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Kovacevic M, Adam VN, Causevic S. Triiodothyronine hormone supplementation therapy in septic shock patients with euthyroid sick syndrome: two pilot, placebo-controlled, randomized trials. Anaesth Crit Care Pain Med 2024; 43:101336. [PMID: 38061681 DOI: 10.1016/j.accpm.2023.101336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND To assess 28-day survival in two pilot groups of septic shock patients with euthyroid sick syndrome (ESS) supplemented with triiodothyronine (T3). METHODS A total of 95 septic shock patients with ESS were divided according to values of the thyroid hormones into low T3 and low T3T4 groups. Among 48 patients with low T3, 24 (50%) were randomized to T3 for 4 days and 24 (50%) to placebo. Among 47 patients with low T3T4, 24 (51%) were randomized to T3 for 4 days and 23 (49%) to placebo. The analysis included 28-day survival as the primary outcome and laboratory with hemodynamics as the secondary outcomes. Laboratory data were analyzed on the day of admission (T0), on the first (T1), third (T2) and seventh day (T3) with hemodynamics analyzed for the first four days. RESULTS In the low T3 population, 18 (75%) patients receiving T3 died at day 28 compared with 8 (33.3%) patients receiving placebo (p = 0.004). In the low T3T4 population, 6 (25%) patients receiving T3 died in ICU compared with 12 (52.1%) patients receiving placebo (p = 0.039). Oral T3 treatment increased mean arterial pressure values at day 1, day 3 and day 7 in the low T3T4 population, (p = 0.015, =0.005 and =0.042 respectively), and had no significant effect on these values in the low T3 population. CONCLUSION T3 supplementation was associated with a low 28-day mortality rate in patients with low T3T4 but with increased mortality in patients with low T3 ESS. These results suggest caution before initiating thyroid supplementation in septic patients. REGISTRATION ClinTrials.gov (NCT05270798).
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Affiliation(s)
- Mirza Kovacevic
- Department of Anesthesiology, Resuscitation and Intensive Care, Cantonal Hospital, Zenica, Bosnia and Herzegovina; Faculty of Medicine, Zenica, Bosnia and Herzegovina.
| | - Visnja Nesek Adam
- University Department of Anesthesiology, Resuscitation and Intensive Care, Clinical Hospital Sveti Duh, Zagreb, Croatia; Faculty of Medicine, Osijek, Croatia; Faculty of Dental Medicine and Health, University of Josip Juraj Strossmayer, Osijek, Croatia.
| | - Senada Causevic
- Department of Anesthesiology, Resuscitation and Intensive Care, Cantonal Hospital, Zenica, Bosnia and Herzegovina; Faculty of Medicine, Zenica, Bosnia and Herzegovina.
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Maiden MJ, Fraser JD, Finnis ME. Venous blood for the analysis of acid–base status in a model of septic shock. Emerg Med Australas 2022; 34:456-458. [PMID: 35398968 PMCID: PMC9324208 DOI: 10.1111/1742-6723.13975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/20/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Matthew J Maiden
- Intensive Care Unit, Royal Adelaide Hospital Adelaide South Australia Australia
- Discipline of Acute Care Medicine The University of Adelaide Adelaide South Australia Australia
- Intensive Care Unit Barwon Health Geelong Victoria Australia
| | - Jonathan D Fraser
- Intensive Care Unit, Royal Adelaide Hospital Adelaide South Australia Australia
- Discipline of Acute Care Medicine The University of Adelaide Adelaide South Australia Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital Adelaide South Australia Australia
- Discipline of Acute Care Medicine The University of Adelaide Adelaide South Australia Australia
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High mobility group box protein 1 neutralization therapy in ovine bacteremia: Lessons learned from an ovine septic shock model incorporating intensive care support. Exp Ther Med 2019; 18:3271-3280. [PMID: 31602200 PMCID: PMC6777221 DOI: 10.3892/etm.2019.7961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/19/2019] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a highly complex and often fatal syndrome which varies widely in its clinical manifestations, and therapies that target the underlying uncontrolled immune status in sepsis are needed. The failure of preclinical approaches to provide significant sepsis survival benefit in the clinic is often attributed to inappropriate animal disease models. It has been demonstrated that high mobility group box protein 1 (HMGB1) blockade can reduce inflammation, mortality and morbidity in experimental sepsis without promoting immunosuppression. Within this study, we explored the use of ovine anti-HMGB1 antibodies in a model of ovine septic shock incorporating intensive care supports (OSSICS). Results: Septic sheep exhibited elevated levels of HMGB1 within 12 h after the induction of sepsis. In this study, sepsis was induced in six anaesthetized adult Border Leicester × Merino ewes via intravenous instillation of E. coli and sheep monitored according to intensive care unit standard protocols for 26 h, with the requirement for noradrenaline as the primary endpoint. Septic sheep exhibited a hyperdynamic circulation, renal dysfunction, deranged coagulation profile and severe metabolic acidosis. Sheep were assigned a severity of illness score, which increased over time. While a therapeutic effect of intravenous anti-HMGB1 antibody could not be observed in this model due to limited animal numbers, a reduced bacterial dose induced a septic syndrome of much lower severity. With modifications including a reduced bacterial dose, a longer timeframe and broad spectrum antibiotics, the OSSICS model may become a robust tool for preclinical assessment of sepsis therapeutics.
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Abstract
Thyroid hormone is integral for normal function, yet during illness, circulating levels of the most active form (triiodothyronine [T3]) decline. Whether this is an adaptive response in critical illness or contributes to progressive disease has remained controversial. This review outlines the basis of thyroid hormone changes during critical illness and considers the evidence regarding T3 replacement.
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Affiliation(s)
- Matthew J Maiden
- Intensive Care Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia 5000, Australia; Intensive Care Unit, Barwon Health, Ryrie St, Geelong, Victoria 3220, Australia; Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia.
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia 5000, Australia
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Maiden MJ, Finnis ME, Peake S, McRae S, Delaney A, Bailey M, Bellomo R. Haemoglobin concentration and volume of intravenous fluids in septic shock in the ARISE trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:118. [PMID: 29724246 PMCID: PMC5934793 DOI: 10.1186/s13054-018-2029-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/06/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Intravenous fluids may contribute to lower haemoglobin levels in patients with septic shock. We sought to determine the relationship between the changes in haemoglobin concentration and the volume of intravenous fluids administered during resuscitation from septic shock. METHODS We performed a retrospective cohort study of patients enrolled in the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial who were not transfused red blood cells (N = 1275). We determined the relationship between haemoglobin concentration, its change over time and volume of intravenous fluids administered over 6, 24 and 72 h using univariate and multivariate analysis. RESULTS Median (IQR) haemoglobin concentration at baseline was 133 (118-146) g/L and decreased to 115 (102-127) g/L within the first 6 h of resuscitation (P < 0.001), 110 (99-122) g/L after 24 h, and 109 (97-121) g/L after 72 h. At the corresponding time points, the cumulative volume of intravenous fluid administered was 1.3 (0.7-2.2) L, 2.9 (1.8-4.3) L and 4.6 (2.7-7.1) L. Haemoglobin concentration and its change from baseline had an independent but weak association with intravenous fluid volume at each time point (R2 < 20%, P < 0.001). After adjusting for covariates, each litre of intravenous fluid administered was associated with a change in haemoglobin concentration of - 1.0 g/L (95% CI -1.5 to -0.6, P < 0.001) at 24 h and - 1.3 g/L (- 1.6 to - 0.9, P < 0.001) at 72 h. CONCLUSIONS Haemoglobin concentration decreases during resuscitation from septic shock, and has a significant but weak association with the volume of intravenous fluids administered.
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Affiliation(s)
- Matthew J Maiden
- Intensive Care Unit, University Hospital Geelong, Barwon Health, PO Pox 281, Geelong, Victoria, Australia. .,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia. .,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Sandra Peake
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Clayton, Victoria, Australia
| | - Simon McRae
- Department of Haematology, SA Pathology, Adelaide, South Australia, Australia
| | - Anthony Delaney
- Intensive Care Unit, Royal North Shore Hospital, St Leonard's, New South Wales, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Clayton, Victoria, Australia.,Northern Clinical School, Sydney Medical School, University of Sydney, Clayton, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Clayton, Victoria, Australia.,Critical Care Services, Monash Health, Clayton, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Clayton, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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Maiden MJ, Otto S, Brealey JK, Finnis ME, Chapman MJ, Kuchel TR, Nash CH, Edwards J, Bellomo R. Structure and Function of the Kidney in Septic Shock. A Prospective Controlled Experimental Study. Am J Respir Crit Care Med 2017; 194:692-700. [PMID: 26967568 DOI: 10.1164/rccm.201511-2285oc] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE It is unclear how septic shock causes acute kidney injury (AKI) and whether this is associated with histological change. OBJECTIVES We aimed to determine the nature and extent of changes in renal structure and function over time in an ovine model of septic shock. METHODS Fifteen sheep were instrumented with a renal artery flow probe and renal vein cannula. Ten were given intravenous Escherichia coli to induce septic shock, and five acted as controls. Animals were mechanically ventilated for 48 hours, while receiving protocol-guided parenteral fluids and a norepinephrine infusion to maintain mean arterial pressure. Renal biopsies were taken every 24 hours or whenever animals were oliguric for 2 hours. A renal pathologist, blinded to tissue source, systematically quantified histological appearance by light and electron microscopy for 31 prespecified structural changes. MEASUREMENTS AND MAIN RESULTS Sheep given E. coli developed septic shock, oliguria, increased serum creatinine, and reduced creatinine clearance (AKI), but there were no changes over time in renal blood flow between groups (P > 0.30) or over time within groups (P > 0.50). Renal oxygen consumption increased only in nonseptic animals (P = 0.01), but there was no between-group difference in renal lactate flux (P > 0.50). There was little structural disturbance in all biopsies and, although some cellular appearances changed over time, the only difference between septic and nonseptic animals was mesangial expansion on electron microscopy. CONCLUSIONS In an intensive care-supported model of gram-negative septic shock, early AKI was not associated with changes in renal blood flow, oxygen delivery, or histological appearance. Other mechanisms must contribute to septic AKI.
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Affiliation(s)
- Matthew J Maiden
- 1 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,2 Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Sophia Otto
- 3 Department of Pathology, SA Pathology, Adelaide, Australia
| | - John K Brealey
- 3 Department of Pathology, SA Pathology, Adelaide, Australia
| | - Mark E Finnis
- 1 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,2 Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Marianne J Chapman
- 1 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,2 Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Tim R Kuchel
- 4 Preclinical, Imaging and Research Laboratories, South Australian Health and Medical Research Institute, Gilles Plains, Australia; and
| | - Coralie H Nash
- 2 Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Jason Edwards
- 1 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
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