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Armandeh M, Bameri B, Baeeri M, Haghi-Aminjan H, Rahimifard M, Hassani S, Hooshangi Shayesteh MR, Khalid M, Samadi M, Hosseini R, Masoudi Fard M, Abdollahi M. The role of levosimendan in phosphine-induced cardiotoxicity: evaluation of electrocardiographic, echocardiographic, and biochemical parameters. Toxicol Mech Methods 2021; 31:631-643. [PMID: 34219611 DOI: 10.1080/15376516.2021.1950248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aluminum phosphide (AlP) causes serious poisoning in which severe cardiac suppression is the significant lethal consequence. According to evidence, levosimendan can exert outstanding cardiac support and protection in different pathological conditions. This study aimed to investigate the mechanisms by which levosimendan may alleviate cardiovascular toxicity due to AlP intoxication in the rat model. The groups included control group (normal saline only), sole levosimendan groups (12, 24, 48 μg/kg), AlP group (10 mg/kg), and AlP + levosimendan groups receiving 12, 24, 48 μg/kg levosimendan intraperitoneally 30 min after AlP administration. Electrocardiographic (ECG) parameters (QRS and PR duration and ST height), heart rate, and blood pressure were monitored for 180 minutes. Also, after 24 h of poisoning, echocardiography was applied to assess left ventricle function. Evaluation of the biochemical parameters in heart tissue, including mitochondrial complexes I, II, IV activity, ADP/ATP ratio, the rate of apoptosis, malondialdehyde (MDA), lactate, and troponin I levels, were done after 12 and 24 h. AlP-induced ECG abnormalities (PR duration and ST height), reduction in heart rate, blood pressure, cardiac output, ejection fraction, and stroke volume were improved by levosimendan administration. Besides, levosimendan significantly improved complex IV activity, the ADP/ATP ratio, apoptosis, MDA, lactate, and troponin I level following AlP-poisoning. Our results suggest that levosimendan might alleviate AlP-induced cardiotoxicity by modulating mitochondrial activity and improving cardiac function. However, the potential clinical use of levosimendan in this toxicity needs more investigations.
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Affiliation(s)
- Maryam Armandeh
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (P SRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Behnaz Bameri
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (P SRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Baeeri
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (P SRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Haghi-Aminjan
- Pharmaceutical Sciences Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mahban Rahimifard
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (P SRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Shokoufeh Hassani
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (P SRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Hooshangi Shayesteh
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (P SRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Madiha Khalid
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (P SRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Mahedeh Samadi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rohollah Hosseini
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Masoudi Fard
- Department of Surgery & Radiology, Faculty of Veterinary Medicine, Tehran University, Tehran, Iran
| | - Mohammad Abdollahi
- Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Toxicology and Diseases Group, Pharmaceutical Sciences Research Center (P SRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
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Levosimendan increases brain tissue oxygen levels after cardiopulmonary resuscitation independent of cardiac function and cerebral perfusion. Sci Rep 2021; 11:14220. [PMID: 34244561 PMCID: PMC8270955 DOI: 10.1038/s41598-021-93621-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/28/2021] [Indexed: 11/11/2022] Open
Abstract
Prompt reperfusion is important to rescue ischemic tissue; however, the process itself presents a key pathomechanism that contributes to a poor outcome following cardiac arrest. Experimental data have suggested the use of levosimendan to limit ischemia–reperfusion injury by improving cerebral microcirculation. However, recent studies have questioned this effect. The present study aimed to investigate the influence on hemodynamic parameters, cerebral perfusion and oxygenation following cardiac arrest by ventricular fibrillation in juvenile male pigs. Following the return of spontaneous circulation (ROSC), animals were randomly assigned to levosimendan (12 µg/kg, followed by 0.3 µg/kg/min) or vehicle treatment for 6 h. Levosimendan-treated animals showed significantly higher brain PbtO2 levels. This effect was not accompanied by changes in cardiac output, preload and afterload, arterial blood pressure, or cerebral microcirculation indicating a local effect. Cerebral oxygenation is key to minimizing damage, and thus, current concepts are aimed at improving impaired cardiac output or cerebral perfusion. In the present study, we showed that NIRS does not reliably detect low PbtO2 levels and that levosimendan increases brain oxygen content. Thus, levosimendan may present a promising therapeutic approach to rescue brain tissue at risk following cardiac arrest or ischemic events such as stroke or traumatic brain injury.
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Pralidoxime improves the hemodynamics and survival of rats with peritonitis-induced sepsis. PLoS One 2021; 16:e0249794. [PMID: 33822820 PMCID: PMC8023460 DOI: 10.1371/journal.pone.0249794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 03/22/2021] [Indexed: 12/29/2022] Open
Abstract
Several studies have suggested that sympathetic overstimulation causes deleterious effects in septic shock. A previous study suggested that pralidoxime exerted a pressor effect through a mechanism unrelated to the sympathetic nervous system; this effect was buffered by the vasodepressor action of pralidoxime mediated through sympathoinhibition. In this study, we explored the effects of pralidoxime on hemodynamics and survival in rats with peritonitis-induced sepsis. This study consisted of two sub-studies: survival and hemodynamic studies. In the survival study, 66 rats, which survived for 10 hours after cecal ligation and puncture (CLP), randomly received saline placebo, pralidoxime, or norepinephrine treatment and were monitored for up to 24 hours. In the hemodynamic study, 44 rats were randomly assigned to sham, CLP-saline placebo, CLP-pralidoxime, or CLP-norepinephrine groups, and hemodynamic measurements were performed using a conductance catheter placed in the left ventricle. In the survival study, 6 (27.2%), 15 (68.1%), and 5 (22.7%) animals survived the entire 24-hour monitoring period in the saline, pralidoxime, and norepinephrine groups, respectively (log-rank test P = 0.006). In the hemodynamic study, pralidoxime but not norepinephrine increased end-diastolic volume (P <0.001), stroke volume (P = 0.002), cardiac output (P = 0.003), mean arterial pressure (P = 0.041), and stroke work (P <0.001). The pressor effect of norepinephrine was short-lived, such that by 60 minutes after the initiation of norepinephrine infusion, it no longer had any significant effect on mean arterial pressure. In addition, norepinephrine significantly increased heart rate (P <0.001) and the ratio of arterial elastance to ventricular end-systolic elastance (P = 0.010), but pralidoxime did not. In conclusion, pralidoxime improved the hemodynamics and 24-hour survival rate in rats with peritonitis-induced sepsis, but norepinephrine did not.
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Merz T, Denoix N, Huber-Lang M, Singer M, Radermacher P, McCook O. Microcirculation vs. Mitochondria-What to Target? Front Med (Lausanne) 2020; 7:416. [PMID: 32903633 PMCID: PMC7438707 DOI: 10.3389/fmed.2020.00416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/29/2020] [Indexed: 01/02/2023] Open
Abstract
Circulatory shock is associated with marked disturbances of the macro- and microcirculation and flow heterogeneities. Furthermore, a lack of tissue adenosine trisphosphate (ATP) and mitochondrial dysfunction are directly associated with organ failure and poor patient outcome. While it remains unclear if microcirculation-targeted resuscitation strategies can even abolish shock-induced flow heterogeneity, mitochondrial dysfunction and subsequently diminished ATP production could still lead to organ dysfunction and failure even if microcirculatory function is restored or maintained. Preserved mitochondrial function is clearly associated with better patient outcome. This review elucidates the role of the microcirculation and mitochondria during circulatory shock and patient management and will give a viewpoint on the advantages and disadvantages of tailoring resuscitation to microvascular or mitochondrial targets.
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Affiliation(s)
- Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Nicole Denoix
- Clinic for Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, Ulm, Germany
| | - Markus Huber-Lang
- Institute for Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Mervyn Singer
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, United Kingdom
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
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Ospina-Tascón GA, Calderón-Tapia LE. Inodilators in septic shock: should these be used? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:796. [PMID: 32647721 PMCID: PMC7333155 DOI: 10.21037/atm.2020.04.43] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Septic shock involves a complex interaction between abnormal vasodilation, relative and/or absolute hypovolemia, myocardial dysfunction, and altered blood flow distribution to the tissues. Fluid administration, vasopressor support and inotropes, represent fundamental pieces of quantitative resuscitation protocols directed to assist the restoration of impaired tissue perfusion during septic shock. Indeed, current recommendations on sepsis management include the use of inotropes in the case of myocardial dysfunction, as suggested by a low cardiac output, increased filling pressures, or persisting signals of tissue hypoperfusion despite an adequate correction of intravascular volume and mean arterial pressure by fluid administration and vasopressor support. Evidence supporting the use of inotropes in sepsis and septic shock is mainly based on physiological studies. Most of them suggest a beneficial effect of inotropes on macro hemodynamics especially when sepsis coexists with myocardial dysfunction; others, however, have demonstrated variable results on regional splanchnic circulation, while others suggest favorable effects on microvascular distribution independently of its impact on cardiac output. Conversely, impact of inodilators on clinical outcomes in this context has been more controversial. Use of dobutamine has not been consistently related with more favorable clinical results, while systematic administration of levosimendan in sepsis do not prevent the development of multiorgan dysfunction, even in patients with evidence of myocardial dysfunction. Nevertheless, a recent metanalysis of clinical studies suggests that cardiovascular support regimens based on inodilators in sepsis and septic shock could provide some beneficial effect on mortality, while other one corroborated such effect on mortality specially in patients with proved lower cardiac output. Thus, using or not inotropes during sepsis and septic shock remains as controversy matter that deserves more research efforts.
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Affiliation(s)
- Gustavo A Ospina-Tascón
- Department of Intensive Care, Fundación Valle del Lili-Universidad Icesi, Cali, Colombia.,Translational Medicine in Critical Care and Experimental Surgery Laboratory, Universidad Icesi, Cali, Colombia
| | - Luis E Calderón-Tapia
- Department of Intensive Care, Fundación Valle del Lili-Universidad Icesi, Cali, Colombia.,Translational Medicine in Critical Care and Experimental Surgery Laboratory, Universidad Icesi, Cali, Colombia
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Guillon A, Preau S, Aboab J, Azabou E, Jung B, Silva S, Textoris J, Uhel F, Vodovar D, Zafrani L, de Prost N, Radermacher P. Preclinical septic shock research: why we need an animal ICU. Ann Intensive Care 2019; 9:66. [PMID: 31183570 PMCID: PMC6557957 DOI: 10.1186/s13613-019-0543-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/03/2019] [Indexed: 12/14/2022] Open
Abstract
Animal experiments are widely used in preclinical medical research with the goal of disease modeling and exploration of novel therapeutic approaches. In the context of sepsis and septic shock, the translation into clinical practice has been disappointing. Classical animal models of septic shock usually involve one-sex-one-age animal models, mostly in mice or rats, contrasting with the heterogeneous population of septic shock patients. Many other factors limit the reliability of preclinical models and may contribute to preclinical research failure in critical care, including the host specificity of several pathogens, the fact that laboratory animals are raised in pathogen-free facilities and that organ support techniques are either absent or minimal. Advanced animal models have been developed with the aim of improving the clinical translatability of experimental findings. So-called animal ICUs refer to the preclinical investigation of adult or even aged animals of either sex, using—in case of rats and mice—miniaturized equipment allowing for reproducing an ICU environment at a small animal scale and integrating chronic comorbidities to more closely reflect the clinical conditions studied. Strength and limitations of preclinical animal models designed to decipher the mechanisms involved in septic cardiomyopathy are discussed. This article reviews the current status and the challenges of setting up an animal ICU.
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Affiliation(s)
- Antoine Guillon
- Service de Médecine Intensive - Réanimation, CHRU de Tours, Tours, France.,Centre d'Etude des Pathologies Respiratoires (CEPR), UMR 1100, INSERM, Faculté de Médecine, Université de Tours, Tours, France
| | - Sebastien Preau
- Service de Médecine Intensive, Hôpital Salengro, CHU Lille, Lille, France.,Lille Inflammation Research International Center (LIRIC), U 995, School of Medicine, INSERM, Univ. Lille, Lille, France
| | - Jérôme Aboab
- Service de Réanimation, Hôpital Delafontaine, Saint-Denis, France
| | - Eric Azabou
- Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Raymond Poincaré, 92380, Garches, France
| | - Boris Jung
- Service de Réanimation, CHU de Montpellier, Montpellier, France
| | - Stein Silva
- Service de Réanimation, CHU Purpan, 31300, Toulouse, France
| | - Julien Textoris
- Département d'Anesthésie-Réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, CHU de Lyon, 69437, Lyon, France.,EA 7426 Pathophysiology of Injury-induced Immunosuppression, University of Lyon1-Hospices Civils de Lyon - bioMérieux, Hôpital Edouard Herriot, 69437, Lyon, France
| | - Fabrice Uhel
- Service de Réanimation Médicale et Maladies Infectieuses, CHU de Rennes, Hôpital Pontchaillou, Rennes, France
| | - Dominique Vodovar
- Centre Antipoison et de Toxicovigilance de Paris - Fédération de Toxicologie, Hôpital Fernand-Widal, Assistance Publique-Hôpitaux de Paris, Paris, France.,UMRS 1144, Faculté de Pharmacie, INSERM, Paris, France
| | - Lara Zafrani
- Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France
| | - Nicolas de Prost
- Service de Réanimation Médicale, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France.
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany
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Effects of Levosimendan on Cellular Metabolic Alterations in Patients With Septic Shock: A Randomized Controlled Pilot Study. Shock 2018; 48:307-312. [PMID: 28234790 PMCID: PMC5516668 DOI: 10.1097/shk.0000000000000851] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Mitochondrial dysfunction and consequent cellular energetic failure play a key role in the development of sepsis-related organs failure. Evidence suggests that the pleiotropic effects of levosimendan may positively affect cellular metabolism during septic shock. Objectives: To investigate changes in the concentration of glucose, lactate, pyruvate, and glycerol in the extracellular fluid of the skeletal muscle following levosimendan administration in patients with septic shock. Methods: The study was designed as a prospective, double-blind, controlled, clinical pilot trial and performed in a multidisciplinary intensive care unit. After achieving normovolemia and a mean arterial pressure of at least 65 mm Hg, 20 septic shock patients were randomized to receive either levosimendan 0.2 μg/kg/min (n = 10), or dobutamine 5 μg/kg/min as active comparator (n = 10). Interstitial tissue concentrations of lactate, pyruvate, glucose, and glycerol were obtained by using muscle microdialysis. All measurements, including data from right heart catheterization, were obtained at baseline and every 6 h for the following 72 h after randomization. The trial is registered with Clinicaltrials.gov, number NCT02963454. Results: Compared with dobutamine, levosimendan increased interstitial tissue pyruvate concentration (153.3 ± 73 and 187. 2 ± 13.5 vs. 210.7 ± 76.2 and 161 ± 64.6; P < 0.05), and lactate clearance (55 vs. 10). Lactate/pyruvate ratio was lower in the levosimendan group at the end of study period (37. 7 ± 18.9 and 29.3 ± 12.7 vs. 10.9 ± 4.5 and 31.4 ± 13. 2; P < 0.05). Conclusion: Although we investigated a small number of patients, our preliminary results suggest that levosimendan may improve cellular metabolic alterations in patients with septic shock.
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Lakshmikanth CL, Jacob SP, Chaithra VH, de Castro-Faria-Neto HC, Marathe GK. Sepsis: in search of cure. Inflamm Res 2016; 65:587-602. [PMID: 26995266 DOI: 10.1007/s00011-016-0937-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 02/23/2016] [Accepted: 02/29/2016] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Sepsis is a complex inflammatory disorder believed to originate from an infection by any types of microbes and/or their products. It is the leading cause of death in intensive care units (ICUs) throughout the globe. The mortality rates depend both on the severity of infection and the host's response to infection. METHODS Literature survey on pathobiology of sepsis in general and failure of more than hundred clinical trials conducted so far in search of a possible cure for sepsis resulted in the preparation of this manuscript. FINDINGS Sepsis lacks a suitable animal model that mimics human sepsis. However, based on the results obtained in animal models of sepsis, clinical trials conducted so far have been disappointing. Although involvement of multiple mediators and pathways in sepsis has been recognized, only few components are being targeted and this could be the major reason behind the failure of clinical trials. CONCLUSION Inability to recognize a single critical mediator of sepsis may be the underlying cause for the poor therapeutic intervention of sepsis. Therefore, sepsis is still considered as a disease-in search of cure.
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Affiliation(s)
| | - Shancy Petsel Jacob
- Department of Studies in Biochemistry, University of Mysore, Manasagangothri, Mysore, 570 006, India
| | | | | | - Gopal Kedihithlu Marathe
- Department of Studies in Biochemistry, University of Mysore, Manasagangothri, Mysore, 570 006, India.
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Heming N, Lamothe L, Ambrosi X, Annane D. Emerging drugs for the treatment of sepsis. Expert Opin Emerg Drugs 2016; 21:27-37. [DOI: 10.1517/14728214.2016.1132700] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Ince C. To beta block or not to beta block; that is the question. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:339. [PMID: 26400614 PMCID: PMC4581102 DOI: 10.1186/s13054-015-1059-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The fast-acting β-1 blocker esmolol has been the center of attention since the landmark article by Morrelli and colleagues suggesting that, in patients with sepsis, reducing heart rate by administering esmolol can result in a survival benefit. However, the use of esmolol for the treatment of sepsis and the underlying mechanism responsible for this benefit remain controversial. This commentary discusses the study by Jacquet-Lagrèze and colleagues, who in a pig model of sepsis tested the hypothesis that administration of esmolol to reduce heart rate may correct sepsis-induced sublingual and gut microcirculatory alterations which are known to be associated with adverse outcome.
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Affiliation(s)
- Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, s-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
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Zangrillo A, Putzu A, Monaco F, Oriani A, Frau G, De Luca M, Di Tomasso N, Bignami E, Lomivorotov V, Likhvantsev V, Landoni G. Levosimendan reduces mortality in patients with severe sepsis and septic shock: A meta-analysis of randomized trials. J Crit Care 2015; 30:908-13. [PMID: 26093802 DOI: 10.1016/j.jcrc.2015.05.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/19/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE There is controversy about the use of inotropes in the treatment of severe sepsis and septic shock. The objective of this study was to evaluate if levosimendan, as compared with standard inotropic therapy (eg, dobutamine), reduces mortality in septic patients. MATERIALS AND METHODS BioMedCentral, PubMed, EMBASE, and the Cochrane Central Register were searched for pertinent studies, up to 1st May 2015. Randomized trials on the use of levosimendan in patients with severe sepsis and septic shock were included if reporting mortality data. The primary outcome was mortality, whereas secondary outcomes were blood lactate, cardiac index, total fluid infused, norepinephrine dosage, and mean arterial pressure. RESULTS Seven studies for a total of 246 patients were included in the analysis. Levosimendan was associated with significantly reduced mortality compared with standard inotropic therapy (59/125 [47%] in the levosimendan group and 74/121 [61%] in the control group; risk difference = -0.14, risk ratio = 0.79 [0.63-0.98], P for effect = .03, I(2) = 0%, numbers needed to treat = 7). Blood lactate was significantly reduced in the levosimendan group, whereas cardiac index and total fluid infused were significantly higher in the levosimendan group. No difference in mean arterial pressure and norepinephrine usage was noted. CONCLUSIONS In patients with severe sepsis and septic shock, levosimendan is associated with a significant reduction in mortality compared with standard inotropic therapy. A large ongoing multicenter randomized trial will have to confirm these findings.
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Affiliation(s)
- Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University of Milan, Milan, Italy.
| | - Alessandro Putzu
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Giovanna Frau
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Monica De Luca
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Nora Di Tomasso
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Elena Bignami
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Valery Likhvantsev
- Anesthesiology & Intensive Care Department, Moscow Regional Clinical & Research Institute, Moscow, Russia.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University of Milan, Milan, Italy.
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El Kalioubie A, Overtchouk P, Ledoux G, Lawson R, Favory R. Effets des vasoconstricteurs sur la microcirculation. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Tsao CM, Li KY, Chen SJ, Ka SM, Liaw WJ, Huang HC, Wu CC. Levosimendan attenuates multiple organ injury and improves survival in peritonitis-induced septic shock: studies in a rat model. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:652. [PMID: 25432865 PMCID: PMC4274679 DOI: 10.1186/s13054-014-0652-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 11/07/2014] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The aim of this study was to investigate the effects of levosimendan on rodent septic shock induced by cecal ligation and puncture (CLP). METHODS Three hours after peritonitis-induced sepsis, male Wistar rats were randomly assigned to receive an intravenous infusion of levosimendan (1.2 μg/kg/min for 10 min and then 0.3 μg/kg/min for 6 h) or an equivalent volume of saline and vehicle (5% dextrose) solution. RESULTS The levosimendan-treated CLP animals had significantly higher arterial pressure and lower biochemical indices of liver and kidney dysfunction compared to the CLP animals (P < 0.05). Plasma interleukin-1β, nitric oxide and organ superoxide levels in the levosimendan-treated CLP group were less than those in CLP rats treated with vehicle (P < 0.05). In addition, the inducible nitric oxide synthase (iNOS) in lung and caspase-3 expressions in spleen were significantly lower in the levosimendan-treated CLP group (P < 0.05). The administration of CLP rats with levosimendan was associated with significantly higher survival (61.9% vs. 40% at 18 h after CLP, P < 0.05). At postmortem examination, the histological changes and neutrophil filtration index in liver and lung were significantly attenuated in the levosimendan-treated CLP group (vs. CLP group, P < 0.05). CONCLUSIONS In this clinically relevant model of septic shock induced by fecal peritonitis, the administration of levosimendan had beneficial effects on haemodynamic variables, liver and kidney dysfunction, and metabolic acidosis. (1) Lower levels of interleukin-1β, nitric oxide and superoxide, (2) attenuation of iNOS and caspase-3 expressions, and (3) decreases of neutrophil infiltration by levosimendan in peritonitis-induced sepsis animals suggest that anti-inflammation and anti-apoptosis effects of levosimendan contribute to prolonged survival.
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Affiliation(s)
- Cheng-Ming Tsao
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan. .,Department of Anesthesiology, Tri-Service General Hospital, National Defence Medical Centre, Taipei, Taiwan.
| | - Kai-Yi Li
- Department of Pharmacology, National Defence Medical Centre, Neihu PO Box 90048-504, Taipei, 114, Taiwan.
| | - Shiu-Jen Chen
- Department of Nursing, Kang-Ning Junior College of Medical Care and Management, Taipei, Taiwan. .,Department of Physiology, National Defence Medical Centre, Taipei, Taiwan.
| | - Shuk-Man Ka
- Graduate Institute of Aerospace and Undersea Medicine, National Defence Medical Centre, Taipei, Taiwan.
| | - Wen-Jinn Liaw
- Department of Anesthesiology, Tri-Service General Hospital, National Defence Medical Centre, Taipei, Taiwan. .,Department of Pharmacology, National Defence Medical Centre, Neihu PO Box 90048-504, Taipei, 114, Taiwan. .,Department of Anesthesiology, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan.
| | - Hsieh-Chou Huang
- Department of Anesthesiology, Cheng-Hsin General Hospital, Taipei, Taiwan. .,Department of Anesthesiology and Pain Clinics, Cheng-Hsin Rehabilitation Medical Centre, 45, Cheng-Hsin St, Taipei, 112, Taiwan.
| | - Chin-Chen Wu
- Department of Pharmacology, National Defence Medical Centre, Neihu PO Box 90048-504, Taipei, 114, Taiwan. .,Department of Pharmacology, Taipei Medical University, Taipei, Taiwan.
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Effects of levosimendan on hemodynamics, local cerebral blood flow, neuronal injury, and neuroinflammation after asphyctic cardiac arrest in rats. Crit Care Med 2014; 42:e410-9. [PMID: 24633188 DOI: 10.1097/ccm.0000000000000308] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Despite advances in cardiac arrest treatment, high mortality and morbidity rates after successful cardiopulmonary resuscitation are still a major clinical relevant problem. The post cardiac arrest syndrome subsumes myocardial dysfunction, impaired microcirculation, systemic inflammatory response, and neurological impairment. The calcium-sensitizer levosimendan was able to improve myocardial function and initial resuscitation success after experimental cardiac arrest/cardiopulmonary resuscitation. We hypothesized that levosimendan exerts beneficial effects on cerebral blood flow, neuronal injury, neurological outcome, and inflammation 24 hours after experimental cardiac arrest/cardiopulmonary resuscitation. DESIGN Laboratory animal study. SETTING University animal research laboratory. SUBJECTS Sixty-one male Sprague-Dawley rats. INTERVENTIONS Animals underwent asphyxial cardiac arrest/cardiopulmonary resuscitation, randomized to groups with levosimendan treatment (bolus 12 µg/kg and infusion for 3 hr [0.3 µg/min/kg]) or vehicle (saline 0.9% bolus and infusion for 3 hr [equivalent fluid volume]). Cardiac index, local cerebral blood flow, and hemodynamic variables were measured for 180 minutes after cardiac arrest/cardiopulmonary resuscitation. Behavioral and neurological evaluations were conducted 24 hours after cardiac arrest/cardiopulmonary resuscitation. Furthermore, neuronal injury, expressed as Fluoro-Jade B-positive cells in the hippocampal formation, cortical and hippocampal inflammatory cytokine gene expression, and blood plasma interleukin-6 values were assessed. MEASUREMENTS AND MAIN RESULTS Treatment with levosimendan reduced neuronal injury and improved neurological outcome after 24 hours of reperfusion and resulted in elevated cardiac index and local cerebral blood flow compared with vehicle after cardiac arrest/cardiopulmonary resuscitation. Mean arterial blood pressure was reduced during the early reperfusion period in the levosimendan group. Cortical and hippocampal inflammatory cytokine gene expression and blood plasma interleukin-6 levels were not influenced. CONCLUSIONS Levosimendan increased cerebral blood flow after experimental cardiac arrest/cardiopulmonary resuscitation. This effect coincided with reduced neuronal injury and improved neurologic outcome. Findings seem to be independent of inflammatory effects because no effects by levosimendan on cerebral or systemic inflammation could be detected. In summary, levosimendan is a promising agent to improve neurological outcome after cardiac arrest/cardiopulmonary resuscitation.
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Orme RML, Perkins GD, McAuley DF, Liu KD, Mason AJ, Morelli A, Singer M, Ashby D, Gordon AC. An efficacy and mechanism evaluation study of Levosimendan for the Prevention of Acute oRgan Dysfunction in Sepsis (LeoPARDS): protocol for a randomized controlled trial. Trials 2014; 15:199. [PMID: 24894386 PMCID: PMC4061524 DOI: 10.1186/1745-6215-15-199] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 05/16/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Organ dysfunction consequent to infection ('severe sepsis') is the leading cause of admission to an intensive care unit (ICU). In both animal models and early clinical studies the calcium channel sensitizer levosimendan has been demonstrated to have potentially beneficial effects on organ function. The aims of the Levosimendan for the Prevention of Acute oRgan Dysfunction in Sepsis (LeoPARDS) trial are to identify whether a 24-hour infusion of levosimendan will improve organ dysfunction in adults who have septic shock and to establish the safety profile of levosimendan in this group of patients. METHODS/DESIGN This is a multicenter, randomized, double-blind, parallel group, placebo-controlled trial. Adults fulfilling the criteria for systemic inflammatory response syndrome due to infection, and requiring vasopressor therapy, will be eligible for inclusion in the trial. Within 24 hours of meeting these inclusion criteria, patients will be randomized in a 1:1 ratio stratified by the ICU to receive either levosimendan (0.05 to 0.2 μg.kg⁻¹.min⁻¹ or placebo for 24 hours in addition to standard care. The primary outcome measure is the mean Sequential Organ Failure Assessment (SOFA) score while in the ICU. Secondary outcomes include: central venous oxygen saturations and cardiac output; incidence and severity of renal failure using the Acute Kidney Injury Network criteria; duration of renal replacement therapy; serum bilirubin; time to liberation from mechanical ventilation; 28-day, hospital, 3 and 6 month survival; ICU and hospital length-of-stay; and days free from catecholamine therapy. Blood and urine samples will be collected on the day of inclusion, at 24 hours, and on days 4 and 6 post-inclusion for investigation of the mechanisms by which levosimendan might improve organ function. Eighty patients will have additional blood samples taken to measure levels of levosimendan and its active metabolites OR-1896 and OR-1855. A total of 516 patients will be recruited from approximately 25 ICUs in the United Kingdom. DISCUSSION This trial will test the efficacy of levosimendan to reduce acute organ dysfunction in adult patients who have septic shock and evaluate its biological mechanisms of action. TRIAL REGISTRATION Current controlled trials ISRCTN12776039 (19 September 2013).
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Affiliation(s)
- Robert M L’E Orme
- Department of Critical Care, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit and Heart of England NHS Foundation Trust, Warwick Medical School, University of Warwick, Gibbet Hill, Coventry CV4 7AL, UK
| | - Daniel F McAuley
- Centre for Infection and Immunity, Queens University of Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California, 521 Parnassus Avenue, Box 0532, San Francisco, CA 94143, USA
| | - Alexina J Mason
- School of Public Health, Imperial College London, Norfolk Place, London W2 1PG, UK
| | - Andrea Morelli
- Department of Anaesthesiology and Intensive Care, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care, University College London, Gower Street, London WC1E 6BT, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, Norfolk Place, London W2 1PG, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
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Place des inotropes en réanimation. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0860-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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17
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Possible interventional therapies in severe sepsis or septic shock. ACTA ACUST UNITED AC 2012; 50:74-7. [PMID: 22769862 DOI: 10.1016/j.aat.2012.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 04/17/2012] [Accepted: 04/20/2012] [Indexed: 01/19/2023]
Abstract
For many years, basic research with relatively straightforward pathophysiologic approaches has driven clinical trials using molecules that supposedly interfere positively with inflammatory processes. However, most of these trials have failed to demonstrate any outcome benefit. Indeed, we need to revisit current paradigms and to think about the possibility that outcome may be predetermined in severe sepsis or septic shock. In addition, an early diagnosis of sepsis prior to the onset of clinical decline is also of particular interest to health practitioners because this information increases the possibilities for early and specific treatment of this life threatening condition. Indeed, the time to initiate therapy is thought to be crucial and the major determent factor in surviving sepsis. Despite substantial progress in sepsis therapy, the gap between the discovery of new effective medical molecules and their implementation in the daily clinical practice of the intensive care unit remains a major hurdle. Fortunately, ongoing research continues to provide new information on the management of sepsis, in particular, severe sepsis or septic shock. High quality and effective management tools are necessary to bring evidence-based therapy to the bedside. On this basis, new therapies could be tested to reduce mortality rates with respect to recently published studies.
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Memiş D, Inal MT, Sut N. The effects of levosimendan vs dobutamine added to dopamine on liver functions assessed with noninvasive liver function monitoring in patients with septic shock. J Crit Care 2012; 27:318.e1-6. [DOI: 10.1016/j.jcrc.2011.06.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 06/01/2011] [Accepted: 06/12/2011] [Indexed: 11/29/2022]
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Effect of charge on microvascular permeability in early experimental sepsis in the rat. Microvasc Res 2011; 82:339-45. [PMID: 21906604 DOI: 10.1016/j.mvr.2011.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 08/02/2011] [Accepted: 08/18/2011] [Indexed: 11/23/2022]
Abstract
A key feature of sepsis is hypovolemia due to increased microvascular permeability. It has been suggested that the negative charge of albumin and of the endothelial glycocalyx is important for maintenance of the normally low permeability for albumin. Here we tested the hypothesis that charge effects contribute to the increased permeability in sepsis. Transcapillary escape rate (TER) and initial distribution volume for (125)I-labeled bovine serum albumin (BSA, isoelectric point pH 4.6) and for (131)I-labeled charge modified BSA (cBSA, average isoelectric point, pH 7.1) was measured 3h after sepsis was induced by cecal ligation and incision (CLI) (n=11) and in control animals (n=12). The importance of charge for permeability in sepsis was estimated by comparing the ratio between TER for cBSA and TER for BSA during control conditions to that after CLI. Plasma concentration of the glycocalyx component glycosaminoglycans (GAGs) was measured in separate control and CLI animals. The initial distribution volume for BSA and cBSA in control animals was 38 ± 3 ml/kg and 47 ± 4 mL/kg and decreased by 17% and 19%, respectively, following CLI. TER for BSA increased from 16.7 ± 4.1% in the controls to 20.1 ± 1.9% following CLI. Corresponding values for cBSA were 26.7 ± 5.6% and 29.8 ± 3.5%, respectively. The ratio between TER for cBSA and TER for BSA was 1.62 ± 0.1 in the control group and 1.49 ± 0.1 following CLI (p<0.05). Plasma GAG concentrations were higher in CLI animals than in the control group. We conclude that CLI induce hypovolemia secondary to increased microvascular permeability. Negative charge contributes to the normally low permeability of albumin and the importance of charge is decreased in early experimental sepsis. The observed charge effects are associated with CLI-induced breakdown of the glycocalyx.
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Chew MS, Hawthorne WJ, Bendall J, Whereat S, Huang S, Ting I, Simond D, McLean A. No beneficial effects of levosimendan in acute porcine endotoxaemia. Acta Anaesthesiol Scand 2011; 55:851-61. [PMID: 21574964 DOI: 10.1111/j.1399-6576.2011.02436.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Levosimendan has been proposed as an attractive alternative to adrenergic agents for the treatment of sepsis-induced heart failure and haemodynamic derangements. Its use in this setting is, however, still not well investigated. The aim of this study was to test the hypothesis that levosimendan is able to attenuate endotoxin-induced pulmonary hypertension and improve myocardial function in a porcine model. The secondary aims were to investigate its effect on renal and liver function, and the plasma cytokine response. METHODS Endotoxaemia was induced in 18 pigs, randomized to placebo and Levosimendan groups. All pigs were fluid resuscitated and Noradrenalin infusion was given according to a predefined protocol. Systemic haemodynamics and myocardial function were measured using pulmonary artery catheterization and transthoracic echocardiography. Renal and liver function tests and cytokine concentrations were measured in plasma. RESULTS Levosimendan did not attenuate endotoxin-induced pulmonary hypertension and did not improve myocardial function. There were no differences in renal or liver function. Increases in arterial lactate and decreases in base excess were observed in the Levosimendan group, as well as significant increases in plasma interleukin (IL)-6 and IL-8. CONCLUSIONS Contrary to our hypothesis, levosimendan given in conjunction with a protocolized vasopressor and fluid resuscitation did not improve cardiac, renal or liver function in this model of acute porcine endotoxaemia. Hyperlactataemia, acidosis and increases in plasma pro-inflammatory cytokines were observed, the mechanisms and implications of which remain unclear.
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Affiliation(s)
- Michelle S Chew
- Department of Intensive Care Medicine, Skåne University Hospital Malmö, Lund University, Sweden.
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Combined arginine vasopressin and levosimendan: A promising therapy for septic shock. Crit Care Med 2011; 39:921-2; author reply 922. [DOI: 10.1097/ccm.0b013e318206b6c8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Morelli A, Donati A, Ertmer C, Rehberg S, Lange M, Orecchioni A, Cecchini V, Landoni G, Pelaia P, Pietropaoli P, Van Aken H, Teboul JL, Ince C, Westphal M. Levosimendan for resuscitating the microcirculation in patients with septic shock: a randomized controlled study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R232. [PMID: 21182783 PMCID: PMC3219978 DOI: 10.1186/cc9387] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 09/30/2010] [Accepted: 12/23/2010] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The purpose of the present study was to investigate microcirculatory blood flow in patients with septic shock treated with levosimendan as compared to an active comparator drug (i.e. dobutamine). The primary end point was a difference of ≥ 20% in the microvascular flow index of small vessels (MFIs) among groups. METHODS The study was designed as a prospective, randomized, double-blind clinical trial and performed in a multidisciplinary intensive care unit. After achieving normovolemia and a mean arterial pressure of at least 65 mmHg, 40 septic shock patients were randomized to receive either levosimendan 0.2 μg·kg(-1)·min(-1) (n = 20) or an active comparator (dobutamine 5 μg·kg(-1)·min(-1); control; n = 20) for 24 hours. Sublingual microcirculatory blood flow of small and medium vessels was assessed by sidestream dark-field imaging. Microcirculatory variables and data from right heart catheterization were obtained at baseline and 24 hours after randomization. Baseline and demographic data were compared by means of Mann-Whitney rank sum test or chi-square test, as appropriate. Microvascular and hemodynamic variables were analyzed using the Mann-Whitney rank sum test. RESULTS Microcirculatory flow indices of small and medium vessels increased over time and were significantly higher in the levosimendan group as compared to the control group (24 hrs: MFIm 3.0 (3.0; 3.0) vs. 2.9 (2.8; 3.0); P = .02; MFIs 2.9 (2.9; 3.0) vs. 2.7 (2.3; 2.8); P < .001). The relative increase of perfused vessel density vs. baseline was significantly higher in the levosimendan group than in the control group (dMFIm 10 (3; 23)% vs. 0 (-1; 9)%; P = .007; dMFIs 47 (26; 83)% vs. 10 (-3; 27); P < .001). In addition, the heterogeneity index decreased only in the levosimendan group (dHI -93 (-100; -84)% vs. 0 (-78; 57)%; P < .001). There was no statistically significant correlation between systemic and microcirculatory flow variables within each group (each P > .05). CONCLUSIONS Compared to a standard dose of 5 μg·kg(-1)·min(-1) of dobutamine, levosimendan at 0.2 μg·kg(-1)·min(-1) improved sublingual microcirculatory blood flow in patients with septic shock, as reflected by changes in microcirculatory flow indices of small and medium vessels. TRIAL REGISTRATION NCT00800306.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, University of Rome, La Sapienza, Viale del Policlinico 155, Rome 00161, Italy.
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Vasopressin, levosimendan, and cardiovascular function in septic shock*. Crit Care Med 2010; 38:2071-3. [DOI: 10.1097/ccm.0b013e3181f3dda0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med 2010; 36:2004-18. [PMID: 20811874 PMCID: PMC2981743 DOI: 10.1007/s00134-010-1970-x] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Accepted: 07/02/2010] [Indexed: 12/19/2022]
Abstract
Purpose The clinical use of vasoactive drugs is not only intended to improve systemic hemodynamic variables, but ultimately to attenuate derangements in organ perfusion and oxygenation during shock. This review aims (1) to discuss basic physiology with respect to manipulating vascular tone and its effect on the microcirculation, and (2) to provide an overview of available clinical data on the relation between vasoactive drugs and organ perfusion, with specific attention paid to recent developments that have enabled direct in vivo observation of the microcirculation and concepts that have originated from it. Methods A MedLine search was conducted for clinical articles in the English language over the last 15 years pertainig to shock, sepsis, organ failure, or critically ill patients in combination with vasoactive drugs and specific variables of organ perfusion/oxygenation (e.g., tonometry, indocyanine clearance, laser Doppler, and sidestream dark field imaging). Results Eighty original papers evaluating the specific relationship between organ perfusion/oxygenation and the use of vasoactive drugs were identified and are discussed in light of physiological theory of vasomotor tone. Conclusions Solid clinical data in support of the idea that increasing blood pressure in shock improves microcirculatory perfusion/oxygenation seem to be lacking, and such a concept might not be in line with physiological theory of microcirculation as a low-pressure vascular compartment. In septic shock no beneficial effect on microcirculatory perfusion above a mean arterial pressure of 65 mmHg has been reported, but a wide range in inter-individual effect seems to exist. Whether improvement of microcirculatory perfusion is associated with better patient outcome remains to be elucidated.
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LEVOSIMENDAN INCREASES PORTAL BLOOD FLOW AND ATTENUATES INTESTINAL INTRAMUCOSAL ACIDOSIS IN EXPERIMENTAL SEPTIC SHOCK. Shock 2010; 34:275-80. [DOI: 10.1097/shk.0b013e3181cd8c5b] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Somani A, Steiner ME, Hebbel RP. The dynamic regulation of microcirculatory conduit function: features relevant to transfusion medicine. Transfus Apher Sci 2010; 43:61-8. [PMID: 20580315 DOI: 10.1016/j.transci.2010.05.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The microcirculation is not merely a passive conduit for red cell transport, nutrient and gas exchange, but is instead a dynamic participant contributing to the multiple processes involved in the maintenance of metabolic homeostasis and optimal end-organ function. The microcirculation's angioarchitechture and surface properties influence conduit function and flow dynamics over a wide spectrum of conditions, accommodating many different mechanical, pathological or organ-specific responses. The endothelium itself plays a critical role as the interface between tissues and blood components, participating in the regulation of coagulation, inflammation, vascular tone, and permeability. The complex nitric oxide pathways affect vasomotor tone and influence vascular conduit caliber and distribution density, alter thrombotic propensity, and modify adhesion molecule expression. Nitric oxide pathways also interact with red blood cells and free hemoglobin moieties in normal and pathological conditions. Red blood cells themselves may affect flow dynamics. Altered rheology and compromised NO bioavailability from medical storage or disease states impede microcirculatory flow and adversely modulate vasodilation. The integration of the microcirculation as a system with respect to flow modulation is delicately balanced, and can be readily disrupted in disease states such as sepsis. This review will provide a description of these varied and intricate functions of the microvasculature.
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Affiliation(s)
- Arif Somani
- Pediatric Critical Care Medicine and Vascular Biology Center, University of Minnesota, USA.
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Kelm RF, Wagenführer J, Schmidtmann I, Engelhard K, Werner C, Noppens RR. Transpulmonary cardiac output measurement in a rat model of cardiac arrest and CPR: Impact of vascular access. Resuscitation 2010; 81:248-54. [DOI: 10.1016/j.resuscitation.2009.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 10/17/2009] [Accepted: 10/25/2009] [Indexed: 01/25/2023]
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Abstract
PURPOSE OF REVIEW To present the recent findings obtained in clinical and experimental studies examining microcirculatory alterations in sepsis, their link to mitochondrial dysfunction, and current knowledge regarding the impact of these alterations on the outcome of septic patients. RECENT FINDINGS Interlinked by a mutual cascade effect and driven by the host-pathogen interaction, microcirculatory and mitochondrial functions are impaired during sepsis. Mitochondrial respiration seems to evolve during the course of sepsis, demonstrating a change from reversible to irreversible inhibition. The spatiotemporal heterogeneity of microcirculatory and mitochondrial dysfunction suggests that these processes may be compartmentalized. Although a causal relationship between mitochondrial and microcirculatory dysfunction and organ failure in sepsis is supported by an increasing number of studies, adaptive processes have also emerged as part of microcirculatory and mitochondrial alterations. Treatments for improving or preserving microcirculatory, mitochondrial function, or both seem to yield a better outcome in patients. SUMMARY Even though there is evidence that microcirculatory and mitochondrial dysfunction plays a role in the development of sepsis-induced organ failure, their interaction and respective contribution to the disease remains poorly understood. Future research is necessary to better define such relationships in order to identify therapeutic targets and refine treatment strategies.
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Abstract
PURPOSE OF REVIEW The present review discusses the evolution of the microcirculation from a theoretical idea to a clinical concept, as a result of the introduction of direct in-vivo observation techniques. RECENT FINDINGS Technical proceedings in the acquisition and assessment of microcirculatory imaging are described, as well as the first report of in-vivo mitochondrial pO2 measurements. Experimental data on immune tolerance, leukocyte dynamics, vascular permeability and regional hypoxia have contributed to unravel the complex origin of microcirculatory alterations. Several reports have highlighted the concept of heterogeneity of microcirculatory blood flow observed within and between different microvascular beds. The previously reported prognostic value of microcirculatory alterations has now been expanded to the early phase of sepsis and in postoperative patients. Finally, a list of interventions in experimental and clinical settings is discussed with regard to their potency to influence microcirculatory changes in shock. SUMMARY Direct in-vivo observation of the microcirculation has enabled the construction of microcirculatory failure as a clinical concept in the critically ill. Aiming for promicrocirculatory recruitment strategies in order to improve outcome will be the challenge for the near future.
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Current World Literature. Curr Opin Anaesthesiol 2009; 22:539-43. [DOI: 10.1097/aco.0b013e32832fa02c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The effect of increasing doses of norepinephrine on tissue oxygenation and microvascular flow in patients with septic shock*. Crit Care Med 2009; 37:1961-6. [DOI: 10.1097/ccm.0b013e3181a00a1c] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
PURPOSE OF REVIEW Paediatric sepsis continues to be a disease with unacceptably high morbidity and mortality, despite huge advances in paediatric intensive care organization and technology. This review examines the epidemiology, pathophysiology and advances in the treatment of paediatric sepsis. RECENT FINDINGS Many studies initially reporting encouraging or positive results on adult patients with sepsis have subsequently been disproved either in further studies on adults or in proof-of-principle studies on children. Publication of treatment guidelines for paediatric sepsis has led to better organization and implementation of care; however, this has yet to translate into demonstrable improvement in outcome. We will examine the major therapeutic advances of recent years and put them into the context of paediatric sepsis, examining why they often have not translated into survival benefit. SUMMARY This review aims to evaluate the recent therapeutic advances and potential for further developments in the management of paediatric sepsis in the ICU.
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Scheiermann P, Ahluwalia D, Hoegl S, Dolfen A, Revermann M, Zwissler B, Muhl H, Boost KA, Hofstetter C. Effects of intravenous and inhaled levosimendan in severe rodent sepsis. Intensive Care Med 2009; 35:1412-9. [DOI: 10.1007/s00134-009-1481-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 02/13/2009] [Indexed: 11/30/2022]
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Langer S, Heiss C, Paulus N, Bektas N, Mommertz G, Rowinska Z, Westenfeld R, Jacobs MJ, Fries M, Koeppel TA. Functional and structural response of arterialized femoral veins in a rodent AV fistula model. Nephrol Dial Transplant 2009; 24:2201-6. [DOI: 10.1093/ndt/gfp033] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Rehberg S, Enkhbaatar P, Traber DL. Role of the Calcium Sensitizer, Levosimendan, in Perioperative Intensive Care Medicine. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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