 295:6357-6371. [PMID: 32205448 PMCID: PMC7212636 DOI: 10.1074/jbc.ra119.010593] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 03/16/2020] [Indexed: 12/18/2022] Open
Abstract
Carbon monoxide (CO) remains the most common cause of human poisoning. The consequences of CO poisoning include cardiac dysfunction, brain injury, and death. CO causes toxicity by binding to hemoglobin and by inhibiting mitochondrial cytochrome c oxidase (CcO), thereby decreasing oxygen delivery and inhibiting oxidative phosphorylation. We have recently developed a CO antidote based on human neuroglobin (Ngb-H64Q-CCC). This molecule enhances clearance of CO from red blood cells in vitro and in vivo Herein, we tested whether Ngb-H64Q-CCC can also scavenge CO from CcO and attenuate CO-induced inhibition of mitochondrial respiration. Heart tissue from mice exposed to 3% CO exhibited a 42 ± 19% reduction in tissue respiration rate and a 33 ± 38% reduction in CcO activity compared with unexposed mice. Intravenous infusion of Ngb-H64Q-CCC restored respiration rates to that of control mice correlating with higher electron transport chain CcO activity in Ngb-H64Q-CCC-treated compared with PBS-treated, CO-poisoned mice. Further, using a Clark-type oxygen electrode, we measured isolated rat liver mitochondrial respiration in the presence and absence of saturating solutions of CO (160 μm) and nitric oxide (100 μm). Both CO and NO inhibited respiration, and treatment with Ngb-H64Q-CCC (100 and 50 μm, respectively) significantly reversed this inhibition. These results suggest that Ngb-H64Q-CCC mitigates CO toxicity by scavenging CO from carboxyhemoglobin, improving systemic oxygen delivery and reversing the inhibitory effects of CO on mitochondria. We conclude that Ngb-H64Q-CCC or other CO scavengers demonstrate potential as antidotes that reverse the clinical and molecular effects of CO poisoning.
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Affiliation(s)
- Jason J Rose
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
- Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, Pennsylvania 15261
| | - Kaitlin A Bocian
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Qinzi Xu
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Ling Wang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Anthony W DeMartino
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Xiukai Chen
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Catherine G Corey
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Danielle A Guimarães
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Ivan Azarov
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Xueyin N Huang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Qin Tong
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Lanping Guo
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Mehdi Nouraie
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Charles F McTiernan
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Christopher P O'Donnell
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Jesús Tejero
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
- Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, Pennsylvania 15261
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Sruti Shiva
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Mark T Gladwin
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
- Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, Pennsylvania 15261
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6
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Hornstrup T, Løwenstein FT, Larsen MA, Helge EW, Póvoas S, Helge JW, Nielsen JJ, Fristrup B, Andersen JL, Gliemann L, Nybo L, Krustrup P. Cardiovascular, muscular, and skeletal adaptations to recreational team handball training: a randomized controlled trial with young adult untrained men. Eur J Appl Physiol 2018; 119:561-573. [PMID: 30474740 DOI: 10.1007/s00421-018-4034-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/07/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE The prevalence of lifestyle diseases has escalated, and effective exercise training programmes are warranted. This study tested the hypothesis that regular participation in small-sided team handball training could provide beneficial health effects on cardiovascular, skeletal, and muscular parameters in young adult untrained men. METHOD Twenty-six untrained 20-30-year-old men were randomly allocated to either a team handball training group (HG; n = 14), which completed 1.9 ± 0.3 training sessions per week over 12 weeks, or an inactive control group (CG; n = 12). Physiological training adaptations were assessed pre- and post interventions by DXA scans, blood samples, muscle biopsies, and physical tests. RESULTS The average heart rate during training was equivalent to 84 ± 4% of maximal heart rate. Compared to CG, HG displayed significant increases in VO2max (11 ± 6%), proximal femur bone mineral density (2 ± 1%), whole-body bone mineral content (2 ± 1%), intermittent endurance performance (32 ± 16%), incremental treadmill test performance (16 ± 7%) and muscle citrate synthase activity (22 ± 28%) as well as decreases in total fat mass (7 ± 7%) and total fat percentage (6 ± 7%) (all p < 0.05). There were no significant changes in muscle mass, blood pressure, resting heart rate, muscle hydroxyl-acyl-dehydrogenase activity, or blood lipids (all p > 0.05). CONCLUSION Participation in regular recreational team handball training was associated with positive cardiovascular, skeletal, and muscular adaptations, including increased maximal oxygen uptake, increased muscle enzymatic activity, and improved bone mineralization as well as lower fat percentage. These findings suggest that recreational team handball training may be an effective health-promoting activity for young adult men.
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Affiliation(s)
- Therese Hornstrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200, Copenhagen N, Denmark.
| | - F T Løwenstein
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200, Copenhagen N, Denmark
| | - M A Larsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200, Copenhagen N, Denmark
| | - E W Helge
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200, Copenhagen N, Denmark
| | - S Póvoas
- Research Center in Sports Sciences, Health Sciences and Human Development, CIDESD, University Institute of Maia, ISMAI, 4475-690, Maia, Portugal
| | - J W Helge
- Center for Healthy Aging, Department of Biomedical Sciences, University of Copenhagen, 2200, Copenhagen N, Denmark
| | - J J Nielsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200, Copenhagen N, Denmark
| | - B Fristrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200, Copenhagen N, Denmark
| | - J L Andersen
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, 2400, Copenhagen NV, Denmark
| | - L Gliemann
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200, Copenhagen N, Denmark
| | - L Nybo
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200, Copenhagen N, Denmark
| | - P Krustrup
- Department of Sports Science and Clinical Biomechanics, SDU Sport and Health Sciences Cluster (SHSC), University of Southern Denmark, 5230, Odense, Denmark
- Sport and Health Sciences, Faculty of Life and Environmental Sciences, University of Exeter, Exeter, EX1 2LU, UK
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7
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Abstract
Exposure to carbon monoxide (CO) during general anesthesia can result from volatile anesthetic degradation by carbon dioxide absorbents and rebreathing of endogenously produced CO. Although adherence to the Anesthesia Patient Safety Foundation guidelines reduces the risk of CO poisoning, patients may still experience subtoxic CO exposure during low-flow anesthesia. The consequences of such exposures are relatively unknown. In contrast to the widely recognized toxicity of high CO concentrations, the biologic activity of low concentration CO has recently been shown to be cytoprotective. As such, low-dose CO is being explored as a novel treatment for a variety of different diseases. Here, we review the concept of anesthesia-related CO exposure, identify the sources of production, detail the mechanisms of overt CO toxicity, highlight the cellular effects of low-dose CO, and discuss the potential therapeutic role for CO as part of routine anesthetic management.
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Affiliation(s)
- Richard J Levy
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York
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8
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Lee GW, Bae MJ, Yang JY, Son JW, Cho JL, Lee SG, Jang BM, Lee HW, Lim JS, Shin DC, Lim YW. Decreased blood pressure associated with in-vehicle exposure to carbon monoxide in Korean volunteers. Environ Health Prev Med 2017; 22:34. [PMID: 29165122 PMCID: PMC5664420 DOI: 10.1186/s12199-017-0622-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 02/09/2017] [Indexed: 02/08/2023] Open
Abstract
Background Carbon monoxide (CO) is one of the primary components of emissions from light-duty vehicles, and reportedly comprises 77% of all pollutants emitted in terms of concentration. Exposure to CO aggravates cardiovascular disease and causes other health disorders. The study was aimed to assess the negative effects by injecting different amounts of CO concentration directly to human volunteers boarding in the car. Methods Human volunteers were exposed to CO concentrations of 0, 33.2, and 72.4 ppm, respectively during the first test and 0, 30.3, and 48.8 ppm respectively during the second test while seated in the car. The volunteers were exposed to each concentration for approximately 45 min. After exposure, blood pressure measurement, blood collection (carboxyhemoglobin [COHb] analysis), medical interview, echocardiography test, and cognitive reaction test were performed. Result In patients who were exposed to a mean concentration of CO for 72.4 ± 1.4 ppm during the first exposure test and 48.8 ± 3.7 ppm during the second exposure test, the COHb level exceeded 2%. Moreover, the diastolic blood pressure was decreased while increasing in CO concentration after exposure. The medical interview findings showed that the degree of fatigue was increased and the degree of concentration was reduced when the exposed concentration of CO was increased. Conclusion Although the study had a limited sample size, we found that even a low concentration of CO flowing into a car could have a negative influence on human health, such as change of blood pressure and degree of fatigue.
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Affiliation(s)
- Geon-Woo Lee
- Department of Public Health, Graduate School, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea.,The Institute for Environmental Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea
| | - Mun-Joo Bae
- Graduate School of Public Health, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea
| | - Ji-Yeon Yang
- The Institute for Environmental Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea
| | - Jung-Woo Son
- Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea
| | - Jae-Lim Cho
- Department of Occupational and Environmental Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sang-Gyu Lee
- The Institute for Environmental Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea
| | - Bo-Mi Jang
- The Institute for Environmental Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea
| | - Hyun-Woo Lee
- Korea Automobile Testing & Research Institute, 200 Samjon-ro, Songsan-myun, Hwaseong-si, Gyeonggi-do, Korea
| | - Jong-Soon Lim
- Korea Automobile Testing & Research Institute, 200 Samjon-ro, Songsan-myun, Hwaseong-si, Gyeonggi-do, Korea
| | - Dong-Chun Shin
- The Institute for Environmental Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea.,Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea
| | - Young-Wook Lim
- The Institute for Environmental Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Korea.
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9
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Rose JJ, Wang L, Xu Q, McTiernan CF, Shiva S, Tejero J, Gladwin MT. Carbon Monoxide Poisoning: Pathogenesis, Management, and Future Directions of Therapy. Am J Respir Crit Care Med 2017; 195:596-606. [PMID: 27753502 PMCID: PMC5363978 DOI: 10.1164/rccm.201606-1275ci] [Citation(s) in RCA: 351] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 10/14/2016] [Indexed: 02/06/2023] Open
Abstract
Carbon monoxide (CO) poisoning affects 50,000 people a year in the United States. The clinical presentation runs a spectrum, ranging from headache and dizziness to coma and death, with a mortality rate ranging from 1 to 3%. A significant number of patients who survive CO poisoning suffer from long-term neurological and affective sequelae. The neurologic deficits do not necessarily correlate with blood CO levels but likely result from the pleiotropic effects of CO on cellular mitochondrial respiration, cellular energy utilization, inflammation, and free radical generation, especially in the brain and heart. Long-term neurocognitive deficits occur in 15-40% of patients, whereas approximately one-third of moderate to severely poisoned patients exhibit cardiac dysfunction, including arrhythmia, left ventricular systolic dysfunction, and myocardial infarction. Imaging studies reveal cerebral white matter hyperintensities, with delayed posthypoxic leukoencephalopathy or diffuse brain atrophy. Management of these patients requires the identification of accompanying drug ingestions, especially in the setting of intentional poisoning, fire-related toxic gas exposures, and inhalational injuries. Conventional therapy is limited to normobaric and hyperbaric oxygen, with no available antidotal therapy. Although hyperbaric oxygen significantly reduces the permanent neurological and affective effects of CO poisoning, a portion of survivors still have substantial morbidity. There has been some early success in therapies targeting the downstream inflammatory and oxidative effects of CO poisoning. New methods to directly target the toxic effect of CO, such as CO scavenging agents, are currently under development.
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Affiliation(s)
- Jason J. Rose
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine
| | - Ling Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine
| | - Qinzi Xu
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
| | | | - Sruti Shiva
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Department of Pharmacology and Chemical, and
- Center for Metabolism and Mitochondrial Medicine, University of Pittsburgh, Pennsylvania
| | - Jesus Tejero
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine
| | - Mark T. Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine
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Levy RJ. Carbon monoxide and anesthesia-induced neurotoxicity. Neurotoxicol Teratol 2016; 60:50-58. [PMID: 27616667 DOI: 10.1016/j.ntt.2016.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 08/10/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
Abstract
The majority of commonly used anesthetic agents induce widespread neuronal degeneration in the developing mammalian brain. Downstream, the process appears to involve activation of the oxidative stress-associated mitochondrial apoptosis pathway. Targeting this pathway could result in prevention of anesthetic toxicity in the immature brain. Carbon monoxide (CO) is a gas that exerts biological activity in the developing brain and low dose exposures have the potential to provide neuroprotection. In recent work, low concentration CO exposures limited isoflurane-induced neuronal apoptosis in a dose-dependent manner in newborn mice and modulated oxidative stress within forebrain mitochondria. Because infants and children are routinely exposed to low levels of CO during low-flow general endotracheal anesthesia, such anti-oxidant and pro-survival cellular effects are clinically relevant. Here we provide an overview of anesthesia-related CO exposure, discuss the biological activity of low concentration CO, detail the effects of CO in the brain during development, and provide evidence for CO-mediated inhibition of anesthesia-induced neurotoxicity.
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Affiliation(s)
- Richard J Levy
- Department of Anesthesiology, Columbia University Medical Center, United States.
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11
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Roderique JD, Josef CS, Feldman MJ, Spiess BD. A modern literature review of carbon monoxide poisoning theories, therapies, and potential targets for therapy advancement. Toxicology 2015; 334:45-58. [PMID: 25997893 DOI: 10.1016/j.tox.2015.05.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 05/01/2015] [Accepted: 05/12/2015] [Indexed: 01/03/2023]
Abstract
The first descriptions of carbon monoxide (CO) and its toxic nature appeared in the literature over 100 years ago in separate publications by Drs. Douglas and Haldane. Both men ascribed the deleterious effects of this newly discovered gas to its strong interaction with hemoglobin. Since then the adverse sequelae of CO poisoning has been almost universally attributed to hypoxic injury secondary to CO occupation of oxygen binding sites on hemoglobin. Despite a mounting body of literature suggesting other mechanisms of injury, this pathophysiology and its associated oxygen centric therapies persists. This review attempts to elucidate the remarkably complex nature of CO as a gasotransmitter. While CO's affinity for hemoglobin remains undisputed, new research suggests that its role in nitric oxide release, reactive oxygen species formation, and its direct action on ion channels is much more significant. In the course of understanding the multifaceted character of this simple molecule it becomes apparent that current oxygen based therapies meant to displace CO from hemoglobin may be insufficient and possibly harmful. Approaching CO as a complex gasotransmitter will help guide understanding of the complex and poorly understood sequelae and illuminate potentials for new treatment modalities.
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Affiliation(s)
- Joseph D Roderique
- Department of Anesthesiology, VCU School of Medicine Sanger Hall, Rm B1-016, 1101 East Marshall Street, P.O. Box 980695, Richmond, VA 23298, United States
| | - Christopher S Josef
- Department of Anesthesiology, VCU School of Medicine Sanger Hall, Rm B1-016, 1101 East Marshall Street, P.O. Box 980695, Richmond, VA 23298, United States.
| | - Michael J Feldman
- Department of Plastic and Reconstructive Surgery, Critical Care Hospital 8th floor, 1213 East Clay St, Richmond, VA 23298, United States
| | - Bruce D Spiess
- Department of Anesthesiology, VCU School of Medicine Sanger Hall, Rm B1-016, 1101 East Marshall Street, P.O. Box 980695, Richmond, VA 23298, United States
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12
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Levy RJ. Carbon monoxide pollution and neurodevelopment: A public health concern. Neurotoxicol Teratol 2015; 49:31-40. [PMID: 25772154 DOI: 10.1016/j.ntt.2015.03.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/05/2015] [Accepted: 03/06/2015] [Indexed: 12/18/2022]
Abstract
Although an association between air pollution and adverse systemic health effects has been known for years, the effect of pollutants on neurodevelopment has been underappreciated. Recent evidence suggests a possible link between air pollution and neurocognitive impairment and behavioral disorders in children, however, the exact nature of this relationship remains poorly understood. Infants and children are uniquely vulnerable due to the potential for exposure in both the fetal and postnatal environments during critical periods in development. Carbon monoxide (CO), a common component of indoor and outdoor air pollution, can cross the placenta to gain access to the fetal circulation and the developing brain. Thus, CO is of particular interest as a known neurotoxin and a potential public health threat. Here we review overt CO toxicity and the policies regulating CO exposure, detail the evidence suggesting a potential link between CO-associated ambient air pollution, tobacco smoke, and learning and behavioral abnormalities in children, describe the effects of subclinical CO exposure on the brain during development, and provide mechanistic insight into a potential connection between CO exposure and neurodevelopmental outcome. CO can disrupt a number of critical processes in the developing brain, providing a better understanding of how this specific neurotoxin may impair neurodevelopment. However, further investigation is needed to better define the effects of perinatal CO exposure on the immature brain. Current policies regarding CO standards were established based on evidence of cardiovascular risk in adults with pre-existing comorbidities. Thus, recent and emerging data highlighted in this review regarding CO exposure in the fetus and developing child may be important to consider when the standards and guidelines are evaluated and revised in the future.
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Affiliation(s)
- Richard J Levy
- Department of Anesthesiology, Columbia University Medical Center, 622 W. 168th Street, New York, NY 10032, United States.
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Aldossary M, Almadni O, Kharoshah M, Alsaif D, Alsowayigh K, Alfaraidy M. Carbon monoxide toxicity in Dammam, KSA: Retrospective study. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2015. [DOI: 10.1016/j.ejfs.2014.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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14
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Cheng Y, Thomas A, Mardini F, Bianchi SL, Tang JX, Peng J, Wei H, Eckenhoff MF, Eckenhoff RG, Levy RJ. Neurodevelopmental consequences of sub-clinical carbon monoxide exposure in newborn mice. PLoS One 2012; 7:e32029. [PMID: 22348142 PMCID: PMC3277503 DOI: 10.1371/journal.pone.0032029] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 01/18/2012] [Indexed: 12/13/2022] Open
Abstract
Carbon monoxide (CO) exposure at high concentrations results in overt neurotoxicity. Exposure to low CO concentrations occurs commonly yet is usually sub-clinical. Infants are uniquely vulnerable to a variety of toxins, however, the effects of postnatal sub-clinical CO exposure on the developing brain are unknown. Apoptosis occurs normally within the brain during development and is critical for synaptogenesis. Here we demonstrate that brief, postnatal sub-clinical CO exposure inhibits developmental neuroapoptosis resulting in impaired learning, memory, and social behavior. Three hour exposure to 5 ppm or 100 ppm CO impaired cytochrome c release, caspase-3 activation, and apoptosis in neocortex and hippocampus of 10 day old CD-1 mice. CO increased NeuN protein, neuronal numbers, and resulted in megalencephaly. CO-exposed mice demonstrated impaired memory and learning and reduced socialization following exposure. Thus, CO-mediated inhibition of neuroapoptosis might represent an important etiology of acquired neurocognitive impairment and behavioral disorders in children.
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Affiliation(s)
- Ying Cheng
- Division of Anesthesiology and Pain Medicine, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States of America
| | - Adia Thomas
- Division of Anesthesiology and Pain Medicine, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States of America
| | - Feras Mardini
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Shannon L. Bianchi
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Junxia X. Tang
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Jun Peng
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Huafeng Wei
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Maryellen F. Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Roderic G. Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Richard J. Levy
- Division of Anesthesiology and Pain Medicine, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States of America
- * E-mail:
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15
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Lange M, Cox RA, Enkhbaatar P, Whorton EB, Nakano Y, Hamahata A, Jonkam C, Esechie A, von Borzyskowski S, Traber LD, Traber DL. Predictive role of arterial carboxyhemoglobin concentrations in ovine burn and smoke inhalation-induced lung injury. Exp Lung Res 2011; 37:239-45. [PMID: 21309735 DOI: 10.3109/01902148.2010.538133] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Inhalation injury frequently occurs in burn patients and contributes to the morbidity and mortality of these injuries. Arterial carboxyhemoglobin has been proposed as an indicator of the severity of inhalation injury; however, the interrelation between arterial carboxyhemoglobin and histological alterations has not yet been investigated. Chronically instrumented sheep were subjected to a third degree burn of 40% of the total body surface area and inhalation of 48 breaths of cotton smoke. Carboxyhemoglobin was measured immediately after injury and correlated to clinical parameters of pulmonary function as well as histopathology scores from lung tissue harvested 24 hours after the injury. The injury was associated with a significant decline in pulmonary oxygenation and increases in pulmonary shunting, lung lymph flow, wet/dry weight ratio, congestion score, edema score, inflammation score, and airway obstruction scores. Carboxyhemoglobin was negatively correlated to pulmonary oxygenation and positively correlated to pulmonary shunting, lung lymph flow, and lung wet/dry weight ratio. No significant correlations could be detected between carboxyhemoglobin and histopathology scores and airway obstruction scores. Arterial carboxyhemoglobin in sheep with combined burn and inhalation injury are correlated with the degree of pulmonary failure and edema formation, but not with certain histological alterations including airway obstruction scores.
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Affiliation(s)
- Matthias Lange
- Department of Anesthesiology, Investigational Intensive Care Unit, University of Texas Medical Branch and Shriners Burns Hospital for Children, Galveston, Texas 77550, USA.
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Nasr V, Emmanuel J, Deutsch N, Slack M, Kanter J, Ratnayaka K, Levy R. Carbon monoxide re-breathing during low-flow anaesthesia in infants and children. Br J Anaesth 2010; 105:836-41. [PMID: 20947594 DOI: 10.1093/bja/aeq271] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Carbon monoxide (CO) has been detected within anaesthesia breathing systems. One potential source in this setting is exhaled endogenous CO. We hypothesized that CO is re-breathed during low-flow anaesthesia (LFA) in infants and children. METHODS Twenty children (age 2 months-7 yr) undergoing general anaesthesia were evaluated in a prospective observation study. LFA was established for 60 min followed by high-flow anaesthesia (HFA) for the next 60 min. Exhaled and inspired CO were measured every 5 min within the breathing circuit. Carboxyhaemoglobin (COHb%) was measured at baseline, at 60 min, after LFA, and at 120 min, after HFA. RESULTS CO concentrations increased during LFA. Inspired CO peaked at 14 ppm. During HFA, exhaled CO levels remained constant whereas inspired CO decreased markedly. Exhaled and inspired CO during HFA differed significantly from LFA. The trajectory of change in exhaled and inspired CO was most closely associated with the fresh-gas flow (FGF):minute ventilation ratio. COHb% significantly increased in children <2 yr of age at 60 min after LFA and remained increased. CONCLUSIONS LFA increased exhaled and inspired CO and increased COHb% in children <2 yr of age. Thus, LFA resulted in re-breathing of exhaled CO and exposure, especially in the youngest children. Re-breathing exhaled gas during LFA could pose a risk for an acute CO exposure in patients who have elevated COHb and high baseline levels of exhaled CO. If practitioners match or exceed minute ventilation with FGF to avoid LFA, CO re-breathing can be limited.
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Affiliation(s)
- V Nasr
- Division of Anesthesiology and Pain Medicine, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, 111 Michigan Ave., NW, Washington, DC 20010, USA
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Al-Khafaji A, Rivers E, Shoemaker W. The prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Article of Shoemaker et al with expert commentary by Dr. Emanuel Rivers. 1988. J Crit Care 2009; 23:603-6. [PMID: 19056029 DOI: 10.1016/j.jcrc.2008.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Accepted: 04/07/2008] [Indexed: 11/30/2022]
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18
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Melley DD, Finney SJ, Elia A, Lagan AL, Quinlan GJ, Evans TW. Arterial carboxyhemoglobin level and outcome in critically ill patients. Crit Care Med 2007; 35:1882-7. [PMID: 17568332 DOI: 10.1097/01.ccm.0000275268.94404.43] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Arterial carboxyhemoglobin is elevated in patients with critical illness. It is an indicator of the endogenous production of carbon monoxide by the enzyme heme oxygenase, which modulates the response to oxidant stress. The objective was to explore the hypothesis that arterial carboxyhemoglobin level is associated with inflammation and survival in patients requiring cardiothoracic intensive care. DESIGN Prospective, observational study. SETTING A cardiothoracic intensive care unit. PATIENTS All patients admitted over a 15-month period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Arterial carboxyhemoglobin, bilirubin, and standard biochemical, hematologic, and physiologic markers of inflammation were measured in 1,267 patients. Associations were sought between levels of arterial carboxyhemoglobin, markers of the inflammatory response, and clinical outcome. Intensive care unit mortality was associated with lower minimum and greater maximal carboxyhemoglobin levels (p < .0001 and p < .001, respectively). After adjustment for age, gender, illness severity, and other relevant variables, a lower minimum arterial carboxyhemoglobin was associated with an increased risk of death from all causes (odds risk of death, 0.391; 95% confidence interval, 0.190-0.807; p = .011). Arterial carboxyhemoglobin correlated with markers of the inflammatory response. CONCLUSIONS Both low minimum and high maximum levels of arterial carboxyhemoglobin were associated with increased intensive care mortality. Although the heme oxygenase system is protective, excessive induction may be deleterious. This suggests that there may be an optimal range for heme oxygenase-1 induction.
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Affiliation(s)
- Daniel D Melley
- Department of Critical Care Medicine, Imperial College School of Medicine, Royal Brompton Hospital, London, UK
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19
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Iheagwara KN, Thom SR, Deutschman CS, Levy RJ. Myocardial cytochrome oxidase activity is decreased following carbon monoxide exposure. Biochim Biophys Acta Mol Basis Dis 2007; 1772:1112-6. [PMID: 17628447 PMCID: PMC2045065 DOI: 10.1016/j.bbadis.2007.06.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Revised: 05/29/2007] [Accepted: 06/04/2007] [Indexed: 10/23/2022]
Abstract
Carbon monoxide (CO) inhalation often leads to cardiac dysfunction, dysrhythmias, ischemia, infarction, and death. However, the underlying mechanism of CO toxicity is poorly understood. We hypothesize that inhaled CO interrupts myocardial oxidative phosphorylation by decreasing the activity of myocardial cytochrome oxidase (CcOX), the terminal oxidase of the electron transport chain. Male C57Bl6 mice were exposed to either 1000 ppm (0.1%) CO or air for 3 h. Cardiac ventricles were harvested and mitochondria were isolated. CcOX kinetics and heme aa(3) content were measured. V(max), K(m), and turnover number were determined. Levels of CcOX subunit I message and protein were evaluated. Carboxyhemoglobin (COHb) levels were measured and tissue hypoxia was assessed with immunohistochemistry for pimonidazole hydrochloride. CO significantly decreased myocardial CcOX activity and V(max) without altering K(m). Heme aa(3) content and CcOX I protein levels significantly decreased following CO exposure while enzyme turnover number and CcOX I mRNA levels remained unchanged. CO exposure increased COHb levels without evidence of tissue hypoxia as compared to sham and hypoxic controls. Decreased CcOX activity following CO inhalation was likely due to decreased heme aa(3) and CcOX subunit I content. Importantly, myocardial CcOX impairment could underlie CO induced cardiac dysfunction.
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Affiliation(s)
- Kelechi N. Iheagwara
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, PA
| | - Stephen R. Thom
- Department of Emergency Medicine and Institute of Environmental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Clifford S. Deutschman
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Richard J. Levy
- Departments of Anesthesiology and Physiology, New York Medical College, Valhalla, NY
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Haskins SC, Pascoe PJ, Ilkiw JE, Fudge M, Hopper K, Aldrich J. The effect of moderate hypovolemia on cardiopulmonary function in dogs. J Vet Emerg Crit Care (San Antonio) 2005. [DOI: 10.1111/j.1476-4431.2005.00129.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Westphal M, Morita N, Enkhbaatar P, Murakami K, Traber L, Traber DL. Carboxyhemoglobin formation following smoke inhalation injury in sheep is interrelated with pulmonary shunt fraction. Biochem Biophys Res Commun 2004; 311:754-8. [PMID: 14623337 DOI: 10.1016/j.bbrc.2003.10.063] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Carboxyhemoglobin (COHb) formation is triggered by the inducible isoform of heme oxygenase (HO-1) catalyzing carbon monoxide (CO) production through breakdown of heme molecules, exposure to CO or both. In the setting of CO poisoning, COHb is regarded as a reliable marker characterizing both severity of injury and efficacy of treatment strategies. This study was designed as a prospective laboratory experiment to elucidate potential interdependencies between COHb generation, oxygenation, and pulmonary shunt fraction (Qs/Qt) in an ovine model of smoke inhalation injury. Chronically instrumented ewes (n=15) were repeatedly subjected to cotton smoke (4 x 12 breaths) according to an established protocol. This approach resulted in a progressive increase in COHb formation that was interrelated with the degree of Qs/Qt (P<0.001) and inversely correlated with both arterial and mixed venous HbO(2) saturation (r=-0.96 and -0.93). Although the arteriovenous COHb gradient successively decreased over time, COHb determined in venous blood underestimated the arterial content.
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Affiliation(s)
- Martin Westphal
- Department of Investigational Intensive Care Unit and Shriners Hospital for Children, University of Texas Medical Branch, Galveston, TX, USA.
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