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Matejic-Spasic M, Lindstedt S, Lebreton G, Dzemali O, Suwalski P, Folliguet T, Geidel S, Klautz RJM, Baufreton C, Livi U, Gunaydin S, Deliargyris EN, Wendt D, Thielmann M. The role of hemoadsorption in cardiac surgery - a systematic review. BMC Cardiovasc Disord 2024; 24:258. [PMID: 38762715 PMCID: PMC11102180 DOI: 10.1186/s12872-024-03938-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Extracorporeal blood purification has been widely used in intensive care medicine, nephrology, toxicology, and other fields. During the last decade, with the emergence of new adsorptive blood purification devices, hemoadsorption has been increasingly applied during CPB in cardiac surgery, for patients at different inflammatory risks, or for postoperative complications. Clinical evidence so far has not provided definite answers concerning this adjunctive treatment. The current systematic review aimed to critically assess the role of perioperative hemoadsorption in cardiac surgery, by summarizing the current knowledge in this clinical setting. METHODS A literature search of PubMed, Cochrane library, and the database provided by CytoSorbents was conducted on June 1st, 2023. The search terms were chosen by applying neutral search keywords to perform a non-biased systematic search, including language variations of terms "cardiac surgery" and "hemoadsorption". The screening and selection process followed scientific principles (PRISMA statement). Abstracts were considered for inclusion if they were written in English and published within the last ten years. Publications were eligible for assessment if reporting on original data from any type of study (excluding case reports) in which a hemoadsorption device was investigated during or after cardiac surgery. Results were summarized according to sub-fields and presented in a tabular view. RESULTS The search resulted in 29 publications with a total of 1,057 patients who were treated with hemoadsorption and 988 control patients. Articles were grouped and descriptively analyzed due to the remarkable variability in study designs, however, all reported exclusively on CytoSorb® therapy. A total of 62% (18/29) of the included articles reported on safety and no unanticipated adverse events have been observed. The most frequently reported clinical outcome associated with hemoadsorption was reduced vasopressor demand resulting in better hemodynamic stability. CONCLUSIONS The role of hemoadsorption in cardiac surgery seems to be justified in selected high-risk cases in infective endocarditis, aortic surgery, heart transplantation, and emergency surgery in patients under antithrombotic therapy, as well as in those who develop a dysregulated inflammatory response, vasoplegia, or septic shock postoperatively. Future large randomized controlled trials are needed to better define proper patient selection, dosing, and timing of the therapy.
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Affiliation(s)
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery and Transplantation, Skane University Hospital, Lund, Sweden
| | - Guillaume Lebreton
- Thoracic and Cardiovascular Surgery Department, Pitié-Salpêtrière University Hospital, Paris, France
| | - Omer Dzemali
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, City Hospital Triemli, Zurich, Switzerland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | | | - Stephan Geidel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Robert J M Klautz
- Department of Cardio-Thoracic Surgery, University Medical Center, Leiden, The Netherlands
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France
| | - Ugolino Livi
- Department of Cardiothoracic Surgery, University Hospital, Udine, Italy
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital Campus, Ankara, Turkey
| | | | - Daniel Wendt
- CytoSorbents Europe GmbH, Berlin, Germany
- Department of Thoracic- and Cardiovascular Surgery, Westgerman Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Matthias Thielmann
- Department of Thoracic- and Cardiovascular Surgery, Westgerman Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
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Wang W, He Z. Gasdermins in sepsis. Front Immunol 2023; 14:1203687. [PMID: 38022612 PMCID: PMC10655013 DOI: 10.3389/fimmu.2023.1203687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Sepsis is a hyper-heterogeneous syndrome in which the systemic inflammatory response persists throughout the course of the disease and the inflammatory and immune responses are dynamically altered at different pathogenic stages. Gasdermins (GSDMs) proteins are pore-forming executors in the membrane, subsequently mediating the release of pro-inflammatory mediators and inflammatory cell death. With the increasing research on GSDMs proteins and sepsis, it is believed that GSDMs protein are one of the most promising therapeutic targets in sepsis in the future. A more comprehensive and in-depth understanding of the functions of GSDMs proteins in sepsis is important to alleviate the multi-organ dysfunction and reduce sepsis-induced mortality. In this review, we focus on the function of GSDMs proteins, the molecular mechanism of GSDMs involved in sepsis, and the regulatory mechanism of GSDMs-mediated signaling pathways, aiming to provide novel ideas and therapeutic strategies for the diagnosis and treatment of sepsis.
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Affiliation(s)
- Wenhua Wang
- Department of Intensive Care Unit, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhihui He
- Department of Intensive Care Unit, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Sepsis Translational Medicine Key Laboratory of Hunan Province, Central South University, Changsha, Hunan, China
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3
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Iba T, Levi M, Levy JH. "Communication from the Scientific and Standardization Committee of the International Society on Thrombosis and Hemostasis on sepsis-induced coagulopathy in the management of sepsis": reply. J Thromb Haemost 2023; 21:1679-1680. [PMID: 37179076 DOI: 10.1016/j.jtha.2023.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, The Netherlands; Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-metabolic Programme-NIHR UCLH/UCL BRC London, UK
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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4
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Pinsky MR, Cecconi M, Chew MS, De Backer D, Douglas I, Edwards M, Hamzaoui O, Hernandez G, Martin G, Monnet X, Saugel B, Scheeren TWL, Teboul JL, Vincent JL. Effective hemodynamic monitoring. Crit Care 2022; 26:294. [PMID: 36171594 PMCID: PMC9520790 DOI: 10.1186/s13054-022-04173-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractHemodynamic monitoring is the centerpiece of patient monitoring in acute care settings. Its effectiveness in terms of improved patient outcomes is difficult to quantify. This review focused on effectiveness of monitoring-linked resuscitation strategies from: (1) process-specific monitoring that allows for non-specific prevention of new onset cardiovascular insufficiency (CVI) in perioperative care. Such goal-directed therapy is associated with decreased perioperative complications and length of stay in high-risk surgery patients. (2) Patient-specific personalized resuscitation approaches for CVI. These approaches including dynamic measures to define volume responsiveness and vasomotor tone, limiting less fluid administration and vasopressor duration, reduced length of care. (3) Hemodynamic monitoring to predict future CVI using machine learning approaches. These approaches presently focus on predicting hypotension. Future clinical trials assessing hemodynamic monitoring need to focus on process-specific monitoring based on modifying therapeutic interventions known to improve patient-centered outcomes.
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5
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Precision Medicine in Sepsis and Septic Shock. J Clin Med 2022; 11:jcm11185332. [PMID: 36142979 PMCID: PMC9501229 DOI: 10.3390/jcm11185332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022] Open
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6
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Lukaszewski RA, Jones HE, Gersuk VH, Russell P, Simpson A, Brealey D, Walker J, Thomas M, Whitehouse T, Ostermann M, Koch A, Zacharowski K, Kruhoffer M, Chaussabel D, Singer M. Presymptomatic diagnosis of postoperative infection and sepsis using gene expression signatures. Intensive Care Med 2022; 48:1133-1143. [PMID: 35831640 PMCID: PMC9281215 DOI: 10.1007/s00134-022-06769-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 05/29/2022] [Indexed: 12/11/2022]
Abstract
Purpose Early accurate diagnosis of infection ± organ dysfunction (sepsis) remains a major challenge in clinical practice. Utilizing effective biomarkers to identify infection and impending organ dysfunction before the onset of clinical signs and symptoms would enable earlier investigation and intervention. To our knowledge, no prior study has specifically examined the possibility of pre-symptomatic detection of sepsis. Methods Blood samples and clinical/laboratory data were collected daily from 4385 patients undergoing elective surgery. An adjudication panel identified 154 patients with definite postoperative infection, of whom 98 developed sepsis. Transcriptomic profiling and subsequent RT-qPCR were undertaken on sequential blood samples taken postoperatively from these patients in the three days prior to the onset of symptoms. Comparison was made against postoperative day-, age-, sex- and procedure- matched patients who had an uncomplicated recovery (n =151) or postoperative inflammation without infection (n =148). Results Specific gene signatures optimized to predict infection or sepsis in the three days prior to clinical presentation were identified in initial discovery cohorts. Subsequent classification using machine learning with cross-validation with separate patient cohorts and their matched controls gave high Area Under the Receiver Operator Curve (AUC) values. These allowed discrimination of infection from uncomplicated recovery (AUC 0.871), infectious from non-infectious systemic inflammation (0.897), sepsis from other postoperative presentations (0.843), and sepsis from uncomplicated infection (0.703). Conclusion Host biomarker signatures may be able to identify postoperative infection or sepsis up to three days in advance of clinical recognition. If validated in future studies, these signatures offer potential diagnostic utility for postoperative management of deteriorating or high-risk surgical patients and, potentially, other patient populations. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06769-z.
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Affiliation(s)
- Roman A. Lukaszewski
- Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire UK
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Helen E. Jones
- Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire UK
| | | | - Paul Russell
- Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire UK
- Salisbury NHS Foundation Trust, Salisbury, Wiltshire UK
| | - Andrew Simpson
- Defence Science and Technology Laboratory, Porton Down, Salisbury, Wiltshire UK
| | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
- Division of Critical Care and, NIHR University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jonathan Walker
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Matt Thomas
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tony Whitehouse
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Marlies Ostermann
- Intensive Care Unit, Guy’s and St Thomas’s, NHS Foundation Trust, London, UK
| | - Alexander Koch
- Klinikum Esslingen, 73707 Esslingen, Germany
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany
| | | | - Damien Chaussabel
- Benaroya Research Institute, Seattle, WA 98101-2795 USA
- Laboratory of Translational Systems Immunology, Sidra Medicine, Doha, Qatar
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
- Division of Critical Care and, NIHR University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
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7
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Monnet X, Shi R, Teboul JL. Prediction of fluid responsiveness. What’s new? Ann Intensive Care 2022; 12:46. [PMID: 35633423 PMCID: PMC9148319 DOI: 10.1186/s13613-022-01022-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
AbstractAlthough the administration of fluid is the first treatment considered in almost all cases of circulatory failure, this therapeutic option poses two essential problems: the increase in cardiac output induced by a bolus of fluid is inconstant, and the deleterious effects of fluid overload are now clearly demonstrated. This is why many tests and indices have been developed to detect preload dependence and predict fluid responsiveness. In this review, we take stock of the data published in the field over the past three years. Regarding the passive leg raising test, we detail the different stroke volume surrogates that have recently been described to measure its effects using minimally invasive and easily accessible methods. We review the limits of the test, especially in patients with intra-abdominal hypertension. Regarding the end-expiratory occlusion test, we also present recent investigations that have sought to measure its effects without an invasive measurement of cardiac output. Although the limits of interpretation of the respiratory variation of pulse pressure and of the diameter of the vena cava during mechanical ventilation are now well known, several recent studies have shown how changes in pulse pressure variation itself during other tests reflect simultaneous changes in cardiac output, allowing these tests to be carried out without its direct measurement. This is particularly the case during the tidal volume challenge, a relatively recent test whose reliability is increasingly well established. The mini-fluid challenge has the advantage of being easy to perform, but it requires direct measurement of cardiac output, like the classic fluid challenge. Initially described with echocardiography, recent studies have investigated other means of judging its effects. We highlight the problem of their precision, which is necessary to evidence small changes in cardiac output. Finally, we point out other tests that have appeared more recently, such as the Trendelenburg manoeuvre, a potentially interesting alternative for patients in the prone position.
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8
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Girardis M, Bettex D, Bojan M, Demponeras C, Fruhwald S, Gál J, Groesdonk HV, Guarracino F, Guerrero-Orriach JL, Heringlake M, Herpain A, Heunks L, Jin J, Kindgen-Milles D, Mauriat P, Michels G, Psallida V, Rich S, Ricksten SE, Rudiger A, Siegemund M, Toller W, Treskatsch S, Župan Ž, Pollesello P. Levosimendan in intensive care and emergency medicine: literature update and expert recommendations for optimal efficacy and safety. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:4. [PMID: 37386589 PMCID: PMC8785009 DOI: 10.1186/s44158-021-00030-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022]
Abstract
The inodilator levosimendan, in clinical use for over two decades, has been the subject of extensive clinical and experimental evaluation in various clinical settings beyond its principal indication in the management of acutely decompensated chronic heart failure. Critical care and emergency medicine applications for levosimendan have included postoperative settings, septic shock, and cardiogenic shock. As the experience in these areas continues to expand, an international task force of experts from 15 countries (Austria, Belgium, China, Croatia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland, and the USA) reviewed and appraised the latest additions to the database of levosimendan use in critical care, considering all the clinical studies, meta-analyses, and guidelines published from September 2019 to November 2021. Overall, the authors of this opinion paper give levosimendan a "should be considered" recommendation in critical care and emergency medicine settings, with different levels of evidence in postoperative settings, septic shock, weaning from mechanical ventilation, weaning from veno-arterial extracorporeal membrane oxygenation, cardiogenic shock, and Takotsubo syndrome, in all cases when an inodilator is needed to restore acute severely reduced left or right ventricular ejection fraction and overall haemodynamic balance, and also in the presence of renal dysfunction/failure.
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Affiliation(s)
- M Girardis
- Anesthesiology Unit, University Hospital of Modena, University of Modena & Reggio Emilia, Modena, Italy
| | - D Bettex
- Cardio-Surgical Intensive Care Unit, Institute of Anesthesiology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - M Bojan
- Anesthesiology and Intensive Care, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - C Demponeras
- Intensive Care Unit, Sotiria General Hospital, Athens, Greece
| | - S Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - J Gál
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - H V Groesdonk
- Clinic for Interdisciplinary Intensive Medicine and Intermediate Care, Helios Clinic, Erfurt, Germany
| | - F Guarracino
- Dipartimento di Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - J L Guerrero-Orriach
- Institute of Biomedical Research in Malaga, Department of Anesthesiology, Virgen de la Victoria University Hospital, Department of Pharmacology and Pediatrics, School of Medicine, University of Malaga, Malaga, Spain
| | - M Heringlake
- Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - A Herpain
- Department of Intensive Care, Erasme University Hospital, Université Libre De Bruxelles, Brussels, Belgium
| | - L Heunks
- Department of Intensive Care, University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J Jin
- The Fourth Hospital of Changsha, Changsha City, Hunan Province, People's Republic of China
| | - D Kindgen-Milles
- Interdisciplinary Surgical Intensive Care Unit, Department of Anesthesiology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - P Mauriat
- Department of Anaesthesia and Critical Care, University of Bordeaux, Haut-Levêque Hospital, Pessac, France
| | - G Michels
- Clinic for Acute and Emergency Medicine, St. Antonius Hospital, Eschweiler, Germany
| | - V Psallida
- Intensive Care Unit, Agioi Anargyroi Hospital, Athens, Greece
| | - S Rich
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - S-E Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - A Rudiger
- Department of Medicine, Limmattal Hospital, Limmartal, Switzerland
| | - M Siegemund
- Intensive Care Unit, Department Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - W Toller
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - S Treskatsch
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Ž Župan
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, KBC Rijeka, Rijeka, Croatia
| | - P Pollesello
- Critical Care, Orion Pharma, P.O. Box 65, FIN-02101, Espoo, Finland.
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Vincent JL, Singer M, Einav S, Moreno R, Wendon J, Teboul JL, Bakker J, Hernandez G, Annane D, de Man AME, Monnet X, Ranieri VM, Hamzaoui O, Takala J, Juffermans N, Chiche JD, Myatra SN, De Backer D. Equilibrating SSC guidelines with individualized care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:397. [PMID: 34789298 PMCID: PMC8596086 DOI: 10.1186/s13054-021-03813-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium.
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, WC1E 6BT, UK
| | - Sharon Einav
- General Intensive Care Unit, Shaare Zedek Medical Centre, and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Rui Moreno
- Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Faculdade de Ciências Médicas de Lisboa, Nova Médical School, Lisbon, Portugal
| | - Julia Wendon
- Department of Critical Care, Liver Sciences, Department of Inflammation Biology, King's College London, London, SE5 9RS, UK
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, GHU APHP, Inserm UMR S_999, Université Paris-Saclay, 94270, Le Kremlin-Bicêtre, France
| | - Jan Bakker
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, NY, 10016, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, 10032, USA.,Department of Intensive Care Adults, Erasmus MC University Medical Center, 3015 GD, Rotterdam, The Netherlands.,Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Glenn Hernandez
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Djillali Annane
- School of Medicine Simone Veil, Raymond Poincaré Hospital (APHP), Department of Intensive Care Medicine, FHU SEPSIS, University of Versailles-University Paris Saclay, 92380, Garches, France
| | - Angélique M E de Man
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Xavier Monnet
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, 94270, Le Kremlin-Bicêtre, France
| | - V Marco Ranieri
- Department of Emergency and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum University of Bologna, 40138, Bologna, Italy
| | - Olfa Hamzaoui
- Service de Réanimation Polyvalente, Hôpital Antoine Béclère, AP-HP, Université Paris-Saclay, 92140, Clamart, France
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Nicole Juffermans
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Location Academic Medical Centre, 1105 AZ, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - Jean-Daniel Chiche
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois, 1011, Lausanne, Switzerland
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, 400012, Mumbai, India
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospital, Université Libre de Bruxelles, Brussels, Belgium
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10
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Use of Organ Dysfunction as a Primary Outcome Variable Following Cecal Ligation and Puncture: Recommendations for Future Studies. Shock 2021; 54:168-182. [PMID: 31764625 DOI: 10.1097/shk.0000000000001485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Outcomes variables for research on sepsis have centered on mortality and changes in the host immune response. However, a recent task force (Sepsis-3) revised the definition of sepsis to "life-threatening organ dysfunction caused by a dysregulated host response to infection." This new definition suggests that human studies should focus on organ dysfunction. The appropriate criteria for organ dysfunction in either human sepsis or animal models are, however, poorly delineated, limiting the potential for translation. Further, in many systems, the difference between "dysfunction" and "injury" may not be clear. In this review, we identify criteria for organ dysfunction and/or injury in human sepsis and in rodents subjected to cecal ligation and puncture (CLP), the most commonly used animal model of sepsis. We further examine instances where overlap between human sepsis and CLP is sufficient to identify translational endpoints. Additional verification may demonstrate that these endpoints are applicable to other animals and to other sepsis models, for example, pneumonia. We believe that the use of these proposed measures of organ dysfunction will facilitate mechanistic studies on the pathobiology of sepsis and enhance our ability to develop animal model platforms to evaluate therapeutic approaches to human sepsis.
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Puskarich MA, Jennaro TS, Gillies CE, Evans CR, Karnovsky A, McHugh CE, Flott TL, Jones AE, Stringer KA. Pharmacometabolomics identifies candidate predictor metabolites of an L-carnitine treatment mortality benefit in septic shock. Clin Transl Sci 2021; 14:2288-2299. [PMID: 34216108 PMCID: PMC8604225 DOI: 10.1111/cts.13088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/22/2021] [Accepted: 05/12/2021] [Indexed: 01/08/2023] Open
Abstract
Sepsis‐induced metabolic dysfunction contributes to organ failure and death. L‐carnitine has shown promise for septic shock, but a recent phase II study of patients with vasopressor‐dependent septic shock demonstrated a non‐significant reduction in mortality. We undertook a pharmacometabolomics study of these patients (n = 250) to identify metabolic profiles predictive of a 90‐day mortality benefit from L‐carnitine. The independent predictive value of each pretreatment metabolite concentration, adjusted for L‐carnitine dose, on 90‐day mortality was determined by logistic regression. A grid‐search analysis maximizing the Z‐statistic from a binomial proportion test identified specific metabolite threshold levels that discriminated L‐carnitine responsive patients. Threshold concentrations were further assessed by hazard ratio and Kaplan‐Meier estimate. Accounting for L‐carnitine treatment and dose, 11 1H‐NMR metabolites and 12 acylcarnitines were independent predictors of 90‐day mortality. Based on the grid‐search analysis numerous acylcarnitines and valine were identified as candidate metabolites of drug response. Acetylcarnitine emerged as highly viable for the prediction of an L‐carnitine mortality benefit due to its abundance and biological relevance. Using its most statistically significant threshold concentration, patients with pretreatment acetylcarnitine greater than or equal to 35 µM were less likely to die at 90 days if treated with L‐carnitine (18 g) versus placebo (p = 0.01 by log rank test). Metabolomics also identified independent predictors of 90‐day sepsis mortality. Our proof‐of‐concept approach shows how pharmacometabolomics could be useful for tackling the heterogeneity of sepsis and informing clinical trial design. In addition, metabolomics can help understand mechanisms of sepsis heterogeneity and variable drug response, because sepsis induces alterations in numerous metabolite concentrations.
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Affiliation(s)
- Michael A Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Theodore S Jennaro
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher E Gillies
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, Michigan, USA.,Michigan Institute for Data Science, Office of Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Charles R Evans
- Michigan Regional Comprehensive Metabolomics Resource Core (MRC2, ), University of Michigan, Ann Arbor, Michigan, USA.,Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alla Karnovsky
- Michigan Regional Comprehensive Metabolomics Resource Core (MRC2, ), University of Michigan, Ann Arbor, Michigan, USA.,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Cora E McHugh
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas L Flott
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Kathleen A Stringer
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, Michigan, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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12
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Fenner BP, Darden DB, Kelly LS, Rincon J, Brakenridge SC, Larson SD, Moore FA, Efron PA, Moldawer LL. Immunological Endotyping of Chronic Critical Illness After Severe Sepsis. Front Med (Lausanne) 2021; 7:616694. [PMID: 33659259 PMCID: PMC7917137 DOI: 10.3389/fmed.2020.616694] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022] Open
Abstract
Improved management of severe sepsis has been one of the major health care accomplishments of the last two decades. Due to enhanced recognition and improved management of severe sepsis, in-hospital mortality has been reduced by up to 40%. With that good news, a new syndrome has unfortunately replaced in-hospital multi-organ failure and death. This syndrome of chronic critical illness (CCI) includes sepsis patients who survive the early "cytokine or genomic storm," but fail to fully recover, and progress into a persistent state of manageable organ injury requiring prolonged intensive care. These patients are commonly discharged to long-term care facilities where sepsis recidivism is high. As many as 33% of sepsis survivors develop CCI. CCI is the result, at least in part, of a maladaptive host response to chronic pattern-recognition receptor (PRR)-mediated processes. This maladaptive response results in dysregulated myelopoiesis, chronic inflammation, T-cell atrophy, T-cell exhaustion, and the expansion of suppressor cell functions. We have defined this panoply of host responses as a persistent inflammatory, immune suppressive and protein catabolic syndrome (PICS). Why is this important? We propose that PICS in survivors of critical illness is its own common, unique immunological endotype driven by the constant release of organ injury-associated, endogenous alarmins, and microbial products from secondary infections. While this syndrome can develop as a result of a diverse set of pathologies, it represents a shared outcome with a unique underlying pathobiological mechanism. Despite being a common outcome, there are no therapeutic interventions other than supportive therapies for this common disorder. Only through an improved understanding of the immunological endotype of PICS can rational therapeutic interventions be designed.
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Affiliation(s)
- Brittany P Fenner
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - D B Darden
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Lauren S Kelly
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Jaimar Rincon
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Scott C Brakenridge
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Shawn D Larson
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Frederick A Moore
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Philip A Efron
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Lyle L Moldawer
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
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13
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium
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14
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Brandenburg K, Schromm AB, Weindl G, Heinbockel L, Correa W, Mauss K, Martinez de Tejada G, Garidel P. An update on endotoxin neutralization strategies in Gram-negative bacterial infections. Expert Rev Anti Infect Ther 2020; 19:495-517. [PMID: 33210958 DOI: 10.1080/14787210.2021.1834847] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gram-negative bacterial infections represent still a severe problem of human health care, regarding the increase in multi-resistance against classical antibiotics and the lack of newly developed antimicrobials. For the fight against these germs, anti-infective agents must overcome and/or bind to the Gram-negative outer membrane consisting of a lipopolysaccharide (LPS, endotoxin) outer leaflet and an inner leaflet from phospholipids, with additional peripheral or integral membrane proteins (OMP's). AREAS COVERED The current article reviews data of existing therapeutic options and summarizes newer approaches for targeting and neutralizing endotoxins, ranging from in vitro over in vivo animal data to clinical applications by using databases such as Medline. EXPERT OPINION Conventional antibiotic treatment of the bacteria leads to their killing, but not necessary LPS neutralization, which may be a severe problem in particular for the systemic pathway. This is the reason why there is an increasing number of therapeutic approaches, which - besides combating whole bacteria - at the same time try to neutralize endotoxin within or outside the bacterial cells mainly responsible for the high inflammation induction in Gram-negative species.
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Affiliation(s)
- Klaus Brandenburg
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany
| | - Andra B Schromm
- FG Immunobiophysik, Forschungszentrum Borstel, Leibniz Lungenzentrum, Borstel, Germany
| | - Günther Weindl
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany.,Universität Bonn, Universität Bonn Pharmazeutisches Institut Pharmakologie Und Toxikologie Bonn, Germany
| | - Lena Heinbockel
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany
| | - Wilmar Correa
- FG Biophysik, Forschungszentrum Borstel, Leibniz Lungenzentrum, Borstel, Germany
| | - Karl Mauss
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany.,Asklepios-Klinik Hamburg-Altona, Hamburg, Germany
| | - Guillermo Martinez de Tejada
- Department of Microbiology and Parasitology, University of Navarra, E-31008 Pamplona, Spain and Navarra Institute for Health Research (Idisna), Pamplona, Spain.,Department de Microbiologia, Universidad De Navarra, Pamplona, Spain
| | - Patrick Garidel
- Martin-Luther-Universität Halle-Wittenberg, Institut für Chemie, Halle/Saale, Germany
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15
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Chaung WW, Brenner M, Yen HT, Ochani ML, Jacob A, Wang P. Recombinant human milk fat globule-EGF factor VIII (rhMFG-E8) as a therapy for sepsis after acute exposure to alcohol. Mol Med 2019; 25:52. [PMID: 31747882 PMCID: PMC6868720 DOI: 10.1186/s10020-019-0118-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/04/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Alcohol intake predisposes to infections and sepsis. Alcohol and sepsis inhibit the expression of milk fat globule epidermal growth factor-factor VIII (MFG-E8), a glycoprotein essential for optimal efferocytosis, resulting in the release of proinflammatory molecules and increased sepsis severity. We previously reported that recombinant mouse (rm) MFG-E8 attenuates sepsis-induced organ injury in rats with acute alcohol intoxication. In order to develop a therapy that can be safely used in humans, we have produced recombinant human (rh) MFG-E8 and evaluated its efficacy to ameliorate sepsis after acute exposure to alcohol. METHODS We induced acute alcohol intoxication with a bolus injection of alcohol (1.75 g/kg BW) followed by an intravenous infusion of 300 mg/kg/h alcohol for 10 h. Sepsis was then induced by cecal ligation and puncture (CLP). At -10, 0, and 10 h relative to CLP, rats received MFG-E8 or vehicle (albumin) intravenously. Animals were euthanized at 20 h after CLP for blood and tissue collection. Additional groups of animals were used for a survival study. RESULTS Compared to vehicle, rhMFG-E8 treatment ameliorated blood levels of proinflammatory cytokines (% improvement: TNF-α 49.8%, IL-6 34.7%) and endotoxin (61.7%), as well as of transaminases (AST 36.2%, ALT 40.1%) and lactate (18.4%). Rats treated with rhMFG-E8 also had a significant histological attenuation of the acute lung injury, as well as a reduction in the number of apoptotic cells in the thymus (43.4%) and cleaved caspase 3 (38.7%) in the spleen. In addition, rhMFG-E8 improved the 10-day sepsis survival rate from 45 to 80% CONCLUSION: rhMFG-E8 significantly ameliorated sepsis in rats with acute alcohol exposure, demonstrating rhMFG-E8's potential to be developed as an effective therapy for sepsis in alcohol abusers.
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Affiliation(s)
| | - Max Brenner
- TheraSource LLC, 350 Community Dr, Manhasset, NY 11030 USA
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY 11030 USA
- Department of Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030 USA
| | - Hao-Ting Yen
- TheraSource LLC, 350 Community Dr, Manhasset, NY 11030 USA
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY 11030 USA
| | - Mahendar L. Ochani
- TheraSource LLC, 350 Community Dr, Manhasset, NY 11030 USA
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY 11030 USA
| | - Asha Jacob
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY 11030 USA
- Department of Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030 USA
| | - Ping Wang
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY 11030 USA
- Department of Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030 USA
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030 USA
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