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Alber S, Tanabe K, Hennigan A, Tregear H, Gilliland S. Year in Review 2023: Noteworthy Literature in Cardiothoracic Critical Care. Semin Cardiothorac Vasc Anesth 2024; 28:66-79. [PMID: 38669120 DOI: 10.1177/10892532241249582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
This article reviews noteworthy investigations and society recommendations published in 2023 relevant to the care of critically ill cardiothoracic surgical patients. We reviewed 3,214 articles to identify 18 publications that add to the existing literature across a variety of topics including resuscitation, nutrition, antibiotic management, extracorporeal membrane oxygenation (ECMO), neurologic care following cardiac arrest, coagulopathy and transfusion, steroids in pulmonary infections, and updated guidelines in the management of acute respiratory distress syndrome (ARDS).
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Whitehouse T, Hossain A, Perkins GD, Gordon AC, Bion J, Young D, McAuley D, Singer M, Lord J, Gates S, Veenith T, MacCallum NS, Yeung J, Innes R, Welters I, Boota N, Skilton E, Ghuman B, Hill M, Regan SE, Mistry D, Lall R. Landiolol and Organ Failure in Patients With Septic Shock: The STRESS-L Randomized Clinical Trial. JAMA 2023; 330:1641-1652. [PMID: 37877587 PMCID: PMC10600724 DOI: 10.1001/jama.2023.20134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/18/2023] [Indexed: 10/26/2023]
Abstract
Importance Patients with septic shock undergo adrenergic stress, which affects cardiac, immune, inflammatory, and metabolic pathways. β-Blockade may attenuate the adverse effects of catecholamine exposure and has been associated with reduced mortality. Objectives To assess the efficacy and safety of landiolol in patients with tachycardia and established septic shock requiring prolonged (>24 hours) vasopressor support. Design, Setting, and Participants An open-label, multicenter, randomized trial involving 126 adults (≥18 years) with tachycardia (heart rate ≥95/min) and established septic shock treated for at least 24 hours with continuous norepinephrine (≥0.1 μg/kg/min) in 40 UK National Health Service intensive care units. The trial ran from April 2018 to December 2021, with early termination in December 2021 due to a signal of possible harm. Intervention Sixty-three patients were randomized to receive standard care and 63 to receive landiolol infusion. Main Outcomes and Measures The primary outcome was the mean Sequential Organ Failure Assessment (SOFA) score from randomization through 14 days. Secondary outcomes included mortality at days 28 and 90 and the number of adverse events in each group. Results The trial was stopped prematurely on the advice of the independent data monitoring committee because it was unlikely to demonstrate benefit and because of possible harm. Of a planned 340 participants, 126 (37%) were enrolled (mean age, 55.6 years [95% CI, 52.7 to 58.5 years]; 58.7% male). The mean (SD) SOFA score in the landiolol group was 8.8 (3.9) compared with 8.1 (3.2) in the standard care group (mean difference [MD], 0.75 [95% CI, -0.49 to 2.0]; P = .24). Mortality at day 28 after randomization in the landiolol group was 37.1% (23 of 62) and 25.4% (16 of 63) in the standard care group (absolute difference, 11.7% [95% CI, -4.4% to 27.8%]; P = .16). Mortality at day 90 after randomization was 43.5% (27 of 62) in the landiolol group and 28.6% (18 of 63) in the standard care group (absolute difference, 15% [95% CI, -1.7% to 31.6%]; P = .08). There were no differences in the number of patients having at least one adverse event. Conclusion and Relevance Among patients with septic shock with tachycardia and treated with norepinephrine for more than 24 hours, an infusion of landiolol did not reduce organ failure measured by the SOFA score over 14 days from randomization. These results do not support the use of landiolol for managing tachycardia among patients treated with norepinephrine for established septic shock. Trial Registration EU Clinical Trials Register Eudra CT: 2017-001785-14; isrctn.org Identifier: ISRCTN12600919.
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Affiliation(s)
- Tony Whitehouse
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Anower Hossain
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Gavin D. Perkins
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine & Intensive Care, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Julian Bion
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Clinical Sciences, University of Birmingham, United Kingdom
| | - Duncan Young
- Kadoorie Centre for Critical Care Research, Nuffield Division of Anaesthesia, University of Oxford, Oxford, United Kingdom
| | - Danny McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, United Kingdom
| | - Mervyn Singer
- Centre for Intensive Care Medicine, Department of Medicine and Wolfson Institute for Biomedical Research, University College, London, United Kingdom
| | - Janet Lord
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Tonny Veenith
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Niall S. MacCallum
- University College London Hospitals NHS Foundation Trust, Gower Street, London, United Kingdom
| | - Joyce Yeung
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Richard Innes
- Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | - Nafisa Boota
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Emma Skilton
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Belinder Ghuman
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Maddy Hill
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Scott E. Regan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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Ma Y, Cheng Z, Zheng Y, Wang W, He S, Zhou X, Yang J, Wei C. LOW DOSE OF ESMOLOL ATTENUATES SEPSIS-INDUCED IMMUNOSUPPRESSION VIA MODULATING T-LYMPHOCYTE APOPTOSIS AND DIFFERENTIATION. Shock 2023; 59:771-778. [PMID: 36852973 PMCID: PMC10125111 DOI: 10.1097/shk.0000000000002104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/16/2023] [Indexed: 03/01/2023]
Abstract
ABSTRACT Background: Immunosuppression caused by immune cell apoptosis and an imbalance of T helper 2 cells (T H 2) and T helper 1 cells (T H 1), is associated with poor outcomes in septic patients. Esmolol was reported to improve survival by modulating immune responses in septic shock. Whether esmolol could alleviate sepsis-induced immunosuppression and the optimal dose are unclear. Methods: Four hours after cecal ligation and puncture (CLP), Wistar rats were randomized into CLP, CLP + E-5 (esmolol: 5 mg·kg -1 ·h -1 ) and CLP + E-18 (esmolol: 18 mg·kg -1 ·h -1 ) groups. Eight rats were underwent sham operation. Eighteen hours after CLP, hemodynamics and organ histological injuries were evaluated, peripheral blood mononuclear cells apoptosis and T-lymphocyte subsets counts were determined by flow cytometry, and the expression of p-Akt, Bcl-2, cleaved Caspase-3, and p-Erk1/2 in splenic CD4 + T-lymphocytes was determined by western blot and immunohistochemistry. β 1 -Adrenoreceptor expressions were evaluated using real-time polymerase chain reaction and immunohistochemistry. Results: Cecal ligation and puncture induced tachycardia, hypotension, hyperlactatemia, and multiple organ injury. Heart rate was unchanged in the CLP + E-5 group but decreased in the CLP + E-18 group. Hypotension, lactatemia, and multiple organ injuries were improved only in the CLP + E-5 group. T-lymphocyte apoptosis and T H 2/T H 1 ratio was decreased in CLP + E-5 but not in CLP + E-18. p-Akt and Bcl-2 expressions were increased, while cleaved Caspase-3 and p-Erk1/2 expressions were decreased in CLP + E-5. β 1 -Adrenoreceptor expressions were unchanged in both CLP + E-5 and CLP + E-18 groups. Conclusions: Low dose of esmolol reduced T-lymphocyte apoptosis and restored T H 2/T H 1 ratio in septic shock. Esmolol might modulate Akt/Bcl-2/Caspase-3 pathway to relieve T-lymphocyte apoptosis and inhibit Erk1/2 activity to decrease T H 0 differentiation to T H 2. Esmolol may be a potential immunoregulator of septic shock.
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Affiliation(s)
- Ying Ma
- Department of Pulmonary and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, China
| | - Zhenshun Cheng
- Department of Pulmonary and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, China
- Hubei Engineering Center for Infectious Disease Prevention, Control and Treatment, Wuhan, China
| | - Yong Zheng
- Department of Anatomy and Embryology, Wuhan University Taikang Medical School (School of Basic Medical Sciences), Wuhan, China
| | - Wei Wang
- Department of Pulmonary and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shaojun He
- Department of Pulmonary and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiaolian Zhou
- Department of Pulmonary and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jiong Yang
- Department of Pulmonary and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chaojie Wei
- Department of Pulmonary and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Wuhan Research Center for Infectious Diseases and Cancer, Chinese Academy of Medical Sciences, Wuhan, China
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Zhang J, Chen C, Liu Y, Yang Y, Yang X, Yang J. Benefits of esmolol in adults with sepsis and septic shock: An updated meta-analysis of randomized controlled trials. Medicine (Baltimore) 2022; 101:e29820. [PMID: 35801730 PMCID: PMC9259117 DOI: 10.1097/md.0000000000029820] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Sepsis affects millions of patients annually, resulting in substantial health and economic burdens globally. The role of esmolol potentially plays in the treatment of sepsis and septic shock in adult patients remains controversial. METHODS We undertook a systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases from their inception to May 12, 2022, for randomized controlled trials that evaluated the efficacy of esmolol for sepsis and septic shock. A random-effects meta-analysis was performed. Two investigators independently screened articles, extracted data, and assessed the quality of included studies. RESULTS Eight studies from 7 randomized controlled trials were included in our meta-analysis of 503 patients with sepsis and/or septic shock. Compared with standard treatment, esmolol significantly decreased 28-day mortality (risk ratio 0.68, 95% confidence interval [CI] 0.52-0.88; P = .004), heart rate (standardized mean difference [SMD] -1.83, 95% CI -2.95 to -0.70, P = .001), tumor necrosis factor-a (SMD -0.48, 95% CI -0.94 to -0.02, P = .04), and the troponin I level (SMD -0.59, 95% CI -1.02 to -0.16, P = .008) 24 hours after treatment. No significant effect was found in terms of length of intensive care unit stay; mean arterial pressure, lactic acid, central venous pressure, or central venous oxygen saturation, interleukin 6, or white blood cell levels; stroke volume index; or the PaO2/FiO2 ratio. CONCLUSIONS Esmolol treatment may be safe and effective in decreasing 28-day mortality, controlling heart rate, and providing cardioprotective function, but has no effect on lung injury in patients with sepsis or septic shock after early fluid resuscitation. Improvement in cardiac function may be related to changes in serum inflammatory mediators. No significant adverse effects on tissue perfusion and oxygen utilization were observed.
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Affiliation(s)
- Jing Zhang
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Chun Chen
- Department of Nephrology, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Yi Liu
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Yi Yang
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Xiaolei Yang
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Jin Yang
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
- * Correspondence: Jin Yang, MD, Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing 401147, China (e-mail: )
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Cocchi MN, Dargin J, Chase M, Patel PV, Grossestreuer A, Balaji L, Liu X, Moskowitz A, Berg K, Donnino MW. Esmolol to Treat the Hemodynamic Effects of Septic Shock: A Randomized Controlled Trial. Shock 2022; 57:508-517. [PMID: 35066509 PMCID: PMC10448435 DOI: 10.1097/shk.0000000000001905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Septic shock is often characterized by tachycardia and a hyperdynamic hemodynamic profile. Use of the beta antagonist esmolol has been proposed as a therapy to lower heart rate, thereby improving diastolic filling time and improving cardiac output, resulting in a reduction in vasopressor support. METHODS We conducted a two-center, open-label, randomized, Phase II trial comparing esmolol to placebo in septic shock patients with tachycardia. The primary endpoint was improvement in hemodynamics as measured by the difference in norepinephrine equivalent dose (NED) between groups at 6 hours after initiation of study drug. Secondary outcomes included assessing differences in inflammatory biomarkers and oxygen consumption (VO2). RESULTS A total of 1,122 patients were assessed for eligibility and met inclusion criteria; 42 underwent randomization, and 40 received study interventions (18 in the esmolol arm and 22 in the usual care arm). The mean NED at 6 h was 0.30 ± 0.17 mcg/kg/min in the esmolol arm compared to 0.21 ± 0.19 in the standard care arm (P = 0.15). There was no difference in number of shock free days between the esmolol (2, IQR 0, 5) and control groups (2.5, IQR 0, 6) (P = 0.32). There were lower levels of C-reactive protein at 12 and 24 h in the esmolol arm, as well as a statistically significant difference in trend over time between groups. There were no differences in terms of IL-4, IL-6, IL-10, and TNFα. Among a subset who underwent VO2 monitoring, there was decreased oxygen consumption in the esmolol patients; the mean difference between groups at 24 h was -2.07 mL/kg/min (95% CI -3.82, -0.31) (P = 0.02), with a significant difference for the trend over time (P < 0.01). CONCLUSION Among patients with septic shock, infusion of esmolol did not improve vasopressor requirements or time to shock reversal. Esmolol was associated with decreased levels of C-reactive protein over 24 h. TRIAL REGISTRATION www.clinicaltrials.gov. Registered February 24, 2015, https://clinicaltrials.gov/ct2/show/NCT02369900.
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Affiliation(s)
- Michael N. Cocchi
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - James Dargin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Maureen Chase
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Parth V. Patel
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Anne Grossestreuer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Lakshman Balaji
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Xiaowen Liu
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ari Moskowitz
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Medicine, Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York
| | - Katherine Berg
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Medicine, Division of Pulmonary Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael W. Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Medicine, Division of Pulmonary Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Liu Y, Wang R, Han H, Li L. Tubastatin A suppresses the proliferation of fibroblasts in epidural fibrosis through phosphatidylinositol-3-kinase/protein kinase B/mammalian target of rapamycin (PI3K/AKT/mTOR) signalling pathway. J Pharm Pharmacol 2022; 74:rgab106. [PMID: 35230444 DOI: 10.1093/jpp/rgab106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 02/21/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVES This study was designed to explore the effect of tubastatin A (Tub A) on epidural fibrosis and the underlying mechanism. METHODS Histone deacetylase 6 (HDAC6)-overexpressed fibroblasts were constructed, and the effect of Tub A on the proliferation of activated fibroblasts was detected by Cell Counting Kit-8, 5-ethynyl-2'-deoxyuridine (EdU) and cell cycle assay. Besides, 20 Sprague-Dawley rats were subjected to animal laminectomy model construction and then randomly treated with 4% dimethyl sulfoxide (DMSO) (diluted in 0.9% saline) or Tub A (10 mg/kg/day), separately. The expression of HDAC6 and phosphatidylinositol-3-kinase/protein kinase B/mammalian target of rapamycin (PI3K/AKT/mTOR) pathway-related proteins was measured in epidural fibrosis tissues. KEY FINDINGS HDAC6 was overexpressed in activated fibroblasts and epidural scar tissues of rat models. Cell proliferation was remarkably elevated in HDAC6-overexpressed fibroblasts, which was reflected by cell viability, EdU and flow cytometry-based cell cycle assay, and paralleled with the increased expression of phosphorylated PI3K, AKT and mTOR, which was remarkably reversed following Tub A treatment. 740Y-P activator addition significantly reversed the declined fibroblast proliferation induced by Tub A. The expressions of PI3K/AKT/mTOR pathway-related proteins were also reduced in epidural tissues in rat models with Tub A treatment. CONCLUSION Tub A could prevent epidural fibrosis formation by inhibiting fibroblast proliferation through mediating PI3K/AKT/mTOR pathway.
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Affiliation(s)
- Yang Liu
- Department of Spine Surgery, Weifang People's Hospital, Weifang, Shandong, China
| | - Ruihong Wang
- Department of Spine Surgery, Weifang People's Hospital, Weifang, Shandong, China
| | - Huimin Han
- Department of Spine Surgery, Weifang People's Hospital, Weifang, Shandong, China
| | - Li Li
- Department of Spine Surgery, Weifang People's Hospital, Weifang, Shandong, China
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Sun X, Liu Y, Wang J, Zhang M, Wang M. Cardioprotection of M2 macrophages-derived exosomal microRNA-24-3p/Tnfsf10 axis against myocardial injury after sepsis. Mol Immunol 2021; 141:309-317. [PMID: 34933177 DOI: 10.1016/j.molimm.2021.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 10/19/2021] [Accepted: 11/05/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Some reports have suggested the involvement of microRNA-24-3p (miR-24-3p) in heart diseases. Here, the intention of this work was to unmask whether miR-24-3p from M2 macrophages-derived exosomes (M2-exo) could protect against myocardial injury after sepsis. METHODS Mice model of sepsis was induced by intraperitoneal injection of lipopolysaccharide (LPS). miR-24-3p and tumor necrosis factor superfamily member 10 (Tnfsf10) expression levels were measured in the myocardial tissue of septic mice. M2-exo were isolated, in which miR-24-3p expression was altered. Then, septic mice were alone or in combination injected with the miR-24-3p-modified M2-exo or siRNA of Tnfsf10. Subsequently, cardiac function, apoptosis and serum inflammatory response were examined. RESULTS miR-24-3p expression dropped while Tnfsf10 expression raised in the myocardial tissue of septic mice. M2-exo-derived miR-24-3p or deficiency of Tnfsf10 had cardioprotective effects on LPS-induced myocardial injury in mice through improving cardiac function and reducing cardiomyocyte apoptosis in the myocardial tissue and serum inflammation. A binding relation exhibited between miR-24-3p and Tnfsf10, and M2-exo-derived miR-24-3p alleviated LPS-induced myocardial injury by inhibiting Tnfsf10. CONCLUSION Up-regulating miR-24-3p from M2-exo imposes cardioprotection against myocardial injury after sepsis through reducing Tnfsf10 expression.
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Affiliation(s)
- XingCheng Sun
- Department of Emergency, The First Affiliated Hospital of Navy Medical University of Chinese People's Liberation Army, Shanghai, 200433, China
| | - Yuee Liu
- Department of Emergency, The First Affiliated Hospital of Navy Medical University of Chinese People's Liberation Army, Shanghai, 200433, China
| | - Jin Wang
- Department of Emergency, The Third Affiliated Hospital of Navy Medical University of Chinese People's Liberation Army, Shanghai, 201805, China
| | - Min Zhang
- Department of Critical Care Medicine, The Second Hospital of Jilin University, Changchun, 130021, Jilin Provence, China
| | - Meitang Wang
- Department of Emergency, The First Affiliated Hospital of Navy Medical University of Chinese People's Liberation Army, Shanghai, 200433, China.
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Hassoun-Kheir N, Henig O, Avni T, Leibovici L, Paul M. The Effect of β-Blockers for Burn Patients on Clinical Outcomes: Systematic Review and Meta-Analysis. J Intensive Care Med 2020; 36:945-953. [PMID: 32686565 DOI: 10.1177/0885066620940188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To assess the effects and safety of β-blockers in hospitalized patients with burns. METHODS A systematic review and meta-analysis of the literature. A broad search was conducted to identify all randomized controlled trials (RCTs) comparing β-blockers to control in hospitalized patients with burns. The primary outcome was 3-month all-cause mortality. Secondary outcomes were clinical patient-relevant end points. We subgrouped results by children/adults and burn severity. Risk of bias was assessed using the individual domain approach. RESULTS Four RCTs reported in 11 publications were included. Primary outcome of mortality was assessed in children (2 trials, n = 424) and adults (2 trials, n = 148) with severe burns. No significant difference was found between propranolol and control for mortality (risk ratio [RR] = 0.82, 95% CI = 0.48-1.39, 4 trials with broad confidence intervals in adults and children), sepsis (RR = 0.81, 95% CI = 0.46-1.43, 2 trials), and survivors' length of stay (absolute mean difference = 2.53, 95% CI = -2.58-7.63, 3 trials). There was no significant difference in bradycardia (RR = 1.33, 95% CI = 0.77-2.3, 2 trials), hypotension (RR = 1.26, 95% CI = 0.73-2.17, 3 trials), or cardiac arrhythmia (RR: 2.97, 95% CI: 0.12-71.87, 1 trial). The evidence was graded as very low certainty, due to trial's internal risk of bias, imprecision, and possible selective reporting. CONCLUSIONS No sufficient evidence was found to support or refute an advantage for β-blocker use in children or adults after burns. Additional studies are needed to create a consensus and formulate practice guidelines on the optimal β-blocker to use, indications for initiation, and duration of treatment.
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Affiliation(s)
- Nasreen Hassoun-Kheir
- Infectious Diseases Unit, 58878Rambam Health Care Campus, Haifa, Israel.,Technion-Israel Institute of Technology, Haifa, Israel
| | - Oryan Henig
- Infectious Diseases Unit, 58878Rambam Health Care Campus, Haifa, Israel
| | - Tomer Avni
- Department of Medicine E, 36632Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonard Leibovici
- Department of Medicine E, 36632Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Mical Paul
- Infectious Diseases Unit, 58878Rambam Health Care Campus, Haifa, Israel.,Technion-Israel Institute of Technology, Haifa, Israel
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Two Gene Set Variation Index as Biomarker of Bacterial and Fungal Sepsis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8182358. [PMID: 32596378 PMCID: PMC7292977 DOI: 10.1155/2020/8182358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/09/2020] [Indexed: 12/23/2022]
Abstract
Background The incidence of sepsis has been increasing in recent years. The molecular mechanism of different pathogenic sepsis remains elusive, and biomarkers of sepsis against different pathogens are still lacking. Methods The microarray data of bacterial sepsis, fungal sepsis, and mock-treated samples were applied to perform differentially expressed gene (DEG) analysis to identify a bacterial sepsis-specific gene set and a fungal sepsis-specific gene set. Functional enrichment analysis was used to explore the body's response to bacterial sepsis and fungal sepsis. Gene set variation analysis (GSVA) was used to score individual samples against the two pathogen-specific gene sets, and each sample gets a GSVA index. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic value of sepsis. An independent data set was used to validate the bacterial sepsis-specific GSVA index. Results The genes differentially expressed only in bacterial sepsis and the genes differentially expressed only in fungal sepsis were significantly involved in different biological processes (BPs) and pathways. This indicated that the body's responses to fungal sepsis and bacterial sepsis are varied. Twenty-two genes were identified as bacterial sepsis-specific genes and upregulated in bacterial sepsis, and 23 genes were identified as fungal sepsis-specific genes and upregulated in fungal sepsis. ROC curve analysis showed that both of the two pathogen sepsis-specific GSVA indexes may be a reliable biomarker for corresponding pathogen-induced sepsis (AUC = 1.000), while the mRNA of CALCA (also known as PCT) have a poor diagnostic value with AUC = 0.512 in bacterial sepsis and AUC = 0.705 in fungi sepsis. In addition, the AUC of the bacterial sepsis-specific GSVA index in the independent data set was 0.762. Conclusion We proposed a bacterial sepsis-specific gene set and a fungal sepsis-specific gene set; the bacterial sepsis GSVA index may be a reliable biomarker for bacterial sepsis.
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Oyama Y, Blaskowsky J, Eckle T. Dose-dependent Effects of Esmolol-epinephrine Combination Therapy in Myocardial Ischemia and Reperfusion Injury. Curr Pharm Des 2020; 25:2199-2206. [PMID: 31258066 DOI: 10.2174/1381612825666190618124829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Animal studies on cardiac arrest found that a combination of epinephrine with esmolol attenuates post-resuscitation myocardial dysfunction. Based on these findings, we hypothesized that esmololepinephrine combination therapy would be superior to a reported cardioprotective esmolol therapy alone in a mouse model of myocardial ischemia and reperfusion (IR) injury. METHODS C57BL/6J mice were subjected to 60 min of myocardial ischemia and 120 min of reperfusion. Mice received either saline, esmolol (0.4 mg/kg/h), epinephrine (0.05 mg/kg/h), or esmolol combined with epinephrine (esmolol: 0.4 mg/kg/h or 0.8 mg/kg/h and epinephrine: 0.05 mg/kg/h) during reperfusion. After reperfusion, infarct sizes in the area-at-risk and serum cardiac troponin-I levels were determined. Hemodynamic effects of drugs infused were determined by measurements of heart rate (HR) and mean arterial blood pressure (MAP) via a carotid artery catheter. RESULTS Esmolol during reperfusion resulted in robust cardioprotection (esmolol vs. saline: 24.3±8% vs. 40.6±3% infarct size), which was abolished by epinephrine co-administration (38.1±15% infarct size). Increasing the esmolol dose, however, was able to restore esmolol-cardioprotection in the epinephrine-esmolol (18.6±8% infarct size) co-treatment group with improved hemodynamics compared to the esmolol group (epinephrine-esmolol vs. esmolol: MAP 80 vs. 75 mmHg, HR 452 vs. 402 beats/min). CONCLUSION These results confirm earlier studies on esmolol-cardioprotection from myocardial IR-injury and demonstrate that a dose optimized epinephrine-esmolol co-treatment maintains esmolol-cardioprotection with improved hemodynamics compared to esmolol treatment alone. These findings might have implications for current clinical practice in hemodynamically unstable patients suffering from myocardial ischemia.
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Affiliation(s)
- Yoshimasa Oyama
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Justin Blaskowsky
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Tobias Eckle
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, United States
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11
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Prognosis of β-adrenergic blockade therapy on septic shock and sepsis: A systematic review and meta-analysis of randomized controlled studies. Cytokine 2019; 126:154916. [PMID: 31756644 DOI: 10.1016/j.cyto.2019.154916] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/21/2019] [Accepted: 10/31/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE β-adrenoceptor antagonist (β-blocker) may have potential in the treatment of septic shock and sepsis. However, the relevant research findings are still controversial. METHODS We conducted a systematic review and meta-analysis to explore the efficacy of β-blocker in patients with septic shock and sepsis. The primary sources of the reviewed studies through August 2018, with restriction on the language of English, were Pubmed and Embase. Randomized controlled trials (RCT) were included to evaluate the efficacy of β-blocker in the treatment of septic shock and sepsis. Meta analysis was performed using a random effect model. Two researchers independently searched articles, extracted data, and assessed the quality of the included studies. RESULTS A total of 6 studies related to 5 original RCTs were qualified for inclusion in this systematic review and meta-analysis with a total of 363 patients with sepsis and/or septic shock. β-blocker was associated with a significantly decreased 28-day mortality compared to usual treatment group as the control (RR = 0.59, 95%CI: 0.48, 0.74; P < 0.00001). Heart rate in β-blocker was significantly lower than that in the standard care group (SMD = -2.01, 95%CI: -3.03, -0.98; P = 0001). CONCLUSION β-blocker of esmolol is safe and effective in improving 28-day mortality and controlling ventricular rate in patients with sepsis after fluid resuscitation, and has no significant adverse effect on tissue perfusion.
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12
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Aller MA, Arias N, Blanco-Rivero J, Arias J. Metabolism in Acute-On-Chronic Liver Failure: The Solution More than the Problem. Arch Med Res 2019; 50:271-284. [PMID: 31593852 DOI: 10.1016/j.arcmed.2019.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 09/09/2019] [Indexed: 12/13/2022]
Abstract
Chronic inflammatory liver disease with an acute deterioration of liver function is named acute-on-chronic inflammation and could be regulated by the metabolic impairments related to the liver dysfunction. In this way, the experimental cholestasis model is excellent for studying metabolism in both types of inflammatory responses. Along the evolution of this model, the rats develop biliary fibrosis and an acute-on-chronic decompensation. The acute decompensation of the liver disease is associated with encephalopathy, ascites, acute renal failure, an acute phase response and a splanchnic increase of pro- and anti-inflammatory cytokines. This multiorgan inflammatory dysfunction is mainly associated with a splanchnic and systemic metabolic switch with dedifferentiation of the epithelial, endothelial and mesothelial splanchnic barriers. Furthermore, a splanchnic infiltration by mast cells occurs, which suggests that these cells could carry out a compensatory metabolic role, especially through the modulation of hepatic and extrahepatic mitochondrial-peroxisome crosstalk. For this reason, we propose the hypothesis that mastocytosis in the acute-on-chronic hepatic insufficiency could represent the development of a survival metabolic mechanisms that mitigates the noxious effect of the hepatic functional deficit. A better understanding the pathophysiological response of the mast cells in liver insufficiency and portal hypertension would help to find new pathways for decreasing the high morbidity and mortality rate of these patients.
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Affiliation(s)
- Maria-Angeles Aller
- Department of Surgery, School of Medicine, Complutense University of Madrid, Madrid, Spain.
| | - Natalia Arias
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; INEUROPA (Instituto de Neurociencias del Principado de Asturias), Oviedo, Spain
| | - Javier Blanco-Rivero
- Department of Physiology, School of Medicine, Autonoma University of Madrid, Madrid, Spain, Instituto de Investigación Biomédica La Paz (IdIPAZ), Madrid, España; Centro de Investigación Biomédica en Red (Ciber) de Enfermedades Cardiovasculares, Madrid, España
| | - Jaime Arias
- Department of Surgery, School of Medicine, Complutense University of Madrid, Madrid, Spain
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13
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Durand M, Louis H, Fritz C, Levy B, Kimmoun A. β-bloquants dans la prise en charge du choc septique. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les adrénorécepteurs α et en particulier β sont les principales cibles de l’adrénaline et de la noradrénaline libérées par le système sympathique activé. Durant le choc septique, la dysautonomie est une stimulation prolongée à un haut niveau d’intensité du système nerveux sympathique à l’origine d’une altération de la contractilité, de la vasoréactivité et d’une immunodépression. Ainsi, l’administration précoce d’un traitement β-bloquant lors du choc septique pourrait pondérer les effets délétères de cette surstimulation sympathique. Néanmoins, si les preuves expérimentales sont en faveur de cette approche, l’accumulation des preuves cliniques reste encore insuffisante.
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14
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Fuchs C, Wauschkuhn S, Scheer C, Vollmer M, Meissner K, Kuhn SO, Hahnenkamp K, Morelli A, Gründling M, Rehberg S. Continuing chronic beta-blockade in the acute phase of severe sepsis and septic shock is associated with decreased mortality rates up to 90 days. Br J Anaesth 2019; 119:616-625. [PMID: 29121280 DOI: 10.1093/bja/aex231] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 12/24/2022] Open
Abstract
Background There is growing evidence that beta-blockade may reduce mortality in selected patients with sepsis. However, it is unclear if a pre-existing, chronic oral beta-blocker therapy should be continued or discontinued during the acute phase of severe sepsis and septic shock. Methods The present secondary analysis of a prospective observational single centre trial compared patient and treatment characteristics, length of stay and mortality rates between adult patients with severe sepsis or septic shock, in whom chronic beta-blocker therapy was continued or discontinued, respectively. The acute phase was defined as the period ranging from two days before to three days after disease onset. Multivariable Cox regression analysis was performed to compare survival outcomes in patients with pre-existing chronic beta-blockade. Results A total of 296 patients with severe sepsis or septic shock and pre-existing, chronic oral beta-blocker therapy were included. Chronic beta-blocker medication was discontinued during the acute phase of sepsis in 129 patients and continued in 167 patients. Continuation of beta-blocker therapy was significantly associated with decreased hospital (P=0.03), 28-day (P=0.04) and 90-day mortality rates (40.7% vs 52.7%; P=0.046) in contrast to beta-blocker cessation. The differences in survival functions were validated by a Log-rank test (P=0.01). Multivariable analysis identified the continuation of chronic beta-blocker therapy as an independent predictor of improved survival rates (HR = 0.67, 95%-CI (0.48, 0.95), P=0.03). Conclusions Continuing pre-existing chronic beta-blockade might be associated with decreased mortality rates up to 90 days in septic patients.
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Affiliation(s)
- C Fuchs
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Strasse, 17475 Greifswald, Germany
| | - S Wauschkuhn
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Strasse, 17475 Greifswald, Germany
| | - C Scheer
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Strasse, 17475 Greifswald, Germany
| | - M Vollmer
- Institute of Bioinformatics, University Hospital of Greifswald, Greifswald, Germany
| | - K Meissner
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Strasse, 17475 Greifswald, Germany
| | - S-O Kuhn
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Strasse, 17475 Greifswald, Germany
| | - K Hahnenkamp
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Strasse, 17475 Greifswald, Germany
| | - A Morelli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, La Sapienza, Rome, Italy
| | - M Gründling
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Strasse, 17475 Greifswald, Germany
| | - S Rehberg
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Strasse, 17475 Greifswald, Germany
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15
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Poveda-Jaramillo R, Monaco F, Zangrillo A, Landoni G. Ultra-Short–Acting β-Blockers (Esmolol and Landiolol) in the Perioperative Period and in Critically Ill Patients. J Cardiothorac Vasc Anesth 2018; 32:1415-1425. [DOI: 10.1053/j.jvca.2017.11.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Indexed: 01/16/2023]
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16
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Lu Y, Yang Y, He X, Dong S, Wang W, Wang D, Zhang P. Esmolol reduces apoptosis and inflammation in early sepsis rats with abdominal infection. Am J Emerg Med 2017; 35:1480-1484. [PMID: 28457762 DOI: 10.1016/j.ajem.2017.04.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Esmolol is a highly selective beta 1 receptor blocker with various effects such as slowing heart rate, lowering blood pressure and reducing myocardial oxygen consumption. However, few studies have reported the use of beta blockers in sepsis with multiple organ dysfunctions. This study aimed to investigate the effects of esmolol on reducing apoptosis and inflammation in early sepsis rats with abdominal infection. METHODS Rats were randomly divided into sham operation group, sepsis group, antibiotic group, Esmolol + antibiotic group with low, median and high dose Esmolol (L group, M group and H group). Values between two or more groups were compared by independent t-tests. RESULTS In the liver and kidney, we found inflammatory infiltration in sepsis group while pathological aspects reduced in L, M and H groups. Bcl-2 mRNA and protein levels increased while Bax mRNA and protein levels decreased in the liver and kidney of L, M and H groups. Serum IL-6, HMGB-1 and TNF-α levels decreased but IL-10 level increased in L, M and H groups, compared to sepsis group. Compared to sepsis and antibiotic groups, the levels of myocardial enzymes were lower in L, M and H groups. CONCLUSION The administration of esmolol in early sepsis may reduce inflammation, inhibit apoptosis and protect key organs.
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Affiliation(s)
- Yang Lu
- Department of Intensive Care Unit, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China
| | - Yang Yang
- Department of Anesthesia, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China
| | - Xin He
- Department of Anesthesia, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China
| | - Shangwen Dong
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, Tianjin, Heping District, 300052, P.R. China
| | - Wanhua Wang
- Department of Anesthesia, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China
| | - Donghao Wang
- Department of Intensive Care Unit, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, Tianjin, Heping District, 300052, P.R. China.
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17
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García-Prieto J, Villena-Gutiérrez R, Gómez M, Bernardo E, Pun-García A, García-Lunar I, Crainiciuc G, Fernández-Jiménez R, Sreeramkumar V, Bourio-Martínez R, García-Ruiz JM, Del Valle AS, Sanz-Rosa D, Pizarro G, Fernández-Ortiz A, Hidalgo A, Fuster V, Ibanez B. Neutrophil stunning by metoprolol reduces infarct size. Nat Commun 2017; 8:14780. [PMID: 28416795 PMCID: PMC5399300 DOI: 10.1038/ncomms14780] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 01/30/2017] [Indexed: 12/12/2022] Open
Abstract
The β1-adrenergic-receptor (ADRB1) antagonist metoprolol reduces infarct size in acute myocardial infarction (AMI) patients. The prevailing view has been that metoprolol acts mainly on cardiomyocytes. Here, we demonstrate that metoprolol reduces reperfusion injury by targeting the haematopoietic compartment. Metoprolol inhibits neutrophil migration in an ADRB1-dependent manner. Metoprolol acts during early phases of neutrophil recruitment by impairing structural and functional rearrangements needed for productive engagement of circulating platelets, resulting in erratic intravascular dynamics and blunted inflammation. Depletion of neutrophils, ablation of Adrb1 in haematopoietic cells, or blockade of PSGL-1, the receptor involved in neutrophil-platelet interactions, fully abrogated metoprolol's infarct-limiting effects. The association between neutrophil count and microvascular obstruction is abolished in metoprolol-treated AMI patients. Metoprolol inhibits neutrophil-platelet interactions in AMI patients by targeting neutrophils. Identification of the relevant role of ADRB1 in haematopoietic cells during acute injury and the protective role upon its modulation offers potential for developing new therapeutic strategies.
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Affiliation(s)
- Jaime García-Prieto
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain
| | | | - Mónica Gómez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain
| | | | - Andrés Pun-García
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain
| | - Inés García-Lunar
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain.,Clinical Department, School of Biomedical Sciences, Universidad Europea, 28670 Madrid, Spain.,Hospital Universitario Quirón, 28223 Madrid, Spain
| | - Georgiana Crainiciuc
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain
| | - Rodrigo Fernández-Jiménez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain.,Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Vinatha Sreeramkumar
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,Clinical Department, School of Biomedical Sciences, Universidad Europea, 28670 Madrid, Spain
| | - Rafael Bourio-Martínez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,Hospital de Basurto, 48013 Bilbao, Spain
| | - José M García-Ruiz
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain.,Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | | | - David Sanz-Rosa
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain.,Clinical Department, School of Biomedical Sciences, Universidad Europea, 28670 Madrid, Spain
| | - Gonzalo Pizarro
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain.,Clinical Department, School of Biomedical Sciences, Universidad Europea, 28670 Madrid, Spain.,Complejo Hospitalario Ruber Juan Bravo-UEM, 28006 Madrid, Spain
| | - Antonio Fernández-Ortiz
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain.,Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Andrés Hidalgo
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians University, 80336 Munich, Germany
| | - Valentín Fuster
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of medicine at Mount Sinai, New York, New York 10029, USA
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), 28029 Madrid, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), 28029 Madrid, Spain.,Department of Cardiology, Instituto de Investigación Sanitaria (IIS)-Fundación Jiménez Díaz, 28040 Madrid, Spain
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18
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Ferreira JA, Bissell BD. Misdirected Sympathy: The Role of Sympatholysis in Sepsis and Septic Shock. J Intensive Care Med 2017; 33:74-86. [DOI: 10.1177/0885066616689548] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The spectrum of sepsis and septic shock remains a highly prevalent disease state, carrying a high risk of morbidity and mortality. The sympathetic nervous system (SNS) plays an important role in this initial cascade, enabling the host to respond to invading pathogens; however, prolonged activation can become pathological. The potential for unregulated sympathetic tone to become of detriment in patients with sepsis has fueled interest in the role and impact of sympatholysis, the selective inhibition of sympathetic tone. The cornerstone of septic shock therapy for decades has been the supplementation of catecholamines and thus potential further perpetuation of this sympathetic dysregulation. Although the theory of sympatholysis circulates around cardiovascular effects and stroke volume optimization, the impact of augmenting the SNS may extend well beyond this, including the impacts on the immune system, inflammatory cascade, and even gene transcription. Presently, the most robust clinical evidence involves the use of the cardioselective β-blocker esmolol in patients with septic shock with persistent tachycardia secondary to catecholamine use. Evidence is isolated only to animal models with α-agonists. Future evidence stands to elucidate the balance of sympathetic and autonomic tone as well as the potential role of redirecting and maximizing sympathetic activity.
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Affiliation(s)
- Jason A. Ferreira
- Department of Pharmacy Services, University of Florida Health Jacksonville, Jacksonville, FL, USA
| | - Brittany D. Bissell
- Department of Pharmacy Services, University of Kentucky Healthcare, Lexington, KY, USA
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19
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Wei C, Louis H, Schmitt M, Albuisson E, Orlowski S, Levy B, Kimmoun A. Effects of low doses of esmolol on cardiac and vascular function in experimental septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:407. [PMID: 27998289 PMCID: PMC5175382 DOI: 10.1186/s13054-016-1580-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 11/25/2016] [Indexed: 12/22/2022]
Abstract
Background Administration of a selective β1-blocker, such as esmolol, in human septic shock has demonstrated cardiovascular protective effects related to heart rate reduction. Certain experimental data also indicate that esmolol exerts systemic anti-inflammatory and beneficial effects on vascular tone. Thus, the present study aimed to determine whether a non-chronotropic dose of esmolol maintains its protective cardiovascular and anti-inflammatory effects in experimental septic shock. Methods Four hours after cecal ligation and puncture (CLP), Wistar male rats were randomly allocated to the following groups (n = 8): CLP, CLP + E-1 (esmolol: 1 mg.kg−1.h−1), CLP + E-5 (esmolol: 5 mg.kg−1.h−1), CLP + E-18 (esmolol: 18 mg.kg−1.h−1). An additional eight rats underwent sham operation. All rats received a continuous infusion of saline, analgesic and antibiotics 4 hours after the surgery. Assessment at 18 hours included in vivo cardiac function assessed by echocardiography and ex vivo vasoreactivity assessed by myography. Circulating cytokine levels (IL-6 and IL-10) were measured by ELISA. Cardiac and vascular protein expressions of p-NF-κB, IκBα, iNOS, p-AKT/AKT and p-eNOS/eNOS were assessed by western blotting. Results CLP induced tachycardia, hypotension, cardiac output reduction, hyperlactatemia and vascular hypo-responsiveness to vasopressors. Compared to CLP animals, heart rate was unchanged in CLP + E-1 and CLP + E-5 but was reduced in CLP + E-18. Stroke volume, cardiac output, mean arterial pressure and lactatemia were improved in CLP + E-1 and CLP + E-5, while vascular responsiveness to phenylephrine was only improved in CLP + E-5 and CLP + E-18. Plasma IL-6 levels were decreased in all esmolol groups. p-NF-κB was decreased in both cardiac and vascular tissues in CLP + E-5 and CLP + E-18. Conclusion In experimental septic shock, low doses of esmolol still improved cardiac function and vasoreactivity. These benefits appear to be associated with a modulation of inflammatory pathways. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1580-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chaojie Wei
- INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, Vandoeuvre les Nancy, France.,Université de Lorraine, Nancy, France
| | - Huguette Louis
- Université de Lorraine, Nancy, France.,INSERM U 1116, Groupe Choc, Equipe 1, Faculté de Médecine, Vandoeuvre les Nancy, France
| | - Margaux Schmitt
- INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, Vandoeuvre les Nancy, France
| | - Eliane Albuisson
- Université de Lorraine, Nancy, France.,Unité ESPRI-BioBase, CHRU Nancy, Vandoeuvre les Nancy, France
| | - Sophie Orlowski
- INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, Vandoeuvre les Nancy, France.,Université de Lorraine, Nancy, France
| | - Bruno Levy
- INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, Vandoeuvre les Nancy, France. .,Université de Lorraine, Nancy, France. .,CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, Vandoeuvre les Nancy, France.
| | - Antoine Kimmoun
- INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, Vandoeuvre les Nancy, France.,Université de Lorraine, Nancy, France.,CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, Vandoeuvre les Nancy, France
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20
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Perner A, Gordon AC, De Backer D, Dimopoulos G, Russell JA, Lipman J, Jensen JU, Myburgh J, Singer M, Bellomo R, Walsh T. Sepsis: frontiers in diagnosis, resuscitation and antibiotic therapy. Intensive Care Med 2016; 42:1958-1969. [PMID: 27695884 DOI: 10.1007/s00134-016-4577-z] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/25/2016] [Indexed: 01/28/2023]
Abstract
Sepsis is a major growing global burden and a major challenge to intensive care clinicians, researchers, guideline committee members and policy makers, because of its high and increasing incidence and great pathophysiological, molecular, genetic and clinical complexity. In spite of recent progress, short-term mortality remains high and there is growing evidence of long-term morbidity and increased long-term mortality in survivors of sepsis both in developed and developing countries. Further improvement in the care of patients with sepsis will impact upon global health. In this narrative review, invited experts describe the expected challenges and progress to be made in the near future. We focus on diagnosis, resuscitation (fluids, vasopressors, inotropes, blood transfusion and hemodynamic targets) and infection (antibiotics and infection biomarkers), as these areas are key, if initial management and subsequent outcomes are to be improved in patients with sepsis.
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Affiliation(s)
- Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - George Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, Medical School, University of Athens, Athens, Greece
| | - James A Russell
- Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey Lipman
- Royal Brisbane and Women's Hospital, The University of Queensland, Brisbane, QLD, Australia
| | - Jens-Ulrik Jensen
- CHIP and PERSIMUNE, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John Myburgh
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Mervyn Singer
- Division of Medicine, Bloomsbury Institute of Intensive Care Medicine, University College London, London, WC1E 6BT, UK
| | - Rinaldo Bellomo
- School of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Timothy Walsh
- Anaesthetics, Critical Care, and Pain Medicine, Edinburgh University, Edinburgh, Scotland, UK
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Beta-blockers in septic shock to optimize hemodynamics? Yes. Intensive Care Med 2016; 42:1607-1609. [PMID: 27349239 DOI: 10.1007/s00134-016-4414-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/31/2016] [Indexed: 01/31/2023]
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22
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Unterberg M, Kreuzer MJ, Schäfer ST, Bazzi Z, Adamzik M, Rump K. NFKB1 Promoter DNA from nt+402 to nt+99 Is Hypomethylated in Different Human Immune Cells. PLoS One 2016; 11:e0156702. [PMID: 27249028 PMCID: PMC4889142 DOI: 10.1371/journal.pone.0156702] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/18/2016] [Indexed: 12/30/2022] Open
Abstract
Sepsis, with a persistently high 90-day mortality of about 46%, is the third most frequent cause of death in intensive care units worldwide. Further understanding of the inflammatory signaling pathways occurring in sepsis is important for new efficient treatment options. Key regulator of the inflammatory response is the transcription factor NFκB. As we have recently shown, the -94 Ins/Del NFKB1 promoter polymorphism influences sepsis mortality. However, a molecular explanation is still missing. Thus, promoter activity might be varying depending on the NFKB1 genotype, explaining the genotype dependent mortality from sepsis, and one likely mechanism is the degree of promoter methylation. Therefore, we tested the hypothesis that NFκB mRNA expression is regulated by promoter methylation in human cell lines and primary immune cell cultures. First, we examined the methylation of the NFKB1 promoter in U937, REH and HL-60 cells. In the promoter region of nt+99/+229 methylation in all analyzed cell lines was below 1%. Following incubation with bacterial cell wall components, no significant changes in the frequency of promoter methylation in U937 and REH cells were measured and the methylation frequency was under 1%. However, NFκB1 mRNA expression was two-fold increased in U937 cells after 24 h incubation with LPS. By contrast, demethylation by 5-Aza-2′-deoxycytidine incubation enhanced NFκB1 expression significantly. In addition, we analyzed NFKB1 promoter methylation in primary cells from healthy volunteers depending on the NFKB1–94 Ins/Del genotype. Methylation in the promoter region from nt+402 to nt+99 was below 1%. Genotype dependent differences occurred in neutrophil cells, where DD-genotype was significantly more methylated compared to II genotype at nt+284/+402. Besides in the promoter region from nt-227/-8 in ID-genotypes methylation of neutrophils was significantly decreased compared to lymphocytes and in II-genotypes methylation in neutrophils was significantly decreased compared to lymphocytes and monocytes. In addition, CHART-PCR showed that the hypomethylated promoter regions are highly accessible. Therefore we assume that the demethylated regions are very important for NFKB1 promoter activity.
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Affiliation(s)
- Matthias Unterberg
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum-Langendreer der Ruhr-Universität Bochum, In der Schornau 23–25, 44892 Bochum, Germany
- * E-mail:
| | - Maxmiliane Julia Kreuzer
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum-Langendreer der Ruhr-Universität Bochum, In der Schornau 23–25, 44892 Bochum, Germany
| | - Simon Thomas Schäfer
- Klinik für Anaesthesiologie, Klinikum der Universität Ludwig-Maximilians Universität München, München, Germany
| | - Zainab Bazzi
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum-Langendreer der Ruhr-Universität Bochum, In der Schornau 23–25, 44892 Bochum, Germany
| | - Michael Adamzik
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum-Langendreer der Ruhr-Universität Bochum, In der Schornau 23–25, 44892 Bochum, Germany
| | - Katharina Rump
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum-Langendreer der Ruhr-Universität Bochum, In der Schornau 23–25, 44892 Bochum, Germany
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23
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Survival benefits of remote ischemic conditioning in sepsis. J Surg Res 2016; 213:131-137. [PMID: 28601305 DOI: 10.1016/j.jss.2016.01.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/20/2016] [Accepted: 01/27/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sepsis remains the leading cause of death in the surgical intensive care unit. Prior studies have demonstrated a survival benefit of remote ischemic conditioning (RIC) in many disease states. The aim of this study was to determine the effects of RIC on survival in sepsis in an animal model and to assess alterations in inflammatory biochemical profiles. We hypothesized that RIC alters inflammatory biochemical profiles resulting in decreased mortality in a septic mouse model. MATERIALS AND METHODS Eight to 12 week C57BL/6 mice received intra-peritoneal injection of 12.5-mg/kg lipopolysaccharide (LPS). Septic animals in the experimental group underwent RIC at 0, 2, and 6 h after LPS by surgical exploration and alternate clamping of the femoral artery. Six 4-min cycles of ischemia-reperfusion were performed. Primary outcome was survival at 5-d after LPS injection. Secondary outcome was to assess the following serum cytokine levels: interferon-γ (IFN-γ), interleukin (IL)-10, IL-1β, and tumor necrosis factoralpha (TNFα) at the baseline before LPS injection, 0 hour after LPS injection, and at 2, 4, 24 hours after induction of sepsis (RIC was performed at 2 h after LPS injection). Kaplan-Meier survival analysis and log-rank test were used. ANOVA test was used to compare cytokine measurements. RESULTS We performed experiments on 44 mice: 14 sham and 30 RIC mice (10 at each time point). Overall survival was higher in the experimental group compared to the sham group (57% versus 21%; P = 0.02), with the highest survival rate observed in the 2-hour post-RIC group (70%). On Kaplan-Meier analysis, 2-h post-RIC group had increased survival at 5 days after LPS (P = 0.04) with hazard ratio of 0.3 (95% confidence interval = 0.09-0.98). In the RIC group, serum concentrations of IFN-γ, IL-10, IL-1β, and TNFα peaked at 2 h after LPS and then decreased significantly over 24 hours (P < 0.0001) compared to the baseline. CONCLUSIONS RIC improves survival in sepsis and has the potential for implementation in the clinical practice. Early implementation of RIC may play an immune-modulatory role in sepsis. Further studies are necessary to refine understanding of the observed survival benefits and its implications in sepsis management.
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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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Walkey AJ, Evans SR, Winter MR, Benjamin EJ. Practice Patterns and Outcomes of Treatments for Atrial Fibrillation During Sepsis: A Propensity-Matched Cohort Study. Chest 2016; 149:74-83. [PMID: 26270396 DOI: 10.1378/chest.15-0959] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) during sepsis is associated with increased morbidity and mortality, but practice patterns and outcomes associated with rate- and rhythm-targeted treatments for AF during sepsis are unclear. METHODS This was a retrospective cohort study using enhanced billing data from approximately 20% of United States hospitals. We identified factors associated with IV AF treatments (?-blockers [BBs], calcium channel blockers [CCBs], digoxin, or amiodarone) during sepsis. We used propensity score matching and instrumental variable approaches to compare mortality between AF treatments. RESULTS Among 39,693 patients with AF during sepsis, mean age was 77 ± 11 years, 49% were women, and 76% were white. CCBs were the most commonly selected initial AF treatment during sepsis (14,202 patients [36%]), followed by BBs (11,290 [28%]), digoxin (7,937 [20%]), and amiodarone (6,264 [16%]). Initial AF treatment selection differed according to geographic location, hospital teaching status, and physician specialty. In propensity-matched analyses, BBs were associated with lower hospital mortality when compared with CCBs (n = 18,720; relative risk [RR], 0.92; 95% CI, 0.86-0.97), digoxin (n = 13,994; RR, 0.79; 95% CI, 0.75-0.85), and amiodarone (n = 5,378; RR, 0.64; 95% CI, 0.61-0.69). Instrumental variable analysis showed similar results (adjusted RR fifth quintile vs first quintile of hospital BB use rate, 0.67; 95% CI, 0.58-0.79). Results were similar among subgroups with new-onset or preexisting AF, heart failure, vasopressor-dependent shock, or hypertension. CONCLUSIONS Although CCBs were the most frequently used IV medications for AF during sepsis, BBs were associated with superior clinical outcomes in all subgroups analyzed. Our findings provide rationale for clinical trials comparing the effectiveness of AF rate- and rhythm-targeted treatments during sepsis.
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Affiliation(s)
- Allan J Walkey
- Division of Pulmonary and Critical Care Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA.
| | - Stephen R Evans
- Data Coordinating Center, Boston University School of Public Health, Boston, MA
| | - Michael R Winter
- Data Coordinating Center, Boston University School of Public Health, Boston, MA
| | - Emelia J Benjamin
- Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, MA; Section of Preventive Medicine, Boston University School of Medicine, Boston, MA; Department of Epidemiology, Boston University School of Public Health, Boston, MA
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Wang Z, Wu Q, Nie X, Guo J, Yang C. Infusion of esmolol attenuates lipopolysaccharide-induced myocardial dysfunction. J Surg Res 2016; 200:283-9. [DOI: 10.1016/j.jss.2015.07.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 12/28/2022]
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Pathophysiology of sepsis-related cardiac dysfunction: driven by inflammation, energy mismanagement, or both? Curr Heart Fail Rep 2015; 12:130-40. [PMID: 25475180 DOI: 10.1007/s11897-014-0247-z] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Sepsis is a systemic inflammatory response that follows bacterial infection. Cardiac dysfunction is an important consequence of sepsis that affects mortality and has been attributed to either elevated inflammation or suppression of both fatty acid and glucose oxidation and eventual ATP depletion. Moreover, cardiac adrenergic signaling is compromised in septic patients and this aggravates further heart function. While anti-inflammatory therapies are important for the treatment of the disease, administration of anti-inflammatory drugs did not improve survival in septic patients. This review article summarizes findings on inflammatory and other mechanisms that are triggered in sepsis and affect cardiac function and mortality. Particularly, it focuses on the effects of the disease in metabolic pathways, as well as in adrenergic signaling and the potential interplay of the latter with inflammation. It is suggested that therapeutic approaches should include combination of anti-inflammatory treatments, stimulation of energy production, and restoration of adrenergic signaling in the heart.
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28
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Is It Time to Beta Block the Septic Patient? BIOMED RESEARCH INTERNATIONAL 2015; 2015:424308. [PMID: 26557668 PMCID: PMC4628753 DOI: 10.1155/2015/424308] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 05/18/2015] [Indexed: 01/20/2023]
Abstract
Beta blockers are some of the most studied drugs in the pharmacopoeia. They are already widely used in medicine for treating hypertension, chronic heart failure, tachyarrhythmias, and tremor. Whilst their use in the immediate perioperative patient has been questioned, the use of esmolol in the patients with established septic shock has been recently reported to have favourable outcomes. In this paper, we review the role of the adrenergic system in sepsis and the evidence for the use of beta stimulation and beta blockers from animal models to critically ill patients.
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Sanfilippo F, Santonocito C, Morelli A, Foex P. Beta-blocker use in severe sepsis and septic shock: a systematic review. Curr Med Res Opin 2015; 31:1817-25. [PMID: 26121122 DOI: 10.1185/03007995.2015.1062357] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Recent growing evidence suggests that beta-blocker treatment could improve cardiovascular dynamics and possibly the outcome of patients admitted to intensive care with severe sepsis or septic shock. DESIGN Systematic review. DATA SOURCES MEDLINE and EMBASE healthcare databases. REVIEW METHODS To investigate this topic, we conducted a systematic review of the above databases up to 31 May 2015. Due to the clinical novelty of the subject, we also included non-randomized clinical studies. We focused on the impact of beta-blocker treatment on mortality, also investigating its effects on cardiovascular, immune and metabolic function. Evidence from experimental studies was reviewed as well. RESULTS From the initial search we selected 10 relevant clinical studies. Five prospective studies (two randomized) assessed the hemodynamic effects of the beta1-blocker esmolol. Heart rate decreased significantly in all, but the impact on other parameters differed. The imbalance between prospective studies' size (10 to 144 patients) and the differences in their design disfavor a meta-analysis. One retrospective study showed improved hemodynamics combining metoprolol and milrinone in septic patients, and another retrospective study found no association between beta-blocker administration and mortality. We also found three case series. Twenty-one experimental studies evaluated the hemodynamic, immune and/or metabolic effects of selective and/or non-selective beta-blockers in animal models of sepsis (dogs, mice, pigs, rats, sheep), yielding conflicting results. CONCLUSIONS Whilst there is not enough prospective data to conduct a meta-analysis, the available clinical data are promising. We discuss the ability of beta blockade to modulate sepsis-induced alterations at cardiovascular, metabolic, immunologic and coagulation levels.
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Affiliation(s)
- Filippo Sanfilippo
- a a Cardiothoracic Intensive Care Unit, Intensive Care Directorate - St George's University Hospitals NHS Foundation Trust , London , United Kingdom
| | - Cristina Santonocito
- b b Cardiothoracic Critical Care Unit, Oxford Heart Centre - John Radcliffe Hospital, Oxford University Hospitals , Oxford , United Kingdom
| | - Andrea Morelli
- c c Department of Cardiovascular , Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome , 'La Sapienza' , Rome , Italy
| | - Pierre Foex
- d d Nuffield Division of Anaesthetics, University of Oxford - John Radcliffe Hospital , Oxford , United Kingdom
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