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Zhang B, Chen X, He C, Su T, Cao K, Li X, Duan J, Chen M, Zhu Z, Yu W. Acute gastrointestinal injury and altered gut microbiota are related to sepsis-induced cholestasis in patients with intra-abdominal infection: a retrospective and prospective observational study. Front Med (Lausanne) 2023; 10:1144786. [PMID: 37575984 PMCID: PMC10414538 DOI: 10.3389/fmed.2023.1144786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Abstract
Background Sepsis-associated liver dysfunction (SALD) has high incidence and mortality in patients with intra-abdominal infection (IAI). The associations between acute gastrointestinal injury (AGI), gut microbiota, and SALD were evaluated in patients with IAI. Methods A retrospective study was conducted to assess the relationship between AGI and SALD in patients with IAI. Patients were divided into non-SALD and sepsis-induced cholestasis (SIC) groups, which is a subtype of SALD. SIC was defined as total bilirubin >2 mg/dL. AGI incidences between the two groups were compared using Chi-square test. Subsequently, a prospective study was conducted to investigate the gut microbiota differences between patients without SALD and those with SIC. Fecal samples were collected on days 1, 3, and 7 after admission to analyze changes in gut microbiota using 16S ribosomal ribonucleic acid sequencing. Results One hundred thirty-four patients with IAI were included retrospectively, with 77 SALD and 57 non-SALD cases. Among patients with SALD, 71 were diagnosed with SIC. Patients with SIC had a higher incidence of AGI compared to those without SALD (28.07% vs. 56.34%, p < 0.05), and a severity-dependent relationship was found between AGI grade and SIC occurrence. Subsequently, 20 patients with IAI were recruited prospectively, with 10 patients each assigned to the non-SALD and SIC groups. Patients with SIC had a more severe gut microbiota disorder on day 7 than those without SALD, including lower microbiota diversities, decreased abundance of Firmicutes and Bacteroidetes, and increased abundance of Proteobacteria and Actinobacteria at the phylum level. Furthermore, Burkholderia - Caballeronia - Paraburkholderia and Delftia, the two most abundant genera, were significantly higher in the SIC group than in the non-SALD group. Functional prediction analysis showed that the top three KEGG pathways were ribosome, pyrimidine metabolism, and the two-component system. During the first week, the abundance of Proteobacteria decreased significantly, whereas Cyanobacteria increased in the non-SALD group; however, the phyla taxa did not change significantly in the SIC group. Conclusion There exists a severity-dependent relationship between AGI grade and SIC occurrence in adult patients with IAI. A severe gut microbiota disorder was discovered in SIC during the first week of the intensive care unit stay.
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Affiliation(s)
- Beiyuan Zhang
- Department of Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Xiancheng Chen
- Department of Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Chenhang He
- Nanjing Drum Tower Clinical College of Xu Zhou Medical University, Nanjing, China
| | - Ting Su
- Department of Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Ke Cao
- Department of Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Xiaoyao Li
- Department of Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Jianfeng Duan
- Department of Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Ming Chen
- Department of Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Zhanghua Zhu
- Department of Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Wenkui Yu
- Department of Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
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Miao H, Cui Z, Guo Z, Chen Q, Su W, Sun Y, Sun M, Ma X, Ding R. IDENTIFICATION OF SUBPHENOTYPES OF SEPSIS-ASSOCIATED LIVER DYSFUNCTION USING CLUSTER ANALYSIS. Shock 2023; 59:368-374. [PMID: 36562264 DOI: 10.1097/shk.0000000000002068] [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: 12/24/2022]
Abstract
ABSTRACT Objectives: We attempted to identify and validate the subphenotypes of sepsis-associated liver dysfunction (SALD) using routine clinical information. Design: This article is a retrospective observational cohort study. Setting: We used the Medical Information Mart for Intensive Care IV database and the eICU Collaborative Research Database. Patients: We included adult patients (age ≥18 years) who developed SALD within the first 48 hours of intensive care unit (ICU) admission. We excluded patients who died or were discharged from the ICU within the first 48 hours of admission. Patients with abnormal liver function before ICU admission were also excluded. Measurements and Main Results: Patients in the MIMIC-IV 1.0 database served as a derivation cohort. Patients in the eICU database were used as validation cohort. We identified four subphenotypes of SALD (subphenotype α, β, γ, δ) using K-means cluster analysis in 5234 patients in derivation cohort. The baseline characteristics and clinical outcomes were compared between the phenotypes using one-way analysis of variance/Kruskal-Wallis test and the χ 2 test. Moreover, we used line charts to illustrate the trend of liver function parameters over 14 days after ICU admission. Subphenotype α (n = 1,055) was the most severe cluster, characterized by shock with multiple organ dysfunction (MODS) group. Subphenotype β (n = 1,179) had the highest median bilirubin level and the highest proportion of patients with underlying liver disease and coexisting coagulopathy (increased bilirubin group). Subphenotype γ (n = 1,661) was the cluster with the highest mean age and had the highest proportion of patients with chronic kidney disease (aged group). Subphenotype δ (n = 1,683) had the lowest 28-day and in-hospital mortality (mild group). The characteristics of clusters in the validation cohort were similar to those in the derivation cohort. In addition, we were surprised to find that GGT levels in subphenotype δ were significantly higher than in other subphenotypes, showing a different pattern from bilirubin. Conclusions: We identified four subphenotypes of SALD that presented with different clinical features and outcomes. These results can provide a valuable reference for understanding the clinical characteristics and associated outcomes to improve the management of patients with SALD in the ICU.
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Affiliation(s)
- He Miao
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zhigang Cui
- School of Nursing, China Medical University, Shenyang, Liaoning Province, China
| | - Zhaotian Guo
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Qianhui Chen
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Wantin Su
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yongqiang Sun
- Neusoft Corporation, Shenyang, Liaoning Province, China
| | - Mu Sun
- Neusoft Corporation, Shenyang, Liaoning Province, China
| | - Xiaochun Ma
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Renyu Ding
- Department of Intensive Care Unit, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
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Perez Ruiz de Garibay A, Kortgen A, Leonhardt J, Zipprich A, Bauer M. Critical care hepatology: definitions, incidence, prognosis and role of liver failure in critically ill patients. Crit Care 2022; 26:289. [PMID: 36163253 PMCID: PMC9511746 DOI: 10.1186/s13054-022-04163-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/10/2022] [Indexed: 01/11/2023] Open
Abstract
AbstractOrgan dysfunction or overt failure is a commonplace event in the critically ill affecting up to 70% of patients during their stay in the ICU. The outcome depends on the resolution of impaired organ function, while a domino-like deterioration of organs other than the primarily affected ones paves the way for increased mortality. “Acute Liver Failure” was defined in the 1970s as a rare and potentially reversible severe liver injury in the absence of prior liver disease with hepatic encephalopathy occurring within 8 weeks. Dysfunction of the liver in general reflects a critical event in “Multiple Organ Dysfunction Syndrome” due to immunologic, regulatory and metabolic functions of liver parenchymal and non-parenchymal cells. Dysregulation of the inflammatory response, persistent microcirculatory (hypoxic) impairment or drug-induced liver injury are leading problems that result in “secondary liver failure,” i.e., acquired liver injury without underlying liver disease or deterioration of preexisting (chronic) liver disease (“Acute-on-Chronic Liver Failure”). Conventional laboratory markers, such as transaminases or bilirubin, are limited to provide insight into the complex facets of metabolic and immunologic liver dysfunction. Furthermore, inhomogeneous definitions of these entities lead to widely ranging estimates of incidence. In the present work, we review the different definitions to improve the understanding of liver dysfunction as a perpetrator (and therapeutic target) of multiple organ dysfunction syndrome in critical care.
Graphic Abstract
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Cornely OA, Cisneros JM, Torre-Cisneros J, Rodríguez-Hernández MJ, Tallón-Aguilar L, Calbo E, Horcajada JP, Queckenberg C, Zettelmeyer U, Arenz D, Rosso-Fernández CM, Jiménez-Jorge S, Turner G, Raber S, O'Brien S, Luckey A. Pharmacokinetics and safety of aztreonam/avibactam for the treatment of complicated intra-abdominal infections in hospitalized adults: results from the REJUVENATE study. J Antimicrob Chemother 2021; 75:618-627. [PMID: 31828337 PMCID: PMC7021089 DOI: 10.1093/jac/dkz497] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/21/2019] [Accepted: 11/03/2019] [Indexed: 12/29/2022] Open
Abstract
Objectives To investigate pharmacokinetics (PK) and safety (primary objectives) and efficacy (secondary objective) of the investigational monobactam/β-lactamase inhibitor combination aztreonam/avibactam in patients with complicated intra-abdominal infection (cIAI). Methods This Phase 2a open-label, multicentre study (NCT02655419; EudraCT 2015-002726-39) enrolled adults with cIAI into sequential cohorts for 5–14 days treatment. Cohort 1 patients received an aztreonam/avibactam loading dose of 500/137 mg (30 min infusion), followed by maintenance doses of 1500/410 mg (3 h infusions) q6h; Cohort 2 received 500/167 mg (30 min infusion), followed by 1500/500 mg (3 h infusions) q6h. Cohort 3 was an extension of exposure at the higher dose regimen. Doses were adjusted for creatinine clearance of 31–50 mL/min (Cohorts 2 + 3). All patients received IV metronidazole 500 mg q8h. PK, safety and efficacy were assessed. Results Thirty-four patients (Cohort 1, n = 16; Cohorts 2 + 3, n = 18) comprised the modified ITT (MITT) population. Mean exposures of aztreonam and avibactam in Cohorts 2 + 3 were consistent with those predicted to achieve joint PK/pharmacodynamic target attainment in >90% patients. Adverse events (AEs) were similar between cohorts. The most common AEs were hepatic enzyme increases [n = 9 (26.5%)] and diarrhoea [n = 5 (14.7%)]. Clinical cure rates at the test-of-cure visit overall were 20/34 (58.8%) (MITT) and 14/23 (60.9%) (microbiological-MITT population). Conclusions Observed AEs were consistent with the known safety profile of aztreonam monotherapy, with no new safety concerns identified. These data support selection of the aztreonam/avibactam 500/167 mg (30 min infusion) loading dose and 1500/500 mg (3 h infusions) maintenance dose q6h regimen, in patients with creatinine clearance >50 mL/min, for the Phase 3 development programme.
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Affiliation(s)
- Oliver A Cornely
- University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Clinical Trials Centre Cologne (CTC Cologne), Faculty of Medicine, University Hospital Cologne, Department I of Internal Medicine, German Centre for Infection Research (DZIF) partner site Cologne, Cologne, Germany
| | | | | | | | | | - Esther Calbo
- Hospital Universitario Mútua de Tarrasa and Universitat Internacional de Catalunya, Barcelona, Spain
| | | | - Christian Queckenberg
- University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Clinical Trials Centre Cologne (CTC Cologne), Faculty of Medicine, University Hospital Cologne, Department I of Internal Medicine, German Centre for Infection Research (DZIF) partner site Cologne, Cologne, Germany
| | - Ulrike Zettelmeyer
- University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Clinical Trials Centre Cologne (CTC Cologne), Faculty of Medicine, University Hospital Cologne, Department I of Internal Medicine, German Centre for Infection Research (DZIF) partner site Cologne, Cologne, Germany
| | - Dorothee Arenz
- University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Clinical Trials Centre Cologne (CTC Cologne), Faculty of Medicine, University Hospital Cologne, Department I of Internal Medicine, German Centre for Infection Research (DZIF) partner site Cologne, Cologne, Germany
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Popescu GA, Bara T, Rad P. Abdominal Compartment Syndrome as a Multidisciplinary Challenge. A Literature Review. J Crit Care Med (Targu Mures) 2018; 4:114-119. [PMID: 30574563 PMCID: PMC6296279 DOI: 10.2478/jccm-2018-0024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 10/30/2018] [Indexed: 01/20/2023] Open
Abstract
Abdominal Compartment Syndrome (ACS), despite recent advances in medical and surgical care, is a significant cause of mortality. The purpose of this review is to present the main diagnostic and therapeutic aspects from the anesthetical and surgical points of view. Intra-abdominal hypertension may be diagnosed by measuring intra-abdominal pressure and indirectly by imaging and radiological means. Early detection of ACS is a key element in the ACS therapy. Without treatment, more than 90% of cases lead to death and according with the last reports, despite all treatment measures, the mortality rate is reported as being between 25 and 75%. There are conflicting reports as to the importance of a conservative therapy approach, although such an approach is the central to treatment guidelines of the World Society of Abdominal Compartment Syndrome, Decompressive laparotomy, although a backup solution in ACS therapy, reduces mortality by 16-37%. The open abdomen management has several variants, but negative pressure wound therapy represents the gold standard of surgical treatment.
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Affiliation(s)
- Gabriel Alexandru Popescu
- University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Târgu MureşRomania
- Surgery Clinic No. 2, Târgu Mureş, Romania
| | - Tivadar Bara
- University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Târgu MureşRomania
- Surgery Clinic No. 2, Târgu Mureş, Romania
| | - Paul Rad
- University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Târgu MureşRomania
- Anesthesiology and Intensive Care Clinic No. 1, Târgu Mureş, Romania
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Huang J, Ren J, Brakert L, Jiao J, Liu Q, Wang G, Wu X, Damink SWMO. A New Scoring System to Predict Blood Stream Infections in Patients with Complicated Intra-Abdominal Infections: Experience from a Tertiary Referral Hospital in China. Surg Infect (Larchmt) 2018; 19:459-466. [PMID: 29768131 DOI: 10.1089/sur.2017.243] [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] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This purpose of this study was to investigate the effects of blood stream infections (BSIs) on the prognosis of patients with complicated intra-abdominal infections (IAIs) and to make predictions based on patients' characteristics on admission. PATIENTS AND METHODS One hundred eighty-seven patients with complicated IAI in 2014 and 2015 were included in our retrospective analysis, except for those diagnosed with central line-associated blood stream infections (CLABSIs). Patients with BSIs were compared with patients without BSIs. Multivariable logistic regression was applied to identify factors associated with BSIs and also the subtypes of BSIs. The predictive score systems were established further. RESULTS Seventy-four patients (39.6%) with complicated IAIs developed BSIs after admission. Four factors evaluated on admission were associated independently with BSIs including alanine aminotransferase (ALT) ≥66 U/L (two scores), insensitivity to initial empirical antibiotic agents (IIEA; three scores), Sepsis-Related Organ Failure Assessment (SOFA) score of two or more (three scores), and generalized peritonitis (four scores). A total score of five or more was regarded as the critical value in the combined test to predict BSIs, with a sensitivity of 0.78 and a specificity of 0.73. Blood stream infections were further divided as secondary BSIs and non-secondary BSIs. The risk factors of secondary BSIs included IIEA (three scores), SOFA score of two or more (five scores), and generalized peritonitis (eight scores), where a total score of nine or more was regarded as the critical value in the combined test, with a sensitivity of 0.68 and a specificity of 0.87, whereas the risk factors of non-secondary BSIs included IIEA (three scores), SOFA score of two or more (three scores) and procalcitonin (PCT) ≥0.43 mcg/L (three scores), where a total score of six or more was regarded as the critical value in the combined test, with a sensitivity of 0.75 and a specificity of 0.70. Moreover, BSIs were linked with the worse clinical outcomes in organ functions, hospitalization costs, and mortality. CONCLUSIONS Our new scoring methods may have potential advantages on the early prediction and recognition of BSIs in patients with complicated IAIs.
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Affiliation(s)
- Jinjian Huang
- 1 Department of Surgery, Jinling Hospital , Nanjing, China .,3 Medical School of Southeast University , Nanjing, China
| | - Jianan Ren
- 1 Department of Surgery, Jinling Hospital , Nanjing, China
| | - Luise Brakert
- 2 University Medical Center of Hamburg-Eppendorf , Hamburg, Germany
| | - Jiao Jiao
- 3 Medical School of Southeast University , Nanjing, China
| | - Qinjie Liu
- 1 Department of Surgery, Jinling Hospital , Nanjing, China
| | - Gefei Wang
- 1 Department of Surgery, Jinling Hospital , Nanjing, China
| | - Xiuwen Wu
- 1 Department of Surgery, Jinling Hospital , Nanjing, China
| | - Steven W M Olde Damink
- 4 Department of Surgery, Maastricht University Medical Centre , Maastricht, The Netherlands
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Li J, Xia K, Xiong M, Wang X, Yan N. Effects of sepsis on the metabolism of sphingomyelin and cholesterol in mice with liver dysfunction. Exp Ther Med 2017; 14:5635-5640. [PMID: 29285103 DOI: 10.3892/etm.2017.5226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 07/27/2017] [Indexed: 11/06/2022] Open
Abstract
Sepsis is characterized by a severe inflammatory response to infection. With the spread of sepsis, various tissues, including the lungs, liver and kidney, may be damaged. This may finally develop into multiple organ dysfunction syndrome. Sphingomyelin and cholesterol are two main lipids involved in sepsis. The metabolism of sphingomyelin and cholesterol in the livers of mice with sepsis needs to be clarified. To achieve this, the present study intraperitoneally injected mice with PBS, lipopolysaccharide (LPS; 10 mg/kg) and LPS + pyrrolidine dithiocarbamate (PDTC; 30 mg/kg). Subsequently, sphingomyelin and cholesterol content were measured using kits, the sphingomyelin synthase (SMS) activity was measured using thin layer chromatography, and the expression levels of SMS1 and 2, hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR), ATP binding cassette subfamily A member 1 (ABCA1), scavenger receptor class B member 1 (SR-B1) and apolipoprotein A1 (Apo A1) were determined by western blotting in the livers of mice. Results demonstrated that, in the LPS group, sphingomyelin and cholesterol content was significantly increased (P<0.001; n=6), the SMS activity significantly enhanced (P<0.001; n=6), the expression levels of SMS2, HMGCR, ABCA1 and SR-B1 were augmented (P<0.05; n=6), and the expression of Apo A1 was decreased (P<0.05; n=6), whereas SMS1 level only slightly increased with no statistical significance (P>0.05; n=6), compared to the levels in the control group. However, PDTC was able to attenuate these alterations. These results indicated that sphingomyelin and cholesterol content may increase in the liver dysfunction of sepsis by increasing the expression of SMS2, HMGCR, SR-B1 and ABCA1, and downregulating Apo A1.
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Affiliation(s)
- Jiaqi Li
- Department of Biochemistry and Molecular Biology, School of Basic Medical Science, Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Kun Xia
- Department of Biochemistry and Molecular Biology, School of Basic Medical Science, Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Mingdi Xiong
- Basic Medical Experiments Center, Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Xi Wang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Science, Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Nianlong Yan
- Department of Biochemistry and Molecular Biology, School of Basic Medical Science, Nanchang University, Nanchang, Jiangxi 330006, P.R. China
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Cholestatic Alterations in the Critically Ill: Some New Light on an Old Problem. Chest 2017; 153:733-743. [PMID: 28847548 DOI: 10.1016/j.chest.2017.08.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/10/2017] [Accepted: 08/14/2017] [Indexed: 12/12/2022] Open
Abstract
Liver dysfunction and jaundice are traditionally viewed as late features of sepsis and other critical illnesses and are associated with a complicated ICU stay. However, study results suggest that cholestatic alterations occur early in the course of critical illnesses, perceived only as minor abnormalities in routinely used biochemical liver tests. Inflammation-induced alterations in the transport of bile acids (BAs) appear to drive BAs and bilirubin toward the systemic circulation. Ongoing BA synthesis with an, at least partial, loss of feedback inhibition further contributes to elevated circulating BAs and bilirubin. To what extent these changes reflect a biochemical epiphenomenon, true illness-induced liver dysfunction, or a beneficial and adaptive response to illness should be investigated further. Because of the lack of specificity of standard laboratory tests, especially in the context of a complex systemic condition such as critical illness, identifying true cholestatic liver dysfunction remains a great challenge. However, high levels of cholestatic markers that are sustained in patients with prolonged critical illness almost always indicate a complicated illness course and should be monitored closely. Preventing cholestatic liver dysfunction comprises minimizing inflammation and hypoxia in the liver and preventing hyperglycemia, avoiding early use of parenteral nutrition, and reducing the administration of avoidable drugs. Future research on the effects of BAs and on modulating underlying drivers of cholestasis induced by critical illness is warranted as this could open perspectives for a targeted diagnostic approach and ultimately for novel therapies to improve outcome.
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Muresan M, Muresan S, Brinzaniuc K, Voidazan S, Sala D, Jimborean O, Hussam AH, Bara T, Popescu G, Borz C, Neagoe R. How much does decompressive laparotomy reduce the mortality rate in primary abdominal compartment syndrome?: A single-center prospective study on 66 patients. Medicine (Baltimore) 2017; 96:e6006. [PMID: 28151898 PMCID: PMC5293461 DOI: 10.1097/md.0000000000006006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 11/26/2022] Open
Abstract
Contribution of decompressive laparotomy within the framework of the complex therapeutic algorithm of abdominal compartment syndrome (ACS) is cited with an extremely heterogeneous percentage in terms of survival. The purpose of this study was to present new data regarding contribution of each therapeutic step toward decreasing the mortality of this syndrome.This is a longitudinal prospective study including 134 patients with risk factors for ACS. The intra-abdominal pressure was measured every hour indirectly based on transvesical approach and the appearance of organ dysfunction. Specific therapy for ACS was based on the 2013 World Society of Abdominal Compartment Syndrome guidelines, which include laparotomy decompression. Management of the temporarily open abdomen included an assisted vacuum wound therapy.Of 134 patients, 66 developed ACS. The average intra-abdominal pressure significantly decreased after therapy and decompression surgery. The overall rate of mortality was 27.3% with statistical significance in necrotizing infected pancreatitis. Surgical decompression performed within the first 24 hours after the onset of ACS had a protective role against mortality (odds ratio <1). The average time after which laparotomy decompression was performed was 16.23 hours. The complications occurred during TAC were 2 wound suppurations and 1 intestinal obstruction. Wound suppurations evolved favorably by using vacuum wound-assisted therapy associated with the general treatment, whereas for occlusion, resurgery was performed after which adhesions dissolved. The final closure of the abdomen was performed at a mean of 11.7 days (min. = 9, max. = 14). The closure type was primary suture of the musculoaponeurotic edges in 4 cases, and the use of dual mesh in the other 11 cases.The highest mortality rate in the study group was registered in patients with necrotizing pancreatitis and the lowest in trauma group. Surgical decompression within the framework of the complex algorithm treatment of ACS contributed to the reduction of mortality by 8.7%. It is extremely important that the elapsed time since the initiation of the ACS until the surgical decompression is minimal (under 24 hours).
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Affiliation(s)
| | | | | | | | | | | | - Al Husseim Hussam
- Cardiovascular Surgery Clinic, University of Medicine and Pharmacy of Tirgu Mures, Tirgu Mures, Romania
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