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Deitch EA. Gut lymph and lymphatics: a source of factors leading to organ injury and dysfunction. Ann N Y Acad Sci 2010; 1207 Suppl 1:E103-11. [PMID: 20961300 DOI: 10.1111/j.1749-6632.2010.05713.x] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Major trauma, shock, sepsis, and other conditions can lead to the acute respiratory distress syndrome (ARDS), which may progress to the highly lethal multiple organ dysfunction syndrome (MODS). Although a number of therapeutic strategies have been initiated, their success has been limited largely due to an incomplete understanding of the biology of MODS. However, recent studies indicate that the intestinal lymphatics serve as the primary route for nonbacterial, tissue injurious gut-derived factors, which can induce acute ARDS and MODS. The gut lymph hypothesis of ARDS and MODS thus helps clarify several important issues. First, because the lung is the first organ exposed to mesenteric lymph and not the liver (i.e., mesenteric lymph enters the subclavian vein via the thoracic duct, which, in turn, empties directly into the heart and lungs), it would explain the clinical observation that the lung is generally the first organ to fail. Second, this hypothesis provides new pathophysiologic information, thereby providing a basis for novel therapies. Finally, by studying the composition of lymph, MODS-inducing factors can be isolated and identified.
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Affiliation(s)
- Edwin A Deitch
- Department of Surgery, University of Medicine and Dentistry New Jersey, Newark, New Jersey, USA.
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Abstract
Hemorrhagic shock (HS) leads to reactive oxygen species production. However, clinicians do not have access to bedside measurements of the redox status during HS. Cyclic voltammetry (CyV) is a simple electrochemical method of measuring redox status. The aims of this study were to 1) report the first application of cyclic voltammetry to measure the acute changes in serum redox status after HS, 2) to contrast it with another severe systemic disease with a different redox pathology (acute pancreatitis [AP]), and 3) to describe the response of CyV over time in a resolving model of AP. In the acute study, 24 male Wistar rats were randomized into three groups: groups 1 (control), 2 (AP), and 3 (HS). In the time-course study, 28 rats were randomized to a sham-control as well as 6 and 24 h post-AP cohorts, respectively.Cyclic voltammetry was performed using a three-electrode system. In the acute study, the first and second voltammetric peaks increased significantly in HS. In contrast, within the AP group, only the first voltammetric peak showed a significant increase. The first voltammetric peak correlated with plasma protein carbonyls (PCs) and with thiobarbituric acid-reactive substances, whereas the second voltammetric peak correlated positively with plasma protein carbonyls. In the second study, the first voltammetric peak correlated with physiological improvements. Here, we showed that serum CyV could respond to the serum redox change in HS and AP. Cyclic voltammetry warrants evaluation as a potential real-time beside measure of a patient's redox status during shock.
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Abstract
The microcirculation plays an essential role in health and disease. Microvascular perfusion can be assessed directly using laser Doppler flowmetry and various imaging techniques or indirectly using regional capnometry and measurement of indicators of mismatch between oxygen delivery and oxygen consumption or indices of disturbed cellular oxygen utilization. Assessment of microvascular oxygen availability implies measurement of oxygen pressure or measurement of hemoglobin oxygen saturation. Microvascular function is assessed using other methods, including venous plethysmography. In this paper, I review current knowledge concerning assessment of the microcirculation with special emphasis on methods that could be used at the bedside.
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Affiliation(s)
- Yasser Sakr
- Department of Anesthesiology and Intensive Care, Friedrich Schiller University Hospital, Erlanger Allee 101, Jena 07743, Germany.
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Deitch EA, Xu DZ, Lu Q. Gut lymph hypothesis of early shock and trauma-induced multiple organ dysfunction syndrome: A new look at gut origin sepsis. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/17471060600551772] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Reis MB, del Pilar Gallardo Garrido A, Cruz Junior RJ, Ribeiro EA, Rocha e Silva M, Poli de Figueiredo LF. Early Restoration of Cocaine-Induced Splanchnic Hypoperfusion in Anesthetized Dogs. J INVEST SURG 2009; 20:291-9. [DOI: 10.1080/08941930701598800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kim J, Kim KY, Jang HS, Yoshida T, Tsuchiya K, Nitta K, Park JW, Bonventre JV, Park KM. Role of cytosolic NADP+-dependent isocitrate dehydrogenase in ischemia-reperfusion injury in mouse kidney. Am J Physiol Renal Physiol 2008; 296:F622-33. [PMID: 19106211 DOI: 10.1152/ajprenal.90566.2008] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cytosolic NADP+-dependent isocitrate dehydrogenase (IDPc) synthesizes reduced NADP (NADPH), which is an essential cofactor for the generation of reduced glutathione (GSH), the most abundant and important antioxidant in mammalian cells. We investigated the role of IDPc in kidney ischemia-reperfusion (I/R) in mice. The activity and expression of IDPc were highest in the cortex, modest in the outer medulla, and lowest in the inner medulla. NADPH levels were greatest in the cortex. IDPc expression in the S1 and S2 segments of proximal tubules was higher than in the S3 segment, which is much more susceptible to I/R. IDPc protein was also highly expressed in the mitochondrion-rich intercalated cells of the collecting duct. IDPc activity was 10- to 30-fold higher than the activity of glucose-6-phosphate dehydrogenase, another producer of cytosolic NADPH, in various kidney regions. This study identifies that IDPc may be the primary source of NADPH in the kidney. I/R significantly reduced IDPc expression and activity and NADPH production and increased the ratio of oxidized glutathione to total glutathione [GSSG/(GSH+GSSG)], resulting in kidney dysfunction, tubular cell damage, and lipid peroxidation. In LLC-PK(1) cells, upregulation of IDPc by IDPc gene transfer protected the cells against hydrogen peroxide, enhancing NADPH production, inhibiting the increase of GSSG/(GSH+GSSG), and reducing lipid peroxidation. IDPc downregulation by small interference RNA treatment presented results contrasting with the upregulation. In conclusion, these results demonstrate that IDPc is expressed differentially along tubules in patterns that may contribute to differences in susceptibility to injury, is a major enzyme in cytosolic NADPH generation in kidney, and is downregulated with I/R.
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Affiliation(s)
- Jinu Kim
- Department of Anatomy and BK 21 Project, Kyungpook National University School of Medicine, Daegu, Republic of Korea
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Kushi H, Miki T, Sakagami Y, Sato J, Saito T, Tanjoh K. Early hemoperfusion with a polymyxin b column improves gastric intramucosal pH in sepsis. Ther Apher Dial 2008; 12:278-84. [PMID: 18789114 DOI: 10.1111/j.1744-9987.2008.00588.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This study had two purposes. One was to assess gastric intramucosal pH (pHi) after early goal-directed therapy in patients with sepsis and septic shock. The other was to determine whether direct hemoperfusion with a polymyxin B fiber column (DHP-PMX) could improve the pHi if it remained low after early goal-directed therapy. The subjects were 32 patients who underwent early goal-directed therapy within 6 h of a diagnosis of sepsis or septic shock, and who achieved the following conditions: (i) central venous pressure of 8-12 mm Hg; (ii) mean arterial blood pressure >or=65 mm Hg; (iii) urine output >or=0.5 mL/kg/h; and (iv) mixed venous oxygen saturation >or=70%. A gastric tonometer was inserted in each patient and the pHi was measured before DHP-PMX, and at 24, 48, and 72 h after the start of treatment. The pHi was 7.22 +/- 0.04 immediately before DHP-PMX, 7.28 +/- 0.03 (P < 0.05) at 24 h, 7.32 +/- 0.03 (P < 0.01) at 48 h, and 7.34 +/- 0.02 (P < 0.01) at 72 h, showing a significant increase from 24 h onward compared with the pretreatment value. In patients with sepsis and septic shock, the pHi remained low after early goal-directed therapy; however, it was significantly improved from 24 h after the start of DHP-PMX and was normalized from 48 h onwards. These findings suggest that DHP-PMX improves pHi. Because this was a prospective uncontrolled observational study on a limited number of patients, larger multicenter clinical trials are required to more accurately assess the benefits of DHP-PMX.
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Affiliation(s)
- Hidehiko Kushi
- Department of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan.
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Abstract
OBJECTIVE The goal of this concise review is to provide an overview of some of the most important intensive care unit issues and approaches that are unique to trauma patients as compared with the general intensive care unit population. STUDY SELECTION Clinical trials in trauma patients focusing on hemorrhage control, issues in resuscitation, staged operative repair of multiple injuries, the diagnosis and therapy of the abdominal compartment syndrome, and the treatment of traumatic brain injury were identified on PubMed. CONCLUSIONS The intensive care unit care of the trauma patient differs from that of other intensive care unit patients in many ways, one of the most important being the need to continuously integrate operative and nonoperative therapy. Although progress in the care of the injured has been made, death due to uncontrolled bleeding, severe head injury, or the development of multiple organ dysfunction syndrome remains all too common in this patient population. Furthermore, due to the potential nature of the injuries, the conundrum not infrequently arises that the optimal treatment for one injury or organ system, such as preoperative permissive hypotension in actively bleeding patients, may result in suboptimal or even deleterious therapy in the presence of another injury, such as traumatic brain injury. LEARNING OBJECTIVES On completion of this article, the reader should be able to:Dr. Deitch has disclosed that he is/was the recipient of grant/research funds from Celgene. Dr. Dayal has disclosed that she has no financial relationships with or interests in any commercial companies pertaining to this educational activity. Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.
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Affiliation(s)
- Edwin A Deitch
- Department of Surgery, New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, USA
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Marik PE. Sublingual capnometry: a non-invasive measure of microcirculatory dysfunction and tissue hypoxia. Physiol Meas 2006; 27:R37-47. [PMID: 16705254 DOI: 10.1088/0967-3334/27/7/r01] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
With improvement in supportive care patients rarely die from their presenting illness but rather from its sequela, namely sequential multi-organ failure. Tissue hypoxia is believed to be the causation of multi-organ dysfunction syndrome (MODS). The expedient detection and correction of tissue hypoxia may therefore limit the development of MODS. The standard oxygenation and hemodynamic variables (blood pressure, arterial oxygenation, cardiac output) which are monitored in critically ill patients are 'upstream' markers and provide little information as to the adequacy of tissue oxygenation. Global 'downstream' markers such as mixed venous oxygen saturation and blood lactate are insensitive indicators of tissue hypoxia. Sublingual PCO(2) is a regional marker of microvascular perfusion and tissue hypoxia that holds great promise for the risk stratification and end-point of goal directed resuscitation in critically ill patients. This paper reviews the technology and application of sublingual PCO(2) monitoring.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Abstract
PURPOSE OF REVIEW Tissue dysoxia is now widely regarded as the major factor leading to organ dysfunction in critically ill patients. Recent data suggests that early aggressive resuscitation of critically ill patients, which limits and/or reverses tissue dysoxia may prevent progression to organ dysfunction and improve outcome. The traditional clinical and laboratory markers used to assess tissue dysoxia are, however, insensitive and have numerous limitations. Regional carbon dioxide monitoring appears to be ideally suited to monitoring the adequacy of resuscitation. This review provides an update on this evolving technology. RECENT FINDINGS Gastric intramucosal carbon dioxide as measured by gastric tonometry has proven to be useful as a prognostic marker, in evaluating the response to specific therapeutic interventions and as an end point of resuscitation. Gastric tonometry is, however, cumbersome and has a number of limitations that may have prevented its widespread adoption. The measurement of carbon dioxide in the sublingual mucosa by sublingual capnometry is technically simple, noninvasive, and provides near instantaneous information. Clinical studies have demonstrated a good correlation between gastric intramucosal carbon dioxide and sublingual mucosa carbon dioxide. Sublingual mucosa carbon dioxide responds more rapidly to therapeutic interventions than does gastric intramucosal carbon dioxide and may be a better prognostic marker. SUMMARY Sublingual capnometry may be the ideal technology for guiding early goal directed therapy. This technology may be useful for monitoring tissue oxygenation, titrating therapeutic interventions, and as an end point for resuscitation in critically ill and injured patients.
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Affiliation(s)
- Paul E Marik
- Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
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Homma H, Deitch EA, Feketeova E, Lu Q, Berezina TL, Zaets SB, Machiedo GW, Xu DZ. Small Volume Resuscitation With Hypertonic Saline Is More Effective in Ameliorating Trauma-Hemorrhagic Shock-Induced Lung Injury, Neutrophil Activation and Red Blood Cell Dysfunction than Pancreatic Protease Inhibition. ACTA ACUST UNITED AC 2005; 59:266-72. [PMID: 16294064 DOI: 10.1097/01.ta.0000184582.55417.77] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Recognition of the limitations of standard crystalloid resuscitation has led to the search for alternative resuscitation strategies that might better limit the development of trauma-hemorrhage-induced organ dysfunction and systemic inflammation. Thus, the goal of this study was to compare the effects of two resuscitation strategies alone, and in combination, with those of standard resuscitation with Ringers lactate (RL). The two strategies were small volume resuscitation with hypertonic saline (HTS) and intraluminal inhibition of pancreatic proteases with the serine protease inhibitor nafamostat. METHODS Male rats were subjected to trauma-hemorrhagic shock (T/HS) or trauma sham-shock (T/SS) and resuscitated with RL, HTS, nafamostat, or the combination of HTS and nafamostat. The T/HS model consisted of a laparotomy plus 90 minutes of shock (MAP 30 mm Hg). Three hours after the end of the shock or sham-shock period, lung permeability, pulmonary neutrophil sequestration, neutrophil activation, red blood cell deformability, and gut injury were assessed. RESULTS Both HTS and nafamostat reduced T/HS-induced pulmonary permeability and neutrophil sequestration, as well as neutrophil activation as compared with resuscitation with RL. However, HTS was more effective than nafamostat in reducing T/HS-induced acute lung injury and neutrophil activation. Additionally, HTS, but not nafamostat, reduced T/HS-induced RBC rigidification. Lastly, gut injury after T/HS was reduced to the greatest extent by the combination of HTS plus nafamostat. CONCLUSION Small volume resuscitation with HTS is more effective than RL and nafamostat in limiting T/HS-induced acute lung injury, neutrophil activation and red blood cell injury.
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Affiliation(s)
- Hiroshi Homma
- Department of Surgery, UMDNJ-New Jersey Medical School, Newark, NJ 07103-1709, USA
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Diebel LN, Liberati DM, Taub JS, Diglio CA, Brown WJ. Intestinal Epithelial Cells Modulate PMN Activation and Apoptosis Following Bacterial and Hypoxic Challenges. ACTA ACUST UNITED AC 2005; 58:1126-33. [PMID: 15995458 DOI: 10.1097/01.ta.0000169952.50045.f4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The post-ischemic gut may serve to prime and activate neutrophils which may lead to the subsequent development of the systemic inflammatory response syndrome (SIRS) and multiple organ failure. However, the initiating event which may trigger this immunoinflammatory cascade from the gut is unknown. Recent studies have indicated that intestinal epithelial cells (IEC) play an integral role in generating and transmitting signals between luminal bacteria and the host cells in the underlying gut tissues. The purpose of this study was to investigate the ability of IEC to modulate PMN responses to bacteria and/or hypoxia/reoxygenation (H/R) challenges in vitro. METHODS Caco2 cell monolayers were established in a two-chamber cell culture system. Neutrophils from normal human volunteers were placed in the basal chamber and the cell co-culture exposed to either apical bacteria (E. coli) and/or H/R challenge. PMN apoptosis, and percentage of CD11b expression, superoxide anion production, and elastase release were subsequently quantitated. RESULTS Coculture of PMNs with Caco2 cells led to a significant reduction in neutrophil apoptosis in both normoxic and H/R conditions. CD11b expression was increased in PMNs exposed to bacteria but the greatest expression was noted with PMN cocultured with Caco2 cells and H/R. Superoxide anion production was increased in all groups following either H/R or bacterial challenge and H/R. Elastase release was highest in neutrophils following H/R and exposure to E. coli. CONCLUSION IEC modulate PMN response to bacteria and H/R insults. This results in the production of activated neutrophils with an exaggerated lifespan which may promote remote organ failure. Attempts to modulate this response may be useful in preventing multiple organ failure following severe traumatic shock.
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Affiliation(s)
- Lawrence N Diebel
- Department of Surgery, Wayne State University Health Center, Detroit, MI 48201, USA.
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Cohn SM, Cohn SM, Kirton O, Brown M, Hameed SM, Cohn SM, Barquist E, Duncan R, Majetshak M, Popkin C, Augenstein J, Byers P, Ginzburg E, Mckenney M, Namias N, Shatz D, Sleeman D. Splanchnic Hypoperfusion-Directed Therapies in Trauma: A Prospective, Randomized Trial. Am Surg 2005. [DOI: 10.1177/000313480507100317] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Splanchnic hypoperfusion as reflected by gastric intramucosal acidosis has been recognized as an important determinant of outcome in shock. A comprehensive splanchnic hypoperfusion-ischemia reperfusion (IRP) protocol was evaluated against conventional shock management protocols in critical trauma patients. The study was a prospective randomized trial comparing three therapeutic approaches to hypoperfusion after severe trauma in 151 trauma patients admitted to the intensive care unit. Group 1 patients received hemodynamic support based on conventional indicators of hypoperfusion. In group 2, resuscitation was further guided by gastric tonometry-derived estimates of splanchnic hypoperfusion and included more invasive hemodynamic monitoring and additional administration of colloid or crystalloid solutions, or inotropic support. Group 3 patients additionally received therapies specifically aimed at optimizing splanchnic perfusion and minimizing oxidant-mediated damage from reperfusion. The three groups were similar based on age, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation II Scores. There were no statistically significant differences in mortality rates, organ dysfunction, ventilator days, or length of stay between any of the interventions. Techniques of optimization of splanchnic perfusion and minimization of oxidant-mediated reperfusion injury evaluated in this study were not advantageous relative to standard resuscitation measures guided by conventional or tonometric measures of hypoperfusion in the therapy of occult and clinical shock in trauma patients.
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Heyland DK, Dhaliwal R, Suchner U, Berger MM. Antioxidant nutrients: a systematic review of trace elements and vitamins in the critically ill patient. Intensive Care Med 2004; 31:327-37. [PMID: 15605227 DOI: 10.1007/s00134-004-2522-z] [Citation(s) in RCA: 239] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Accepted: 11/08/2004] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Critical illness is associated with the generation of oxygen free radicals and low endogenous antioxidant capacity leading to a condition of oxidative stress. We investigated whether supplementing critically ill patients with antioxidants, trace elements, and vitamins improves their survival. METHODS We searched four bibliographic databases from 1980 to 2003 and included studies that were randomized, reported clinically important endpoints in critically ill patients, and compared various trace elements and vitamins to placebo. RESULTS Eleven articles met the inclusion criteria. When the results of all the trials were aggregated, overall antioxidants were associated with a significant reduction in mortality [Risk Ratio (RR) 0.65, 95% confidence intervals (CI) 0.44-0.97, p=0.03] but had no effect on infectious complications. Studies that utilized a single trace element were associated with a significant reduction in mortality [RR 0.52, 95% CI 0.27-0.98, p=0.04] whereas combined antioxidants had no effect. Studies using parenteral antioxidants were associated with a significant reduction in mortality [RR 0.56, 95% CI 0.34-0,92, p=0.02] whereas studies of enteral antioxidants were not. Selenium supplementation (alone and in combination with other antioxidants) may be associated with a reduction in mortality [RR 0.59, 95% CI 0.32-1.08, p=0.09] while nonselenium antioxidants had no effect on mortality. CONCLUSIONS Trace elements and vitamins that support antioxidant function, particularly high-dose parenteral selenium either alone or in combination with other antioxidants, are safe and may be associated with a reduction in mortality in critically ill patients.
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Affiliation(s)
- Daren K Heyland
- Department of Medicine, Queen's University, Kingston, ONT, Canada.
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Schulman AM, Claridge JA, Carr G, Diesen DL, Young JS. Predictors of Patients Who Will Develop Prolonged Occult Hypoperfusion following Blunt Trauma. ACTA ACUST UNITED AC 2004; 57:795-800. [PMID: 15514533 DOI: 10.1097/01.ta.0000140835.65944.54] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prolonged occult hypoperfusion or POH (serum lactate >2.4 mmol/L persisting >12 hours from admission) represents a reversible risk factor for adverse outcomes following traumatic injury. We hypothesized that patients at increased risk for POH could be identified at the time of admission. METHODS Prospective data from adult trauma admissions between January 1, 1998 and December 31, 2000 were analyzed. Potential risk factors for POH were determined by univariate analysis (p < or =0.10= significant). Significant factors were tested in a logistic regression model (LR) (p < or =0.05= significant). The predictive ability of the LR was tested by receiver operating curve (ROC) analysis (p < or =0.05= significant). RESULTS Three hundred seventy-eight patients were analyzed, 129 with POH. Injury Severity Score (ISS), emergency department Glasgow Coma Scale score, hypotension, and the individual Abbreviated Injury Scale score (AIS) for Head (H), Abdominal/Pelvic Viscera (A) and Pelvis/Bony Extremity (P) were significantly associated with POH. LR demonstrated that ISS, A-AIS > or =3 and P-AIS > or =3 were independent predictors of POH (p <0.05). ROC analysis of the LR equation was statistically significant (Area=0.69, p <0.001). CONCLUSIONS We identified factors at admission that placed patients at higher risk for developing POH. Select patients may benefit from rapid, aggressive monitoring and resuscitation, possibly preventing POH and its associated morbidity and mortality.
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Affiliation(s)
- Andrew M Schulman
- Trauma Research Laboratory, University of Virginia Health System, Department of Surgery, Charlottesville, Virginia 22908-0709, USA
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Osband AJ, Deitch EA, Hauser CJ, Lu Q, Zaets S, Berezina T, Machiedo GW, Rajwani KK, Xu DZ. Albumin protects against gut-induced lung injury in vitro and in vivo. Ann Surg 2004; 240:331-9. [PMID: 15273559 PMCID: PMC1356411 DOI: 10.1097/01.sla.0000133359.12284.6b] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Since albumin has the ability to detoxify, we assessed whether low-dose albumin could protect against trauma/hemorrhagic shock (T/HS)-induced endothelial cell, lung, gut, and red blood cell (RBC) injury in vivo and endothelial cell injury in vitro. SUMMARY BACKGROUND DATA T/HS cause ischemic insult to the gut, resulting in the release of biologically active factors into the mesenteric lymph, which then cause injury to multiple distant organs. METHODS In vitro experiments tested the ability of albumin to reduce the cytotoxicity of mesenteric lymph from male rats subjected to T/HS (laparotomy + MAP 30 mm Hg for 90 minutes) for human umbilical vein endothelial cell (HUVEC). In subsequent in vivo experiments, the ability of albumin given as part of the resuscitation regimen to protect against T/HS-induced injury was tested by comparing the magnitude of injury in T/HS rats receiving human albumin (shed blood + 0.12, 0.24, or 0.36 g/kg) or lactated Ringer's solution (shed blood + 2 x volume of shed blood as LR) with that observed in rats subjected to trauma/sham shock. Rats were killed after a 3-hour recovery period and had lung permeability evaluated by bronchoalveolar lavage and myeloperoxidase assays, intestinal microvillous injury by histology, and RBC deformability using ektacytometry. RESULTS Both bovine and human albumin prevented T/HS lymph-induced HUVEC cytotoxicity in vitro, even when added 30 minutes after the lymph (viability 15 +/- 4% to 88 +/- 3%, P < 0.01). In vivo RBC deformability was better preserved by blood plus albumin than blood plus lactated Ringer's solution (P < 0.01). Likewise, albumin administration reduced T/HS-induced lung permeability and neutrophil sequestration in a dose-dependent fashion, with 0.36 g/kg of albumin effecting total lung protection (P < 0.01). In contrast, albumin treatment did not prevent T/HS-induced gut injury. CONCLUSIONS Low-dose albumin protects against gut lymph-induced lung, HUVEC, and RBC injury by neutralizing T/HS lymph toxicity.
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Affiliation(s)
- Adena J Osband
- Department of Surgery, New Jersey Medical School, Newark, NJ 07101-1709, USA
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Marshall AP, West SH. Gastric tonometry and monitoring gastrointestinal perfusion: using research to support nursing practice. Nurs Crit Care 2004; 9:123-33. [PMID: 15152754 DOI: 10.1111/j.1478-5153.2004.00056.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The principles and physiological underpinnings of gastric tonometry are reviewed. Tonometric variables, including the PtCO2, pHi and CO2 gap, are described and critiqued as measurements of gastrointestinal perfusion. Increases in gastrointestinal CO2 unrelated to gastrointestinal hypoperfusion are discussed within different clinical contexts. The technical limitations of gastric tonometry, including procedural errors and PtCO2 measurement are discussed in relation to the accuracy of tonometric measurements. Tonometric measurement using semi-continuous air tonometry is introduced as a strategy to minimize technical limitations.
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Affiliation(s)
- Andrea P Marshall
- Department of Clinical Nursing, The University of Sydney, Sydney, Australia.
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Baylor AE, Diebel LN, Liberati DM, Dulchavsky SA, Brown WJ, Diglio CA. The synergistic effects of hypoxia/reoxygenation or tissue acidosis and bacteria on intestinal epithelial cell apoptosis. THE JOURNAL OF TRAUMA 2003; 55:241-7; discussion 247-8. [PMID: 12913632 DOI: 10.1097/01.ta.0000079249.50967.c5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Clinical data indicate that gut perfusion deficits must be rectified within 24 hours after traumatic injury to decrease organ failure and death. Ischemia/reperfusion injury to the gut causes enterocyte apoptosis (Apo), which may contribute to intestinal barrier failure. The temporal response of enterocyte Apo to acidosis and hypoxia/reoxygenation (H/R) in vitro is unknown. The purpose of this study was to examine the effect of various time points of acidosis or H/R on enterocyte apoptosis and monolayer integrity in an in vitro model. METHODS Caco-2 cell monolayers were made acidic (Dulbecco's modified Eagle's medium, pH 6.9) by hydrochloric acid or exposed to 95% nitrogen/5% carbon dioxide (hypoxia) and then 21% oxygen (reoxygenation). Escherichia coli C-25 were added to the apical media in subsets. Apo and necrosis were quantified by flow cytometry. Permeability was determined by fluorescein isothiocyanate-dextran. Transepithelial electrical resistance (TEER) indexed monolayer. RESULTS Extracellular acidosis and C-25 significantly increased apoptosis of Caco-2 cells at 18 hours (extracellular acidosis [EC] + C-25, 14.5 +/- 3.0; control, 3.8 +/- 0.8; p < 0.001 by analysis of variance). Similarly, the H/R + C-25 group showed a significant increase in apoptosis at 12 hours (H/R + C-25 vs. control, 22.86 +/- 2.12 vs. 3.74 +/- 0.7; p < 0.001 by analysis of variance). The permeability difference was not significant for EC + C-25 versus control at 18 hours (0.68 +/- 0.25 vs. 0.43 +/- 0.0.0.36, respectively; p > 0.05). The H/R + C-25 group had a profound increase in permeability over control at 12 hours (10.8 +/- 0.5 vs. 2.1 +/- 0.3, respectively; p < 0.001). The TEER was significantly lowered for EC versus control at 18 hours (458 +/- 1.5 vs. 468 +/- 8.2) and at 0, 6, and 18 hours for EC + C-25 (409 +/- 28.1, 443 +/- 16.8, and 438 +/- 8.9 vs. 455 +/- 6.5, 467 +/- 6.5, and 469 +/- 8.2, respectively). There was no significant change in the H/R and H/R + C-25 groups. CONCLUSION Synergism of H/R or tissue acidosis and bacteria caused increased Apo, TEER, and permeability in vitro.
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Affiliation(s)
- Alfred E Baylor
- Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan 48201, USA.
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Deitch EA, Shi HP, Lu Q, Feketeova E, Xu DZ. Serine proteases are involved in the pathogenesis of trauma-hemorrhagic shock-induced gut and lung injury. Shock 2003; 19:452-6. [PMID: 12744489 DOI: 10.1097/01.shk.0000048899.46342.f6] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The objective of this work was to test the hypothesis that Intraluminal serine proteases are involved in trauma-hemorrhagic shock (T/HS)-induced intestinal and lung injury. Male Sprague-Dawley rats were administrated the serine protease inhibitor (6-amidino-2-naphthyl p-guanidinobenzoate dimethanesulfate, Nafamostat) either intraluminally into the gut or intravenously after a laparotomy (trauma) and then subjected to 90 min of hemorrhagic shock (T/HS) or sham shock (T/SS). Intestinal and lung injury was assessed at 3 h after resuscitation with Ringer's lactate solution. In a second set of experiments, mesenteric lymph was collected from the groups of rats subjected to T/HS or T/SS and its ability to activate normal neutrophils was tested. Lung permeability, pulmonary myeloperoxidase levels, and the bronchoalveolar lavage fluid protein to plasma protein ratio were increased after T/HS but were significantly decreased in the T/HS rats receiving intraluminal (P < 0.05), but not intravenous, nafamostat. Likewise, T/HS-induced intestinal villus injury was less in the nafamostat-treated shock rats (P < 0.05). Last, the ability of T/HS mesenteric lymph to increase PMN CD11b expression or prime neutrophils for an augmented respiratory burst was significantly reduced by the intraluminal administration of nafamostat. Because intraluminal nafamostat reduced T/HS-induced gut and lung injury as well as the neutrophil activating ability of intestinal T/HS lymph, the presence of serine proteases in the ischemic gut may play an important role in T/HS-induced gut and hence lung injury.
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Affiliation(s)
- Edwin A Deitch
- Department of Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey 07103, USA
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Knudson MM, Lee S, Erickson V, Morabito D, Derugin N, Manley GT. Tissue oxygen monitoring during hemorrhagic shock and resuscitation: a comparison of lactated Ringer's solution, hypertonic saline dextran, and HBOC-201. THE JOURNAL OF TRAUMA 2003; 54:242-52. [PMID: 12579047 DOI: 10.1097/01.ta.0000037776.28201.75] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The ideal resuscitation fluid for the trauma patient would be readily available to prehospital personnel, universally compatible, effective when given in small volumes, and capable of reversing tissue hypoxia in critical organ beds. Recently developed hemoglobin-based oxygen-carrying solutions possess many of these properties, but their ability to restore tissue oxygen after hemorrhagic shock has not been established. We postulated that a small-volume resuscitation with HBOC-201 (Biopure) would be more effective than either lactated Ringer's (LR) solution or hypertonic saline dextran (HSD) in restoring baseline tissue oxygen tension levels in selected tissue beds after hemorrhagic shock. We further hypothesized that changes in tissue oxygen tension measurements in the deltoid muscle would reflect the changes seen in the liver and could thus be used as a monitor of splanchnic resuscitation. METHODS This study was a prospective, blinded, randomized resuscitation protocol using anesthetized swine (n = 30), and was modeled to approximate an urban prehospital clinical time course. After instrumentation and splenectomy, polarographic tissue oxygen probes were placed into the liver (liver PO2) and deltoid muscle (muscle PO2) for continuous tissue oxygen monitoring. Swine were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg over 20 minutes, shock was maintained for another 20 minutes, and then 100% oxygen was administered. Animals were then randomized to receive one of three solutions: LR (12 mL/kg), HSD (4 mL/kg), or HBOC-201 (6 mL/kg). Physiologic variables were monitored continuously during all phases of the experiment and for 2 hours postresuscitation. RESULTS At a MAP of 40 mm Hg, tissue PO2 was 20 mm Hg or less in both the liver and muscle beds. There were no significant differences in measured liver or muscle PO2 values after resuscitation with any of the three solutions in this model of hemorrhagic shock. When comparing the hemodynamic effects of resuscitation, the cardiac output was increased from shock values in all three animal groups with resuscitation, but was significantly higher in the animals resuscitated with HSD. Similarly, MAP was increased by all solutions during resuscitation, but remained significantly below baseline except in the group of animals receiving HBOC-201 (p < 0.01). HBOC-201 was most effective in both restoring and sustaining MAP and systolic blood pressure. There was excellent correlation between liver and deltoid muscle tissue oxygen values (r = 0.8, p < 0.0001). CONCLUSION HBOC-201 can be administered safely in small doses and compared favorably to resuscitation with HSD and LR solution in this prehospital model of hemorrhagic shock. HBOC-201 is significantly more effective than HSD and LR solution in restoring MAP and systolic blood pressure to normal values. Deltoid muscle PO2 reflects liver PO2 and thus may serve as an index of the adequacy of resuscitation in critical tissue beds.
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Flint RS, Windsor JA. The role of the intestine in the pathophysiology and management of severe acute pancreatitis. HPB (Oxford) 2003; 5:69-85. [PMID: 18332961 PMCID: PMC2020573 DOI: 10.1080/13651820310001108] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The outcome of severe acute pancreatitis has scarcely improved in 10 years. Further impact will require new paradigms in pathophysiology and treatment. There is accumulating evidence to support the concept that the intestine has a key role in the pathophysiology of severe acute pancreatitis which goes beyond the notion of secondary pancreatic infection. Intestinal ischaemia and reperfusion and barrier failure are implicated in the development of multiple organ failure. DISCUSSION Conventional management of severe acute pancreatitis has tended to ignore the intestine. More recent attempts to rectify this problem have included 1) resuscitation aimed at restoring intestinal blood flow through the use of appropriate fluids and splanchnic-sparing vasoconstrictors or inotropes; 2) enteral nutrition to help maintain the integrity of the intestinal barrier; 3) selective gut decontamination and prophylactic antibiotics to reduce bacterial translocation and secondary infection. Novel therapies are being developed to limit intestinal injury, and these include antioxidants and anti-cytokine agents. This paper focuses on the role of the intestine in the pathogenesis of severe acute pancreatitis and reviews the implications for management.
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Affiliation(s)
- RS Flint
- Pancreatitis Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of AucklandAucklandNew Zealand
| | - JA Windsor
- Pancreatitis Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of AucklandAucklandNew Zealand
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Abstract
Although it has never been prospectively validated, the base excess (BE) is regarded as the standard end-point of resuscitation in trauma patients. In a rat hemorrhage model, in this edition of Critical Care, Totapally and colleagues demonstrate that the BE is an insensitive and slowly responsive indicator of changes in intravascular volume. This contrasts with changes in the esophageal-arterial carbon dioxide gap which more closely followed changes in blood volume. Esophageal or sublingual capnometry may prove to be a useful tool for monitoring the adequacy of resuscitation in trauma victims.
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Affiliation(s)
- Paul E Marik
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Chapman MV, Woolf RL, Bennett-Guerrero E, Mythen MG. The effect of hypothermia on calculated values using saline and automated air tonometry. J Cardiothorac Vasc Anesth 2002; 16:304-7. [PMID: 12073201 DOI: 10.1053/jcan.2002.124138] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To quantify in vitro the effect of hypothermia on results obtained when performing automated air tonometry (Tonocap, Datex-Ohmeda, Instrumentarium Corp, Helsinki, Finland) and saline tonometry. DESIGN In vitro validation study. SETTING University hospital research laboratory. INTERVENTIONS Two TRIP sigmoid catheters, one connected to the Tonocap device and the other instilled with 2.5 mL of 0.9% saline, were placed in a saline bath at 30.3 degrees C (mean) through which 5% carbon dioxide (CO(2)) was bubbled. MEASUREMENTS AND MAIN RESULTS A total of 50 paired measurements were taken at 30-minute equilibration times of saline bath CO(2) tension and saline tonometry and air tonometry readings. Saline samples were analyzed at 37 degrees C and corrected for temperature. Bias and precision of each technique as a percentage of predicted CO(2) values were calculated. The Tonocap device had bias and precision values of -2.6% and +/-1.4%. Measurement of CO(2) is in the gaseous phase so that temperature correction is not required. Saline tonometry readings processed at 37 degrees C exhibited a large positive bias of 23.06% (precision +/- 7.02%). Correction for temperature improved bias to -10.98 % with a similar precision profile of +/-5.78%. CONCLUSION When using gastrointestinal tonometry during hypothermic cardiopulmonary bypass, saline tonometry samples should be temperature corrected. The Tonocap device proved the most accurate and precise measurement technique independent of the need for temperature correction.
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Monitoring Intensive Care Patients. Intensive Care Med 2002. [DOI: 10.1007/978-1-4757-5551-0_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
The central concept of this review is that gut-derived factors contained primarily in the mesenteric lymph rather than the portal blood contribute to distant organ injury. This hypothesis is supported by recent studies indicating that division of the mesenteric lymphatic ducts prevents lung injury after hemorrhagic shock and significantly ameliorates lung injury after thermal injury. The mechanism of hemorrhagic shock-induced lung injury appears to be through mesenteric lymph-induced activation of neutrophils and activation/injury of endothelial cells. This notion is supported by in vitro studies indicating that mesenteric lymph, but not portal vein plasma, collected after a nonlethal episode of hemorrhagic shock activates neutrophils, increases endothelial cell monolayer permeability, and can even cause endothelial cell death. This concept that gut-derived factors contained primarily in the mesenteric lymph rather than the portal system potentiate the development of distant organ (lung) injury, if correct, would help clarify several important issues. First, because the lung is the first organ exposed to mesenteric lymph (i.e., mesenteric lymph enters the subclavian via the thoracic duct), it would help explain the clinical observation of why the lung is generally the first organ to fail in severely injured patients. Second, this gut lymphatic hypothesis would provide new information on the pathophysiology of gut-induced lung injury. Finally, it would help explain the discordant results between experimental and some clinical studies on the role of gut injury and loss of gut barrier function in the development of a systemic inflammatory state and distant organ injury.
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Affiliation(s)
- E A Deitch
- Department of Surgery, New Jersey Medical School, Room G-506, 185 South Orange Avenue, Newark, NJ 07103, USA.
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Abstract
Gastric tonometry has proved to be a sensitive but not specific predictor of outcome in the critically ill. The data accumulated to date indicate that those patients able to achieve or maintain a normal gastric mucosal pH do better than those who do not. In addition, therapy aimed at improving an abnormal gastric mucosal pH has proved to be less successful. These findings may simply indicate that tonometry identifies those "responders" and "nonresponders," as becomes increasingly apparent in populations of critical care patients receiving interventional therapy. Gastric tonometry has undergone a number of methodologic changes over the last decade, seeing a switch from saline to automated gas tonometry. Along with this switch of methodology has come a deeper scrutiny of the indices used to assess gut perfusion. Most studies (including all the interventional ones) have used gastric mucosal pH. The newer indices of gut luminal PCO2 (PgCO2) referenced to arterial CO2 (PgCO2-PaCO2) or end tidal CO2 (PgCO2-PeCO2), although relatively well validated, remain to be proven as predictors of outcome or guides to interventional therapy. If we take a fresh look at the interventional trials in intensive care patients, there is a very definite trend toward benefit in the protocol groups, although they are generally reported as negative studies. There is much to be accomplished, however, before we accept the gastric tonometer as a routine tool with which to guide therapy based on gastrointestinal perfusion, including a greater understanding of gastrointestinal physiology and, as ever, the call for an adequately powered prospective randomized controlled trial to evaluate the clinical utility of gas tonometry.
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Affiliation(s)
- M A Hamilton
- Center for Anesthesia, Middlesex Hospital, and Center for Anesthesia, University College, London, UK
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Träger K, Radermacher P, Brinkmann A, Calzia E, Kiefer P. Gastrointestinal tract resuscitation in critically ill patients. Curr Opin Clin Nutr Metab Care 2001; 4:131-5. [PMID: 11224658 DOI: 10.1097/00075197-200103000-00009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Particular research interest is currently focusing on the resuscitation of the gastrointestinal tract, because the gut is regarded to be both the "canary of the body", i.e. a sentinel organ during situations of compromised oxygen or substrate supply, as well as the "motor of multiple organ failure". Several therapeutic strategies have recently been proposed for the resuscitation of this organ system, aimed primarily at the augmentation of blood flow and oxygenation but also integrating nutritional or metabolic support and antioxidant administration.
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Affiliation(s)
- K Träger
- Postoperative Intensive Care Medicine, University Medical School, D-89073 Ulm, Germany
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Noone RB, Bolden JE, Mythen MG, Vaslef SN. Comparison of the response of saline tonometry and an automated gas tonometry device to a change in CO2. Crit Care Med 2000; 28:3728-33. [PMID: 11098981 DOI: 10.1097/00003246-200011000-00032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the speed of response of saline tonometry and an automated gas tonometry system by using standard tonometry catheters. DESIGN In vitro validation study. SETTING Experimental research laboratory. INTERVENTIONS Tonometry catheters were placed in a test chamber designed to simulate the lumen of a hollow viscus and were exposed to a rapid change in CO2 from 0% to 5% or 10%. Measured CO2 over time was fit to a mathematical model to determine the response time constant (the time to reach 63% of the final value) for each system. MEASUREMENTS AND MAIN RESULTS Response time to a change in CO2 was significantly faster with the automated gas system than with traditional saline tonometry. The mathematical time constant for a 5% change in CO2 in a gas environment was 2.8 mins (95% confidence interval, 2.6-3.0 mins) for the gas and 6.3 mins (95% confidence interval, 5.8-7.3 mins) for the saline technique. These times were longer for the CO2 change in a liquid environment: The time constant was 4.6 mins (95% confidence interval, 4.5-4.7 mins) for the gas system and 7.8 mins (95% confidence interval, 7.15-8.6 mins) for the saline tonometry. There was a significantly lower final equilibration value for the CO2 measurement with saline tonometry. There was essentially no difference in time constants for each system for a 5% change compared with a 10% CO2 change, except for a slightly faster time constant for the gas tonometry system with a 5% change in the gas environment (5%: 2.8 mins vs. 10%: 3.3 mins). CONCLUSIONS The automated gas tonometry system has a significantly faster response to a change in CO2 than conventional saline tonometry.
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Affiliation(s)
- R B Noone
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Gastrointestinal PCO2 tonometry in 1998. Curr Opin Crit Care 1999. [DOI: 10.1097/00075198-199906000-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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FitzGerald JF, Fox SH, Civetta JM, Kirton OC, Hudson-Civetta JA. Strategies to prevent organ failure. Curr Opin Anaesthesiol 1999; 12:115-9. [PMID: 17013301 DOI: 10.1097/00001503-199904000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The gastrointestinal tract and the generalized inflammatory response initiated by severe injury or infection have been implicated in the pathophysiology of multiple-organ system failure. Once multiple-organ system failure has occurred, treatment focuses on supporting end-organ function. Recent studies have shown, however, that it may be possible to reduce the incidence and prevalence of multiple-organ system failure by controlling the reperfusion injury cascade, normalizing gastrointestinal blood flow and preserving the integrity of the gastrointestinal immune barrier.
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