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Sigg AA, Zivkovic V, Bartussek J, Schuepbach RA, Ince C, Hilty MP. The physiological basis for individualized oxygenation targets in critically ill patients with circulatory shock. Intensive Care Med Exp 2024; 12:72. [PMID: 39174691 PMCID: PMC11341514 DOI: 10.1186/s40635-024-00651-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 07/21/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Circulatory shock, defined as decreased tissue perfusion, leading to inadequate oxygen delivery to meet cellular metabolic demands, remains a common condition with high morbidity and mortality. Rapid restitution and restoration of adequate tissue perfusion are the main treatment goals. To achieve this, current hemodynamic strategies focus on adjusting global physiological variables such as cardiac output (CO), hemoglobin (Hb) concentration, and arterial hemoglobin oxygen saturation (SaO2). However, it remains a challenge to identify optimal targets for these global variables that best support microcirculatory function. Weighting up the risks and benefits is especially difficult for choosing the amount of oxygen supplementation in critically ill patients. This review assesses the physiological basis for oxygen delivery to the tissue and provides an overview of the relevant literature to emphasize the importance of considering risks and benefits and support decision making at the bedside. PHYSIOLOGICAL PREMISES Oxygen must reach the tissue to enable oxidative phosphorylation. The human body timely detects hypoxia via different mechanisms aiming to maintain adequate tissue oxygenation. In contrast to the pulmonary circulation, where the main response to hypoxia is arteriolar vasoconstriction, the regulatory mechanisms of the systemic circulation aim to optimize oxygen availability in the tissues. This is achieved by increasing the capillary density in the microcirculation and the capillary hematocrit thereby increasing the capacity of oxygen diffusion from the red blood cells to the tissue. Hyperoxia, on the other hand, is associated with oxygen radical production, promoting cell death. CURRENT STATE OF RESEARCH Clinical trials in critically ill patients have primarily focused on comparing macrocirculatory endpoints and outcomes based on stroke volume and oxygenation targets. Some earlier studies have indicated potential benefits of conservative oxygenation. Recent trials show contradictory results regarding mortality, organ dysfunction, and ventilatory-free days. Empirical studies comparing various targets for SaO2, or partial pressure of oxygen indicate a U-shaped curve balancing positive and negative effects of oxygen supplementation. CONCLUSION AND FUTURE DIRECTIONS To optimize risk-benefit ratio of resuscitation measures in critically ill patients with circulatory shock in addition to individual targets for CO and Hb concentration, a primary aim should be to restore tissue perfusion and avoid hyperoxia. In the future, an individualized approach with microcirculatory targets will become increasingly relevant. Further studies are needed to define optimal targets.
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Affiliation(s)
- Anne-Aylin Sigg
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Vanja Zivkovic
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Jan Bartussek
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Reto A Schuepbach
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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Magnin M, Gavet M, Ngo TT, Louzier V, Victoni T, Ayoub JY, Allaouchiche B, Bonnet-Garin JM, Junot S. A multimodal tissue perfusion measurement approach for the evaluation of the effect of pimobendan, an inodilator, in a porcine sepsis model. Microvasc Res 2024; 154:104687. [PMID: 38614155 DOI: 10.1016/j.mvr.2024.104687] [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: 02/08/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 04/15/2024]
Abstract
Sepsis is associated with hypoperfusion and organ failure. The aims of the study were: 1) to assess the effect of pimobendan on macrocirculation and perfusion and 2) to describe a multimodal approach to the assessment of perfusion in sepsis and compare the evolution of the perfusion parameters. Eighteen anaesthetized female piglets were equipped for macrocirculation monitoring. Sepsis was induced by an infusion of Pseudomonas aeruginosa. After the occurrence of hypotension, animals were resuscitated. Nine pigs received pimobendan at the start of resuscitation maneuvers, the others received saline. Tissue perfusion was assessed using temperature gradients measured with infrared thermography (TG = core temperature - tarsus temperature), urethral perfusion index (uPI) derived from photoplethysmography and sublingual microcirculation (Sidestream dark field imaging device): De Backer score (DBs), proportion of perfused vessels (PPV), microvascular flow index (MFI) and heterogeneity index (HI). Arterial lactate and ScvO2 were also measured. Pimobendan did not improve tissue perfusion nor macrocirculation. It did not allow a reduction in the amount of noradrenaline and fluids administered. Sepsis was associated with tissue perfusion disorders: there were a significant decrease in uPI, PPV and ScvO2 and a significant rise in TG. TG could significantly predict an increase in lactate. Resuscitation was associated with a significant increase in uPI, DBs, MFI, lactate and ScvO2. There were fair correlations between the different perfusion parameters. In this model, pimobendan did not show any benefit. The multimodal approach allowed the detection of tissue perfusion alteration but only temperature gradients predicted the increase in lactatemia.
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Affiliation(s)
- Mathieu Magnin
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Morgane Gavet
- Université de Lyon, VetAgro Sup, Service d'Anesthésie, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Thien-Tam Ngo
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France
| | - Vanessa Louzier
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Tatiana Victoni
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Jean Yves Ayoub
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Bernard Allaouchiche
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Réanimation Médicale, 165 Chemin du Grand Revoyet, F-69310 Pierre-Bénite, France
| | - Jeanne-Marie Bonnet-Garin
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
| | - Stéphane Junot
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, Vetagro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France; Université de Lyon, VetAgro Sup, Service d'Anesthésie, 1 avenue Bourgelat, F-69280 Marcy l'Etoile, France.
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3
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Moretti EH, Lino CA, Steiner AA. INTERPLAY BETWEEN BRAIN OXYGENATION AND THE DEVELOPMENT OF HYPOTHERMIA IN ENDOTOXIC SHOCK. Shock 2024; 61:861-868. [PMID: 38662598 DOI: 10.1097/shk.0000000000002350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
ABSTRACT There is evidence to suggest that the hypothermia observed in the most severe cases of systemic inflammation or sepsis is a regulated response with potential adaptive value, but the mechanisms involved are poorly understood. Here, we investigated the interplay between brain oxygenation (assessed by tissue P o2 ) and the development of hypothermia in unanesthetized rats challenged with a hypotension-inducing dose of bacterial LPS (1 mg/kg i.v.). At an ambient temperature of 22°C, oxygen consumption (V̇O 2 ) began to fall only a few minutes after the LPS injection, and this suppression in metabolic rate preceded the decrease in core temperature. No reduction in brain P o2 was observed prior to the development of the hypometabolic, hypothermic response, ruling out the possibility that brain hypoxia served as a trigger for hypothermia in this model. Brain P o2 was even increased. Such an improvement in brain oxygenation could reflect either an increased O 2 delivery or a decreased O 2 consumption. The former explanation seems unlikely because blood flow (cardiac output) was being progressively decreased during the recording period. On the other hand, the decrease in V̇O 2 usually preceded the rise in P o2 , and an inverse correlation between V̇O 2 and brain P o2 was consistently observed. These findings do not support the existence of a closed-loop feedback relationship between brain oxygenation and hypothermia in systemic inflammation. The data are consistent with a feedforward mechanism in which hypothermia is triggered (possibly by cryogenic inflammatory mediators) in anticipation of changes in brain oxygenation to prevent the development of tissue hypoxia.
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Affiliation(s)
- Eduardo H Moretti
- Departamento de Imunologia, Instituto de Ciencias Biomedicas, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Carp B, Weinberg L, Fletcher LR, Hinton JV, Cohen A, Slifirski H, Le P, Woodford S, Tosif S, Liu D, Muralidharan V, Perini MV, Nikfarjam M, Lee DK. The effect of an intraoperative patient-specific, surgery-specific haemodynamic algorithm in improving textbook outcomes for hepatobiliary-pancreatic surgery: a multicentre retrospective study. Front Surg 2024; 11:1353143. [PMID: 38859998 PMCID: PMC11163073 DOI: 10.3389/fsurg.2024.1353143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 05/06/2024] [Indexed: 06/12/2024] Open
Abstract
Background The concept of a "textbook outcome" is emerging as a metric for ideal surgical outcomes. We aimed to evaluate the impact of an advanced haemodynamic monitoring (AHDM) algorithm on achieving a textbook outcome in patients undergoing hepatobiliary-pancreatic surgery. Methods This retrospective, multicentre observational study was conducted across private and public teaching sectors in Victoria, Australia. We studied patients managed by a patient-specific, surgery-specific haemodynamic algorithm or via usual care. The primary outcome was the effect of using a patient-specific, surgery-specific AHDM algorithm for achieving a textbook outcome, with adjustment using propensity score matching. The textbook outcome criteria were defined according to the International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery and Nationwide Analysis of a Novel Quality Measure in Pancreatic Surgery. Results Of the 780 weighted cases, 477 (61.2%, 95% CI: 57.7%-64.6%) achieved the textbook outcome. Patients in the AHDM group had a higher rate of textbook outcomes [n = 259 (67.8%)] than those in the Usual care group [n = 218 (54.8%); p < 0.001, estimated odds ratio (95% CI) 1.74 (1.30-2.33)]. The AHDM group had a lower rate of surgery-specific complications, severe complications, and a shorter hospital length of stay (LOS) [OR 2.34 (95% CI: 1.30-4.21), 1.79 (95% CI: 1.12-2.85), and 1.83 (95% CI: 1.35-2.46), respectively]. There was no significant difference between the groups for hospital readmission and mortality. Conclusions AHDM use was associated with improved outcomes, supporting its integration in hepatobiliary-pancreatic surgery. Prospective trials are warranted to further evaluate the impact of this AHDM algorithm on achieving a textbook impact on long-term outcomes.
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Affiliation(s)
- Bradly Carp
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Luke R. Fletcher
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Data Analytical Research Unit, Austin Health, Melbourne, VIC, Australia
| | - Jake V. Hinton
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Adam Cohen
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Hugh Slifirski
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Peter Le
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen Woodford
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Shervin Tosif
- Department of Anaesthesia, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - David Liu
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | | | - Marcos V. Perini
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
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Yamamoto R, Fujishima S, Yamakawa K, Abe T, Ogura H, Saitoh D, Gando S, Sasaki J. Hyperoxia for sepsis and development of acute lung injury with increased mortality. BMJ Open Respir Res 2023; 10:e001968. [PMID: 38097355 PMCID: PMC10729230 DOI: 10.1136/bmjresp-2023-001968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Supraphysiological oxygen administration causes unfavourable clinical outcomes in various diseases. This study aimed to determine whether hyperoxia would be associated with increased mortality in patients with severe infection. METHODS A post-hoc analysis of a nationwide multicentre prospective observational study on sepsis (SPICE Study) was conducted, including adult patients admitted to the intensive care unit with available arterial partial pressure of oxygen (PaO2) at the treatment initiation for severe infection. Hyperoxia was defined as a PaO2 level of ≥300 mm Hg and in-hospital mortality was compared between patients with and without hyperoxia. RESULTS Of the 563 patients eligible for the study, 49 had hyperoxia at treatment initiation for severe infection. The in-hospital all-cause mortality rates of patients with and without hyperoxia were 14 (29.2%) and 90 (17.6%), respectively. Inverse probability weighting analyses with propensity scores revealed the association between hyperoxia and increased in-hospital mortality rate (28.8% vs 18.8%; adjusted OR 1.75 (1.03 to 2.97); p=0.038), adjusting for patient demographics, comorbidities, site of infection, severity of infection, haemodynamic and respiratory status, laboratory data and location of patient at infection development. Acute lung injury developed more frequently in patients with hyperoxia on the following days after infection treatment, whereas sepsis-related mortality was comparable regardless of hyperoxia exposure. CONCLUSION Hyperoxia with PaO2 ≥300 mm Hg at treatment initiation of severe infection was associated with an increased in-hospital mortality rate in patients requiring intensive care. The amount of oxygen to administer to patients with severe infection should be carefully determined. TRIAL REGISTRATION NUMBER University Hospital Medical Information Network Clinical Trial Registry (UMIN000027452).
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seitaro Fujishima
- Center for Preventive Medicine, Keio University Hospital, Tokyo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Toshikazu Abe
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
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Chalkias A, O'Donnell EP. Mechanisms of landiolol-mediated positive inotropy in critical care settings. Eur J Clin Pharmacol 2023; 79:1607-1612. [PMID: 37864722 DOI: 10.1007/s00228-023-03584-3] [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: 06/02/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE To present the potential mechanisms by which landiolol enhances a positive inotropic response in critically ill patients. METHODS Analysis of preclinical, animal, and clinical data to provide novel knowledge and translate research findings into potential clinical application. RESULTS The super-selective β1-antagonist landiolol may increase inotropy and may be associated with positive outcomes in critically ill patients with acute decompensated heart failure or sepsis. CONCLUSION This review sheds light on the potential mechanisms by which landiolol enhances a positive inotropic response, potentially alleviating the long-held concern over possible negative hemodynamic effects in critically ill patients.
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Affiliation(s)
- Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104-5158, USA.
- Outcomes Research Consortium, Cleveland, OH, 44195, USA.
| | - E Paul O'Donnell
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Downers Grove, IL, 60515, USA
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Merdji H, Levy B, Jung C, Ince C, Siegemund M, Meziani F. Microcirculatory dysfunction in cardiogenic shock. Ann Intensive Care 2023; 13:38. [PMID: 37148451 PMCID: PMC10164225 DOI: 10.1186/s13613-023-01130-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/13/2023] [Indexed: 05/08/2023] Open
Abstract
Cardiogenic shock is usually defined as primary cardiac dysfunction with low cardiac output leading to critical organ hypoperfusion, and tissue hypoxia, resulting in high mortality rate between 40% and 50% despite recent advances. Many studies have now evidenced that cardiogenic shock not only involves systemic macrocirculation, such as blood pressure, left ventricular ejection fraction, or cardiac output, but also involves significant systemic microcirculatory abnormalities which seem strongly associated with the outcome. Although microcirculation has been widely studied in the context of septic shock showing heterogeneous alterations with clear evidence of macro and microcirculation uncoupling, there is now a growing body of literature focusing on cardiogenic shock states. Even if there is currently no consensus regarding the treatment of microcirculatory disturbances in cardiogenic shock, some treatments seem to show a benefit. Furthermore, a better understanding of the underlying pathophysiology may provide hypotheses for future studies aiming to improve cardiogenic shock prognosis.
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Affiliation(s)
- Hamid Merdji
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Bruno Levy
- Institut Lorrain du Cœur et des Vaisseaux, Medical Intensive Care Unit Brabois, Université de Lorraine, CHRU de Nancy, INSERM U1116, Nancy, France
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, 40225, Düsseldorf, Germany
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Ferhat Meziani
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Strasbourg, France.
- Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
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Effects of Fluids on the Sublingual Microcirculation in Sepsis. J Clin Med 2022; 11:jcm11247277. [PMID: 36555895 PMCID: PMC9786137 DOI: 10.3390/jcm11247277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Sepsis is one of the most common and deadly syndromes faced in Intensive Care settings globally. Recent advances in bedside imaging have defined the changes in the microcirculation in sepsis. One of the most advocated interventions for sepsis is fluid therapy. Whether or not fluid bolus affects the microcirculation in sepsis has not been fully addressed in the literature. This systematic review of the evidence aims to collate studies examining the microcirculatory outcomes after a fluid bolus in patients with sepsis. We will assimilate the evidence for using handheld intra vital microscopes to guide fluid resuscitation and the effect of fluid bolus on the sublingual microcirculation in patients with sepsis and septic shock. We conducted a systematic search of Embase, CENTRAL and Medline (PubMed) using combinations of the terms "microcirculation" AND "fluid" OR "fluid resuscitation" OR "fluid bolus" AND "sepsis" OR "septic shock". We found 3376 potentially relevant studies. Fifteen studies published between 2007 and 2021 fulfilled eligibility criteria to be included in analysis. The total number of participants was 813; we included six randomized controlled trials and nine non-randomized, prospective observational studies. Ninety percent used Sidestream Dark Field microscopy to examine the microcirculation and 50% used Hydroxyethyl Starch as their resuscitation fluid. There were no clear effects of fluid on the microcirculation parameters. There was too much heterogeneity between studies and methodology to perform meta-analysis. Studies identified heterogeneity of affect in the sepsis population, which could mean that current clinical classifications were not able to identify different microcirculation characteristics. Use of microcirculation as a clinical endpoint in sepsis could help to define sepsis phenotypes. More research into the effects of different resuscitation fluids on the microcirculation is needed.
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Stenson EK, Kendrick J, Dixon B, Thurman JM. The complement system in pediatric acute kidney injury. Pediatr Nephrol 2022; 38:1411-1425. [PMID: 36203104 PMCID: PMC9540254 DOI: 10.1007/s00467-022-05755-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/08/2022] [Accepted: 09/09/2022] [Indexed: 10/24/2022]
Abstract
The complement cascade is an important part of the innate immune system. In addition to helping the body to eliminate pathogens, however, complement activation also contributes to the pathogenesis of a wide range of kidney diseases. Recent work has revealed that uncontrolled complement activation is the key driver of several rare kidney diseases in children, including atypical hemolytic uremic syndrome and C3 glomerulopathy. In addition, a growing body of literature has implicated complement in the pathogenesis of more common kidney diseases, including acute kidney injury (AKI). Complement-targeted therapeutics are in use for a variety of diseases, and an increasing number of therapeutic agents are under development. With the implication of complement in the pathogenesis of AKI, complement-targeted therapeutics could be trialed to prevent or treat this condition. In this review, we discuss the evidence that the complement system is activated in pediatric patients with AKI, and we review the role of complement proteins as biomarkers and therapeutic targets in patients with AKI.
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Affiliation(s)
- Erin K. Stenson
- grid.430503.10000 0001 0703 675XSection of Pediatric Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, 13121 E 17th Avenue, MS8414, Aurora, CO 80045 USA
| | - Jessica Kendrick
- grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Bradley Dixon
- grid.430503.10000 0001 0703 675XRenal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Joshua M. Thurman
- grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA
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Raia L, Zafrani L. Endothelial Activation and Microcirculatory Disorders in Sepsis. Front Med (Lausanne) 2022; 9:907992. [PMID: 35721048 PMCID: PMC9204048 DOI: 10.3389/fmed.2022.907992] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/16/2022] [Indexed: 11/19/2022] Open
Abstract
The vascular endothelium is crucial for the maintenance of vascular homeostasis. Moreover, in sepsis, endothelial cells can acquire new properties and actively participate in the host's response. If endothelial activation is mostly necessary and efficient in eliminating a pathogen, an exaggerated and maladaptive reaction leads to severe microcirculatory damage. The microcirculatory disorders in sepsis are well known to be associated with poor outcome. Better recognition of microcirculatory alteration is therefore essential to identify patients with the worse outcomes and to guide therapeutic interventions. In this review, we will discuss the main features of endothelial activation and dysfunction in sepsis, its assessment at the bedside, and the main advances in microcirculatory resuscitation.
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Affiliation(s)
- Lisa Raia
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
- INSERM UMR 976, University of Paris Cité, Paris, France
- *Correspondence: Lara Zafrani
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11
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Wijnands KAP, Meesters DM, Vandendriessche B, Briedé JJ, van Eijk HMH, Brouckaert P, Cauwels A, Lamers WH, Poeze M. Microcirculatory Function during Endotoxemia-A Functional Citrulline-Arginine-NO Pathway and NOS3 Complex Is Essential to Maintain the Microcirculation. Int J Mol Sci 2021; 22:ijms222111940. [PMID: 34769369 PMCID: PMC8584871 DOI: 10.3390/ijms222111940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 02/02/2023] Open
Abstract
Competition for the amino acid arginine by endothelial nitric-oxide synthase (NOS3) and (pro-)inflammatory NO-synthase (NOS2) during endotoxemia appears essential in the derangement of the microcirculatory flow. This study investigated the role of NOS2 and NOS3 combined with/without citrulline supplementation on the NO-production and microcirculation during endotoxemia. Wildtype (C57BL6/N background; control; n = 36), Nos2-deficient, (n = 40), Nos3-deficient (n = 39) and Nos2/Nos3-deficient mice (n = 42) received a continuous intravenous LPS infusion alone (200 μg total, 18 h) or combined with L-citrulline (37.5 mg, last 6 h). The intestinal microcirculatory flow was measured by side-stream dark field (SDF)-imaging. The jejunal intracellular NO production was quantified by in vivo NO-spin trapping combined with electron spin-resonance (ESR) spectrometry. Amino-acid concentrations were measured by high-performance liquid chromatography (HPLC). LPS infusion decreased plasma arginine concentration in control and Nos3−/− compared to Nos2−/− mice. Jejunal NO production and the microcirculation were significantly decreased in control and Nos2−/− mice after LPS infusion. No beneficial effects of L-citrulline supplementation on microcirculatory flow were found in Nos3−/− or Nos2−/−/Nos3−/− mice. This study confirms that L-citrulline supplementation enhances de novo arginine synthesis and NO production in mice during endotoxemia with a functional NOS3-enzyme (control and Nos2−/− mice), as this beneficial effect was absent in Nos3−/− or Nos2−/−/Nos3−/− mice.
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Affiliation(s)
- Karolina A. P. Wijnands
- Department of Surgery, NUTRIM School of Nutrition, Translational Research in Metabolism, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands; (D.M.M.); (H.M.H.v.E.); (M.P.)
- Correspondence: ; Tel.: +31-650-513-913
| | - Dennis M. Meesters
- Department of Surgery, NUTRIM School of Nutrition, Translational Research in Metabolism, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands; (D.M.M.); (H.M.H.v.E.); (M.P.)
- Department of Genetics & Cell Biology, NUTRIM School of Nutrition, Translational Research in Metabolism, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - Benjamin Vandendriessche
- VIB Inflammation Research Center, 9052 Ghent, Belgium; (B.V.); (P.B.); (A.C.)
- Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
- Byteflies, 2600 Antwerp, Belgium
- Department of Electrical, Computer and Systems Engineering, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Jacob J. Briedé
- Department of Toxicogenomics, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands;
| | - Hans M. H. van Eijk
- Department of Surgery, NUTRIM School of Nutrition, Translational Research in Metabolism, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands; (D.M.M.); (H.M.H.v.E.); (M.P.)
| | - Peter Brouckaert
- VIB Inflammation Research Center, 9052 Ghent, Belgium; (B.V.); (P.B.); (A.C.)
- Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Anje Cauwels
- VIB Inflammation Research Center, 9052 Ghent, Belgium; (B.V.); (P.B.); (A.C.)
- Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
- Orionis Biosciences, 9052 Ghent, Belgium
| | - Wouter H. Lamers
- Department of Anatomy & Embryology, NUTRIM School of Nutrition, Translational Research in Metabolism, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands;
| | - Martijn Poeze
- Department of Surgery, NUTRIM School of Nutrition, Translational Research in Metabolism, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands; (D.M.M.); (H.M.H.v.E.); (M.P.)
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12
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Sada H, Egi H, Ide K, Sawada H, Sumi Y, Hattori M, Sentani K, Oue N, Yasui W, Ohdan H. Peritoneal lavage with hydrogen-rich saline can be an effective and practical procedure for acute peritonitis. Surg Today 2021; 51:1860-1871. [PMID: 33787966 DOI: 10.1007/s00595-021-02271-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 02/28/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Acute peritonitis has remained a fatal disease despite of recent advances in care and treatment, including antibiotic and anticoagulant treatments. The cause of death is mostly sepsis-induced multiple organ failure. Oxidative stress can play an important role in this situation, but antioxidant therapy to capture any excessive reactive oxygen species has not yet been fully established. METHODS Two experiments were performed. In the first experiment, we confirmed the effects of peritoneal lavage with hydrogen-rich saline (HRS) after a cecal ligation and puncture (CLP) operation in rats. In the second experiment, the changes in the hemodynamic state following this procedure were observed in a porcine model of abdominal sepsis to evaluate its safety and utility. RESULTS Peritoneal lavage with HRS significantly improved the survival after CLP in rats, and it ameliorated the levels of sepsis-induced organ failure. Moreover, it showed anti-inflammatory and anti-apoptosis as well as antioxidant effects. The second experiment demonstrated the potential safety and feasibility of this procedure in a large animal model. CONCLUSION This procedure can improve survival after sepsis through mitigating the sepsis-induced organ failure by inhibiting oxidative stress, apoptosis, and inflammatory pathways. Peritoneal lavage with HRS may therefore be an effective, safe, and practical therapy for patients with acute peritonitis.
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Affiliation(s)
- Haruki Sada
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Surgery, Kure Medical Center and Chugoku Cancer Center, National Hospital Organization, Hiroshima, Japan
| | - Hiroyuki Egi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
- Department of Gastrointestinal Surgery and Surgical Oncology, Ehime University Graduate School of Medicine, 454 Shizukawa, Toon, Ehime, 791-0295, Japan.
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Sawada
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yusuke Sumi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Minoru Hattori
- Center for Medical Education, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuhiro Sentani
- Department of Molecular Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naohide Oue
- Department of Molecular Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Wataru Yasui
- Department of Molecular Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Zhou XF, Yu RG, Chen Q, Xue YM, Chen H. Performance of Lactate and CO 2-Derived Parameters in Predicting Major Postoperative Complications After Cardiac Surgery With Cardiopulmonary Bypass: Protocol of a Diagnostic Accuracy Study. Front Cardiovasc Med 2021; 8:724713. [PMID: 34660725 PMCID: PMC8517114 DOI: 10.3389/fcvm.2021.724713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: CO2-derived parameters are increasingly used to identify either low-flow status or anaerobic metabolism in shock resuscitation. However, the performance of CO2-derived parameters in cardiac surgical patients is poorly understood. This study aims to compare the performance of lactate and CO2-derived parameters in predicting major postoperative complications after cardiac surgery with cardiopulmonary bypass. Methods: This is a prospective, single-center, diagnostic accuracy study. All patients who receive elective cardiac surgery involving cardiopulmonary bypass will be screened for study eligibility. Blood samples will be taken for the calculation of CO2-derived parameters, including the venous-arterial difference in CO2 partial pressure (PCO2 gap), venous-arterial difference in CO2 content to arterial-venous O2 content ratio (Cv-aCO2/Ca-vO2), and venous-arterial difference in CO2 partial pressure to arterial-venous O2 content ratio (Pv-aCO2/Ca-vO2) at ICU admission, and 3, 6, and 12 h later. Baseline, perioperative data will be collected daily for 7 days; patients will be followed up for 28 days to collect outcome data. The primary endpoint is the occurrence of major postoperative complications. Receiver-operating characteristics (ROC) curve analysis will be carried out to assess the predictive performance of lactate and CO2-derived parameters. The performance of the ROC curves will be compared. Discussion: The performance of lactate and CO2-derived parameters in predicting major postoperative complications will be investigated in the non-sepsis population, which has not been extensively investigated. Our study will compare the two surrogates of respiratory quotient directly, which is an important strength. Trial Registration: ChiCTR, ChiCTR2000029365. Registered January 26th, 2020, http://www.chictr.org.cn/showproj.aspx?proj=48744.
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Affiliation(s)
| | | | | | | | - Han Chen
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
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14
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Visualization of three-dimensional microcirculation of rodents' retina and choroid for studies of critical illness using optical coherence tomography angiography. Sci Rep 2021; 11:14302. [PMID: 34253747 PMCID: PMC8275781 DOI: 10.1038/s41598-021-93631-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/08/2021] [Indexed: 02/06/2023] Open
Abstract
We developed a method to measure the relative blood flow speed using optical coherence tomography angiography (OCTA) in retina and choroid, and investigated the feasibility of this method for assessing microcirculatory function in rat models of sepsis and hemorrhagic shock. Two sepsis models, 6-h severe sepsis without treatment and 30-h moderate sepsis maintaining mean arterial pressure, and volume controlled hemorrhagic shock and fluid resuscitation model were used to see the change of microcirculation. The blood flow index (BFI), which was calculated from the OCTA images to represent the average relative blood flow, was decreasing during the 6-h severe sepsis model. Its change is in parallel with the mean arterial blood pressure (MAP) and blood lactate levels. In the 30-h moderate sepsis model, the BFI was decreased while maintaining MAP, and lactate was increased. In the hemorrhagic shock model, the change of BFI is in line with MAP and lactate levels. In all models, BFI change is more sensitive in choroid than in retina. This study presents the OCTA-based retinal and choroidal microcirculatory blood flow monitoring method and shows its utility for assessment of critical illness.
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15
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Effect of mean arterial pressure change by norepinephrine on peripheral perfusion index in septic shock patients after early resuscitation. Chin Med J (Engl) 2021; 133:2146-2152. [PMID: 32842018 PMCID: PMC7508439 DOI: 10.1097/cm9.0000000000001017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background The peripheral perfusion index (PI), as a real-time bedside indicator of peripheral tissue perfusion, may be useful for determining mean arterial pressure (MAP) after early resuscitation of septic shock patients. The aim of this study was to explore the response of PI to norepinephrine (NE)-induced changes in MAP. Methods Twenty septic shock patients with pulse-induced contour cardiac output catheter, who had usual MAP under NE infusion after early resuscitation, were enrolled in this prospective, open-label study. Three MAP levels (usual MAP −10 mmHg, usual MAP, and usual MAP +10 mmHg) were obtained by NE titration, and the corresponding global hemodynamic parameters and PI were recorded. The general linear model with repeated measures was used for analysis of variance of related parameters at three MAP levels. Results With increasing NE infusion, significant changes were found in MAP (F = 502.46, P < 0.001) and central venous pressure (F = 27.45, P < 0.001) during NE titration. However, there was not a significant and consistent change in continuous cardiac output (CO) (F = 0.41, P = 0.720) and PI (F = 0.73, P = 0.482) at different MAP levels. Of the 20 patients enrolled, seven reached the maximum PI value at usual MAP −10 mmHg, three reached the maximum PI value at usual MAP, and ten reached the maximum PI value at usual MAP +10 mmHg. The change in PI was not significantly correlated with the change in CO (r = 0.260, P = 0.269) from usual MAP −10 mmHg to usual MAP. There was also no significant correlation between the change in PI and change in CO (r = 0.084, P = 0.726) from usual MAP to usual MAP +10 mmHg. Conclusions Differing MAP levels by NE infusion induced diverse PI responses in septic shock patients, and these PI responses may be independent of the change in CO. PI may have potential applications for MAP optimization based on changes in peripheral tissue perfusion.
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16
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Brinkworth JF, Valizadegan N. Sepsis and the evolution of human increased sensitivity to lipopolysaccharide. Evol Anthropol 2021; 30:141-157. [PMID: 33689211 DOI: 10.1002/evan.21887] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/29/2020] [Accepted: 01/30/2021] [Indexed: 01/03/2023]
Abstract
Among mammals, humans are exquisitely sensitive to lipopolysaccharide (LPS), an environmentally pervasive bacterial cell membrane component. Very small doses of LPS trigger powerful immune responses in humans and can even initiate symptoms of sepsis. Close evolutionary relatives such as African and Asian monkeys require doses that are an order of magnitude higher to do the same. Why humans have evolved such an energetically expensive antimicrobial strategy is a question that biological anthropologists are positioned to help address. Here we compare LPS sensitivity in primate/mammalian models and propose that human high sensitivity to LPS is adaptive, linked to multiple immune tactics against pathogens, and part of multi-faceted anti-microbial strategy that strongly overlaps with that of other mammals. We support a notion that LPS sensitivity in humans has been driven by microorganisms that constitutively live on us, and has been informed by human behavioral changes over our species' evolution (e.g., meat eating, agricultural practices, and smoking).
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Affiliation(s)
- Jessica F Brinkworth
- Evolutionary Immunology and Genomics Laboratory, Department of Anthropology, University of Illinois Urbana-Champaign, Urbana, Illinois, USA.,Carl R Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA.,Department of Animal Biology, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Negin Valizadegan
- Evolutionary Immunology and Genomics Laboratory, Department of Anthropology, University of Illinois Urbana-Champaign, Urbana, Illinois, USA.,Carl R Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
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17
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Virág M, Leiner T, Rottler M, Ocskay K, Molnar Z. Individualized Hemodynamic Management in Sepsis. J Pers Med 2021; 11:157. [PMID: 33672267 PMCID: PMC7926902 DOI: 10.3390/jpm11020157] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/13/2021] [Accepted: 02/18/2021] [Indexed: 02/06/2023] Open
Abstract
Hemodynamic optimization remains the cornerstone of resuscitation in the treatment of sepsis and septic shock. Delay or inadequate management will inevitably lead to hypoperfusion, tissue hypoxia or edema, and fluid overload, leading eventually to multiple organ failure, seriously affecting outcomes. According to a large international survey (FENICE study), physicians frequently use inadequate indices to guide fluid management in intensive care units. Goal-directed and "restrictive" infusion strategies have been recommended by guidelines over "liberal" approaches for several years. Unfortunately, these "fixed regimen" treatment protocols neglect the patient's individual needs, and what is shown to be beneficial for a given population may not be so for the individual patient. However, applying multimodal, contextualized, and personalized management could potentially overcome this problem. The aim of this review was to give an insight into the pathophysiological rationale and clinical application of this relatively new approach in the hemodynamic management of septic patients.
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Affiliation(s)
- Marcell Virág
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
| | - Tamas Leiner
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Anaesthetic Department, North West Anglia NHS Foundation Trust, Hinchingbrooke Hospital, Huntingdon PE29 6NT, UK
| | - Mate Rottler
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
| | - Klementina Ocskay
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
| | - Zsolt Molnar
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 61-701 Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Markusovszky Teaching Hospital, 9700 Szombathely, Hungary
- Multidisciplinary Doctoral School, University of Szeged, 6720 Szeged, Hungary
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18
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Abstract
PURPOSE OF REVIEW This review discusses the macrocirculatory and microcirculatory aspects of renal perfusion, as well as novel methods by which to measure renal blood flow. Finally, therapeutic options are briefly discussed, including renal-specific microcirculatory effects. RECENT FINDINGS The optimal mean arterial pressure (MAP) needed for preservation of renal function has been debated but is most likely a MAP of 60-80 mmHg. In addition, attention should be paid to renal outflow pressure, typically central venous pressure. Heterogeneity in microcirculation can exist and may be mitigated through appropriate use of vasopressors with unique microcirculatory effects. Excessive catecholamines have been shown to be harmful and should be avoided. Both angiotensin II and vasopressin may improve glomerular flow through a number of mechanisms. Macrocirculatory and microcirculatory blood flow can be measured through a number of bedside ultrasound modalities, sublingual microscopy and urinary oxygen measurement, SUMMARY: Acute kidney injury (AKI) is a common manifestation of organ failure in shock, and avoidance of hemodynamic instability can mitigate this risk. Measurement of renal haemodynamics is not routinely performed but may help to guide therapeutic goals. A thorough understanding of pathophysiology, measurement techniques and therapeutic options may allow for a personalized approach to blood pressure management in patients with septic shock and may ultimately mitigate AKI.
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19
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Biochemical markers for clinical monitoring of tissue perfusion. Mol Cell Biochem 2021; 476:1313-1326. [PMID: 33387216 PMCID: PMC7921020 DOI: 10.1007/s11010-020-04019-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/09/2020] [Indexed: 12/25/2022]
Abstract
The assessment and monitoring of the tissue perfusion is extremely important in critical conditions involving circulatory shock. There is a wide range of established methods for the assessment of cardiac output as a surrogate of oxygen delivery to the peripheral tissues. However, the evaluation of whether particular oxygen delivery is sufficient to ensure cellular metabolic demands is more challenging. In recent years, specific biochemical parameters have been described to indicate the status between tissue oxygen demands and supply. In this review, the authors summarize the application of some of these biochemical markers, including mixed venous oxygen saturation (SvO2), lactate, central venous–arterial carbon dioxide difference (PCO2 gap), and PCO2 gap/central arterial-to-venous oxygen difference (Ca–vO2) for hemodynamic assessment of tissue perfusion. The thorough monitoring of the adequacy of tissue perfusion and oxygen supply in critical conditions is essential for the selection of the most appropriate therapeutic strategy and it is associated with improved clinical outcomes.
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20
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Dubin A, Kanoore Edul VS, Caminos Eguillor JF, Ferrara G. Monitoring Microcirculation: Utility and Barriers - A Point-of-View Review. Vasc Health Risk Manag 2020; 16:577-589. [PMID: 33408477 PMCID: PMC7780856 DOI: 10.2147/vhrm.s242635] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/27/2020] [Indexed: 12/22/2022] Open
Abstract
Microcirculation is a particular organ of the cardiovascular system. The goal of this narrative review is a critical reappraisal of the present knowledge of microcirculation monitoring, mainly focused on the videomicroscopic evaluation of sublingual microcirculation in critically ill patients. We discuss the technological developments in handheld videomicroscopy, which have resulted in adequate tools for the bedside monitoring of microcirculation. By means of these techniques, a large body of evidence has been acquired about the role of microcirculation in the pathophysiological mechanisms of shock, especially septic shock. We review the characteristics of sublingual microcirculation in septic shock, which mainly consist in a decrease in the perfused vascular density secondary to a reduction in the proportion of perfused vessels along with a high heterogeneity in perfusion. Even in patients with high cardiac output, red blood cell velocity is decreased. Thus, hyperdynamic flow is absent in the septic microcirculation. We also discuss the dissociation between microcirculation and systemic hemodynamics, particularly after shock resuscitation, and the different behavior among microvascular beds. In addition, we briefly comment the effects of some treatments on microcirculation. Despite the fact that sublingual microcirculation arises as a valuable goal for the resuscitation in critically ill patients, significant barriers remain present for its clinical application. Most of them are related to difficulties in video acquisition and analysis. We comprehensively analyzed these shortcomings. Unfortunately, a simpler approach, such as the central venous minus arterial PCO2 difference, is a misleading surrogate for sublingual microcirculation. As conclusion, the monitoring of sublingual microcirculation is an appealing method for monitoring critically ill patients. Nevertheless, the lack of controlled studies showing benefits in terms of outcome, as well as technical limitations for its clinical implementation, render this technique mainly as a research tool.
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Affiliation(s)
- Arnaldo Dubin
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | | | | | - Gonzalo Ferrara
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
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21
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Sadeghmousavi S, Rezaei N. COVID-19 infection and stroke risk. Rev Neurosci 2020; 32:341-349. [PMID: 33580645 DOI: 10.1515/revneuro-2020-0066] [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] [Received: 07/07/2020] [Accepted: 10/09/2020] [Indexed: 12/19/2022]
Abstract
Coronavirus disease 2019 (COVID-19), due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan city, China in December 2019 and rapidly spread to other countries. The most common reported symptoms are fever, dry cough, myalgia and fatigue, headache, anorexia, and breathlessness. Anosmia and dysgeusia as well as gastrointestinal symptoms including nausea and diarrhea are other notable symptoms. This virus also can exhibit neurotropic properties and may also cause neurological diseases, including epileptic seizures, cerebrovascular accident, Guillian barre syndrome, acute transverse myelitis, and acute encephalitis. In this study, we discuss stroke as a complication of the new coronavirus and its possible mechanisms of damage.
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Affiliation(s)
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Children's Medical Center, Dr. Qarib St, Keshavarz Blvd, Tehran, 14194, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, 14194, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran1419783151, Iran
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22
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Roy TK, Secomb TW. Effects of impaired microvascular flow regulation on metabolism-perfusion matching and organ function. Microcirculation 2020; 28:e12673. [PMID: 33236393 DOI: 10.1111/micc.12673] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Impaired tissue oxygen delivery is a major cause of organ damage and failure in critically ill patients, which can occur even when systemic parameters, including cardiac output and arterial hemoglobin saturation, are close to normal. This review addresses oxygen transport mechanisms at the microcirculatory scale, and how hypoxia may occur in spite of adequate convective oxygen supply. The structure of the microcirculation is intrinsically heterogeneous, with wide variations in vessel diameters and flow pathway lengths, and consequently also in blood flow rates and oxygen levels. The dynamic processes of structural adaptation and flow regulation continually adjust microvessel diameters to compensate for heterogeneity, redistributing flow according to metabolic needs to ensure adequate tissue oxygenation. A key role in flow regulation is played by conducted responses, which are generated and propagated by endothelial cells and signal upstream arterioles to dilate in response to local hypoxia. Several pathophysiological conditions can impair local flow regulation, causing hypoxia and tissue damage leading to organ failure. Therapeutic measures targeted to systemic parameters may not address or may even worsen tissue oxygenation at the microvascular level. Restoration of tissue oxygenation in critically ill patients may depend on restoration of endothelial cell function, including conducted responses.
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Affiliation(s)
- Tuhin K Roy
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Timothy W Secomb
- Department of Physiology, University of Arizona, Tucson, AZ, 85724, USA
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23
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Martini R. The compelling arguments for the need of microvascular investigation in COVID-19 critical patients. Clin Hemorheol Microcirc 2020; 75:27-34. [PMID: 32568186 PMCID: PMC7458519 DOI: 10.3233/ch-200895] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The burden of pandemic COVID-19 is growing worldwide, as the continuous increases of contagion. Only 10–15% of the entire infected population has the necessity of intensive care unit (ICU) treatments. But, this relatively low rate of patients has absorbed almost the whole availability of ICU during few days, becoming at least in Italy, an emergency for the national health system. In COVID-19 ICU patients massive aggression of lung with severe pulmonary failure, as well as kidney and liver injuries, heart, brain, bowel and spleen damages with lymph nodes necrosis and even cutaneous manifestations have been observed. Moreover, increased levels of cytokines so-called “cytokines storm (CS), and overt intravascular disseminated coagulation have been also reported. The hypercoagulation and CS would speculate about a microvascular dysfunction. Unfortunately, no specific observations have been performed on microcirculatory dysfunction in COVID-19 patients. Hence the presumed pathophysiological pathways and models about a microvascular involvement can be gathered by sepsis models studies. But despite this lack of evidence, the COVID-19 has emphasized the compelling need for microcirculation monitoring at the bedside in ICU patients.
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Affiliation(s)
- Romeo Martini
- Unità Operativa di Angiologia, Azienda Ospedaliera Universitaria di Padova, Padova, Italy
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Luiking YC, Poeze M, Deutz NE. A randomized-controlled trial of arginine infusion in severe sepsis on microcirculation and metabolism. Clin Nutr 2020; 39:1764-1773. [DOI: 10.1016/j.clnu.2019.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/24/2019] [Accepted: 08/13/2019] [Indexed: 01/27/2023]
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Sheikh T, Shuja H, Bin Waqar SH. Frequency of Hyperlactatemia in Intensive Care Patients within Tertiary Care Hospital in Pakistan. Cureus 2020; 12:e8264. [PMID: 32596081 PMCID: PMC7314370 DOI: 10.7759/cureus.8264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective The aim of this study is to determine the frequency of hyperlactatemia in intensive care patients with sepsis in Civil Hospital Karachi. Method The cross-sectional study was conducted at a tertiary care hospital for six months and comprised all those participants who were older than 12 years of age, had sepsis, and were admitted in the intensive care unit (ICU) within 24 hours. Participants with suspected secondary acidemia from acute liver failure, end-stage renal disease, on anti-retroviral therapy, an overdose of salicylates, alcohols, acetaminophen, metformin user, intestinal resection, or bacterial overgrowth were excluded from the study. Arterial blood samples were collected for lactate levels by the researcher himself, within 24 hours of admission to the ICU. The samples were stored in fluoride tubes and were kept at around four-degree centigrade temperature to avoid any alteration in lactate levels. Demographic details, diagnoses, vitals (blood pressure, heart rate, and respiratory rate) along with lactate levels and criteria for sepsis (including SIRS) of all patients were recorded in the proforma. Lactate level above 1.6 millimoles per liter (mmol/L) was taken as elevated (i.e. hyperlactatemia). SPSS version 16.0 was used for data analysis. Frequency and percentage were calculated for age categories, gender, and hyperlactatemia. Mean, and the standard deviation was calculated for the age of the patient and lactate levels. Effect modifiers were controlled through stratification for age, gender, co-morbidities, and duration of illness. p-value ≤ 0.05 was taken as significant. Results A total of 354 patients with sepsis were included in the study. The mean age of the patients was 42.93 (±19.03) years. Out of 354 patients, 169 (47.7%) were males, and 185 (52.3%) were females. Overall, the frequency of hyperlactatemia in intensive care patients with sepsis was 36.4%. The mean value of lactate was 1.963 mmol/L. With respect to stratification for age, hyperlactatemia was more frequent in the elderly patient population (47%) as compared to the young (31%) and middle (30%) aged patients with sepsis (p-value = 0.013). For gender, hyperlactatemia was more frequent in females (39%) than in males (33%). Concerning the duration of illness, hyperlactatemia was more frequent in those patients who were ill for more than one month (80%) than in those who were ill for less than seven days (30%) or 7 to 30-day period (36%) (p-value <0.001). Concerning co-morbidities, hypertension was the most common co-morbid condition in the study population (30%). Hyperlactatemia was significantly frequent in those patients who already had cardiac problem or stroke (66% [p value = 0.003] and 51% [p value = 0.013], respectively). Conclusion Hyperlactatemia is a common finding in patients with sepsis in an ICU. Being a marker of hypoxia, lactate level measurements can be of vital importance in a critical care setup, where they can be utilized to determine various factors such as mortality, morbidity, and duration of intensive care. Lactate levels thus should be evaluated in clinical studies, in correlation with various parameters more frequently. Lactate levels can also rise in various conditions apart from sepsis which merits further investigation.
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Affiliation(s)
- Taha Sheikh
- Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Hina Shuja
- Internal Medicine, Abbasi Shaheed Hospital, Karachi, PAK
| | - Syed Hamza Bin Waqar
- Internal Medicine, State University of New York Downstate Health Sciences Center, New York, USA.,Internal Medicine, NYC Health + Hospitals/Kings County, New York City, USA.,Internal Medicine, Veterans Affairs Harbor Health Care, New York City, USA
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Relevance of Microvascular Flow Assessments in Critically Ill Neonates and Children: A Systematic Review. Pediatr Crit Care Med 2020; 21:373-384. [PMID: 31834246 PMCID: PMC10061570 DOI: 10.1097/pcc.0000000000002201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Resolution of impaired microvascular flow may lag the normalization of macrocirculatory variables. The significance of microcirculatory dysfunction in critically ill children and neonates is unknown, but microcirculatory variables can be measured using Doppler or videomicroscopy imaging techniques. We outline the current understanding of the role of the microcirculation in critical illness, review methods for its assessment, and perform a systematic review of how it has been monitored in critically ill neonates and children. DESIGN Systematic review (PROSPERO CRD42019117993). SETTING Not applicable. SUBJECTS Not applicable. INTERVENTIONS None. MEASUREMENTS AND RESULTS We systematically searched MEDLINE, EMBASE, PubMed, and Web of Science. We included studies of critically ill patients 0 to 18 years old investigating microcirculatory blood flow. Two reviewers analyzed abstracts and articles. Results were qualitatively analyzed due to study heterogeneity. A total of 2,559 abstracts met search criteria, of which 94 underwent full-text review. Of those, 36 met inclusion criteria. Seven studies investigated microcirculatory changes in critically ill children. Twenty studies investigated the microcirculatory changes in neonates with variable diagnoses compared with a diverse set of clinical endpoints. Nine studies assessed the effects of age, sex, and birth weight on microvascular flow in neonates. Across all studies, microcirculatory dysfunction was associated with poor outcomes and may not correlate with observed macrovascular function. CONCLUSIONS Assessment of microvascular flow in critically ill children and neonates is possible, although significant challenges remain. In many such patients, microvascular blood flow is disrupted despite medical management targeting normalized macrovascular variables. Future studies are needed to define normal pediatric microvascular flow variables and to assess the impact of patient and treatment factors on its function.
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Vasopressors and Nutrition Therapy: Safe Dose for the Outset of Enteral Nutrition? Crit Care Res Pract 2020; 2020:1095693. [PMID: 32104602 PMCID: PMC7035530 DOI: 10.1155/2020/1095693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 11/04/2019] [Accepted: 11/15/2019] [Indexed: 12/24/2022] Open
Abstract
Background and Aims Patients with hemodynamic instability need to receive intensive treatment as fluid replacement and vasoactive drugs. In the meantime, it is supposed to initiate nutritional therapy within 24 to 48 hours after admission to the intensive care unit (ICU), as an essential part of patient's intensive care and better outcomes. However, there are many controversies tangential to the prescription of enteral nutrition (EN) concomitant to the use of vasopressor and its doses. In this way, the present study aimed to identify what the literature presents of evidence to guide the clinical practice concerning the safe dose of vasopressors for the initiation of nutritional therapy in critically ill patients. Methods This review was carried out in PubMed, ProQuest, Web of Science, and Medline databases. The descriptors were used to perform the search strategy: Critical Care, Intensive Care Units, Vasoconstrictor Agents, and Enteral Nutrition. Inclusion criteria were patients of both genders, over 18 years of age, using vasoactive drugs, with the possibility of receiving EN therapy, and articles written in English, Portuguese, and Spanish. In addition, exclusion criteria were case reports, non-papers, and repeated papers. Results 10 articles met our inclusion criteria. Conclusion It was observed that there are many controversies about the supply of EN in critically ill patients using vasopressor, especially about the safe dose, and it was not possible to identify a cutoff value for the beginning therapy. Despite the drug doses, clinical signs are still the most important parameters in the evaluation of EN tolerance.
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Guven G, Hilty MP, Ince C. Microcirculation: Physiology, Pathophysiology, and Clinical Application. Blood Purif 2019; 49:143-150. [PMID: 31851980 DOI: 10.1159/000503775] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/28/2019] [Indexed: 12/17/2022]
Abstract
This paper briefly reviews the physiological components of the microcirculation, focusing on its function in homeostasis and its central function in the realization of oxygen transport to tissue cells. Its pivotal role in the understanding of circulatory compromise in states of shock and renal compromise is discussed. Our introduction of hand-held vital microscopes (HVM) to clinical medicine has revealed the importance of the microcirculation as a central target organ in states of critical illness and inadequate response to therapy. Technical and methodological developments have been made in hardware and in software including our recent introduction and validation of automatic analysis software called MicroTools, which now allows point-of-care use of HVM imaging at the bedside for instant availability of functional microcirculatory parameters needed for microcirculatory targeted resuscitation procedures to be a reality.
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Affiliation(s)
- Goksel Guven
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands,
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Cumpstey AF, Hennis PJ, Gilbert-Kawai ET, Fernandez BO, Grant D, Jenner W, Poudevigne M, Moyses H, Levett DZ, Cobb A, Meale P, Mitchell K, Pöhnl H, Mythen MG, Grocott MP, Martin DS, Feelisch M. Effects of dietary nitrate supplementation on microvascular physiology at 4559 m altitude - A randomised controlled trial (Xtreme Alps). Nitric Oxide 2019; 94:27-35. [PMID: 31604146 PMCID: PMC6970220 DOI: 10.1016/j.niox.2019.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/28/2019] [Accepted: 10/07/2019] [Indexed: 12/17/2022]
Abstract
Native highlanders (e.g. Sherpa) demonstrate remarkable hypoxic tolerance, possibly secondary to higher levels of circulating nitric oxide (NO) and increased microcirculatory blood flow. As part of the Xtreme Alps study (a randomised placebo-controlled trial of dietary nitrate supplementation under field conditions of hypobaric hypoxia), we investigated whether dietary supplementation with nitrate could improve NO availability and microvascular blood flow in lowlanders. Plasma measurements of nitrate, nitrite and nitroso species were performed together with measurements of sublingual (sidestream dark-field camera) and forearm blood flow (venous occlusion plethysmography) in 28 healthy adult volunteers resident at 4559 m for 1 week; half receiving a beetroot-based high-nitrate supplement and half receiving an identically-tasting low nitrate ‘placebo’. Dietary supplementation increased plasma nitrate concentrations 4-fold compared to the placebo group, both at sea level (SL; 19.2 vs 76.9 μM) and at day 5 (D5) of high altitude (22.9 vs 84.3 μM, p < 0.001). Dietary nitrate supplementation also significantly increased both plasma nitrite (0.78 vs. 0.86 μM SL, 0.31 vs. 0.41 μM D5, p = 0.03) and total nitroso product (11.3 vs. 19.7 nM SL, 9.7 vs. 12.3 nM D5, p < 0.001) levels both at sea level and at 4559 m. However, plasma nitrite concentrations were more than 50% lower at 4559 m compared to sea level in both treatment groups. Despite these significant changes, dietary nitrate supplementation had no effect on any measured read-outs of sublingual or forearm blood flow, even when environmental hypoxia was experimentally reversed using supplemental oxygen. In conclusion, dietary nitrate supplementation does not improve microcirculatory function at 4559 m. Xtreme Alps is a randomised controlled field study of dietary nitrate at altitude. Dietary nitrate significantly increased plasma nitrate, nitrite & nitroso species. No changes in sublingual blood flow were seen in response to high dietary nitrate. Dietary nitrate did not alter forearm blood flow under any experimental condition. Dietary nitrate supplementation did not improve microcirculatory function at 4559 m
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Affiliation(s)
- Andrew F Cumpstey
- Critical Care Research Area, Southampton, NIHR Southampton Biomedical Research Centre, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Philip J Hennis
- UCL Centre for Altitude, Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise & Health, 170 Tottenham Court Road, London, W1T 7HA, UK
| | - Edward T Gilbert-Kawai
- UCL Centre for Altitude, Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise & Health, 170 Tottenham Court Road, London, W1T 7HA, UK
| | - Bernadette O Fernandez
- Clinical & Experimental Sciences, Faculty of Medicine, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK; Warwick Medical School, Division of Metabolic and Vascular Health, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - Daniel Grant
- UCL Centre for Altitude, Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise & Health, 170 Tottenham Court Road, London, W1T 7HA, UK
| | - William Jenner
- UCL Centre for Altitude, Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise & Health, 170 Tottenham Court Road, London, W1T 7HA, UK
| | - Matthieu Poudevigne
- Clinical & Experimental Sciences, Faculty of Medicine, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Helen Moyses
- Clinical & Experimental Sciences, Faculty of Medicine, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Denny Zh Levett
- Critical Care Research Area, Southampton, NIHR Southampton Biomedical Research Centre, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Alexandra Cobb
- UCL Centre for Altitude, Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise & Health, 170 Tottenham Court Road, London, W1T 7HA, UK
| | - Paula Meale
- UCL Centre for Altitude, Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise & Health, 170 Tottenham Court Road, London, W1T 7HA, UK
| | - Kay Mitchell
- Critical Care Research Area, Southampton, NIHR Southampton Biomedical Research Centre, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Helmut Pöhnl
- AURAPA, Paul-Heidelbauer-Straße 26, 74321, Bietigheim-Bissingen, Germany
| | - Monty G Mythen
- UCL Centre for Altitude, Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise & Health, 170 Tottenham Court Road, London, W1T 7HA, UK
| | - Michael Pw Grocott
- Critical Care Research Area, Southampton, NIHR Southampton Biomedical Research Centre, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK; Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Daniel S Martin
- UCL Centre for Altitude, Space and Extreme Environment (CASE) Medicine, UCLH NIHR Biomedical Research Centre, Institute of Sport Exercise & Health, 170 Tottenham Court Road, London, W1T 7HA, UK.
| | - Martin Feelisch
- Critical Care Research Area, Southampton, NIHR Southampton Biomedical Research Centre, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK; Clinical & Experimental Sciences, Faculty of Medicine, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK; Warwick Medical School, Division of Metabolic and Vascular Health, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK.
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Ferrara G, Kanoore Edul VS, Caminos Eguillor JF, Buscetti MG, Canales HS, Lattanzio B, Gatti L, Ince C, Dubin A. Effects of fluid and norepinephrine resuscitation in a sheep model of endotoxin shock and acute kidney injury. J Appl Physiol (1985) 2019; 127:788-797. [DOI: 10.1152/japplphysiol.00172.2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The pathophysiology of renal failure in septic shock is complex. Although microvascular dysfunction has been proposed as a mechanism, there are controversial findings about the characteristics of microvascular redistribution and the effects of resuscitation. Our hypothesis was that the normalization of systemic hemodynamics with fluids and norepinephrine fails to improve acute kidney injury. To test this hypothesis, we assessed systemic and renal hemodynamics and oxygen metabolism in 24 anesthetized and mechanically ventilated sheep. Renal cortical microcirculation was evaluated by SDF-videomicroscopy. Shock ( n = 12) was induced by intravenous administration of endotoxin. After 60 min of shock, 30 mL/kg of saline solution was infused and norepinephrine was titrated to reach a mean blood pressure of 70 mmHg for 2 h. These animals were compared with a sham group ( n = 12). After endotoxin administration, mean blood pressure, cardiac index, and systemic O2 transport and consumption decreased ( P < 0.05 for all). Resuscitation improved these variables. Endotoxin shock also reduced renal blood flow and O2 transport and consumption (205[157–293] vs. 131 [99–185], 28.4[19.0–38.2] vs. 15.8[13.5–23.2], and 5.4[4.0–8.8] vs. 3.7[3.3–4.5] mL·min−1·100 g−1, respectively); cortical perfused capillary density (23.8[23.5–25.9] vs. 17.5[15.1–19.0] mm/mm2); and creatinine clearance (62.4[39.2–99.4] vs. 10.7[4.4–23.5] mL/min). After 2 h of resuscitation, these variables did not improve (174[91–186], 20.5[10.8–22.7], and 3.8[1.9–4.8] mL·min−1·100 g−1, 19.9[18.6–22.1] mm/mm2, and 5.9[1.0–11.9] mL/min). In conclusion, endotoxin shock induced severe renal failure associated with decreased renal flow, O2 transport and consumption, and cortical microcirculation. Normalization of systemic hemodynamics with fluids and norepinephrine failed to improve renal perfusion, oxygenation, and function. NEW & NOTEWORTHY This experimental model of endotoxin shock induced severe renal failure, which was associated with abnormalities in renal regional blood flow, microcirculation, and oxygenation. Derangements included the compromise of peritubular microvascular perfusion. Improvements in systemic hemodynamics through fluids and norepinephrine were unable to correct these abnormalities.
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Affiliation(s)
- Gonzalo Ferrara
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Cátedra de Farmacología Aplicada, La Plata, Argentina
| | - Vanina Siham Kanoore Edul
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Cátedra de Farmacología Aplicada, La Plata, Argentina
| | | | - María Guillermina Buscetti
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Cátedra de Farmacología Aplicada, La Plata, Argentina
| | - Héctor Saúl Canales
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Cátedra de Farmacología Aplicada, La Plata, Argentina
| | - Bernardo Lattanzio
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Cátedra de Farmacología Aplicada, La Plata, Argentina
| | - Luis Gatti
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Cátedra de Farmacología Aplicada, La Plata, Argentina
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arnaldo Dubin
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Cátedra de Farmacología Aplicada, La Plata, Argentina
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Dumas G, Lavillegrand JR, Joffre J, Bigé N, de-Moura EB, Baudel JL, Chevret S, Guidet B, Maury E, Amorim F, Ait-Oufella H. Mottling score is a strong predictor of 14-day mortality in septic patients whatever vasopressor doses and other tissue perfusion parameters. Crit Care 2019; 23:211. [PMID: 31182133 PMCID: PMC6558704 DOI: 10.1186/s13054-019-2496-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/28/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Mottling score, a tissue perfusion parameter, is correlated with outcome in septic shock patients. However, its predictive value on mortality according to prognostic covariates such as vasopressor dose and other tissue perfusion parameters remains unknown. METHODS Mottling score and tissue perfusion parameters were recorded at ICU admission (H0), H-6, H 12, and H-24 and used to assess the predictive value of mottling score on 14-day mortality in a development cohort. Results were then validated in an independent cohort of septic shock patients in Brazil. RESULTS Overall, 259 patients with sepsis or septic shock were included, 14-day mortality was 37%. Factors associated with death were mottling score (OR 2.26 [95% CI, 1.72-2.97]), arterial lactate level (OR 1.29 [1.11-1.5]), and urine output < 0.5 ml/Kg/h (OR 3.03 [1.37-6.69]). The C statistic for the model was 0.90 in the development cohort and 0.76 in the validation cohort. The predictive value of mottling score was not affected by vasopressor doses (p for interaction = 0.33): OR for mottling score ranged from 2.34 [1.10-3.15] in patients without vasopressor to 3.84 [1.98-7.43] in patients infused with high doses of vasopressor (> 0.8 μg/kg/min). There was no difference in the effect of mottling score on mortality according to mean arterial pressure, heart rate, cardiac index, and urine output, but we found a significant interaction between arterial lactate level and mottling score (p = 0.04). The predictive value of the mottling score remains significant when using the recent SEPSIS-3 definition of septic shock. Finally, a decrease of mottling score during resuscitation was significantly associated with better outcome after adjustment on SOFA score (p = 0.001). CONCLUSIONS Our results support the high prognostic value of mottling score for 14-day mortality in septic patients, whatever vasopressor dosage and other perfusion parameters. Mottling score variations during resuscitation are also predictive of mortality.
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Affiliation(s)
- Guillaume Dumas
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Jean-Rémi Lavillegrand
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
| | - Jérémie Joffre
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
| | - Naïke Bigé
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
| | | | - Jean-Luc Baudel
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
| | - Sylvie Chevret
- ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Bertrand Guidet
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- Inserm U1136, F-75012 Paris, France
| | - Eric Maury
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- Inserm U1136, F-75012 Paris, France
| | - Fabio Amorim
- Adult Intensive Care Unit, Hospital Santa Luzia, School of Medicine, Brasília, Brazil
| | - Hafid Ait-Oufella
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- Université de Paris, Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France
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Mignemi NA, McClatchey PM, Kilchrist KV, Williams IM, Millis BA, Syring KE, Duvall CL, Wasserman DH, McGuinness OP. Rapid changes in the microvascular circulation of skeletal muscle impair insulin delivery during sepsis. Am J Physiol Endocrinol Metab 2019; 316:E1012-E1023. [PMID: 30860883 PMCID: PMC6620574 DOI: 10.1152/ajpendo.00501.2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/21/2019] [Accepted: 03/07/2019] [Indexed: 01/07/2023]
Abstract
Sepsis costs the healthcare system $23 billion annually and has a mortality rate between 10 and 40%. An early indication of sepsis is the onset of hyperglycemia, which is the result of sepsis-induced insulin resistance in skeletal muscle. Previous investigations have focused on events in the myocyte (e.g., insulin signaling and glucose transport and subsequent metabolism) as the causes for this insulin-resistant state. However, the delivery of insulin to the skeletal muscle is also an important determinant of insulin action. Skeletal muscle microvascular blood flow, which delivers the insulin to the muscle, is known to be decreased during sepsis. Here we test whether the reduced capillary blood flow to skeletal muscle belies the sepsis-induced insulin resistance by reducing insulin delivery to the myocyte. We hypothesize that decreased capillary flow and consequent decrease in insulin delivery is an early event that precedes gross cardiovascular alterations seen with sepsis. This hypothesis was examined in mice treated with either lipopolysaccharide (LPS) or polymicrobial sepsis followed by intravital microscopy of the skeletal muscle microcirculation. We calculated insulin delivery to the myocyte using two independent methods and found that LPS and sepsis rapidly reduce insulin delivery to the skeletal muscle by ~50%; this was driven by decreases in capillary flow velocity and the number of perfused capillaries. Furthermore, the changes in skeletal muscle microcirculation occur before changes in both cardiac output and arterial blood pressure. These data suggest that a rapid reduction in skeletal muscle insulin delivery contributes to the induction of insulin resistance during sepsis.
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Affiliation(s)
- Nicholas A Mignemi
- Department of Molecular Physiology and Biophysics, Vanderbilt University , Nashville, Tennessee
| | - P Mason McClatchey
- Department of Molecular Physiology and Biophysics, Vanderbilt University , Nashville, Tennessee
| | - Kameron V Kilchrist
- Department of Biomedical Engineering, Vanderbilt University , Nashville, Tennessee
| | - Ian M Williams
- Department of Molecular Physiology and Biophysics, Vanderbilt University , Nashville, Tennessee
| | - Bryan A Millis
- Department of Cell and Developmental Biology, Vanderbilt University , Nashville, Tennessee
- Vanderbilt Biophotonics Center, Vanderbilt University , Nashville, Tennessee
| | - Kristen E Syring
- Department of Molecular Physiology and Biophysics, Vanderbilt University , Nashville, Tennessee
| | - Craig L Duvall
- Department of Biomedical Engineering, Vanderbilt University , Nashville, Tennessee
| | - David H Wasserman
- Department of Molecular Physiology and Biophysics, Vanderbilt University , Nashville, Tennessee
- Vanderbilt Mouse Metabolic Phenotyping Center , Nashville, Tennessee
| | - Owen P McGuinness
- Department of Molecular Physiology and Biophysics, Vanderbilt University , Nashville, Tennessee
- Vanderbilt Mouse Metabolic Phenotyping Center , Nashville, Tennessee
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He HW, Long Y, Liu DW, Ince C. Resuscitation incoherence and dynamic circulation-perfusion coupling in circulatory shock. Chin Med J (Engl) 2019; 132:1218-1227. [PMID: 30896570 PMCID: PMC6511427 DOI: 10.1097/cm9.0000000000000221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Poor tissue perfusion/cellular hypoxia may persist despite restoration of the macrocirculation (Macro). This article reviewed the literatures of coherence between hemodynamics and tissue perfusion in circulatory shock. DATA SOURCES We retrieved information from the PubMed database up to January 2018 using various search terms or/and their combinations, including resuscitation, circulatory shock, septic shock, tissue perfusion, hemodynamic coherence, and microcirculation (Micro). STUDY SELECTION The data from peer-reviewed journals printed in English on the relationships of tissue perfusion, shock, and resuscitation were included. RESULTS A binary (coherence/incoherence, coupled/uncoupled, or associated/disassociated) mode is used to describe resuscitation coherence. The phenomenon of resuscitation incoherence (RI) has gained great attention. However, the RI concept requires a more practical, systematic, and comprehensive framework for use in clinical practice. Moreover, we introduce a conceptual framework of RI to evaluate the interrelationship of the Macro, Micro, and cell. The RI is divided into four types (Type 1: Macro-Micro incoherence + impaired cell; Type 2: Macro-Micro incoherence + normal cell; Type 3: Micro-Cell incoherence + normal Micro; and Type 4: both Macro-Micro and Micro-cell incoherence). Furthermore, we propose the concept of dynamic circulation-perfusion coupling to evaluate the relationship of circulation and tissue perfusion during circulatory shock. CONCLUSIONS The concept of RI and dynamic circulation-perfusion coupling should be considered in the management of circulatory shock. Moreover, these concepts require further studies in clinical practice.
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Affiliation(s)
- Huai-Wu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100730, China
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam 3015 CE, the Netherlands
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Abstract
This paper describes a new model for the oxygen-haemoglobin dissociation curve in humans. The model is based on the known structural alterations that occur in the quaternary haemoglobin molecule during oxygenation and deoxygenation. The two alternative structures, tense and relaxed, are described using hyperbolic tangent curves and linked with a probability function to obtain the completed mathematical description of the oxygen-haemoglobin dissociation curve. Model accuracy is assessed by a bias/precision analysis of calculated logit (S) and P50 against gold standard data. A mechanism for the transition between the two structures involving the chloride ion as a major allosteric effector is proposed. Results were analysed against the Siggaard-Andersen model for bias, precision and calculated P50 in four saturation ranges—0.00<SO 2< 1.00, 0.20<SO 2< 0.80, 0.90<SO 2< 1.00 and 0.97<SO 2< 1.00. In each range except for 0.20<SO 2 <0.80, bias, precision and calculated P50 for the new model are significantly better (P<0.05). Analysis of calculated P50 across the entire saturation range revealed significant drift out of the acceptable range in the Siggaard-Andersen model for SO 2 >0.92. The new model remained within tolerance across the saturation range 0.00<SO 2 <1.00. The new model is significantly more accurate than the popular Siggaard-Andersen model, particularly in the range SO 2> 0.90.
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Affiliation(s)
- C. Anstey
- Intensive Care Unit, Nambour Hospital, Nambour, Queensland
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35
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Veenstra G, Ince C, Barendrecht BW, Zijlstra HW, Boerma EC. Differences in capillary recruitment between cardiac surgery and septic patients after fluid resuscitation. Microvasc Res 2018; 123:14-18. [PMID: 30448399 DOI: 10.1016/j.mvr.2018.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Clinical evaluation of the effects of fluid therapy remains cumbersome and strategies are based on the assumption that normalization of macrohemodynamic variables will result in parallel improvement in organ perfusion. Recently, we and others suggested the use of direct in-vivo observation of the microcirculation to evaluate the effects of fluid therapy. METHODS A single-centre observational study, using in-vivo microscopy to assess total vessel density (TVD) in two subsets of ICU patients. RESULTS After fluid resuscitation TVD showed no difference between sepsis patients (N = 47) and cardiac surgery patients (N = 52): 18.4[16.8-20.8] vs 18.7[16.8-20.9] mm/mm2, p = 0.59. In cardiac surgery patients there was a significant correlation between the amount of fluids administered and TVD, with an optimum in the third quartile. However, such correlation was absent in septic patients. CONCLUSIONS TVD after fluid administration is not different between 2 subtypes of intensive care patients. However, only in septic patients we observed a lack of coherence between the amount of fluids administered and TVD. Further research is needed to determine if TVD may serve as potential endpoint for fluid administration.
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Affiliation(s)
- Gerke Veenstra
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands; Department of Translational Physiology, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Can Ince
- Department of Translational Physiology, Amsterdam UMC, Amsterdam, The Netherlands; Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands.
| | - Bart W Barendrecht
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Hendrik W Zijlstra
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
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36
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Cai M, Li S, Shuai Y, Li J, Tan J, Zeng Q. Genome-wide CRISPR-Cas9 viability screen reveals genes involved in TNF-α-induced apoptosis of human umbilical vein endothelial cells. J Cell Physiol 2018; 234:9184-9193. [PMID: 30317623 DOI: 10.1002/jcp.27595] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 09/19/2018] [Indexed: 01/09/2023]
Abstract
Tumor necrosis factor α (TNF-α), a pivotal cytokine in sepsis, protects the host against pathogens by promoting an inflammatory response while simultaneously inducing apoptosis of the vascular endothelium. Unfortunately, inhibitors targeting certain components of the TNF-α signaling pathway to reduce cellular apoptosis have failed to translate into clinical applications, partly due to the adverse effects of excessive immunosuppression. In an attempt to discover potential targets in the TNF-α signaling pathway to modulate moderate inflammation and apoptosis during the development of sepsis, we performed a pooled genome-wide CRISPR/Cas9 knockout screen in human umbilical vein endothelial cells (HUVECs). Tumor necrosis factor receptor superfamily member 1A (TNFRSF1A), B-cell lymphoma 2 (BCL2), Bcl2-associated death promoter (BAD), and NLR family member X1 (NLRX1) deficiencies were identified as the effective genetic suppressors of TNF-α cytotoxicity on a list of candidate regulators. CRISPR-mediated NLRX1 knockout conferred cellular resistance to challenge with TNF-α, and NLRX1 could be induced to colocalize with mitochondria following TNF-α stimulation. Thus, our work demonstrates the advantage of genome-scale screening with Cas9 and validates NLRX1 as a potential modulator of TNF-α-induced vascular endothelial apoptosis during sepsis.
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Affiliation(s)
- Meng Cai
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Sitao Li
- Department of Pediatrics, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yunfei Shuai
- Department of Pediatrics, The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Jie Li
- Center for Medical Genetics and School of Life Science, Central South University, Changsha, China
| | - Jieqiong Tan
- Center for Medical Genetics and School of Life Science, Central South University, Changsha, China
| | - Qiyi Zeng
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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37
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Hashimoto R, Kurata T, Sekine M, Nakano K, Ohnishi T, Haneishi H. Two-wavelength oximetry of tissue microcirculation based on sidestream dark-field imaging. JOURNAL OF BIOMEDICAL OPTICS 2018; 24:1-8. [PMID: 30378349 PMCID: PMC6975279 DOI: 10.1117/1.jbo.24.3.031013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/10/2018] [Indexed: 05/24/2023]
Abstract
Monitoring oxygen saturation (SO2) in microcirculation is effective for understanding disease dynamics. We have developed an SO2 estimation method, sidestream dark-field (SDF) oximetry, based on SDF imaging. SDF imaging is a noninvasive and clinically applicable technique to observe microcirculation. We report the first in vivo experiment observing the changes in SO2 of microcirculation using SDF oximetry. First, heat from the light-emitting diodes used for the SDF imaging might affect hemodynamics in microcirculation, hence, we performed an experiment to evaluate the influence of that on the SDF oximetry. The result suggested that SDF oximetry had enough stability for long-term experiments. Then, to evaluate the sensitivity of SDF oximetry to alterations in the hemodynamics of the microcirculation, we observed the time-lapsed SO2 changes in the dermis microcirculation of rats under hypoxic stimulation. We confirmed that the SO2 estimated by SDF oximetry was in accordance with changes in the fraction of inspired oxygen (FiO2). Thus, SDF oximetry is considered to be able to observe SO2 changes that occur in accordance with alteration of the microcirculation.
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Affiliation(s)
- Ryohei Hashimoto
- Chiba University, Graduate School of Science and Engineering, Chiba, Japan
| | | | - Masashi Sekine
- Chiba University, Center for Frontier Medical Engineering, Chiba, Japan
| | - Kazuya Nakano
- Chiba University, Center for Frontier Medical Engineering, Chiba, Japan
| | - Takashi Ohnishi
- Chiba University, Center for Frontier Medical Engineering, Chiba, Japan
| | - Hideaki Haneishi
- Chiba University, Center for Frontier Medical Engineering, Chiba, Japan
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38
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Holmgaard F, Vedel AG, Ravn HB, Nilsson JC, Rasmussen LS. Impact of mean arterial pressure on sublingual microcirculation during cardiopulmonary bypass-Secondary outcome from a randomized clinical trial. Microcirculation 2018; 25:e12459. [DOI: 10.1111/micc.12459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Frederik Holmgaard
- Department of Cardiothoracic Anesthesia; Heart Centre; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Anne G. Vedel
- Department of Cardiothoracic Anesthesia; Heart Centre; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anesthesia; Heart Centre; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Jens C. Nilsson
- Department of Cardiothoracic Anesthesia; Heart Centre; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Lars S. Rasmussen
- Department of Anesthesia; Centre of Head and Orthopedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Perry DA, Salvin JW, Romfh P, Chen P, Krishnamurthy K, Thomson LM, Polizzotti BD, McGowan FX, Vakhshoori D, Kheir JN. Responsive monitoring of mitochondrial redox states in heart muscle predicts impending cardiac arrest. Sci Transl Med 2018; 9:9/408/eaan0117. [PMID: 28931652 DOI: 10.1126/scitranslmed.aan0117] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/20/2017] [Accepted: 08/15/2017] [Indexed: 11/02/2022]
Abstract
Assessing the adequacy of oxygen delivery to tissues is vital, particularly in the fields of intensive care medicine and surgery. As oxygen delivery to a cell becomes deficient, changes in mitochondrial redox state precede changes in cellular function. We describe a technique for the continuous monitoring of the mitochondrial redox state on the epicardial surface using resonance Raman spectroscopy. We quantify the reduced fraction of specific electron transport chain cytochromes, a metric we name the resonance Raman reduced mitochondrial ratio (3RMR). As oxygen deficiency worsens, heme moieties within the electron transport chain become progressively more reduced, leading to an increase in 3RMR. Myocardial 3RMR increased from baseline values of 18.1 ± 5.9 to 44.0 ± 16.9% (P = 0.0039) after inferior vena cava occlusion in rodents (n = 8). To demonstrate the diagnostic power of this measurement, 3RMR was continuously measured in rodents (n = 31) ventilated with 5 to 8% inspired oxygen for 30 min. A 3RMR value exceeding 40% at 10 min predicted subsequent cardiac arrest with 95% sensitivity and 100% specificity [area under the curve (AUC), 0.98], outperforming all current measures, including contractility (AUC, 0.51) and ejection fraction (AUC, 0.39). 3RMR correlated with indices of intracellular redox state and energy production. This technique may permit the real-time identification of critical defects in organ-specific oxygen delivery.
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Affiliation(s)
- Dorothy A Perry
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Joshua W Salvin
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | | | - Peili Chen
- Pendar Technologies, Cambridge, MA 02138, USA
| | | | - Lindsay M Thomson
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA
| | - Brian D Polizzotti
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Francis X McGowan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, PA 19104, USA.,Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA. .,Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
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40
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Saemann L, Wenzel F. Cutaneous microcirculation during operations with a cardiopulmonary bypass. Clin Hemorheol Microcirc 2018; 69:13-21. [DOI: 10.3233/ch-189102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Lars Saemann
- Faculty Medical and Life Science, Furtwangen University, Villingen-Schwenningen, Germany
| | - Folker Wenzel
- Faculty Medical and Life Science, Furtwangen University, Villingen-Schwenningen, Germany
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41
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Ince C, Boerma EC, Cecconi M, De Backer D, Shapiro NI, Duranteau J, Pinsky MR, Artigas A, Teboul JL, Reiss IKM, Aldecoa C, Hutchings SD, Donati A, Maggiorini M, Taccone FS, Hernandez G, Payen D, Tibboel D, Martin DS, Zarbock A, Monnet X, Dubin A, Bakker J, Vincent JL, Scheeren TWL. Second consensus on the assessment of sublingual microcirculation in critically ill patients: results from a task force of the European Society of Intensive Care Medicine. Intensive Care Med 2018; 44:281-299. [DOI: 10.1007/s00134-018-5070-7] [Citation(s) in RCA: 219] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/17/2018] [Indexed: 12/17/2022]
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42
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Molnar Z, Nemeth M. Monitoring of Tissue Oxygenation: an Everyday Clinical Challenge. Front Med (Lausanne) 2018; 4:247. [PMID: 29387683 PMCID: PMC5775968 DOI: 10.3389/fmed.2017.00247] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/19/2017] [Indexed: 01/28/2023] Open
Abstract
Purpose of review The aim of this article is to study the overview of pathophysiology and clinical application of central venous oxygen saturation monitoring in critically ill patients and during the perioperative period. Recent findings There are several clinical studies and animal experiments evaluating the effects of goal-directed hemodynamic stabilization on critically ill patients. Recent systematic reviews and meta-analyses found that advanced hemodynamic endpoints-targeted management has a positive effect on outcome in high-risk surgical patients. As all interventions aim to improve tissue oxygenation, it is of utmost importance to monitor the balance between oxygen delivery and consumption. For this purpose, central venous blood gas analysis provides an easily available tool in the everyday clinical practice. The adequate interpretation of central venous oxygen saturation renders the need of careful evaluation of several physiological and pathophysiological circumstances. When appropriately evaluated, central venous oxygen saturation can be a valuable component of a multimodal individualized approach, in which components of oxygen delivery are put in the context of the patients' individual oxygen consumption. In addition to guide therapy, central venous oxygen saturation may also serve as an early warning sign of inadequate oxygen delivery, which would otherwise remain hidden from the attending physician. Summary With the incorporation of central venous oxygen saturation in the everyday clinical routine, treatment could be better tailored for the patients' actual needs; hence, it may also improve outcome.
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Affiliation(s)
- Zsolt Molnar
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Marton Nemeth
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
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43
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Arterioportal shunting, splanchnic capillary perfusion, and the effects of colloids during capnoperitoneum in neonatal and adolescent pigs. Surg Endosc 2017; 32:2923-2931. [PMID: 29282572 DOI: 10.1007/s00464-017-6005-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Clinical and experimental data indicate that neonates are sensitive to the CO2 pneumoperitoneum. An impaired splanchnic perfusion during laparoscopy in adults has been reported. We recently confirmed that intravenous colloids improve macrocirculatory function in neonates. We aimed to determine the impact of CO2 pneumoperitoneum on the perfusion of splanchnic organs in the young including effects of colloid application. METHODS Male piglets (n = 25) were divided into four groups: (1) neonatal controls, (2) neonates with crystalloid restitution, (3) neonates with colloidal restitution, and (4) adolescents with crystalloid restitution. Animals were ventilated and subjected to a 3-h, 10 mmHg CO2 pneumoperitoneum followed by 2 h resuscitation. Hepatic, splanchnic, and arteriovenous shunt perfusion was assessed via central and portal venous catheters. Capillary organ flow was detected by fluorescent microspheres. The rate of bile flow was measured. RESULTS The neonatal crystalloid group showed a significant decrease in the intestinal capillary perfusion at the end of the recovery period. This was not detectable in the adolescent and colloid group. There was a significant increase in microcirculatory arterioportal shunt flow during the CO2 pneumoperitoneum in both neonatal groups but not in the sham and adolescent groups (p < 0.05). Hepatic arterial perfusion increased after insufflation in all groups and dropped during capnoperitoneum to levels of about 70% baseline. There was no significant impairment of splanchnic perfusion or bile flow as a result of the pneumoperitoneum in all groups. CONCLUSIONS Capillary perfusion of the abdominal organs was stable during capnoperitoneum and recovery in adolescents and neonates with colloid restitution, but not with crystalloid restitution. Significant arterioportal shunting during capnoperitoneum could affect hepatic microcirculation in neonates. Our data confirm that moderate pressure capnoperitoneum has no major effect on the perfusion of abdominal organs in neonates with adequate substitution.
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44
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Ince C. Personalized physiological medicine. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:308. [PMID: 29297391 PMCID: PMC5751773 DOI: 10.1186/s13054-017-1907-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This paper introduces the concept of personalized physiological medicine that is specifically directed at the needs of the critically ill patient. This differs from the conventional view of personalized medicine, characterized by biomarkers and gene profiling, instead focusing on time-variant changes in the pathophysiology and regulation of various organ systems and their cellular and subcellular constituents. I propose that personalized physiological medicine is composed of four pillars relevant to the critically ill patient. Pillar 1 is defined by the frailty and fitness of the patient and their physiological reserve to cope with the stress of critical illness and therapy. Pillar 2 involves monitoring of the key physiological variables of the different organ systems and their response to disease and therapy. Pillar 3 concerns the evaluation of the success of resuscitation by assessment of the hemodynamic coherence between the systemic and microcirculation and parenchyma of the organ systems. Finally, pillar 4 is defined by the integration of the physiological and clinical data into a time-learning adaptive model of the patient to provide feedback about the function of organ systems and to guide and assess the response to disease and therapy. I discuss each pillar and describe the challenges to research and development that will allow the realization of personalized physiological medicine to be practiced at the bedside for critically ill patients.
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Affiliation(s)
- Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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45
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Davies T, Wythe S, O'Beirne J, Martin D, Gilbert-Kawai E. Review article: the role of the microcirculation in liver cirrhosis. Aliment Pharmacol Ther 2017; 46:825-835. [PMID: 29023881 DOI: 10.1111/apt.14279] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 04/11/2017] [Accepted: 08/06/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intrahepatic microvascular derangements and microcirculatory dysfunction are key in the development of liver cirrhosis and its associated complications. While much has been documented relating to cirrhosis and the dysfunction of the microcirculation in the liver parenchyma, far less is known about the state of the extrahepatic microcirculation and the role this may have in the pathogenesis of multiple organ failure in end stage liver cirrhosis. AIM To provide an update on the role of the microcirculation in the pathophysiology of cirrhosis and its associated complications and briefly discuss some of the imaging techniques which may be used to directly investigate the microcirculation. METHODS A Medline literature search was conducted using the following search terms: 'cirrhosis', 'microcirculation', 'circulation', 'systemic', 'inflammation', 'peripheral', 'hepatorenal' and 'hepatopulmonary'. RESULTS Significant heterogeneous microvascular alterations exist in patients with cirrhosis. Data suggest that the systemic inflammation, associated with advanced cirrhosis, induces microcirculatory dysregulation and contributes to haemodynamic derangement. The resultant vasoconstriction and hypoperfusion in the systemic extrahepatic microvasculature, is likely to be instrumental in the pathophysiology of organ failure in decompensated cirrhosis, however the mechanistic action of vasoactive agents used to correct the circulatory disturbance of advanced cirrhosis is poorly understood. CONCLUSIONS Further research into the role of the microcirculation in patients with liver cirrhosis, will improve physicians understanding of the pathophysiology of cirrhosis, and may provide a platform for real time evaluation of an individual's microcirculatory response to vasoactive mediators, thus guiding their therapy.
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Affiliation(s)
- T Davies
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - S Wythe
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - J O'Beirne
- Department of Hepatology, Nambour General Hospital, Sunshine Coast Hospital and Health Service, Nambour, Qld, Australia
| | - D Martin
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - E Gilbert-Kawai
- Intensive Care Department, Royal Free Hospital, London, UK.,UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
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Abstract
Sepsis-associated organ dysfunction involves multiple responses to inflammation, including endothelial and microvascular dysfunction, immune and autonomic dysregulation, and cellular metabolic reprogramming. The effect of targeting these mechanistic pathways on short- and long-term outcomes depends highly on the timing of therapeutic intervention. Furthermore, there is a need to understand the adaptive or maladaptive character of these mechanisms, to discover phase-specific biomarkers to guide therapy, and to conceptualize these mechanisms in terms of resistance and tolerance.
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Affiliation(s)
- Rachel Pool
- Department of Anesthesiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Hernando Gomez
- Center for Critical Care Nephrology, The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh, 3347 Forbes Avenue, Suite 220, Pittsburgh, PA 15213, USA.
| | - John A Kellum
- Center for Critical Care Nephrology, The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh, 3347 Forbes Avenue, Suite 220, Pittsburgh, PA 15213, USA
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47
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Chan YL, Han ST, Li CH, Wu CC, Chen KF. Transfusion of Red Blood Cells to Patients with Sepsis. Int J Mol Sci 2017; 18:ijms18091946. [PMID: 28891973 PMCID: PMC5618595 DOI: 10.3390/ijms18091946] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/26/2017] [Accepted: 09/08/2017] [Indexed: 12/14/2022] Open
Abstract
Sepsis is one of the major causes of death worldwide, and is the host response to infection which renders our organs malfunctioning. Insufficient tissue perfusion and oxygen delivery have been implicated in the pathogenesis of sepsis-related organ dysfunction, making transfusion of packed red blood cells (pRBCs) a reasonable treatment modality. However, clinical trials have generated controversial results. Even the notion that transfused pRBCs increase the oxygen-carrying capacity of blood has been challenged. Meanwhile, during sepsis, the ability of our tissues to utilize oxygen may also be reduced, and the increased blood concentrations of lactate may be the results of strong inflammation and excessive catecholamine release, rather than impaired cell respiration. Leukodepleted pRBCs more consistently demonstrated improvement in microcirculation, and the increase in blood viscosity brought about by pRBC transfusion helps maintain functional capillary density. A restrictive strategy of pRBC transfusion is recommended in treating septic patients.
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Affiliation(s)
- Yi-Ling Chan
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Taoyuan 330, Taiwan.
| | - Shih-Tsung Han
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Taoyuan 330, Taiwan.
| | - Chih-Huang Li
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Taoyuan 330, Taiwan.
| | - Chin-Chieh Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital Keelung, Keelung 204, Taiwan.
| | - Kuan-Fu Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Taoyuan 330, Taiwan.
- Department of Emergency Medicine, Chang Gung Memorial Hospital Keelung, Keelung 204, Taiwan.
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan 330, Taiwan.
- Community Medicine Research Center, Chang Gung Memorial Hospital Keelung, Keelung 204, Taiwan.
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Edmonds HL, Ganzel BL, Austin EH. Cerebral Oximetry for Cardiac and Vascular Surgery. Semin Cardiothorac Vasc Anesth 2017; 8:147-66. [PMID: 15248000 DOI: 10.1177/108925320400800208] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The technology of transcranial near-infrared spectroscopy (NIRS) for the measurement of cerebral oxygen balance was introduced 25 years ago. Until very recently, there has been only occasional interest in its use during surgical monitoring. Now, however, substantial technologic advances and numerous clinical studies have, at least partly, succeeded in overcoming long-standing and widespread misunderstanding and skepticism regarding its value. Our goals are to clarify common misconceptions about near-infrared spectroscopy and acquaint the reader with the substantial literature that now supports cerebral oximetric monitoring in cardiac and major vascular surgery.
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Affiliation(s)
- Harvey L Edmonds
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, Louisville, Kentucky 40202-3619, USA.
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Kolb L, Orbegozo D, Creteur J, Preiser JC, Vincent JL, De Backer D. Oral Nitrate Increases Microvascular Reactivity and the Number of Visible Perfused Microvessels in Healthy Volunteers. J Vasc Res 2017; 54:209-216. [DOI: 10.1159/000468541] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 03/05/2017] [Indexed: 12/13/2022] Open
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Effects of Dexmedetomidine on Intestinal Microcirculation and Intestinal Epithelial Barrier in Endotoxemic Rats. Anesthesiology 2017; 125:355-67. [PMID: 27111533 DOI: 10.1097/aln.0000000000001135] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Dexmedetomidine reduces cytokine production in septic patients and reduces inflammation and mortality in experimental models of endotoxemia and sepsis. This study investigated whether dexmedetomidine attenuates endothelial dysfunction, intestinal microcirculatory dysfunction, and intestinal epithelial barrier disruption in endotoxemic rats. METHODS Ninety-two male Wistar rats were randomly assigned to the following four groups: (1) Sham; (2) lipopolysaccharide, received IV lipopolysaccharide 15 and 10 mg/kg at 0 and 120 min; (3) dexmedetomidine, received IV dexmedetomidine for 240 min; and (4) lipopolysaccharide + dexmedetomidine, received both lipopolysaccharide and dexmedetomidine. Sidestream dark-field videomicroscope, tissue oxygen monitor, and full-field laser perfusion image were used to investigate the microcirculation of the terminal ileum. Serum endocan level was measured. The Ussing chamber permeability assay, lumen-to-blood gadodiamide passage by magnetic resonance imaging, and bacterial translocation were conducted to determine epithelial barrier function. Mucosal apoptotic levels and tight junctional integrity were also examined. RESULTS The density of perfused small vessels in mucosa, serosal muscular layer, and Peyer patch in the lipopolysaccharide + dexmedetomidine group was higher than that of the lipopolysaccharide group. Serum endocan level was lower in the lipopolysaccharide + dexmedetomidine group than in the lipopolysaccharide group. Mucosal ratio of cleaved to full-length occludin and spleen bacterial counts were significantly lower in the lipopolysaccharide + dexmedetomidine group than in the lipopolysaccharide group. CONCLUSION The study finding suggests that dexmedetomidine protects against intestinal epithelial barrier disruption in endotoxemic rats by attenuating intestinal microcirculatory dysfunction and reducing mucosal cell death and tight junctional damage. (Anesthesiology 2016; 125:355-67).
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