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Ventilation Strategies During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches Among Level IV Neonatal ICUs. Crit Care Explor 2022; 4:e0779. [DOI: 10.1097/cce.0000000000000779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hatami S, Hefler J, Freed DH. Inflammation and Oxidative Stress in the Context of Extracorporeal Cardiac and Pulmonary Support. Front Immunol 2022; 13:831930. [PMID: 35309362 PMCID: PMC8931031 DOI: 10.3389/fimmu.2022.831930] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal circulation (ECC) systems, including cardiopulmonary bypass, and extracorporeal membrane oxygenation have been an irreplaceable part of the cardiothoracic surgeries, and treatment of critically ill patients with respiratory and/or cardiac failure for more than half a century. During the recent decades, the concept of extracorporeal circulation has been extended to isolated machine perfusion of the donor organ including thoracic organs (ex-situ organ perfusion, ESOP) as a method for dynamic, semi-physiologic preservation, and potential improvement of the donor organs. The extracorporeal life support systems (ECLS) have been lifesaving and facilitating complex cardiothoracic surgeries, and the ESOP technology has the potential to increase the number of the transplantable donor organs, and to improve the outcomes of transplantation. However, these artificial circulation systems in general have been associated with activation of the inflammatory and oxidative stress responses in patients and/or in the exposed tissues and organs. The activation of these responses can negatively affect patient outcomes in ECLS, and may as well jeopardize the reliability of the organ viability assessment, and the outcomes of thoracic organ preservation and transplantation in ESOP. Both ECLS and ESOP consist of artificial circuit materials and components, which play a key role in the induction of these responses. However, while ECLS can lead to systemic inflammatory and oxidative stress responses negatively affecting various organs/systems of the body, in ESOP, the absence of the organs that play an important role in oxidant scavenging/antioxidative replenishment of the body, such as liver, may make the perfused organ more susceptible to inflammation and oxidative stress during extracorporeal circulation. In the present manuscript, we will review the activation of the inflammatory and oxidative stress responses during ECLP and ESOP, mechanisms involved, clinical implications, and the interventions for attenuating these responses in ECC.
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Affiliation(s)
- Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Joshua Hefler
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Department of Physiology, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Darren H. Freed,
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Cho HW, Song IA, Oh TK. Prior Statin Therapy and Mortality After Extracorporeal Membrane Oxygenation Therapy: A Retrospective, Population-Based, Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3612-3619. [PMID: 33715948 DOI: 10.1053/j.jvca.2021.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate whether prior statin therapy is associated with an improvement in mortality among patients who undergo extracorporeal membrane oxygenation (ECMO) therapy. DESIGN Retrospective, population-based, cohort study. SETTING Health records were obtained from the National Health Insurance Service database in South Korea. PATIENTS All adult patients (≥18 y) who underwent ECMO therapy in the intensive care unit between 2005 and 2018 were enrolled. EXPOSURES Statin users were defined as patients who were prescribed continuous oral statins ≥90 days before ECMO. MEASUREMENTS AND MAIN RESULTS The primary endpoint of this study was 90-day mortality. A total of 21,129 adult patients from 128 hospitals were included (4,737 [22.4%] statin users and 16,392 [77.6%] nonusers). After propensity score matching, 9,474 ECMO patients (4,737 in each group) were included in the final analysis. In the propensity-score-matched cohort, statin users exhibited lower 90-day mortality than did nonusers (58.6% [2,774/4,737] in statin users v 65.6% [3,106/4,737] in nonusers). In addition, on Cox regression, 90-day mortality in statin users was 14% less than that in nonusers (hazard ratio 0.86, 95% confidence interval 0.81-0.90; p < 0.001). CONCLUSION Among patients who underwent ECMO in South Korea, prior statin therapy was found to be associated with lower 90-day mortality rates after ECMO therapy. However, because this study had a retrospective design, future prospective trials are needed to confirm the findings.
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Affiliation(s)
- Hyoung-Won Cho
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
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Study Protocol for a Pilot, Open-Label, Prospective, and Observational Study to Evaluate the Pharmacokinetics of Drugs Administered to Patients during Extracorporeal Circulation; Potential of In Vivo Cytochrome P450 Phenotyping to Optimise Pharmacotherapy. Methods Protoc 2019; 2:mps2020038. [PMID: 31164617 PMCID: PMC6632166 DOI: 10.3390/mps2020038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/05/2019] [Accepted: 05/07/2019] [Indexed: 12/05/2022] Open
Abstract
Pharmacokinetic alterations of medications administered during surgeries involving cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) have been reported. The impact of CPB on the cytochrome P450 (CYP) enzymes’ activity is the key factor. The metabolic rates of caffeine, dextromethorphan, midazolam, omeprazole, and Losartan to the CYP-specific metabolites are validated measures of in vivo CYP 1A2, 2D6, 3A4, 2C19, and 2C9 activities, respectively. The study aim is to assess the activities of major CYPs in patients on extracorporeal circulation (EC). This is a pilot, prospective, open-label, observational study in patients undergoing surgery using EC and patients undergoing laparoscopic cholecystectomy as a control group. CYP activities will be measured on the day, and 1–2 days pre-surgery/3–4 days post-surgery (cardiac surgery and Laparoscopic cholecystectomy) and 1–2 days after starting ECMO, 1–2 weeks after starting ECMO, and 1–2 days after discontinuation from ECMO. Aforementioned CYP substrates will be administered to the patient and blood samples will be collected at 0, 1, 2, 4, and 6 h post-dose. Major CYP enzymes’ activities will be compared in each participant on the day, and before/after surgery. The CYP activities will be compared in three study groups to investigate the impact of CYPs on EC.
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Raffaeli G, Ghirardello S, Passera S, Mosca F, Cavallaro G. Oxidative Stress and Neonatal Respiratory Extracorporeal Membrane Oxygenation. Front Physiol 2018; 9:1739. [PMID: 30564143 PMCID: PMC6288438 DOI: 10.3389/fphys.2018.01739] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/19/2018] [Indexed: 12/16/2022] Open
Abstract
Oxidative stress is a frequent condition in critically ill patients, especially if exposed to extracorporeal circulation, and it is associated with worse outcomes and increased mortality. The inflammation triggered by the contact of blood with a non-endogenous surface, the use of high volumes of packed red blood cells and platelets transfusion, the risk of hyperoxia and the impairment of antioxidation systems contribute to the increase of reactive oxygen species and the imbalance of the redox system. This is responsible for the increased production of superoxide anion, hydrogen peroxide, hydroxyl radicals, and peroxynitrite resulting in increased lipid peroxidation, protein oxidation, and DNA damage. The understanding of the pathophysiologic mechanisms leading to redox imbalance would pave the way for the future development of preventive approaches. This review provides an overview of the clinical impact of the oxidative stress during neonatal extracorporeal support and concludes with a brief perspective on the current antioxidant strategies, with the aim to focus on the potential oxidative stress-mediated cell damage that has been implicated in both short and long-term outcomes.
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Affiliation(s)
- Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sofia Passera
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Abstract
OBJECTIVES Hemolysis is a known complication of pediatric extracorporeal membrane oxygenation associated with renal failure and mortality. We sought to identify predictors of hemolysis in pediatric extracorporeal membrane oxygenation patients and determine its influence on outcomes. DESIGN Retrospective, single-center study. SETTING Urban, quaternary care center pediatric and neonatal ICU. PATIENTS Ninety-six patients requiring extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Daily measurements of plasma-free hemoglobin were obtained while patients were on extracorporeal membrane oxygenation. Patients with a prior extracorporeal membrane oxygenation run, on extracorporeal membrane oxygenation for less than 24 hours, or without complete medical records were excluded from the study. Ninety-six patients met inclusion criteria, of which, 25 patients (26%) had plasma-free hemoglobin greater than 30 mg/dL. Of those patients, 15 of 25(60%) had plasma-free hemoglobin greater than 50 mg/dL, and 21 of 25(84%) occurred during the first 7 days on extracorporeal membrane oxygenation. Compared with patients without hemolysis, those with hemolysis were younger (0.2 mo [0.06-3.2 mo] vs 8.2 mo [0.6-86 mo]; p < 0.001), had a higher pericannulation international normalized ratio (3.9 [3.5-5.5] vs 2.6 [1.8-3.7]; p = 0.003), lower pericannulation platelet count (33 × 10/μL [22-42 × 10/μL] vs 61 × 10/μL [38-86 × 10/μL]; p < 0.001), and had a less negative inlet pressure (-3.5 mm Hg [-14 to 11.5 mm Hg] vs -19 mm Hg [-47 to 0 mm Hg]; p = 0.01). A greater proportion of patients with hemolysis had a heparin assay less than 0.2 mg/dL (50% vs 17%; p = 0.001) and had fluid removal via slow continuous ultrafiltration (32% vs 6%; p < 0.001). Patients with hemolysis had increased risk of in-hospital mortality (odds ratio 10.0; 95% CI 3.4-32; p < 0.001). On multivariable analysis, continuous ultrafiltration (odds ratio, 8.0; 95% CI, 1.9-42; p = 0.007) and pericannulation international normalized ratio greater than 3.5 (odds ratio, 7.2; 95% CI, 2.3-26; p = 0.001) were significantly associated with hemolysis. CONCLUSIONS Hemolysis is a common complication of pediatric extracorporeal membrane oxygenation. We found that patients with hemolysis (plasma-free hemoglobin > 30 mg/dL) had a 10-fold increase in in-hospital mortality. In our study cohort, hemolysis was associated with continuous ultrafiltration use, but not continuous renal replacement therapy. Additionally, our results suggest that the degree of coagulopathy (international normalized ratio > 3.5) at the time of cannulation influences hemolysis. Additional prospective studies are necessary to define further strategies to prevent hemolysis and improve outcomes in pediatric extracorporeal membrane oxygenation patients.
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Yost G, Bhat G, Pappas P, Tatooles A. The neutrophil to lymphocyte ratio in patients supported with extracorporeal membrane oxygenation. Perfusion 2018; 33:562-567. [PMID: 29701504 DOI: 10.1177/0267659118772455] [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] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The neutrophil to lymphocyte ratio (NLR) has proven to be a robust predictor of mortality in a wide range of cardiovascular diseases. This study investigated the predictive value of the NLR in patients supported by extracorporeal membrane oxygenation (ECMO) systems. METHODS This study included 107 patients who underwent ECMO implantation for cardiogenic shock. Median preoperative NLR was used to divide the cohort, with Group 1 NLR <14.2 and Group 2 with NLR ≥14.2. Survival, the primary outcome, was compared between groups. RESULTS The study cohort was composed of 64 (60%) males with an average age 53.1 ± 14.9 years. Patients in Group 1 had an average NLR of 7.5 ± 3.5 compared to 27.1 ± 19.9 in Group 2. Additionally, those in Group 2 had significantly higher preoperative blood urea nitrogen (BUN) and age. Survival analysis indicated a thirty-day survival of 56.2%, with significantly worsened mortality in patients with NLR greater than 14.2, p=0.047. DISCUSSION Our study shows the NLR has prognostic value in patients undergoing ECMO implantation. Leukocytes are known contributors to myocardial damage and neutrophil infiltration is associated with damage caused by myocardial ischemia.
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Affiliation(s)
- Gardner Yost
- Advocate Christ Medical Center, Center for Heart Transplant and Assist Devices, Heart and Vascular Institute Administration, Oak Lawn, IL, USA
| | - Geetha Bhat
- Advocate Christ Medical Center, Center for Heart Transplant and Assist Devices, Heart and Vascular Institute Administration, Oak Lawn, IL, USA
| | - Patroklos Pappas
- Advocate Christ Medical Center, Center for Heart Transplant and Assist Devices, Heart and Vascular Institute Administration, Oak Lawn, IL, USA
| | - Antone Tatooles
- Advocate Christ Medical Center, Center for Heart Transplant and Assist Devices, Heart and Vascular Institute Administration, Oak Lawn, IL, USA
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Millar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:387. [PMID: 27890016 PMCID: PMC5125043 DOI: 10.1186/s13054-016-1570-4] [Citation(s) in RCA: 403] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a technology capable of providing short-term mechanical support to the heart, lungs or both. Over the last decade, the number of centres offering ECMO has grown rapidly. At the same time, the indications for its use have also been broadened. In part, this trend has been supported by advances in circuit design and in cannulation techniques. Despite the widespread adoption of extracorporeal life support techniques, the use of ECMO remains associated with significant morbidity and mortality. A complication witnessed during ECMO is the inflammatory response to extracorporeal circulation. This reaction shares similarities with the systemic inflammatory response syndrome (SIRS) and has been well-documented in relation to cardiopulmonary bypass. The exposure of a patient’s blood to the non-endothelialised surface of the ECMO circuit results in the widespread activation of the innate immune system; if unchecked this may result in inflammation and organ injury. Here, we review the pathophysiology of the inflammatory response to ECMO, highlighting the complex interactions between arms of the innate immune response, the endothelium and coagulation. An understanding of the processes involved may guide the design of therapies and strategies aimed at ameliorating inflammation during ECMO. Likewise, an appreciation of the potentially deleterious inflammatory effects of ECMO may assist those weighing the risks and benefits of therapy.
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Affiliation(s)
- Jonathan E Millar
- Critical Care Research Group, University of Queensland, Brisbane, Australia. .,Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Queensland, 4032, Australia.
| | - Jonathon P Fanning
- Critical Care Research Group, University of Queensland, Brisbane, Australia
| | - Charles I McDonald
- Critical Care Research Group, University of Queensland, Brisbane, Australia
| | - Daniel F McAuley
- Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John F Fraser
- Critical Care Research Group, University of Queensland, Brisbane, Australia
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Miura Y, Saito M, Usuda H, Woodward E, Rittenschober-Böhm J, Kannan PS, Musk GC, Matsuda T, Newnham JP, Kemp MW. Ex-Vivo Uterine Environment (EVE) Therapy Induced Limited Fetal Inflammation in a Premature Lamb Model. PLoS One 2015; 10:e0140701. [PMID: 26473607 PMCID: PMC4608829 DOI: 10.1371/journal.pone.0140701] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 09/28/2015] [Indexed: 11/25/2022] Open
Abstract
Introduction Ex-vivo uterine environment (EVE) therapy uses an artificial placenta to provide gas exchange and nutrient delivery to a fetus submerged in an amniotic fluid bath. Development of EVE may allow us to treat very premature neonates without mechanical ventilation. Meanwhile, elevations in fetal inflammation are associated with adverse neonatal outcomes. In the present study, we analysed fetal survival, inflammation and pulmonary maturation in preterm lambs maintained on EVE therapy using a parallelised umbilical circuit system with a low priming volume. Methods Ewes underwent surgical delivery at 115 days of gestation (term is 150 days), and fetuses were transferred to EVE therapy (EVE group; n = 5). Physiological parameters were continuously monitored; fetal blood samples were intermittently obtained to assess wellbeing and targeted to reference range values for 2 days. Age-matched animals (Control group; n = 6) were surgically delivered at 117 days of gestation. Fetal blood and tissue samples were analysed and compared between the two groups. Results Fetal survival time in the EVE group was 27.0 ± 15.5 (group mean ± SD) hours. Only one fetus completed the pre-determined study period with optimal physiological parameters, while the other 4 animals demonstrated physiological deterioration or death prior to the pre-determined study end point. Significant elevations (p<0.05) in: i) inflammatory proteins in fetal plasma; ii) selected cytokine/chemokine mRNA expression levels in fetal tissues; and iii) histological inflammatory score in fetal lung, were observed in the EVE group compared to the Control group. There was no significant difference (p>0.05) in surfactant protein mRNA expression level between the two groups. Conclusion In this study, we achieved limited fetal survival using EVE therapy. Despite this, EVE therapy only induced a modest fetal inflammatory response and did not promote lung maturation. These data provide additional insight into markers of treatment efficacy for the assessment of future studies.
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Affiliation(s)
- Yuichiro Miura
- School of Women's and Infants' Health, The University of Western Australia, Crawley, Western Australia, Australia
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- * E-mail:
| | - Masatoshi Saito
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Haruo Usuda
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Eleanor Woodward
- School of Women's and Infants' Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Judith Rittenschober-Böhm
- School of Women's and Infants' Health, The University of Western Australia, Crawley, Western Australia, Australia
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University of Vienna, Vienna, Austria
| | - Paranthaman S. Kannan
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Gabrielle C. Musk
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, Western Australia, Australia
- Animal Care Services, The University of Western Australia, Crawley, Western Australia, Australia
| | - Tadashi Matsuda
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - John P. Newnham
- School of Women's and Infants' Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Matthew W. Kemp
- School of Women's and Infants' Health, The University of Western Australia, Crawley, Western Australia, Australia
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[Acute respiratory distress syndrome and septic cardiomyopathy : successful application of veno-venoarterial extracorporeal membrane oxygenation]. Anaesthesist 2013; 62:639-43. [PMID: 23917895 DOI: 10.1007/s00101-013-2213-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 06/30/2013] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
Abstract
A 30-year-old patient was admitted to hospital with fever and respiratory insufficiency due to community acquired pneumonia. Within a few days the patient developed septic cardiomyopathy and severe acute respiratory distress syndrome (ARDS) which deteriorated under conventional mechanical ventilation. Peripheral venoarterial extracorporeal membrane oxygenation (va-ECMO) was initiated by the retrieval team of an ARDS/ECMO centre at a paO2/FIO2 ratio of 73 mmHg and a left ventricular ejection fraction (EF) of 10 %. After 12 h va-ECMO was converted to veno-venoarterial ECMO (vva-ECMO) for improvement of pulmonary and systemic oxygenation. Left ventricular function improved (EF 45 %) 36 h after starting ECMO and the patient was weaned from vva-ECMO and converted to vv-ECMO. The patient was weaned successfully from vv-ECMO after 5 additional days and transferred back to the referring hospital for weaning from the ventilator.
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Boulate D, Luyt CE, Pozzi M, Niculescu M, Combes A, Leprince P, Kirsch M. Acute lung injury after mechanical circulatory support implantation in patients on extracorporeal life support: an unrecognized problem†. Eur J Cardiothorac Surg 2013; 44:544-9; discussion 549-50. [DOI: 10.1093/ejcts/ezt125] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Mu TS, Palmer EG, Batts SG, Lentz-Kapua SL, Uyehara-Lock JH, Uyehara CFT. Continuous renal replacement therapy to reduce inflammation in a piglet hemorrhage-reperfusion extracorporeal membrane oxygenation model. Pediatr Res 2012; 72:249-55. [PMID: 22669297 DOI: 10.1038/pr.2012.69] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND During extracorporeal membrane oxygenation (ECMO), circulation of blood across synthetic surfaces triggers an inflammatory response. Therefore, we evaluated the ability of continuous renal replacement therapy (CRRT) to remove cytokines and reduce the inflammatory response in a piglet hemorrhage-reperfusion ECMO model. METHODS Three groups were studied: (i) uninjured controls (n = 11); (ii) hemorrhage-reperfusion while on venoarterial ECMO (30% hemorrhage with subsequent blood volume replacement within 60 min) (n = 8); (iii) treatment with CRRT after hemorrhage-reperfusion while on ECMO (n = 7). Hemodynamic parameters, oxygen utilization, and plasma and broncho-alveolar lavage (BAL) cytokine levels were recorded and lung tissue samples collected for histologic comparison. RESULTS Whereas mean arterial pressures decreased among hemorrhage-reperfusion piglets, ECMO with CRRT did not significantly alter mean arterial pressures or systemic vascular resistance and was able to maintain blood flow as well as oxygen delivery after hemorrhage-reperfusion. Plasma interleukin (IL)-6 and IL-10, and BAL tumor necrosis factor (TNF)-α, IL-1β, IL-6, IL-8, and IL-10 increased as a result of hemorrhage-reperfusion while on ECMO. After a 6-h period of CRRT, plasma IL-6 and BAL TNF-α, IL-6, and IL-8 levels decreased. CONCLUSION Data suggest CRRT may decrease inflammatory cytokine levels during the initial phase of ECMO therapy following hemorrhage-reperfusion while maintaining cardiac output and oxygen utilization.
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Affiliation(s)
- Thornton S Mu
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, Hawaii, USA.
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Schöffmann G, Winter P, Palme R, Pollak A, Trittenwein G, Golej J. Haemodynamic changes and stress responses of piglets to surgery during total intravenous anaesthesia with propofol and fentanyl. Lab Anim 2009; 43:243-8. [DOI: 10.1258/la.2008.0080026] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of the study was to assess the haemodynamic (blood pressure and heart rate) changes and stress responses (serum cortisol and serum amyloid A [SAA] concentrations) to surgery in piglets during total intravenous anaesthesia (TIVA) with propofol and fentanyl. After preanaesthetic medication with intramuscular midazolam (0.5 mg/kg body mass), ketamine (10 mg/kg) and butorphanol (0.5 mg/kg) anaesthesia was induced in five piglets, with intravenous propofol (1 mg/kg) followed by tracheal intubation and mechanical lung ventilation. Soft tissue surgery was performed in the jugular and inguinal regions during TIVA with propofol (8 mg/kg/h) and fentanyl (35 μg/kg/h). Anaesthesia was maintained for 300 min after surgery as the piglets were the control group of a project involving extracorporeal membrane oxygenation. Mean plasma cortisol concentration decreased significantly ( P < 0.05) from 59 ± 39.9 nmol/L (mean ± 1 SD) before surgery to 7.5 ± 2.5 nmol/L 300 min after end of surgical procedure. The mean SAA concentrations increased over the same period from 1.6 ± 2.3 μg/mL to 4.2 ± 5.6 μg/mL without statistical significance. The baseline (presurgery) mean arterial pressure (MAP) was 72 ± 9 mmHg compared with 72 ± 11 mmHg 300 min after end of surgery. Neither heart rate nor lactate concentrations changed significantly over the same time points: heart rate was 104 ± 11 and 103 ± 15 beats/min whereas mean lactate concentrations were reduced from 1.14 ± 0.45 mmol/L to 0.90 ± 0.22 mmol/L. Haemodynamic stability, a decrease in serum cortisol and a non-statistically significant rise in mean SAA concentrations suggest that the anaesthetic described suppresses the stress response of piglets to surgery without adverse cardiovascular effects. Therefore, it may prove useful in cardiovascular research.
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Affiliation(s)
- G Schöffmann
- Clinic of Anaesthesiology and Perioperative Intensive Care, Clinical Department of Small Animals and Horses, University of Veterinary Medicine Vienna, Austria
| | - P Winter
- Clinic for Ruminants, Clinical Department for Farm Animals and Heard Health Management, University of Veterinary Medicine Vienna, Austria
| | - R Palme
- Department of Natural Sciences, Institute of Biochemistry, University of Veterinary Medicine Vienna, Austria
| | - A Pollak
- Department of Pediatrics, Division of Neonatology and Pediatric Intensive Care, Medical University of Vienna, Waehringer Guertel 18–20, A-1090 Vienna, Austria
| | - G Trittenwein
- Department of Pediatrics, Division of Neonatology and Pediatric Intensive Care, Medical University of Vienna, Waehringer Guertel 18–20, A-1090 Vienna, Austria
| | - J Golej
- Department of Pediatrics, Division of Neonatology and Pediatric Intensive Care, Medical University of Vienna, Waehringer Guertel 18–20, A-1090 Vienna, Austria
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Tam CS, Wong M, Tam K, Aouad L, Waters KA. The effect of acute intermittent hypercapnic hypoxia treatment on IL-6, TNF-alpha, and CRP levels in piglets. Sleep 2007; 30:723-7. [PMID: 17580593 PMCID: PMC1978356 DOI: 10.1093/sleep/30.6.723] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is characterized by repeated episodes of upper-airway obstruction during sleep leading to significant hypercapnic hypoxic conditions. These conditions are associated with increased levels of proinflammatory cytokines (including interleukin [IL]-6, tumor necrosis factor [TNF]-alpha, and C-reactive protein [CRP]) and subsequent increased cardiovascular risk. It is unclear whether hypercapnic hypoxia itself causes inflammatory perturbations. DESIGN We evaluated circulating IL-6, TNF- a and CRP in a piglet model of infant OSA, following exposure to acute intermittent hypercapnic hypoxia (IHH). Study groups comprised of treatment (n = 8) and control (n = 8) groups. Treatment was two 90-minute sessions of IHH with arterial blood sampled before and after each IHH session. MEASUREMENTS AND RESULTS IL-6, TNF-alpha and CRP levels were measured before and after IHH treatment sessions. Results showed an increase in IL-6 following the first session of IHH that was neither sustained, nor repeated, during a subsequent exposure. Using mixed-modelling, TNF-alpha changed between time points and groups. There were no changes in CRP over the duration of the study. CONCLUSION These results suggest that acute hypoxia causes a transient increase in IL-6 levels and has implications for the pathogenesis of increased cardiovascular disease in OSA, especially in childhood.
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Affiliation(s)
| | - Melanie Wong
- The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Kimberley Tam
- Department of Medicine, The University of Sydney, NSW, Australia
| | - Leyla Aouad
- Department of Medicine, The University of Sydney, NSW, Australia
| | - Karen A. Waters
- The Children's Hospital at Westmead, Sydney, NSW, Australia
- Department of Medicine, The University of Sydney, NSW, Australia
- Address correspondence to: Dr. Karen A. Waters,
Department of Medicine, Room 206, Blackburn Building, DO6, University of Sydney, NSW 2006, Australia61 2 9351 516561 2 9550 3851
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15
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Munkeby BH, Børke WB, Bjørnland K, Sikkeland LIB, Borge GIA, Lømo J, Rivera S, Khrestchatisky M, Halvorsen B, Saugstad OD. Resuscitation of hypoxic piglets with 100% O2 increases pulmonary metalloproteinases and IL-8. Pediatr Res 2005; 58:542-8. [PMID: 16148071 DOI: 10.1203/01.pdr.0000179407.46810.2d] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We hypothesized that resuscitation with 100% O2 compared with 21% O2 is detrimental to pulmonary tissue. The pulmonary injury was assessed by matrix metalloproteinase (MMP) activity, oxidative stress, IL-8, and histology 2.5 h after resuscitation from a hypoxic state. In pulmonary tissue extracts, MMP activity was analyzed by broad matrix-degrading capacity (total MMP) and zymography. MMP-2 mRNA expression was evaluated by quantitative real-time PCR. Total endogenous antioxidant capacity was measured by the oxygen radical absorbance capacity (ORAC) assay, and IL-8 was analyzed by ELISA technique. In bronchoalveolar lavage (BAL) fluid, MMPs were analyzed by zymography. In pulmonary tissue, pro- and active MMP-2 levels were increased in piglets that were resuscitated with 100% O2 compared with 21% O2. Pro-MMP-9, total MMP activity, and MMP-2 mRNA levels were significantly increased in resuscitated piglets compared with baseline. Net gelatinolytic activity increased in submucosa and blood vessels after 100% O2 and only in the blood vessels after 21% O2. Compared with baseline, ORAC values were considerably lowered in the resuscitated piglets and significantly reduced in the 100% O2 versus 21% O2 group. In BAL fluid, both pro-MMP-9 and pro-MMP-2 increased 2-fold in the 100% O2 group compared with 21% O2. Moreover, IL-8 concentration increased significantly in piglets that were resuscitated with 100% O2 compared with 21% O2, suggesting a marked proinflammatory response in the pulmonary tissue. Altogether, these data strongly suggest that caution must be taken when applying pure O2 to the newborn infant.
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Affiliation(s)
- Berit Holthe Munkeby
- Department of Pediatric Research, Rikhospitalet University Hospital, Oslo, Norway.
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16
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de Mendonça-Filho HTF, Gomes RV, de Almeida Campos LA, Tura B, Nunes EM, Gomes R, Bozza F, Bozza PT, Castro-Faria-Neto HC. Circulating levels of macrophage migration inhibitory factor are associated with mild pulmonary dysfunction after cardiopulmonary bypass. Shock 2005; 22:533-7. [PMID: 15545824 DOI: 10.1097/01.shk.0000142817.84070.df] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Macrophage migration inhibitory factor (MIF) is a central mediator of inflammatory response and acute lung injury that is secreted in response to corticosteroids. A rise in systemic MIF levels was described after cardiac surgery in steroid-treated patients. This study aimed to investigate the circulating levels of MIF and the possible relationship of this cytokine to pulmonary dysfunction after cardiopulmonary bypass (CPB). We included 74 patients without previous organ dysfunction undergoing elective coronary artery bypass surgery (CABS). The same team performed all CABS via a standard technique adding methylprednisolone (15 mg/kg) to the CPB priming solution (Group MP, n = 37). In the remaining patients (Group NS, n = 37), methylprednisolone was withdrawn from the CPB priming. MIF, C-reactive protein (CRP), and total C3 were assayed in peripheral blood sampled immediately before anesthesia induction and 3, 6, and 24 h post-CPB. Preoperative risk scores and peri- and postoperative variables were documented. Postoperative kinetics of MIF and C3 were similar for both groups. Levels of CRP 24 h post-CPB were higher in Group MP (P = 0.003). Higher MIF levels were detected 6 h post-CPB, and returned to preoperative levels 24 h after CPB. MIF levels 6 h post-CPB were inversely related to the postoperative PaO2/FiO2 ratio (P = 0.0021) and were directly related to the duration of mechanical ventilation (P = 0.014). Perioperative use of methylprednisolone did not modify the MIF response to CPB, but it was related to an enhanced acute phase response. Higher circulating MIF levels 6 h post-CPB were associated with worse postoperative pulmonary short-course outcome.
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