1
|
Kemper DAG, Otsuki DA, Maia DRR, Mossoco CDO, Marcasso RA, Cunha LCC, Auler JOC, Fantoni DT. Sildenafil in endotoxin-induced pulmonary hypertension: an experimental study. Braz J Anesthesiol 2021:S0104-0014(21)00239-6. [PMID: 34118261 PMCID: PMC10362450 DOI: 10.1016/j.bjane.2021.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Sepsis and septic shock still represent great challenges in critical care medicine. Sildenafil has been largely used in the treatment of pulmonary arterial hypertension, but its effects in sepsis are unknown. The aim of this study was to investigate the hypothesis that sildenafil can attenuate endotoxin-induced pulmonary hypertension in a porcine model of endotoxemia. METHODS Twenty pigs were randomly assigned to Control group (n = 10), which received saline solution; or to Sildenafil group (n = 10), which received sildenafil orally (100 mg). After 30 minutes, both groups were submitted to endotoxemia with intravenous bacterial lipopolysaccharide endotoxin (LPS) infusion (4 µg.kg-1.h-1) for 180 minutes. We evaluated hemodynamic and oxygenation functions, and also lung histology and plasma cytokine (TNFα, IL-1β, IL6, and IL10) and troponin I response. RESULTS Significant hemodynamic alterations were observed after 30 minutes of LPS continuous infusion, mainly in pulmonary arterial pressure (from Baseline 19 ± 2 mmHg to LPS30 52 ± 4 mmHg, p < 0.05). There was also a significant decrease in PaO2/FiO2 (from Baseline 411 ± 29 to LPS180 334 ± 49, p < 0.05). Pulmonary arterial pressure was significantly lower in the Sildenafil group (35 ± 4 mmHg at LPS30, p < 0.05). The Sildenafil group also presented lower values of systemic arterial pressure. Sildenafil maintained oxygenation with higher PaO2/FiO2 and lower oxygen extraction rate than Control group but had no effect on intrapulmonary shunt. All cytokines and troponin increased after LPS infusion in both groups similarly. CONCLUSION Sildenafil attenuated endotoxin-induced pulmonary hypertension preserving the correct heart function without improving lung lesions or inflammation.
Collapse
Affiliation(s)
- Daniella Aparecida Godoi Kemper
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, LIM08 - Laboratório de Anestesiologia, São Paulo, SP, Brazil
| | - Denise Aya Otsuki
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, LIM08 - Laboratório de Anestesiologia, São Paulo, SP, Brazil
| | - Débora Rothstein Ramos Maia
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, LIM08 - Laboratório de Anestesiologia, São Paulo, SP, Brazil
| | - Cristina de Oliveira Mossoco
- Universidade de São Paulo, Faculdade de Medicina Veterinária e Zootecnia, Departamento de Patologia, São Paulo, SP, Brazil
| | | | - Ligia Cristina Câmara Cunha
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | - José Otávio Costa Auler
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, LIM08 - Laboratório de Anestesiologia, São Paulo, SP, Brazil.
| | - Denise Tabacchi Fantoni
- Universidade de São Paulo, Faculdade de Medicina Veterinária e Zootecnia, Departamento de Cirurgia, São Paulo, SP, Brazil
| |
Collapse
|
2
|
Abstract
Pulmonary hypertension is a multifactorial disease with a high morbidity and
mortality. Right ventricular function is the most important predictor of
morbidity and mortality in patients suffering from pulmonary hypertension, but
currently there are no approved treatments directly supporting the failing right
ventricle. Levosimendan is a calcium sensitizing agent with inotropic, pulmonary
vasodilatory, and cardioprotective properties. Given its pharmacodynamic
profile, levosimendan could be a potential novel agent for the treatment of
right ventricular failure caused by pulmonary hypertension. The aim of this
review is to provide an overview of the current knowledge on the effects of
levosimendan in pulmonary hypertension and right heart failure.
Collapse
Affiliation(s)
- Mona Sahlholdt Hansen
- Department of Cardiology, Institute of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Asger Andersen
- Department of Cardiology, Institute of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Institute of Clinical Medicine, Aarhus University Hospital, Denmark
| |
Collapse
|
3
|
Abstract
Clinicians have greatly improved care for septic shock. Urgent resuscitation using intravenous fluids and vasopressors as well as rapid administration of broad spectrum antibiotics are probably the most basic and universally accepted interventions. Various trials have compared different types of vasopressors, associations of vasopressors and inotropes, and pressure targets. End goal-directed therapy algorithms are designed to optimize oxygen delivery by use of fluids, vasopressors, inotropes, and blood products. Patients who have a poor response to resuscitation and patients with known severe ventricular dysfunction might merit advanced hemodynamic monitoring. This review examines important vasopressor and septic shock trials.
Collapse
|
4
|
Zangrillo A, Putzu A, Monaco F, Oriani A, Frau G, De Luca M, Di Tomasso N, Bignami E, Lomivorotov V, Likhvantsev V, Landoni G. Levosimendan reduces mortality in patients with severe sepsis and septic shock: A meta-analysis of randomized trials. J Crit Care 2015; 30:908-13. [PMID: 26093802 DOI: 10.1016/j.jcrc.2015.05.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/19/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE There is controversy about the use of inotropes in the treatment of severe sepsis and septic shock. The objective of this study was to evaluate if levosimendan, as compared with standard inotropic therapy (eg, dobutamine), reduces mortality in septic patients. MATERIALS AND METHODS BioMedCentral, PubMed, EMBASE, and the Cochrane Central Register were searched for pertinent studies, up to 1st May 2015. Randomized trials on the use of levosimendan in patients with severe sepsis and septic shock were included if reporting mortality data. The primary outcome was mortality, whereas secondary outcomes were blood lactate, cardiac index, total fluid infused, norepinephrine dosage, and mean arterial pressure. RESULTS Seven studies for a total of 246 patients were included in the analysis. Levosimendan was associated with significantly reduced mortality compared with standard inotropic therapy (59/125 [47%] in the levosimendan group and 74/121 [61%] in the control group; risk difference = -0.14, risk ratio = 0.79 [0.63-0.98], P for effect = .03, I(2) = 0%, numbers needed to treat = 7). Blood lactate was significantly reduced in the levosimendan group, whereas cardiac index and total fluid infused were significantly higher in the levosimendan group. No difference in mean arterial pressure and norepinephrine usage was noted. CONCLUSIONS In patients with severe sepsis and septic shock, levosimendan is associated with a significant reduction in mortality compared with standard inotropic therapy. A large ongoing multicenter randomized trial will have to confirm these findings.
Collapse
Affiliation(s)
- Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University of Milan, Milan, Italy.
| | - Alessandro Putzu
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Giovanna Frau
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Monica De Luca
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Nora Di Tomasso
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Elena Bignami
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Valery Likhvantsev
- Anesthesiology & Intensive Care Department, Moscow Regional Clinical & Research Institute, Moscow, Russia.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University of Milan, Milan, Italy.
| |
Collapse
|
5
|
Schellekens WJM, van Hees HWH, Linkels M, Dekhuijzen PNR, Scheffer GJ, van der Hoeven JG, Heunks LMA. Levosimendan affects oxidative and inflammatory pathways in the diaphragm of ventilated endotoxemic mice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:69. [PMID: 25888356 PMCID: PMC4355991 DOI: 10.1186/s13054-015-0798-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 02/11/2015] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Controlled mechanical ventilation and endotoxemia are associated with diaphragm muscle atrophy and dysfunction. Oxidative stress and activation of inflammatory pathways are involved in the pathogenesis of diaphragmatic dysfunction. Levosimendan, a cardiac inotrope, has been reported to possess anti-oxidative and anti-inflammatory properties. The aim of the present study was to investigate the effects of levosimendan on markers for diaphragm nitrosative and oxidative stress, inflammation and proteolysis in a mouse model of endotoxemia and mechanical ventilation. METHODS Three groups were studied: (1) unventilated mice (CON, n =8), (2) mechanically ventilated endotoxemic mice (MV LPS, n =17) and (3) mechanically ventilated endotoxemic mice treated with levosimendan (MV LPS + L, n =17). Immediately after anesthesia (CON) or after 8 hours of mechanical ventilation, blood and diaphragm muscle were harvested for biochemical analysis. RESULTS Mechanical ventilation and endotoxemia increased expression of inducible nitric oxide synthase (iNOS) mRNA and cytokine levels of interleukin (IL)-1β, IL-6 and keratinocyte-derived chemokine, and decreased IL-10, in the diaphragm; however, they had no effect on protein nitrosylation and 4-hydroxy-2-nonenal protein concentrations. Levosimendan decreased nitrosylated proteins by 10% (P <0.05) and 4-hydroxy-2-nonenal protein concentrations by 13% (P <0.05), but it augmented the rise of iNOS mRNA by 47% (P <0.05). Levosimendan did not affect the inflammatory response in the diaphragm induced by mechanical ventilation and endotoxemia. CONCLUSIONS Mechanical ventilation in combination with endotoxemia results in systemic and diaphragmatic inflammation. Levosimendan partly decreased markers of nitrosative and oxidative stress, but did not affect the inflammatory response.
Collapse
Affiliation(s)
- Willem-Jan M Schellekens
- Department of Anesthesiology, Radboud University Medical Centre, Postbox 9101, Nijmegen, 6500 HB, the Netherlands.
| | - Hieronymus W H van Hees
- Department of Pulmonary Diseases, Radboud University Medical Centre, Postbox 9101, Nijmegen, 6500 HB, the Netherlands.
| | - Marianne Linkels
- Department of Pulmonary Diseases, Radboud University Medical Centre, Postbox 9101, Nijmegen, 6500 HB, the Netherlands.
| | - P N Richard Dekhuijzen
- Department of Pulmonary Diseases, Radboud University Medical Centre, Postbox 9101, Nijmegen, 6500 HB, the Netherlands.
| | - Gert Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Centre, Postbox 9101, Nijmegen, 6500 HB, the Netherlands.
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Centre, Postbox 9101, Nijmegen, 6500 HB, the Netherlands.
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Radboud University Medical Centre, Postbox 9101, Nijmegen, 6500 HB, the Netherlands.
| |
Collapse
|
6
|
Antonucci E, Fiaccadori E, Donadello K, Taccone FS, Franchi F, Scolletta S. Myocardial depression in sepsis: From pathogenesis to clinical manifestations and treatment. J Crit Care 2014; 29:500-11. [DOI: 10.1016/j.jcrc.2014.03.028] [Citation(s) in RCA: 171] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 03/27/2014] [Accepted: 03/29/2014] [Indexed: 12/28/2022]
|
7
|
Yilmaz MB, Grossini E, Silva Cardoso JC, Édes I, Fedele F, Pollesello P, Kivikko M, Harjola VP, Hasslacher J, Mebazaa A, Morelli A, le Noble J, Oldner A, Oulego Erroz I, Parissis JT, Parkhomenko A, Poelzl G, Rehberg S, Ricksten SE, Rodríguez Fernández LM, Salmenperä M, Singer M, Treskatsch S, Vrtovec B, Wikström G. Renal effects of levosimendan: a consensus report. Cardiovasc Drugs Ther 2013; 27:581-90. [PMID: 23929366 PMCID: PMC3830192 DOI: 10.1007/s10557-013-6485-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Renal dysfunction is common in clinical settings in which cardiac function is compromised such as heart failure, cardiac surgery or sepsis, and is associated with high morbidity and mortality. Levosimendan is a calcium sensitizer and potassium channel opener used in the treatment of acute heart failure. This review describes the effects of the inodilator levosimendan on renal function. A panel of 25 scientists and clinicians from 15 European countries (Austria, Finland, France, Hungary, Germany, Greece, Italy, Portugal, the Netherlands, Slovenia, Spain, Sweden, Turkey, the United Kingdom, and Ukraine) convened and reached a consensus on the current interpretation of the renal effects of levosimendan described both in non-clinical research and in clinical study reports. Most reports on the effect of levosimendan indicate an improvement of renal function in heart failure, sepsis and cardiac surgery settings. However, caution should be applied as study designs differed from randomized, controlled studies to uncontrolled ones. Importantly, in the largest HF study (REVIVE I and II) no significant changes in the renal function were detected. As it regards the mechanism of action, the opening of mitochondrial KATP channels by levosimendan is involved through a preconditioning effect. There is a strong rationale for randomized controlled trials seeking beneficial renal effects of levosimendan. As an example, a study is shortly to commence to assess the role of levosimendan for the prevention of acute organ dysfunction in sepsis (LeoPARDS).
Collapse
Affiliation(s)
- Mehmet B. Yilmaz
- Department of Cardiology, Cumhuriyet University School of Medicine, Sivas, Turkey
| | - Elena Grossini
- Laboratorio di Fisiologia, Dipartimento di Medicina Traslazionale, Università degli Studi del Piemonte Orientale A. Avogadro, Piemonte, Italy
| | - José C. Silva Cardoso
- Faculdade de Medicina, Alameda Prof. Hernâni Monteiro, Universidade do Porto, Porto, Portugal
| | - István Édes
- Institute of Cardiology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrological, and Geriatric Sciences, La Sapienza University of Rome, Rome, Italy
| | | | - Matti Kivikko
- Cardiology and Critical Care, Orion Pharma, Espoo, Finland
| | - Veli-Pekka Harjola
- Departments of Cardiology, Helsinki University Hospital, Helsinki, Finland
| | - Julia Hasslacher
- Internistische Intensiv- und Notfallmedizin, Universitätsklinik für Innere Medizin, Innsbruck, Austria
| | - Alexandre Mebazaa
- Department of Anaesthesia and Intensive Care, INSERM UMR 942, Lariboisière Hospital, University of Paris, Paris, France
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, and Geriatric Sciences, La Sapienza University of Rome, Rome, Italy
| | - Jos le Noble
- Department of Intensive Care, VieCuri Medical Center, Venlo, The Netherlands
| | - Anders Oldner
- Department of Physiology & Pharmacology, Section of Anaesthesiology & Intensive CareMedicine, Karolinska Institute, Stockholm, Sweden
| | - Ignacio Oulego Erroz
- Department of Pediatrics, Complejo Asistencial Universitario de León, León, Spain
| | | | | | - Gerhard Poelzl
- Department of Cardiology, Medical University Innsbruck, Innsbruck, Austria
| | - Sebastian Rehberg
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Muenster, Muenster, Germany
| | - Sven-Erik Ricksten
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Markku Salmenperä
- Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Mervyn Singer
- Intensive Care Medicine, University College London, London, UK
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Bojan Vrtovec
- Advanced Heart Failure and Transplantation Center, Department of Cardiology, Ljubljana University Medical Center, Ljubljana, Slovenia
| | | |
Collapse
|
8
|
Mayeux PR, MacMillan-Crow LA. Pharmacological targets in the renal peritubular microenvironment: implications for therapy for sepsis-induced acute kidney injury. Pharmacol Ther 2012; 134:139-55. [PMID: 22274552 DOI: 10.1016/j.pharmthera.2012.01.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 12/19/2011] [Indexed: 01/15/2023]
Abstract
One of the most frequent and serious complications to develop in septic patients is acute kidney injury (AKI), a disorder characterized by a rapid failure of the kidneys to adequately filter the blood, regulate ion and water balance, and generate urine. AKI greatly worsens the already poor prognosis of sepsis and increases cost of care. To date, therapies have been mostly supportive; consequently there has been little change in the mortality rates over the last decade. This is due, at least in part, to the delay in establishing clinical evidence of an infection and the associated presence of the systemic inflammatory response syndrome and thus, a delay in initiating therapy. A second reason is a lack of understanding regarding the mechanisms leading to renal injury, which has hindered the development of more targeted therapies. In this review, we summarize recent studies, which have examined the development of renal injury during sepsis and propose how changes in the peritubular capillary microenvironment lead to and then perpetuate microcirculatory failure and tubular epithelial cell injury. We also discuss a number of potential therapeutic targets in the renal peritubular microenvironment, which may prevent or lessen injury and/or promote recovery.
Collapse
Affiliation(s)
- Philip R Mayeux
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | | |
Collapse
|
9
|
Yang JJ, Ji MH, Sun J, Peng YG. Levosimendan for treatment of septic shock: homeotherapy or inadequate therapy? Acta Anaesthesiol Scand 2011; 55:1147; author reply 1147-8. [PMID: 22092214 DOI: 10.1111/j.1399-6576.2011.02503.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
10
|
CHEW M. Reply: levosimendan in septic shock - high time for a critical appraisal! Acta Anaesthesiol Scand 2011. [DOI: 10.1111/j.1399-6576.2011.02514.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|