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Sammito S, Thielmann B, Klussmann A, Deußen A, Braumann KM, Böckelmann I. Guideline for the application of heart rate and heart rate variability in occupational medicine and occupational health science. J Occup Med Toxicol 2024; 19:15. [PMID: 38741189 DOI: 10.1186/s12995-024-00414-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 04/24/2024] [Indexed: 05/16/2024] Open
Abstract
This updated guideline replaces the "Guideline for the application of heart rate and heart rate variability in occupational medicine and occupational health science" first published in 2014. Based on the older version of the guideline, the authors have reviewed and evaluated the findings on the use of heart rate (HR) and heart rate variability (HRV) that have been published in the meantime and incorporated them into a new version of this guideline.This guideline was developed for application in clinical practice and research purposes in the fields of occupational medicine and occupational science to complement evaluation procedures with respect to exposure and risk assessment at the workplace by the use of objective physiological workload indicators. In addition, HRV is also suitable for assessing the state of health and for monitoring the progress of illnesses and preventive medical measures. It gives an overview of factors influencing the regulation of the HR and HRV at rest and during work. It further illustrates methods for measuring and analyzing these parameters under standardized laboratory and real workload conditions, areas of application as well as the quality control procedures to be followed during the recording and evaluation of HR and HRV.
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Affiliation(s)
- Stefan Sammito
- Department of Occupational Medicine, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.
- German Air Force Centre of Aerospace Medicine, Experimental Aerospace Medicine Research, Flughafenstraße 1, Cologne, 51147, Germany.
| | - Beatrice Thielmann
- Department of Occupational Medicine, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Andre Klussmann
- Competence Centre Health (CCG), Department Health Sciences, University of Applied Sciences (HAW) Hamburg, Hamburg, Germany
| | - Andreas Deußen
- Department of Physiology, Medical Faculty, TU Dresden, Dresden, Germany
| | | | - Irina Böckelmann
- Department of Occupational Medicine, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Adam J, Rupprecht S, Künstler ECS, Hoyer D. Heart rate variability as a marker and predictor of inflammation, nosocomial infection, and sepsis - A systematic review. Auton Neurosci 2023; 249:103116. [PMID: 37651781 DOI: 10.1016/j.autneu.2023.103116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/11/2023] [Accepted: 08/11/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE The autonomic nervous system interacts with the immune system via the inflammatory response. Heart rate variability (HRV), a marker of autonomic activity, is associated with inflammation, and nosocomial infections/sepsis, and has clinical implications for the monitoring of at-risk patients. Due to the vagal tone's influence on anti-inflammatory immune response, this association may predominately be reflected by vagally-mediated HRV indices. However, HRV's predictive significance on inflammation/infection remains unclear. METHODS 843 studies examining the associations/prognostic value of HRV indices on inflammation, and nosocomial infection/sepsis were screened in this systematic review. According to inclusion and exclusion criteria, 68 associative studies and 14 prediction studies were included. RESULTS HRV and pro-inflammatory state were consistently associated in healthy subjects and patient groups. Pro-inflammatory state was related to reduced total power HRV including vagally- and non-vagally-mediated HRV indices. Similar, compared to controls, HRV reductions were observed during nosocomial infections/sepsis. Only limited evidence supports the predictive value of HRV in the development of nosocomial infections/sepsis. Reduced very low frequency power HRV showed the highest predictive value in adults, even with different clinical conditions. In neonates, an increased heart rate characteristic score, combining reduced total power HRV, decreased complexity, and vagally-dominated asymmetry, predicted sepsis. CONCLUSIONS Pro-inflammatory state is related to an overall reduction in HRV rather than a singular reduction in vagally-mediated HRV indices, reflecting the complex autonomic-regulatory changes occurring during inflammation. The potential benefit of using continuous HRV monitoring for detecting nosocomial infection-related states, and the implications for clinical outcome, need further clarification.
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Affiliation(s)
- Josephine Adam
- Department of Neurology, Jena University Hospital, Jena, Germany.
| | - Sven Rupprecht
- Department of Neurology, Jena University Hospital, Jena, Germany; Interdisciplinary Centre for Sleep and Ventilatory Medicine, Jena University Hospital, Jena, Germany
| | - Erika C S Künstler
- Department of Neurology, Jena University Hospital, Jena, Germany; Interdisciplinary Centre for Sleep and Ventilatory Medicine, Jena University Hospital, Jena, Germany
| | - Dirk Hoyer
- Department of Neurology, Jena University Hospital, Jena, Germany
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Li S, Yang Q, Wu P, Lu Y, Yang Z, Jiang L. HEART RATE VARIABILITY PARAMETERS WERE NOT ASSOCIATED WITH 30-DAY ALL-CAUSE MORTALITY IN INTENSIVE CARE UNIT PATIENTS WITH OR WITHOUT ATRIAL FIBRILLATION: A RETROSPECTIVE STUDY OF THE MIMIC-IV DATABASE. Shock 2023; 60:24-33. [PMID: 37219462 DOI: 10.1097/shk.0000000000002149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
ABSTRACT Objective: Our study aims to evaluate the association between heart rate variability (HRV) and short- and long-term prognosis in patients admitted to intensive care unit (ICU). Methods and Results: Adult patients continuously monitored for over 24 h in ICUs from the the American Medical Information Mart for Intensive Care (MIMIC)-IV Waveform Database were recruited in our study. Twenty HRV-related variables (8 time domain, 6 frequency domain, and 6 nonlinear variables) were calculated based on RR intervals. The association between HRV and all-cause mortality was assessed. Ninety-three patients met the inclusion criteria and were classified into atrial fibrillation (AF) and sinus rhythm (SR) groups, which were further divided into 30-day survivor group and nonsurvivor\groups based on their survival status. The 30-day all-cause mortality rates in AF and SR groups were 36.3% and 14.6%, respectively. All the time domain, frequency domain, and nonlinear HRV parameters did not differ significantly between survivors and nonsurvivors with or without AF (all P > 0.05). Presence of renal failure, malignancy, and elevated blood urea nitrogen level were associated with increased 30-day all-cause mortality in SR patients, while presence of sepsis, infection, higher platelet count, and magnesium level were associated with increased 30-day all-cause mortality in AF patients. Conclusions: Heart rate variability variables were not associated with increased 30-day all-cause mortality in ICU patients with or without AF.
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Affiliation(s)
- Sheran Li
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiyu Yang
- School of Automation, Guangdong University of Technology, Guangzhou, China
| | - Peiyu Wu
- School of Automation, Guangdong University of Technology, Guangzhou, China
| | - Yujing Lu
- School of Automation, Guangdong University of Technology, Guangzhou, China
| | - Zhengfei Yang
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Longyuan Jiang
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
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Takla M, Saadeh K, Tse G, Huang CLH, Jeevaratnam K. Ageing and the Autonomic Nervous System. Subcell Biochem 2023; 103:201-252. [PMID: 37120470 DOI: 10.1007/978-3-031-26576-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
The vertebrate nervous system is divided into central (CNS) and peripheral (PNS) components. In turn, the PNS is divided into the autonomic (ANS) and enteric (ENS) nervous systems. Ageing implicates time-related changes to anatomy and physiology in reducing organismal fitness. In the case of the CNS, there exists substantial experimental evidence of the effects of age on individual neuronal and glial function. Although many such changes have yet to be experimentally observed in the PNS, there is considerable evidence of the role of ageing in the decline of ANS function over time. As such, this chapter will argue that the ANS constitutes a paradigm for the physiological consequences of ageing, as well as for their clinical implications.
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Affiliation(s)
| | | | - Gary Tse
- Kent and Medway Medical School, Canterbury, UK
- University of Surrey, Guildford, UK
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5
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Okazaki T, Yoshida T, Uchino S, Sasabuchi Y. Association of onset time of new-onset atrial fibrillation with in-hospital mortality among critically ill patients: A secondary analysis of a prospective multicenter observational study. IJC HEART & VASCULATURE 2021; 36:100880. [PMID: 34632043 PMCID: PMC8488237 DOI: 10.1016/j.ijcha.2021.100880] [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: 08/08/2021] [Revised: 09/01/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022]
Abstract
Background New-onset atrial fibrillation (AF) in critically ill patients is associated with adverse outcomes. In non-critical settings, the circadian variation in paroxysmal AF is of significant interest; however, circadian variation in critically ill patients with new-onset AF has not been thoroughly studied. This study aimed to examine the association between AF onset time and in-hospital mortality. Methods This was a secondary analysis of a prospective multicenter observational study enrolling adult critically ill patients. According to AF onset time, patients were divided into nighttime (0:00–7:59), daytime (8:00–15:59), and evening (16:00–23:59). We conducted a multiple logistic regression analysis to assess the potential association between AF onset time and in-hospital mortality. We also assessed the distribution of AF onset, crude in-hospital mortality, and adjusted in-hospital mortality according to bihourly intervals. Results Of 423 patients, in-hospital mortality was 26%. During nighttime, 135 patients (32%) developed new-onset AF. AF emerged during daytime for 141 (33%) and during evening for 147 (35%). Daytime AF was significantly associated with an increased risk of in-hospital mortality (adjusted OR: 1.92; 95% CI: 1.07–3.44; p = 0.030). Bihourly interval analysis showed that adjusted in-hospital mortality was unevenly distributed and bimodal with troughs between 6:00 and 7:59 and between 18:00 and 19:59. A similar trend was seen in the distribution of the number of new-onset AF. Conclusions We found that the bihourly adjusted in-hospital mortality was distributed in a bimodal fashion. Further research is needed to determine the causes of the diurnal variation and its impact on patient outcomes.
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Affiliation(s)
- Tomoya Okazaki
- Emergency Medical Center, Kagawa University Hospital, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Japan.,Department of Intensive Care Medicine, Tokyo Women's Medical University, Japan
| | - Shigehiko Uchino
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Japan
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Ali Abdelhamid Y, Phillips LK, White MG, Presneill J, Horowitz M, Deane AM. Survivors of Intensive Care With Type 2 Diabetes and the Effect of Shared-Care Follow-Up Clinics: The SWEET-AS Randomized Controlled Pilot Study. Chest 2021; 159:174-185. [PMID: 32800818 DOI: 10.1016/j.chest.2020.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 07/28/2020] [Accepted: 08/02/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Follow-up clinics after ICU admission have demonstrated limited benefit. However, existing trials have evaluated heterogeneous cohorts and used physicians who had limited training in outpatient care. RESEARCH QUESTION What are the effects of a "shared-care" intensivist-endocrinologist clinic for ICU survivors with type 2 diabetes on process measures and clinical outcomes 6 months after hospital discharge, and is it feasible to conduct a larger trial? STUDY DESIGN AND METHODS This was a prospective, randomized, single-center pilot study with blinded outcome assessment. Patients with type 2 diabetes, who required ≥ 5 days of ICU care (mixed medical-surgical ICU) and survived to ICU discharge, were eligible. Participants were randomized to attendance at the shared-care clinic 1 month after hospital discharge or usual care. Six months after hospital discharge, participants were assessed for outcomes including glycated hemoglobin, neuropathy, nephropathy, quality of life, return to employment, frailty, and health-care use. The primary outcome was participant recruitment and retention. RESULTS During an 18-month period, 42 of 82 eligible patients (51%) were recruited. Four participants (10%) withdrew before assessment at 6 months and 11 (26%) died. At 6 months, only 18 of 38 participants who did not withdraw (47%) were living independently without support, and 24 (63%) required at least one subsequent hospital admission. In the intervention group (n = 21), 16 (76%) attended the clinic. Point estimates did not indicate that the intervention improved glycated hemoglobin (+5.6 mmol/mol; 95% CI, -6.3 to 17; P = .36) or quality of life (36-Item Short Form Survey physical summary score, 32 [9] vs. 32 [7]; P = 1.0). INTERPRETATION Outcomes for ICU survivors with type 2 diabetes are poor. Because of low participation and high mortality, a larger trial of a shared-care follow-up clinic in this cohort, using the present design, does not appear feasible. TRIAL REGISTRY Australian New Zealand Clinical Trials Registry (ANZCTR); No.: ACTRN12616000206426; URL: www.anzctr.org.au.
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Affiliation(s)
- Yasmine Ali Abdelhamid
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia; ICU, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Radiology, University of Melbourne, Melbourne, Australia.
| | - Liza K Phillips
- Discipline of Medicine, University of Adelaide, Adelaide, Australia; Endocrine and Metabolic Service, Royal Adelaide Hospital, Adelaide, Australia; National Health and Medical Research Council Centre of Research Excellence (CRE) in the Translation of Nutritional Science into Good Health, University of Adelaide, Adelaide, Australia
| | - Mary G White
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia; ICU, Royal Adelaide Hospital, Adelaide, Australia
| | - Jeffrey Presneill
- ICU, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Radiology, University of Melbourne, Melbourne, Australia
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Adelaide, Australia; Endocrine and Metabolic Service, Royal Adelaide Hospital, Adelaide, Australia; National Health and Medical Research Council Centre of Research Excellence (CRE) in the Translation of Nutritional Science into Good Health, University of Adelaide, Adelaide, Australia
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia; ICU, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine and Radiology, University of Melbourne, Melbourne, Australia
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Coldewey SM, Neu C, Baumbach P, Scherag A, Goebel B, Ludewig K, Bloos F, Bauer M. Identification of cardiovascular and molecular prognostic factors for the medium-term and long-term outcomes of sepsis (ICROS): protocol for a prospective monocentric cohort study. BMJ Open 2020; 10:e036527. [PMID: 32580988 PMCID: PMC7312455 DOI: 10.1136/bmjopen-2019-036527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Sepsis is one of the most prevalent life-threatening conditions in the intensive care unit. Patients suffer from impaired organ function, reduced physical functional capacity and decreased quality of life even after surviving sepsis. The identification of prognostic factors for the medium-term and long-term outcomes of this condition is necessary to develop personalised theragnostic approaches. Sepsis can cause cardiac impairment. The impact of this septic cardiomyopathy on patient's long-term outcome remains unclear. This study aims to evaluate cardiovascular risk factors, particularly the occurrence of septic cardiomyopathy, regarding their suitability as prognostic factors for the short-term and long-term outcomes of septic patients. Additionally, the study seeks to validate preclinical pathophysiological findings of septic cardiomyopathy in the clinical setting. METHODS AND ANALYSIS In this prospective monocentric cohort study, patients will be clinically assessed during the acute and postacute phase of sepsis and two follow-ups after 6 and 12 months. To determine the effect of septic cardiomyopathy and concomitant cellular and molecular changes on patient mortality and morbidity, a comprehensive cardiovascular and molecular deep phenotyping of patients will be performed. This includes an echocardiographic and electrocardiographic assessment, and the evaluation of heart rate variability, body composition, mitochondrial oxygen metabolism, macrocirculation and microcirculation, and endothelial barrier function. These analyses are complemented by routine immunological, haematological and biochemical laboratory tests and analyses of the serum metabolome and lipidome, microbiome and epigenetic modifications of immune cells. The reversibility of patients' organ dysfunction, their quality of life and physical functional capacity will be investigated in the follow-ups. Patients with cardiomyopathy without infection and healthy subjects will serve as control groups. ETHICS AND DISSEMINATION Approval was obtained from the Ethics Committee of the Friedrich Schiller University Jena (5276-09/17). The results will be published in peer-reviewed journals and presented at appropriate conferences. TRIAL REGISTRATION NUMBERS DRKS00013347; NCT03620409.
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Affiliation(s)
- Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Jena, Germany
- Centre for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Charles Neu
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Jena, Germany
- Centre for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Philipp Baumbach
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Jena, Germany
| | - Andre Scherag
- Centre for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Björn Goebel
- Department of Cardiology, Zentralklinik Bad Berka GmbH, Bad Berka, Germany
| | - Katrin Ludewig
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Septomics Research Centre, Jena University Hospital, Jena, Germany
| | - Frank Bloos
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Centre for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Michael Bauer
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Centre for Sepsis Control and Care, Jena University Hospital, Jena, Germany
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Johnston BW, Barrett-Jolley R, Krige A, Welters ID. Heart rate variability: Measurement and emerging use in critical care medicine. J Intensive Care Soc 2020; 21:148-157. [PMID: 32489411 PMCID: PMC7238479 DOI: 10.1177/1751143719853744] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Variation in the time interval between consecutive R wave peaks of the QRS complex has long been recognised. Measurement of this RR interval is used to derive heart rate variability. Heart rate variability is thought to reflect modulation of automaticity of the sinus node by the sympathetic and parasympathetic components of the autonomic nervous system. The clinical application of heart rate variability in determining prognosis post myocardial infarction and the risk of sudden cardiac death is well recognised. More recently, analysis of heart rate variability has found utility in predicting foetal deterioration, deterioration due to sepsis and impending multiorgan dysfunction syndrome in critically unwell adults. Moreover, reductions in heart rate variability have been associated with increased mortality in patients admitted to the intensive care unit. It is hypothesised that heart rate variability reflects and quantifies the neural regulation of organ systems such as the cardiovascular and respiratory systems. In disease states, it is thought that there is an 'uncoupling' of organ systems, leading to alterations in 'inter-organ communication' and a clinically detectable reduction in heart rate variability. Despite the increasing evidence of the utility of measuring heart rate variability, there remains debate as to the methodology that best represents clinically relevant outcomes. With continuing advances in technology, our understanding of the physiology responsible for heart rate variability evolves. In this article, we review the current understanding of the physiological basis of heart rate variability and the methods available for its measurement. Finally, we review the emerging use of heart rate variability analysis in intensive care medicine and conditions in which heart rate variability has shown promise as a potential physiomarker of disease.
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Affiliation(s)
- Brian W Johnston
- University of Liverpool and The Royal Liverpool University Hospital, Liverpool Healthcare Partners, Liverpool, UK
| | - Richard Barrett-Jolley
- University of Liverpool and The Royal Liverpool University Hospital, Liverpool Healthcare Partners, Liverpool, UK
| | - Anton Krige
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Ingeborg D Welters
- University of Liverpool and The Royal Liverpool University Hospital, Liverpool Healthcare Partners, Liverpool, UK
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Bento L, Fonseca-Pinto R, Póvoa P. Autonomic nervous system monitoring in intensive care as a prognostic tool. Systematic review. Rev Bras Ter Intensiva 2018; 29:481-489. [PMID: 29340538 PMCID: PMC5764561 DOI: 10.5935/0103-507x.20170072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 04/18/2017] [Indexed: 01/13/2023] Open
Abstract
Objective To present a systematic review of the use of autonomic nervous system
monitoring as a prognostic tool in intensive care units by assessing heart
rate variability. Methods Literature review of studies published until July 2016 listed in
PubMed/Medline and conducted in intensive care units, on autonomic nervous
system monitoring, via analysis of heart rate variability as a prognostic
tool (mortality study). The following English terms were entered in the
search field: ("autonomic nervous system" OR "heart rate variability") AND
("intensive care" OR "critical care" OR "emergency care" OR "ICU") AND
("prognosis" OR "prognoses" OR "mortality"). Results There was an increased likelihood of death in patients who had a decrease in
heart rate variability as analyzed via heart rate variance, cardiac
uncoupling, heart rate volatility, integer heart rate variability, standard
deviation of NN intervals, root mean square of successive differences, total
power, low frequency, very low frequency, low frequency/high frequency
ratio, ratio of short-term to long-term fractal exponents, Shannon entropy,
multiscale entropy and approximate entropy. Conclusion In patients admitted to intensive care units, regardless of the pathology,
heart rate variability varies inversely with clinical severity and
prognosis.
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Affiliation(s)
- Luis Bento
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, EPE - Lisboa, Portugal
| | - Rui Fonseca-Pinto
- Instituto Politécnico de Leiria - Leiria, Portugal.,Instituto de Telecomunicações, MSP - Leiria, Portugal
| | - Pedro Póvoa
- Unidade de Cuidados Intensivos Polivalente, Hospital São Francisco Xavier - Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal.,NOVA Medical School, CEDOC, Universidade Nova de Lisboa - Lisboa, Portugal
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Wen W, Wang K, Jiang ZM, Zhang ZH, Zhou L. Continuous blood purification ameliorates clinical signs and corrects the plasma phospholipid levels of patients with multiple organ dysfunction syndromes. J Clin Lab Anal 2018; 32:e22411. [PMID: 29457280 DOI: 10.1002/jcla.22411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 01/24/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Multiple organ dysfunction syndromes (MODS) is reported as a leading cause of mortality in intensive care units. Recently, continuous blood purification (CBP) has been mostly applied for MODS treatment. Thus, the purpose of this study was to investigate the effects of CBP on plasma phospholipid level in patients with MODS. METHODS A total of 126 patients with MODS and 120 healthy people were collected. The serum cytokine levels, blood biochemical parameters, and blood gas indexes were detected, and the correlation among phospholipid compounds with serum cytokine levels, blood biochemical parameters, and blood gas indexes was analyzed. RESULTS Before CBP, levels of body temperature, RR, HR, CVP, IL-6, IL-10, TNF-α, BUN, SCr, PaCO2 , SM747, and LPC540 were obviously higher, and pH, HCO3- , PaO2 , SaO2 , PE750, PI885, PC792, PC826, PC830, PC854, PC802, and PG747 were lower in the MODS group than those in the control group. During CBP, the MODS group had gradually declined RR, CVP, levels of IL-6, IL-10 and TNF-α, BUN, SCr, PaCO2 , SM747, and LPC540 and increased HCO3- , PaO2 and SaO2 , PE750, PI885, PC792, PC826, PC830, PC854, PC802, and PG747. Besides, levels of PE750, PI885, PC792, PC826, PC830, PC854, PC802, and PG747 had an obvious negative correlation with levels of TNF-α, IL-10, IL-6, BUN, SCr, and PaCO2 , and a significant positive correlation with levels of HCO3- , PaO2 , and SaO2 . CONCLUSION CBP could effectively ameliorate clinical signs of patients with MODS and correct the plasma phospholipid levels.
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Affiliation(s)
- Wei Wen
- Department of Intensive Care Unit, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Kun Wang
- Department of Business Management, Shandong Center for Disease Control and Prevention, Jinan, China
| | - Zhi-Ming Jiang
- Department of Intensive Care Unit, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Zhong-Hui Zhang
- Department of Intensive Care Unit, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Lei Zhou
- Department of Intensive Care Unit, Shandong Provincial Qianfoshan Hospital, Jinan, China
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Porta A, Colombo R, Marchi A, Bari V, De Maria B, Ranuzzi G, Guzzetti S, Fossali T, Raimondi F. Association between autonomic control indexes and mortality in subjects admitted to intensive care unit. Sci Rep 2018; 8:3486. [PMID: 29472594 PMCID: PMC5823868 DOI: 10.1038/s41598-018-21888-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 02/13/2018] [Indexed: 11/23/2022] Open
Abstract
This study checks whether autonomic markers derived from spontaneous fluctuations of heart period (HP) and systolic arterial pressure (SAP) and from their interactions with spontaneous or mechanical respiration (R) are associated with mortality in patients admitted to intensive care unit (ICU). Three-hundred consecutive HP, SAP and R values were recorded during the first day in ICU in 123 patients. Population was divided into survivors (SURVs, n = 83) and non-survivors (NonSURVs, n = 40) according to the outcome. SURVs and NonSURVs were aged- and gender-matched. All subjects underwent modified head-up tilt (MHUT) by tilting the bed back rest segment to 60°. Autonomic control indexes were computed using time-domain, spectral, cross-spectral, complexity, symbolic and causality techniques via univariate, bivariate and conditional approaches. SAP indexes derived from time-domain, model-free complexity and symbolic approaches were associated with the endpoint, while none of HP variability markers was. The association was more powerful during MHUT. Linear cross-spectral and causality indexes were useless to separate SURVs from NonSURVs, while nonlinear bivariate symbolic markers were successful. When indexes were combined with clinical scores, only SAP variance provided complementary information. Cardiovascular control variability indexes, especially when derived after an autonomic challenge such as MHUT, can improve mortality risk stratification in ICU.
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Affiliation(s)
- Alberto Porta
- Department of Biomedical Sciences for Health, University of Milan, Milan, 20133, Italy. .,Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, 20097, Italy.
| | | | - Andrea Marchi
- Department of Electronics Information and Bioengineering, Politecnico di Milano, Milan, 20133, Italy
| | - Vlasta Bari
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, 20097, Italy
| | - Beatrice De Maria
- IRCCS Istituti Clinici Scientifici Maugeri, Istituto di Milano, Milan, 20138, Italy
| | - Giovanni Ranuzzi
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, 20097, Italy
| | | | - Tommaso Fossali
- Department of Emergency, L. Sacco Hospital, Milan, 20157, Italy
| | - Ferdinando Raimondi
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Clinical and Research Center, Rozzano, 20089, Italy
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Di Lullo L, Bellasi A, Barbera V, Russo D, Russo L, Di Iorio B, Cozzolino M, Ronco C. Pathophysiology of the cardio-renal syndromes types 1-5: An uptodate. Indian Heart J 2017; 69:255-265. [PMID: 28460776 PMCID: PMC5415026 DOI: 10.1016/j.ihj.2017.01.005] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/06/2016] [Accepted: 01/10/2017] [Indexed: 12/19/2022] Open
Abstract
According to the recent definition proposed by the Consensus conference on Acute Dialysis Quality Initiative Group, the term cardio-renal syndrome (CRS) has been used to define different clinical conditions in which heart and kidney dysfunction overlap. Type 1 CRS (acute cardio- renal syndrome) is characterized by acute worsening of cardiac function leading to AKI (5, 6) in the setting of active cardiac disease such as ADHF, while type - 2 CRS occurs in a setting of chronic heart disease. Type 3 CRS is closely link to acute kidney injury (AKI), while type 4 represent cardiovascular involvement in chronic kidney disese (CKD) patients. Type 5 CRS represent cardiac and renal involvement in several diseases such as sepsis, hepato - renal syndrome and immune - mediated diseases.
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Affiliation(s)
- L Di Lullo
- Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro Rome, Italy.
| | - A Bellasi
- Department of Nephrology and Dialysis, S. Anna Hospital, Como, Italy
| | - V Barbera
- Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro Rome, Italy
| | - D Russo
- Division of Nephrology, University of Naples "Federico II", Napoli, Italy
| | - L Russo
- Division of Nephrology, University of Naples "Federico II", Napoli, Italy
| | - B Di Iorio
- Department of Nephrology and Dialysis, A. Landolfi Hospital, Solofra, Avellino, Italy
| | - M Cozzolino
- Department of Health Sciences, Renal Division, San Paolo Hospital, University of Milan, Italy
| | - C Ronco
- International Renal Research Institute, S. Bortolo Hospital, Vicenza, Italy
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Autonomic outcome is better after endarterectomy than after stenting in patients with asymptomatic carotid stenosis. J Vasc Surg 2016; 64:975-84. [DOI: 10.1016/j.jvs.2016.04.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/12/2016] [Indexed: 11/17/2022]
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Toner A, Jenkins N, Ackland G. Baroreflex impairment and morbidity after major surgery. Br J Anaesth 2016; 117:324-31. [DOI: 10.1093/bja/aew257] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2016] [Indexed: 01/24/2023] Open
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Bishop DG, Wise RD, Lee C, von Rahden RP, Rodseth RN. Heart rate variability predicts 30-day all-cause mortality in intensive care units. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2016. [DOI: 10.1080/22201181.2016.1202605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Axer H, Grimm A, Pausch C, Teschner U, Zinke J, Eisenach S, Beck S, Guntinas-Lichius O, Brunkhorst FM, Witte OW. The impairment of small nerve fibers in severe sepsis and septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:64. [PMID: 26984636 PMCID: PMC4793743 DOI: 10.1186/s13054-016-1241-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/13/2016] [Indexed: 11/10/2022]
Abstract
Background A decrease of small nerve fibers in skin biopsies during the course of critical illness has been demonstrated recently. However, the diagnostic use of skin biopsies in sepsis and its time course is not known. Methods Patients (n=32) with severe sepsis or septic shock were examined using skin biopsies, neurological examination, nerve conduction studies, and sympathetic skin response in the first week after onset of sepsis, 2 weeks and 4 months later and compared to gender- and age-matched healthy controls. Results Skin biopsies at the ankle and thigh revealed a significant decrease of intraepidermal nerve fiber density (IENFD) during the first week of sepsis and 2 weeks later. All patients developed critical illness polyneuropathy (CIP) according to electrophysiological criteria and 11 showed IENFD values lower than the 0.05 quantile. Four patients were biopsied after 4 months and still showed decreased IENFD. Results of nerve conduction studies and IENFD did considerably change over time. No differences for survival time between patients with IEFND lower and larger than 3.5 fibers/mm were found. Conclusions Skin biopsy is able to detect an impairment of small sensory nerve fibers early in the course of sepsis. However, it may not be suited as a prognostic parameter for survival. Trial registration German Clinical Trials Register, DRKS-ID: DRKS00000642, 12/17/2010 Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1241-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany.
| | - Alexander Grimm
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany.,Department of Neurology and Epileptology, University of Tuebingen, Tuebingen, Germany
| | - Christine Pausch
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University Leipzig, Leipzig, Germany
| | - Ulrike Teschner
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
| | - Sven Eisenach
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
| | - Sindy Beck
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
| | | | | | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
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Ali Abdelhamid Y, Phillips L, Horowitz M, Deane A. Survivors of intensive care with type 2 diabetes and the effect of shared care follow-up clinics: study protocol for the SWEET-AS randomised controlled feasibility study. Pilot Feasibility Stud 2016; 2:62. [PMID: 27965877 PMCID: PMC5153915 DOI: 10.1186/s40814-016-0104-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 10/01/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Many patients who survive the intensive care unit (ICU) experience long-term complications such as peripheral neuropathy and nephropathy which represent a major source of morbidity and affect quality of life adversely. Similar pathophysiological processes occur frequently in ambulant patients with diabetes mellitus who have never been critically ill. Some 25 % of all adult ICU patients have diabetes, and it is plausible that ICU survivors with co-existing diabetes are at heightened risk of sequelae from their critical illness. ICU follow-up clinics are being progressively implemented based on the concept that interventions provided in these clinics will alleviate the burdens of survivorship. However, there is only limited information about their outcomes. The few existing studies have utilised the expertise of healthcare professionals primarily trained in intensive care and evaluated heterogenous cohorts. A shared care model with an intensivist- and diabetologist-led clinic for ICU survivors with type 2 diabetes represents a novel targeted approach that has not been evaluated previously. Prior to undertaking any definitive study, it is essential to establish the feasibility of this intervention. METHODS This will be a prospective, randomised, parallel, open-label feasibility study. Eligible patients will be approached before ICU discharge and randomised to the intervention (attending a shared care follow-up clinic 1 month after hospital discharge) or standard care. At each clinic visit, patients will be assessed independently by both an intensivist and a diabetologist who will provide screening and targeted interventions. Six months after discharge, all patients will be assessed by blinded assessors for glycated haemoglobin, peripheral neuropathy, cardiovascular autonomic neuropathy, nephropathy, quality of life, frailty, employment and healthcare utilisation. The primary outcome of this study will be the recruitment and retention at 6 months of all eligible patients. DISCUSSION This study will provide preliminary data about the potential effects of critical illness on chronic glucose metabolism, the prevalence of microvascular complications, and the impact on healthcare utilisation and quality of life in intensive care survivors with type 2 diabetes. If feasibility is established and point estimates are indicative of benefit, funding will be sought for a larger, multi-centre study. TRIAL REGISTRATION ANZCTR ACTRN12616000206426.
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Affiliation(s)
- Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| | - Liza Phillips
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| | - Michael Horowitz
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| | - Adam Deane
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
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Huang C, Alamili M, Rosenberg J, Gögenur I. Heart rate variability is reduced during acute uncomplicated diverticulitis. J Crit Care 2015; 32:189-95. [PMID: 26776154 DOI: 10.1016/j.jcrc.2015.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 09/30/2015] [Accepted: 12/07/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND The aim of the present study was to report the trajectory of heart rate variability (HRV) indices during a low-grade acute inflammation and their associations to biomarkers for infection. METHODS Twelve patients with uncomplicated acute diverticulitis completed this observational study, which composed of 3 sessions of continuous HRV recording from 9 PM to 8 AM during ongoing diverticulitis and at complete remission (baseline). The blood samples were collected at each study session measuring C-reactive protein (CRP) and leukocytes. RESULTS This study showed that the trajectories of the HRV indices were decreased both in time and frequency domains during acute diverticulitis compared to baseline. In particular, the indices reflecting the balance of sympathetic and parasympathetic activities were affected: standard deviation of normal-to-normal beats (P = .003), low-frequency power (P < .001), and total power (P = .001). These HRV changes indicate alterations in the autonomic nervous system during acute inflammation. All reductions of mean HRV indices had significant (P < .001) correlations to increased CRP correlations to increased CRP levels during diverticulitis suggesting inflammatory involvement in the observed HRV alterations. CONCLUSION We found substantial HRV depression in relation to acute uncomplicated diverticulitis, and this was associated with the elevated CRP levels.
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Affiliation(s)
- Chenxi Huang
- Department of Surgery, University of Copenhagen, Roskilde and Køge Hospitals, DK-4600, Køge, Denmark; Department of Surgical Gastroenterology, University of Copenhagen, Herlev Hospital, DK-2730, Herlev, Denmark.
| | - Mahdi Alamili
- Department of Surgery, University of Copenhagen, Roskilde and Køge Hospitals, DK-4600, Køge, Denmark
| | - Jacob Rosenberg
- Department of Surgical Gastroenterology, University of Copenhagen, Herlev Hospital, DK-2730, Herlev, Denmark
| | - Ismail Gögenur
- Department of Surgery, University of Copenhagen, Roskilde and Køge Hospitals, DK-4600, Køge, Denmark
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The C-Reactive Protein/Albumin Ratio as an Independent Predictor of Mortality in Patients with Severe Sepsis or Septic Shock Treated with Early Goal-Directed Therapy. PLoS One 2015; 10:e0132109. [PMID: 26158725 PMCID: PMC4497596 DOI: 10.1371/journal.pone.0132109] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 06/10/2015] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis, including severe sepsis and septic shock, is a major cause of morbidity and mortality. Albumin and C-reactive protein (CRP) are considered as good diagnostic markers for sepsis. Thus, initial CRP and albumin levels were combined to ascertain their value as an independent predictor of 180-day mortality in patients with severe sepsis and septic shock. Materials and Methods We conducted a retrospective cohort study involving 670 patients (>18 years old) who were admitted to the emergency department and who had received a standardized resuscitation algorithm (early goal-directed therapy) for severe sepsis and septic shock, from November 2007 to February 2013, at a tertiary hospital in Seoul, Korea. The outcome measured was 180-day all-cause mortality. A multivariate Cox proportional hazard model was used to identify the independent risk factors for mortality. A receiver operating characteristic (ROC) curve analysis was conducted to compare the predictive accuracy of the CRP/albumin ratio at admission. Results The 180-day mortality was 28.35% (190/670). Based on the multivariate Cox proportional hazard analysis, age, the CRP/albumin ratio at admission (adjusted HR 1.06, 95% CI 1.03–1.10, p<0.001), lactate level at admission (adjusted HR 1.10, 95% CI 1.05–1.14, p<0.001), and the Sequential Organ Failure Assessment (SOFA) score at admission (adjusted HR 1.12, 95% CI 1.07–1.18, p<0.001) were independent predictors of 180-day mortality. The area under the curve of CRP alone and the CRP/albumin ratio at admission for 180-day mortality were 0.5620 (P<0.001) and 0.6211 (P<0.001), respectively. Conclusion The CRP/albumin ratio was an independent predictor of mortality in patients with severe sepsis or septic shock.
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Role of heart rate variability in predicting the severity of severe acute pancreatitis. Dig Dis Sci 2014; 59:2557-64. [PMID: 24821463 DOI: 10.1007/s10620-014-3192-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 04/28/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Infected pancreatic necrosis (IPN) and multiple organ dysfunction syndrome (MODS) are major complications of acute pancreatitis which determine disease severity and outcome. AIMS The aim of this study is to investigate the value of admission heart rate variability as a marker of IPN or MODS in severe acute pancreatitis (SAP) patients. METHODS Forty-one SAP patients within 72 h of symptoms onset were included in this prospective observational study. General demographics, laboratory data and the acute physiology and chronic health evaluation (APACHE) II scores were recorded at admission. 5-minute ECG signals were obtained at the same time for heart rate variability analyses to assess SAP severity. RESULTS The baseline heart rate variability measurements, levels of low frequency/high frequency (LF/HF) were significantly lower whereas high frequency norm (nHF) levels were significantly higher in patients who present with IPN and MODS or died (P < 0.01). Low frequency (LF) levels were lower in patients who present with IPN or MODS as compared to patients without these complications. Levels of low frequency norm (nLF) were lower in MODS and non-survival patients. nHF and LF/HF were good predictors of IPN and MODS, superior to procalcitonin. nHF and LF/HF were better than APACHE II in predicting IPN and LF/HF showed superiority over APACHE II in the prediction of MODS. CONCLUSIONS Admission heart rate variability is a good marker of IPN and MODS in SAP patients.
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Schmidt H, Lotze U, Ghanem A, Anker S, Said S, Braun-Dullaeus R, Oltmanns G, Rose S, Buerke M, Müller-Werdan U, Werdan K, Rauchhaus M. Relation of impaired interorgan communication and parasympathetic activity in chronic heart failure and multiple-organ dysfunction syndrome. J Crit Care 2014; 29:367-73. [DOI: 10.1016/j.jcrc.2013.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 11/17/2013] [Accepted: 12/22/2013] [Indexed: 11/28/2022]
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I(f) blocking potency of ivabradine is preserved under elevated endotoxin levels in human atrial myocytes. J Mol Cell Cardiol 2014; 72:64-73. [PMID: 24583250 PMCID: PMC4046244 DOI: 10.1016/j.yjmcc.2014.02.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 01/23/2014] [Accepted: 02/14/2014] [Indexed: 11/21/2022]
Abstract
Lower heart rate is associated with better survival in patients with multiple organ dysfunction syndrome (MODS), a disease mostly caused by sepsis. The benefits of heart rate reduction by ivabradine during MODS are currently being investigated in the MODIfY clinical trial. Ivabradine is a selective inhibitor of the pacemaker current If and since If is impaired by lipopolysaccharide (LPS, endotoxin), a trigger of sepsis, we aimed to explore If blocking potency of ivabradine under elevated endotoxin levels in human atrial cardiomyocytes. Treatment of myocytes with S-LPS (containing the lipid A moiety, a core oligosaccharide and an O-polysaccharide chain) but not R595 (an O-chain lacking LPS-form) caused If inhibition under acute and chronic septic conditions. The specific interaction of S-LPS but not R595 to pacemaker channels HCN2 and HCN4 proves the necessity of O-chain for S-LPS–HCN interaction. The efficacy of ivabradine to block If was reduced under septic conditions, an observation that correlated with lower intracellular ivabradine concentrations in S-LPS- but not R595-treated cardiomyocytes. Computational analysis using a sinoatrial pacemaker cell model revealed that despite a reduction of If under septic conditions, ivabradine further decelerated pacemaking activity. This novel finding, i.e. If inhibition by ivabradine under elevated endotoxin levels in vitro, may provide a molecular understanding for the efficacy of this drug on heart rate reduction under septic conditions in vivo, e.g. the MODIfY clinical trial. S-LPS impairs If via interaction of its O-chain to HCN channels. Efficacy of ivabradine for If blockage is reduced under elevated endotoxin levels. S-LPS reduces intracellular ivabradine concentrations. Ivabradine is efficient to decelerate sinoatrial pacemaking activity under septic conditions in silico.
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Abstract
Cardiorenal syndrome (CRS) includes a broad spectrum of diseases within which both the heart and kidneys are involved, acutely or chronically. An effective classification of CRS in 2008 essentially divides CRS in two main groups, cardiorenal and renocardiac CRS, based on primum movens of disease (cardiac or renal); both cardiorenal and renocardiac CRS are then divided into acute and chronic, according to onset of disease. The fifth type of CRS integrates all cardiorenal involvement induced by systemic disease. This article addresses the pathophysiology, diagnosis, treatment, and outcomes of the 5 distinct types of CRS.
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Affiliation(s)
- Claudio Ronco
- International Renal Research Institute, S. Bortolo Hospital, Viale F. Ridolfi 37, Vicenza 36100, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, L. Parodi-Delfino Hospital, Piazza A. Moro, Colleferro, Roma 1-00034, Italy.
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Mazloom R, Shirazi AH, Hajizadeh S, Dehpour AR, Mani AR. The effect of endotoxin on the controllability of cardiac rhythm in rats. Physiol Meas 2014; 35:339-49. [PMID: 24480859 DOI: 10.1088/0967-3334/35/3/339] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Decreased heart rate variability (HRV) has both diagnostic and prognostic value in patients with sepsis. However, it is not known whether reduced HRV in sepsis reflects an altered input from the autonomic nervous system or a remodeling of the cardiac pacemaker cells by inflammatory mediators. The present study aimed to investigate the effect of endotoxin on the heart rate dynamics of a denervated isolated heart in rats. Saline or endotoxin was injected into rats and their hearts were isolated and perfused. Atrial electrical activity was recorded and memory length in the time-series was assessed using inverse statistical analysis. Memory was defined as a statistical feature that lasts for a period of time and distinguishes the time-series from a random process. Endotoxaemic hearts exhibited a prolonged memory compared to the controls with respect to observing rare events. This indicates that a sudden decelerating event could potentially affect the cardiac rhythm of an endotoxaemic heart for a longer time than the controls. The prolongation of memory is indirectly linked to a reduced controllability in a complex system; therefore our data may provide evidence for a reduced controllability in cardiac rhythm following endotoxaemia.
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Affiliation(s)
- Roham Mazloom
- Department of Physiology, School of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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Huang CT, Tsai YJ, Lin JW, Ruan SY, Wu HD, Yu CJ. Application of heart-rate variability in patients undergoing weaning from mechanical ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R21. [PMID: 24456585 PMCID: PMC4056081 DOI: 10.1186/cc13705] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/20/2014] [Indexed: 01/08/2023]
Abstract
Introduction The process of weaning may impose cardiopulmonary stress on ventilated patients. Heart-rate variability (HRV), a noninvasive tool to characterize autonomic function and cardiorespiratory interaction, may be a promising modality to assess patient capability during the weaning process. We aimed to evaluate the association between HRV change and weaning outcomes in critically ill patients. Methods This study included 101 consecutive patients recovering from acute respiratory failure. Frequency-domain analysis, including very low frequency, low frequency, high frequency, and total power of HRV was assessed during a 1-hour spontaneous breathing trial (SBT) through a T-piece and after extubation after successful SBT. Results Of 101 patients, 24 (24%) had SBT failure, and HRV analysis in these patients showed a significant decrease in total power (P = 0.003); 77 patients passed SBT and were extubated, but 13 (17%) of them required reintubation within 72 hours. In successfully extubated patients, very low frequency and total power from SBT to postextubation significantly increased (P = 0.003 and P = 0.004, respectively). Instead, patients with extubation failure were unable to increase HRV after extubation. Conclusions HRV responses differ between patients with different weaning outcomes. Measuring HRV change during the weaning process may help clinicians to predict weaning results and, in the end, to improve patient care and outcome.
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Brämer D, Hoyer H, Günther A, Nowack S, Brunkhorst FM, Witte OW, Hoyer D. Study protocol: prediction of stroke associated infections by markers of autonomic control. BMC Neurol 2014; 14:9. [PMID: 24410797 PMCID: PMC3900463 DOI: 10.1186/1471-2377-14-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 01/06/2014] [Indexed: 11/28/2022] Open
Abstract
Background Infection is the most important complication after acute stroke. This is substantially based on a stroke-induced immunosuppression. Heart rate variability (HRV) represents the autonomic nervous system activity in connection with stroke-induced immunomodulation and infections. We demonstrated in a feasibility study that HRV indices obtained in patients without acute post-stroke infections can predict infections in the subsequent sub-acute phase. Methods/Design The study PRED-SEP is a prospective observational study. Adult patients with acute ischemic infarction in the territory of the middle cerebral artery and severe neurological deficit (National Institutes of Health Stroke Scale: NIHSS ≥ 8) are recruited. Primary endpoint is the development of infections, secondary endpoints are SIRS and severe sepsis in the sub-acute phase (day 3–5) after stroke and the functional outcome after 3 months. Infection is defined according to the PANTHERIS study and comprises pneumonia, urinary tract infection and infections without determined focus. SIRS and severe sepsis are defined according to German Sepsis Society guidelines. Functional outcome is measured by lethality and neurological scores (modified Rankin Scale, Barthel Index). Prognostic factors are HRV risk indices calculated from selected intervals of 24 h ECG measurements within 48 hours after symptom onset. It is planned to recruit 240 patients. HRV risk indices (predictors) will be calculated according to standards and procedures previously developed and published by the authors. The predictive effects of HRV indices on infections will be estimated by fitting logistic regression models and estimating odds ratios with 95% confidence intervals. A prespecified modelling procedure will be applied to estimate unadjusted and confounder adjusted odds ratios. Secondary endpoints will be analysed in the same way. The functional outcome scales will be dichotomized. The association between HRV indices and pro- and anti-inflammatory markers will be quantified by calculating the appropriate correlation coefficients according to scale (Person or Spearman). Discussion Since a general prophylactic antibiotic treatment after stroke is not recommended, results of this study could have essential implications for an early identification and hence, timely appropriate treating of stroke-induced infections. Trial registration Prädiktoren für die Sepsis - Pred Sep, German Clinical Trials Register:
DRKS00003392.
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Affiliation(s)
| | | | | | | | | | | | - Dirk Hoyer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany.
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Axer H, Grimm A, Porzelius C, Teschner U, Schumacher U, Witte OW, Brunkhorst FM. Impairment of small somatic and autonomic nerve fibres in intensive care unit patients with severe sepsis and critical illness polyneuropathy--a single center controlled observational study. BMC Neurol 2013; 13:159. [PMID: 24176121 PMCID: PMC4228411 DOI: 10.1186/1471-2377-13-159] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/30/2013] [Indexed: 11/26/2022] Open
Abstract
Background Axonal damage in large myelinated nerve fibres occurs in about 70% of patients with severe sepsis, known as critical illness polyneuropathy and contributes significantly to an increased short- and long-term morbidity and mortality in this population. Among other pathophysiological mechanisms, autonomic dysregulation, characterized by high concentrations of circulating catecholamines in the presence of impaired sympathetic modulation of heart and vessels have been discussed. We hypothesize that autonomic small fibre neuropathy play an important role in autonomic failure. Methods/Design Single center, non-randomized, controlled, observational study. Skin biopsies of patients with severe sepsis and/or septic shock are compared with those of age-matched controls. In order to assess impairment of small nerve fibres, skin biopsies are taken at onset of severe sepsis, and two and 16 weeks later. Intraepidermal nerve fibre densities are histologically analyzed using anti protein gene product (PGP) 9.5 immunostaining. In addition, standardized clinical examinations, as Medical Research Council (MRC) scores of muscle strength, Rankin scores, and standardized nerve conduction studies of the right median nerve, the right tibial nerve, the left fibular nerve, and both sural nerves are performed, to identify critical illness polyneuropathy and to neurophysiologically quantify the damage of large nerve fibres. Discussion The study will allow to describe the frequency of small fibre neuropathy in patients with severe sepsis up to four months after onset of severe sepsis and to evaluate its relationship to critical illness polyneuropathy. Trial registration The trial has been registered to the German Clinical Trials Register. The trial registration number is DRKS-ID: DRKS00000642.
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Affiliation(s)
- Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Friedrich-Schiller-University Jena, Erlanger Allee 101, D-07747 Jena, Germany.
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Abstract
PURPOSE OF REVIEW This review discusses the current developments in biomarkers for sepsis. RECENT FINDINGS With quantum leaps in technology, an array of biomarkers will become available within the next decade as point-of-care tools that will likely revolutionize the management of sepsis. These markers will facilitate early and accurate diagnosis, faster recognition of impending organ dysfunction, optimal selection and titration of appropriate therapies, and more reliable prognostication of risk and outcome. These diagnostics will also enable an improved characterization of the biological phenotype underlying sepsis and thus a better appreciation of the condition. SUMMARY The potential for novel biomarkers in sepsis will need to be properly realized with considerable funding, academic-industry collaborations, appropriate investigations and validation in heterogenous populations, but these developments do hold the capacity to transform patient care and outcomes.
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Abstract
Objective: Bidirectional links between the nervous and immune systems modulate inflammation. The cellular mechanisms underlying the detection of danger-associated molecular patterns and pathogen-associated molecular patterns by the nervous system are not well understood. We hypothesized that the carotid body, a tissue of neural crest origin, detect pathogen associated molecular patterns and danger associated molecular patterns via an inflammasome-dependent mechanism similar to that described in immune cells. Design: Randomized, controlled laboratory investigation. Setting: University laboratory. Subjects: C57Bl/6J mice; juvenile Sprague-Dawley rats, primary human neutrophils. Interventions: Rat carotid body chemosensitive cells, and human neutrophils, were treated with TLR agonists to activate inflammasome-dependent pathways. In mice, systemic inflammation was induced by the pathogen associated molecular pattern zymosan (intraperitoneal injection; 500 mg/kg). Isolated carotid body/carotid sinus nerve preparations were used to assess peripheral chemoafferent activity. Ventilation was measured by whole-body plethysmography. Measurements and Main Results: Chemosensitive carotid body glomus cells exhibited toll-like receptor (TLR-2 and TLR-4), NLRP1, and NLRP3 inflammasome immunoreactivities. Zymosan increased NLRP3 inflammasome and interleukin-1β expression in glomus cells (p < 0.01). Human neutrophils demonstrated similar LPS-induced changes in inflammasome expression. Carotid body glomus cells also expressed IL-1 receptor and responded to application of IL-1β with increases in intracellular [Ca2+]. Four hours after injection of zymosan carotid sinus nerve chemoafferent discharge assessed in vitro (i.e., in the absence of acidosis/circulating inflammatory mediators) was increased five-fold (p < 0.001). Accordingly, zymosan-induced systemic inflammation was accompanied by enhanced respiratory activity. Conclusions: In carotid body chemosensitive glomus cells, activation of toll-like receptors increases NLRP3 inflammasome expression, and enhances IL-1β production, which is capable of acting in an autocrine manner to enhance peripheral chemoreceptor drive.
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Gastrodin attenuation of the inflammatory response in H9c2 cardiomyocytes involves inhibition of NF-κB and MAPKs activation via the phosphatidylinositol 3-kinase signaling. Biochem Pharmacol 2013; 85:1124-33. [DOI: 10.1016/j.bcp.2013.01.020] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 01/22/2013] [Accepted: 01/23/2013] [Indexed: 02/01/2023]
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Sim DS, Jeong MH, Cho KH, Ahn Y, Kim YJ, Chae SC, Hong TJ, Seong IW, Chae JK, Kim CJ, Cho MC, Rha SW, Bae JH, Seung KB, Park SJ. Effect of early statin treatment in patients with cardiogenic shock complicating acute myocardial infarction. Korean Circ J 2013; 43:100-9. [PMID: 23508129 PMCID: PMC3596656 DOI: 10.4070/kcj.2013.43.2.100] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/07/2012] [Accepted: 11/13/2012] [Indexed: 12/20/2022] Open
Abstract
Background and Objectives The benefit of early statin treatment following acute myocardial infarction (MI) complicated with cardiogenic shock (CS) has not been well studied. We sought to assess the effect of early statin therapy in patients with CS complicating acute MI. Subjects and Methods We studied 553 statin-naive patients with acute MI and CS (Killip class IV) who underwent revascularization therapy between November 2005 and January 2008 at 51 hospitals in the Korea Acute Myocardial Infarction Registry. Patients were divided into 2 groups: those who received statins during hospitalization (n=280) and those who did not (n=273). The influence of statin treatment on a 12-month clinical outcome was examined using a matched-pairs analysis (n=200 in each group) based on the propensity for receiving statin therapy during hospitalization. Results Before adjustment, patients receiving statin, compared to those not receiving statin, had a more favorable clinical profile, were less likely to suffer procedural complications, and more likely to receive adequate medical therapy. Patients receiving statin had lower unadjusted in-hospital mortality and composite rate of mortality, MI, and repeat revascularization at 12 months, which remained significantly lower after adjustment for patient risk, procedural characteristics, and treatment propensity. Conclusion In CS patients with acute MI undergoing revascularization therapy, early statin treatment initiated during hospitalization was associated with lower rates of in-hospital death and 12-month adverse cardiac events.
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Affiliation(s)
- Doo Sun Sim
- Department of Cardiovascular Medicine, Chonnam National University College of Medicine, Gwangju, Korea
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Abstract
PURPOSE OF REVIEW New developments in mechanical ventilation have focused on increasing the patient's control of the ventilator by implementing information on lung mechanics and respiratory drive. Effort-adapted modes of assisted breathing are presented and their potential advantages are discussed. RECENT FINDINGS Adaptive support ventilation, proportional assist ventilation with load adjustable gain factors and neurally adjusted ventilatory assist are ventilatory modes that follow the concept of adapting the assist to a defined target, instantaneous changes in respiratory drive or lung mechanics. Improved patient ventilator interaction, sufficient unloading of the respiratory muscles and increased comfort have been recently associated with these ventilator modalities. There are, however, scarce data with regard to outcome improvement, such as length of mechanical ventilation, ICU stay or mortality (commonly accepted targets to demonstrate clinical superiority). SUMMARY Within recent years, a major step forward in the evolution of assisted (effort-adapted) modes of mechanical ventilation was accomplished. There is growing evidence that supports the physiological concept of closed-loop effort-adapted assisted modes of mechanical ventilation. However, at present, the translation into a clear outcome benefit remains to be proven. In order to fill the knowledge gap that impedes the broader application, larger randomized controlled trials are urgently needed. However, with clearly proven drawbacks of conventional assisted modes such as pressure support ventilation, it is probably about time to leave these modes introduced decades ago behind.
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Heart rate as an independent risk factor in patients with multiple organ dysfunction: a prospective, observational study. Clin Res Cardiol 2011; 101:139-47. [DOI: 10.1007/s00392-011-0375-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 10/21/2011] [Indexed: 02/07/2023]
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Mazzeo AT, La Monaca E, Di Leo R, Vita G, Santamaria LB. Heart rate variability: a diagnostic and prognostic tool in anesthesia and intensive care. Acta Anaesthesiol Scand 2011; 55:797-811. [PMID: 21658013 DOI: 10.1111/j.1399-6576.2011.02466.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The autonomic nervous system (ANS) plays an important role in the human response to various internal and external stimuli, which can modify homeostasis, and exerts a tight control on essential functions such as circulation, respiration, thermoregulation and hormonal secretion. ANS dysfunction may complicate the perioperative course in the surgical patient undergoing anesthesia, increasing morbidity and mortality, and, therefore, it should be considered as an additional risk factor during pre-operative evaluation. Furthermore, ANS dysfunction may complicate the clinical course of critically ill patients admitted to intensive care units, in the case of trauma, sepsis, neurologic disorders and cardiovascular diseases, and its occurrence adversely affects the outcome. In the care of these patients, the assessment of autonomic function may provide useful information concerning pathophysiology, risk stratification, early prognosis prediction and treatment strategies. Given the role of ANS in the maintenance of systemic homeostasis, anesthesiologists and intensivists should recognize as critical the evaluation of ANS function. Measurement of heart rate variability (HRV) is an easily accessible window into autonomic activity. It is a low-cost, non-invasive and simple to perform method reflecting the balance of the ANS regulation of the heart rate and offers the opportunity to detect the presence of autonomic neuropathy complicating several illnesses. The present review provides anesthesiologists and intensivists with a comprehensive summary of the possible clinical implications of HRV measurements, suggesting that autonomic dysfunction testing could potentially represent a diagnostic and prognostic tool in the care of patients both in the perioperative setting as well as in the critical care arena.
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Affiliation(s)
- Anna Teresa Mazzeo
- Anaesthesia and NeuroIntensive Care Unit, Department of Neurosciences, Psychiatry and Anaesthesiology, University of Messina, Messina, Italy.
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Klöckner U, Rueckschloss U, Grossmann C, Ebelt H, Müller-Werdan U, Loppnow H, Werdan K, Gekle M. Differential reduction of HCN channel activity by various types of lipopolysaccharide. J Mol Cell Cardiol 2011; 51:226-35. [PMID: 21609720 DOI: 10.1016/j.yjmcc.2011.05.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 05/05/2011] [Accepted: 05/06/2011] [Indexed: 01/31/2023]
Abstract
Recently it was shown that lipopolysaccharide (LPS) impairs the pacemaker current in human atrial myocytes. It was speculated that reduced heart rate variability (HRV), typical of patients with severe sepsis, may partially be explained by this impairment. We evaluated the effect of various types of LPS on the activity of human hyperpolarization-activated cyclic nucleotide-gated channel 2 (hHCN2) expressed in HEK293 cells, and on pacemaker channels in native murine sino-atrial node (SAN) cells, in order to determine the structure of LPS necessary to modulate pacemaker channel function. Application of LPS caused a robust inhibition of hHCN2-mediated current (I(hHCN2)) owing to a negative shift of the voltage dependence of current activation and to a reduced maximal conductance. In addition, kinetics of channel gating were modulated by LPS. Pro-inflammatory LPS-types lacking the O-chain did not reduce I(hHCN2), whereas pro-inflammatory LPS-types containing the O-chain reduced I(hHCN2). On the other hand, a detoxified LPS without inflammatory activity, but containing the O-chain reduced I(hHCN2). Similar observations were made in HEK293 cells expressing hHCN4 and in murine SAN cells. This mechanistic analysis showed the novel finding that the O-chain of LPS is required for reduction of HCN channel activity. In the clinical situation the observed modulation of HCN channels may slow down diastolic depolarization of pacemaker cells and, hence, influence heart rate variability and heart rate.
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Affiliation(s)
- Udo Klöckner
- Julius-Bernstein-Institut für Physiologie, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany.
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Abstract
SummaryThe autonomic nervous system comprises the sympathetic, parasympathetic and enteric nervous systems and plays an integral role in homeostasis. This includes cardiovascular and temperature control, glucose metabolism, gastrointestinal and reproductive function and increasing evidence to support its involvement in the inflammatory response to infection and cancer. Ageing is associated with autonomic dysfunction, and many clinical syndromes associated with older adults are due to inadequate autonomic responses to physiological stressors. The aim of this review is to explore the relationship between autonomic dysfunction and ageing illustrated with examples of maladaptive autonomic responses in a variety of different clinical syndromes including an exploration of autonomic cellular changes. Appropriate investigation and management strategies are outlined, recognizing the fine balance needed to improve symptoms without creating further medical complications.
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Bruchfeld A, Goldstein RS, Chavan S, Patel NB, Rosas-Ballina M, Kohn N, Qureshi AR, Tracey KJ. Whole blood cytokine attenuation by cholinergic agonists ex vivo and relationship to vagus nerve activity in rheumatoid arthritis. J Intern Med 2010; 268:94-101. [PMID: 20337855 PMCID: PMC2937357 DOI: 10.1111/j.1365-2796.2010.02226.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The central nervous system regulates innate immunity in part via the cholinergic anti-inflammatory pathway, a neural circuit that transmits signals in the vagus nerve that suppress pro-inflammatory cytokine production by an alpha-7 nicotinic acetylcholine receptors (alpha7nAChR) dependent mechanism. Vagus nerve activity is significantly suppressed in patients with autoimmune diseases, including rheumatoid arthritis (RA). It has been suggested that stimulating the cholinergic anti-inflammatory pathway may be beneficial to patients, but it remains theoretically possible that chronic deficiencies in this pathway will render these approaches ineffective. METHODS Here we addressed the hypothesis that inflammatory cells from RA patients can respond to cholinergic agonists with reduced cytokine production in the setting of reduced vagus nerve activity. RESULTS Measurement of RR interval variability (heart rate variability, HRV), in RA patients (n = 13) and healthy controls (n = 10) revealed that vagus nerve activity was significantly depressed in patients. Whole blood cultures stimulated by exposure to endotoxin produced significantly less tumour necrosis factor in samples from RA patients as compared to healthy controls. Addition of cholinergic agonists (nicotine and GTS-21) to the stimulated whole blood cultures however significantly suppressed cytokine production to a similar extent in patients and healthy controls. CONCLUSION These findings suggest that it is possible to pharmacologically target the alpha7nAChR dependent control of cytokine release in RA patients with suppressed vagus nerve activity. As alpha7nAChR agonists ameliorate the clinical course of collagen induced arthritis in animals, it may be possible in the future to explore whether alpha7nAChR agonists can improve clinical activity in RA patients.
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Affiliation(s)
- A Bruchfeld
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
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ACE-inhibitor therapy and survival among patients with multiorgan dysfunction syndrome (MODS) of cardiac and non-cardiac origin. Int J Cardiol 2010; 140:296-303. [DOI: 10.1016/j.ijcard.2008.11.104] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Accepted: 11/15/2008] [Indexed: 01/18/2023]
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Werdan K, Schmidt H, Ebelt H, Zorn-Pauly K, Koidl B, Hoke RS, Heinroth K, Müller-Werdan U. Impaired regulation of cardiac function in sepsis, SIRS, and MODS. Can J Physiol Pharmacol 2009; 87:266-74. [PMID: 19370080 DOI: 10.1139/y09-012] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
In sepsis, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS), a severe prognostically relevant cardiac autonomic dysfunction exists, as manifested by a strong attenuation of sympathetically and vagally mediated heart rate variability (HRV). The mechanisms underlying this attenuation are not limited to the nervous system. They also include alterations of the cardiac pacemaker cells on a cellular level. As shown in human atrial cardiomyocytes, endotoxin interacts with cardiac hyperpolarization-activated cyclic nucleotide-gated (HCN) ion channels, which mediate the pacemaker current If and play an important role in transmitting sympathetic and vagal signals on heart rate and HRV. Moreover, endotoxin sensitizes cardiac HCN channels to sympathetic signals. These findings identify endotoxin as a pertinent modulator of the autonomic nervous regulation of heart function. In MODS, the vagal pathway of the autonomic nervous system is particularly compromised, leading to an attenuation of the cholinergic antiinflammatory reflex. An amelioration of the blunted vagal activity appears to be a promising novel therapeutic target to achieve a suppression of the inflammatory state and thereby an improvement of prognosis in MODS patients. Preliminary data revealed therapeutic benefits (increased survival rates and improvements of the depressed vagal activity) of the administration of statins, beta-blockers, and angiotensin-converting enzyme inhibitors in patients with MODS.
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Affiliation(s)
- Karl Werdan
- Department of Medicine III, Martin Luther University Halle-Wittenberg, Ernst-Grube Str. 40, D-06097 Halle, Saale, Germany.
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Role of nuclear factor-kappaB-dependent induction of cytokines in the regulation of vasopressin V1A-receptors during cecal ligation and puncture-induced circulatory failure. Crit Care Med 2008; 36:1990. [PMID: 18596633 DOI: 10.1097/ccm.0b013e31817c3b6a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Here we characterize the impact of nuclear factor-kappaB and cytokines on cecal ligation and puncture-induced circulatory failure and regulation of vasopressin V1A-receptors during inflammation. DESIGN Prospective animal trial. SETTING Laboratory of the Department of Anesthesiology. SUBJECTS Male C57/BL6 mice. INTERVENTIONS The effects of cecal ligation and puncture on hemodynamic parameters and V1A-receptor expression were measured in cytokine knock-out mice, in mice with/without treatment with glucocorticoids or NF-kappaB-inhibitors, in mice pretreated with small interfering RNA silencing NF-kappaB and in mice treated with V1 receptor agonists. Furthermore, the effects of cytokines on V1A-receptor expression were determined. MEASUREMENTS AND MAIN RESULTS Cecal ligation and puncture resulted in a hyperdynamic circulatory failure with diminished blood pressor dose response to V1 receptor agonists and down-regulation of V1A-receptors. Dexamethasone inhibited proinflammatory cytokine production and attenuated cecal ligation and puncture-induced cardiovascular failure in parallel with attenuated down-regulation of V1A-receptor expression. Tumor necrosis factor-alpha, interleukin-1beta, interferon-gamma or interleukin-6 dose-dependently decreased V1A-receptor expression, whereas cecal ligation and puncture-induced down-regulation of V1A-receptors was not affected in cytokine knock-out mice. In contrast, inhibition of NF-kappaB strongly reduced induction of cytokines, prevented septic circulatory failure and down-regulation of V1A-receptor gene expression and improved survival of septic animals. CONCLUSIONS Our data demonstrate that down-regulation of V1A-receptor expression during sepsis may be due to proinflammatory cytokines. Our findings explain the failure of therapeutic strategies targeting single cytokines as well as the success of glucocorticoid therapy and define a critical role for NF-kappaB in the pathogenesis of septic shock.
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Stein PK. Measures of parasympathetic function and risk stratification in critical care. Crit Care Med 2008; 36:1025-7. [PMID: 18431317 DOI: 10.1097/ccm.0b013e318164ec6d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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