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Premraj L, Brown A, Fraser JF, Pellegrino V, Pilcher D, Burrell A. Oxygenation During Venoarterial Extracorporeal Membrane Oxygenation: Physiology, Current Evidence, and a Pragmatic Approach to Oxygen Titration. Crit Care Med 2024; 52:637-648. [PMID: 38059745 DOI: 10.1097/ccm.0000000000006134] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES This review aims to: 1) identify the key circuit and patient factors affecting systemic oxygenation, 2) summarize the literature reporting the association between hyperoxia and patient outcomes, and 3) provide a pragmatic approach to oxygen titration, in patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (ECMO). DATA SOURCES Searches were performed using PubMed, SCOPUS, Medline, and Google Scholar. STUDY SELECTION All observational and interventional studies investigating the association between hyperoxia, and clinical outcomes were included, as well as guidelines from the Extracorporeal Life Support Organization. DATA EXTRACTION Data from relevant literature was extracted, summarized, and integrated into a concise narrative review. For ease of reference a summary of relevant studies was also produced. DATA SYNTHESIS The extracorporeal circuit and the native cardiorespiratory circuit both contribute to systemic oxygenation during venoarterial ECMO. The ECMO circuit's contribution to systemic oxygenation is, in practice, largely determined by the ECMO blood flow, whereas the native component of systemic oxygenation derives from native cardiac output and residual respiratory function. Interactions between ECMO outflow and native cardiac output (as in differential hypoxia), the presence of respiratory support, and physiologic parameters affecting blood oxygen carriage also modulate overall oxygen exposure during venoarterial ECMO. Physiologically those requiring venoarterial ECMO are prone to hyperoxia. Hyperoxia has a variety of definitions, most commonly Pa o2 greater than 150 mm Hg. Severe hypoxia (Pa o2 > 300 mm Hg) is common, seen in 20%. Early severe hyperoxia, as well as cumulative hyperoxia exposure was associated with in-hospital mortality, even after adjustment for disease severity in both venoarterial ECMO and extracorporeal cardiopulmonary resuscitation. A pragmatic approach to oxygenation during peripheral venoarterial ECMO involves targeting a right radial oxygen saturation target of 94-98%, and in selected patients, titration of the fraction of oxygen in the mixture via the air-oxygen blender to target postoxygenator Pa o2 of 150-300 mm Hg. CONCLUSIONS Hyperoxia results from a range of ECMO circuit and patient-related factors. It is common during peripheral venoarterial ECMO, and its presence is associated with poor outcome. A pragmatic approach that avoids hyperoxia, while also preventing hypoxia has been described for patients receiving peripheral venoarterial ECMO.
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Affiliation(s)
- Lavienraj Premraj
- Griffith University School of Medicine and Dentistry, Brisbane, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Hopkins Education, Research, and Advancement in Life Support Devices (HERALD) Group, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- St Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - Alastair Brown
- Griffith University School of Medicine and Dentistry, Brisbane, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Hopkins Education, Research, and Advancement in Life Support Devices (HERALD) Group, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- St Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Vincent Pellegrino
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - Aidan Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
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Hemilä H, Chalker E, de Man AME. Vitamin C May Improve Left Ventricular Ejection Fraction: A Meta-Analysis. Front Cardiovasc Med 2022; 9:789729. [PMID: 35282368 PMCID: PMC8913583 DOI: 10.3389/fcvm.2022.789729] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/21/2022] [Indexed: 01/02/2023] Open
Abstract
Background Vitamin C deprivation can lead to fatigue, dyspnea, oedema and chest pain, which are also symptoms of heart failure (HF). In animal studies vitamin C has improved contractility and mechanical efficiency of the heart. Compared with healthy people, patients with HF have lower vitamin C levels, which are not explained by differences in dietary intake levels, and more severe HF seems to be associated with lower plasma vitamin C levels. This meta-analysis looks at the effect of vitamin C on left ventricular ejection fraction (LVEF). Methods We searched for trials reporting the effects of vitamin C on LVEF. We assessed the quality of the trials, and pooled selected trials using the inverse variance, fixed effect options. We used meta-regression to examine the association between the effect of vitamin C on LVEF level and the baseline LVEF level. Results We identified 15 trials, three of which were excluded from our meta-analysis. In six cardiac trials with 246 patients, vitamin C increased LVEF on average by 12.0% (95% CI 8.1–15.9%; P < 0.001). In six non-cardiac trials including 177 participants, vitamin C increased LVEF on average by 5.3% (95% CI 2.0–8.5%; P = 0.001). In meta-regression analysis we found that the effect of vitamin C was larger in trials with the lowest baseline LVEF levels with P = 0.001 for the test of slope. The meta-regression line crossed the null effect level at a baseline LVEF level close to 70%, with progressively greater benefit from vitamin C with lower LVEF levels. Some of the included trials had methodological limitations. In a sensitivity analysis including only the four most methodologically sound cardiac trials, the effect of vitamin C was not substantially changed. Conclusions In this meta-analysis, vitamin C increased LVEF in both cardiac and non-cardiac patients, with a strong negative association between the size of the vitamin C effect and the baseline LVEF. Further research on vitamin C and HF should be carried out, particularly in patients who have low LVEF together with low vitamin C intake or low plasma levels. Different dosages and different routes of administration should be compared.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, Helsinki, Finland
- *Correspondence: Harri Hemilä
| | - Elizabeth Chalker
- Biological Data Science Institute, Australian National University, Canberra, ACT, Australia
| | - Angelique M. E. de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
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The Complex Relationship of Extracorporeal Membrane Oxygenation and Acute Kidney Injury: Causation or Association? BIOMED RESEARCH INTERNATIONAL 2016; 2016:1094296. [PMID: 27006941 PMCID: PMC4783537 DOI: 10.1155/2016/1094296] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 01/29/2016] [Accepted: 01/31/2016] [Indexed: 12/23/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a modified cardiopulmonary bypass (CPB) circuit capable of providing prolonged cardiorespiratory support. Recent advancement in ECMO technology has resulted in increased utilisation and clinical application. It can be used as a bridge-to-recovery, bridge-to-bridge, bridge-to-transplant, or bridge-to-decision. ECMO can restitute physiology in critically ill patients, which may minimise the risk of progressive multiorgan dysfunction. Alternatively, iatrogenic complications of ECMO clearly contribute to worse outcomes. These factors affect the risk : benefit ratio of ECMO which ultimately influence commencement/timing of ECMO. The complex interplay of pre-ECMO, ECMO, and post-ECMO pathophysiological processes are responsible for the substantial increased incidence of ECMO-associated acute kidney injury (EAKI). The development of EAKI significantly contributes to morbidity and mortality; however, there is a lack of evidence defining a potential benefit or causative link between ECMO and AKI. This area warrants investigation as further research will delineate the mechanisms involved and subsequent strategies to minimise the risk of EAKI. This review summarizes the current literature of ECMO and AKI, considers the possible benefits and risks of ECMO on renal function, outlines the related pathophysiology, highlights relevant investigative tools, and ultimately suggests an approach for future research into this under investigated area of critical care.
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Rochette L, Zeller M, Cottin Y, Vergely C. Diabetes, oxidative stress and therapeutic strategies. Biochim Biophys Acta Gen Subj 2014; 1840:2709-29. [PMID: 24905298 DOI: 10.1016/j.bbagen.2014.05.017] [Citation(s) in RCA: 315] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 05/12/2014] [Accepted: 05/27/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diabetes has emerged as a major threat to health worldwide. SCOPE OF REVIEW The exact mechanisms underlying the disease are unknown; however, there is growing evidence that excess generation of reactive oxygen species (ROS), largely due to hyperglycemia, causes oxidative stress in a variety of tissues. Oxidative stress results from either an increase in free radical production, or a decrease in endogenous antioxidant defenses, or both. ROS and reactive nitrogen species (RNS) are products of cellular metabolism and are well recognized for their dual role as both deleterious and beneficial species. In type 2 diabetic patients, oxidative stress is closely associated with chronic inflammation. Multiple signaling pathways contribute to the adverse effects of glucotoxicity on cellular functions. There are many endogenous factors (antioxidants, vitamins, antioxidant enzymes, metal ion chelators) that can serve as endogenous modulators of the production and action of ROS. Clinical trials that investigated the effect of antioxidant vitamins on the progression of diabetic complications gave negative or inconclusive results. This lack of efficacy might also result from the fact that they were administered at a time when irreversible alterations in the redox status are already under way. Another strategy to modulate oxidative stress is to exploit the pleiotropic properties of drugs directed primarily at other targets and thus acting as indirect antioxidants. MAJOR CONCLUSIONS It appears important to develop new compounds that target key vascular ROS producing enzymes and mimic endogenous antioxidants. GENERAL SIGNIFICANCE This strategy might prove clinically relevant in preventing the development and/or retarding the progression of diabetes associated with vascular diseases.
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Affiliation(s)
- Luc Rochette
- Laboratoire de Physiopathologie et Pharmacologie Cardio-Métaboliques, INSERM UMR866, Université de Bourgogne, Facultés de Médecine et Pharmacie, 7 Boulevard Jeanne d'Arc, 21079 Dijon, France.
| | - Marianne Zeller
- Laboratoire de Physiopathologie et Pharmacologie Cardio-Métaboliques, INSERM UMR866, Université de Bourgogne, Facultés de Médecine et Pharmacie, 7 Boulevard Jeanne d'Arc, 21079 Dijon, France
| | - Yves Cottin
- Laboratoire de Physiopathologie et Pharmacologie Cardio-Métaboliques, INSERM UMR866, Université de Bourgogne, Facultés de Médecine et Pharmacie, 7 Boulevard Jeanne d'Arc, 21079 Dijon, France
| | - Catherine Vergely
- Laboratoire de Physiopathologie et Pharmacologie Cardio-Métaboliques, INSERM UMR866, Université de Bourgogne, Facultés de Médecine et Pharmacie, 7 Boulevard Jeanne d'Arc, 21079 Dijon, France
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McDonald CI, Fraser JF, Coombes JS, Fung YL. Oxidative stress during extracorporeal circulation. Eur J Cardiothorac Surg 2014; 46:937-43. [PMID: 24482384 DOI: 10.1093/ejcts/ezt637] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
There is an increased oxidative stress response in patients having cardiac surgery, haemodialysis or extracorporeal membrane oxygenation that is related to poorer outcomes and increased mortality. Exposure of the patients' blood to the artificial surfaces of these extracorporeal devices, coupled with inflammatory responses, hyperoxia and the pathophysiological aspects of the underlying illness itself, all contribute to this oxidative stress response. Oxidative stress occurs when there is a disruption of redox signalling and loss of control of redox balance. Ongoing oxidative stress occurring during extracorporeal circulation (ECC) results in damage to lipids, proteins and DNA and contributes to morbidity and mortality. This review discusses reactive species generation and the potential clinical consequences of oxidative stress during ECC as well as provides an overview of some current antioxidant compounds that are available to potentially mitigate the oxidative stress response.
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Affiliation(s)
- Charles Ian McDonald
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD, Australia
| | - John Francis Fraser
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD, Australia
| | - Jeff S Coombes
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD, Australia
| | - Yoke Lin Fung
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, QLD, Australia
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Nikolić A, Mijalković D, Nikolić A, Kastratović D, Blagojevć D, Davidović B, Spasić M. Elevated serum uric acid reduce heart damage in patients undergoing opern-heart surgery. ACTA CHIRURGICA IUGOSLAVICA 2006; 53:29-33. [PMID: 17338197 DOI: 10.2298/aci0603029n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
OBJECTIVES Peroxynitrite is species claimed to propagate ischemia/reperfusion damage. In this report levels of serum uric acid (UA), a peroxynitrite scavenger, are compared with creatine phosphokinase (CPK) in male patients before and after open-heart surgery in order to asses if increased levels of UA may protect heart from biochemical damage induced by peroxynitrite during the coronary by-pass grafting (CABG) intervention. METHODS 45 male patients (16 carvedilol pretreated (6.25 mg/ daily, during 6 weeks before surgery, mean age 55.3+/-1.7 years, range 50-71) and 29 patients without carvedilol pretreatment (mean age 58.3+/-1.4 years, range 47-73) underwent elective CABG were examined. Study inclusion criteria were CABG performed on two and more coronary-vessels with aortic cross-clamp during 30-40 minutes. For assessment of patients objective health status before operations EuroSCORE were used. Serum uric acid (UA) levels and creatine phosphokinase (CPK) were measured spectrophotometricaly by using a quantitative enzymatic assay. RESULTS Carvedilol pretreated patients had higher amount of serum UA (p<0.05) comparing to non-treated patients. During the surgical procedure patients are subjected to temporary ischemia due to transfer from corporeal to extracorporeal circulation. In this period of time the amount of UA decreased in carvedilol pretreated group (406+/-46 (tl) vs. 300+/-22 mmol/L (t2)) to the level of non-treated patients (328+/-14 (t1) vs. 322+18 mmol/L. Carvedilol pretreated patients and non-treated patients had the same level of CPK at the beginning of the surgical procedure (tl) (78+/-6 vs. 83+13 U/L) but lower increase (p<0.05) in CPK activity in carvedilol pretreated patients in respect to non-treated patients (338+46 vs. 644+103 U/L) at the end of procedure (t2). Such results suggest that open heart surgery led to elevated CPK levels, but this effect was less pronounced in patients with higher level of UA. CONCLUSIONS Our results suggest possible role of UA in the protection from reperfusion injury. Increase of UA before surgery may be beneficial factor during CABG procedure in patients treated with carvedilol by decreasing level of peroxynitrite as one of molecular causes of reperfusion injury. Our results showed influence of UA on CPK levels at the end of surgical procedure, indicating that increased levels of UA may protect heart from biochemical damage induced by peroxynitrite during the CABG intervention.
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Affiliation(s)
- A Nikolić
- Institute for cardiovascular disease Dedinje Belgrade
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