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Guijo Gonzalez P, Gracia Romero MA, Gil Cano A, Garcia Rojo M, Cecconi M, Monge Garcia IM. Hemodynamic resuscitation with fluids bolus and norepinephrine increases severity of lung damage in an experimental model of septic shock. Med Intensiva 2021; 45:532-540. [PMID: 34839884 DOI: 10.1016/j.medine.2020.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 05/18/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Hemodynamic resuscitation is considered a cornerstone of the initial treatment of septic shock. However, there is growing concern about its side effects. Our objective was to assess the relationship between fluid administration and norepinephrine infusion and the development of lung injury. DESIGN Randomized in vivo study in rabbits. SETTING University animal research laboratory. PATIENTS Eighteen New Zealand rabbits. Control group (SHAM, n=6), Sepsis group with or without hemodynamic resuscitation (ETX-R, n=6; ETX-NR, n=6). INTERVENTIONS Sepsis was induced by intravenous lipopolysaccharide administration and animals were followed-up for 4h. Hemodynamic resuscitation with Ringer lactate (20mL·kg-1) was administered and later norepinephrine was initiated 3h after sepsis induction. At the end, the left lung was excised. MAIN VARIABLES OF INTEREST An indwelling arterial catheter and an esophageal Doppler were placed. Lung mechanics were monitored with side stream spirometry. Lung damage was analyzed by histopathological examination. RESULTS The SHAM group did not show hemodynamic or respiratory changes. Lipopolysaccharide administration aimed an increase in cardiac output and arterial hypotension. In the ETX-NR group, animals remained hypotensive until the end of the experiment. Resuscitation with fluids and norepinephrine reversed arterial hypotension. Compared to the ETX-NR group, the remaining lung of the ETX-R group showed greater accumulation of neutrophils and reactive type-II pneumocytes, thicker alveolar wall, alveolar hemorrhage and non-aerated pulmonary areas. Lung injury score was larger in the ETX-R group. CONCLUSIONS In our experimental study, following a strategy with bolus fluids and late norepinephrine used in the early phase of endotoxic septic shock has a negative influence on the development of lung injury.
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Affiliation(s)
- P Guijo Gonzalez
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain; Research Group in Critical Disorders (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Critical Care Department, Hospital del Mar, Barcelona, Spain.
| | - M A Gracia Romero
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
| | - A Gil Cano
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
| | - M Garcia Rojo
- Derpartment of Pathology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - M Cecconi
- Department of Anaesthesia and Intensive Care, IRCCS Instituto Clínico Humanitas, Humanitas University, Milan, Italy
| | - I M Monge Garcia
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
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Pecchiari M, Pontikis K, Alevrakis E, Vasileiadis I, Kompoti M, Koutsoukou A. Cardiovascular Responses During Sepsis. Compr Physiol 2021; 11:1605-1652. [PMID: 33792902 DOI: 10.1002/cphy.c190044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sepsis is the life-threatening organ dysfunction arising from a dysregulated host response to infection. Although the specific mechanisms leading to organ dysfunction are still debated, impaired tissue oxygenation appears to play a major role, and concomitant hemodynamic alterations are invariably present. The hemodynamic phenotype of affected individuals is highly variable for reasons that have been partially elucidated. Indeed, each patient's circulatory condition is shaped by the complex interplay between the medical history, the volemic status, the interval from disease onset, the pathogen, the site of infection, and the attempted resuscitation. Moreover, the same hemodynamic pattern can be generated by different combinations of various pathophysiological processes, so the presence of a given hemodynamic pattern cannot be directly related to a unique cluster of alterations. Research based on endotoxin administration to healthy volunteers and animal models compensate, to an extent, for the scarcity of clinical studies on the evolution of sepsis hemodynamics. Their results, however, cannot be directly extrapolated to the clinical setting, due to fundamental differences between the septic patient, the healthy volunteer, and the experimental model. Numerous microcirculatory derangements might exist in the septic host, even in the presence of a preserved macrocirculation. This dissociation between the macro- and the microcirculation might account for the limited success of therapeutic interventions targeting typical hemodynamic parameters, such as arterial and cardiac filling pressures, and cardiac output. Finally, physiological studies point to an early contribution of cardiac dysfunction to the septic phenotype, however, our defective diagnostic tools preclude its clinical recognition. © 2021 American Physiological Society. Compr Physiol 11:1605-1652, 2021.
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Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Konstantinos Pontikis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Emmanouil Alevrakis
- 4th Department of Pulmonary Medicine, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Ioannis Vasileiadis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Maria Kompoti
- Intensive Care Unit, Thriassio General Hospital of Eleusis, Magoula, Greece
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
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Monge Garcia MI, Guijo González P, Saludes Orduña P, Gracia Romero M, Gil Cano A, Messina A, Rhodes A, Cecconi M. Dynamic Arterial Elastance During Experimental Endotoxic Septic Shock: A Potential Marker of Cardiovascular Efficiency. Front Physiol 2020; 11:562824. [PMID: 33123025 PMCID: PMC7567029 DOI: 10.3389/fphys.2020.562824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/11/2020] [Indexed: 11/13/2022] Open
Abstract
Dynamic arterial elastance (Eadyn), the ratio between pulse pressure variation (PPV) and stroke volume variation (SVV), has been suggested as a dynamic parameter relating pressure and flow. We aimed to determine the effects of endotoxic septic shock and hemodynamic resuscitation on Eadyn in an experimental study in 18 New Zealand rabbits. Animals received placebo (SHAM, n = 6) or intravenous lipopolysaccharide (E. Coli 055:B5, 1 mg⋅kg - 1) with or without (EDX-R, n = 6; EDX, n = 6) hemodynamic resuscitation (fluid bolus of 20 ml⋅kg - 1 and norepinephrine for restoring mean arterial pressure). Continuous arterial pressure and aortic blood flow measurements were obtained simultaneously. Cardiovascular efficiency was evaluated by the oscillatory power fraction [%Osc: oscillatory work/left ventricular (LV) total work] and the energy efficiency ratio (EER = LV total work/cardiac output). Eadyn increased in septic animals (from 0.73 to 1.70; p = 0.012) and dropped after hemodynamic resuscitation. Eadyn was related with the %Osc and EER [estimates: -0.101 (-0.137 to -0.064) and -9.494 (-11.964 to -7.024); p < 0.001, respectively]. So, the higher the Eadyn, the better the cardiovascular efficiency (lower %Osc and EER). Sepsis resulted in a reduced %Osc and EER, reflecting a better cardiovascular efficiency that was tracked by Eadyn. Eadyn could be a potential index of cardiovascular efficiency during septic shock.
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Affiliation(s)
- Manuel Ignacio Monge Garcia
- Unidad de Gestión Clínica de Cuidados Intensivos, Hospital Universitario SAS de Jerez, Jerez de la Frontera, Spain
| | - Pedro Guijo González
- Department of Intensive Care Medicine, St. George's Healthcare NHS Trust and St George's University of London, London, United Kingdom
| | - Paula Saludes Orduña
- Department of Intensive Care Medicine, St. George's Healthcare NHS Trust and St George's University of London, London, United Kingdom
| | - Manuel Gracia Romero
- Department of Intensive Care Medicine, St. George's Healthcare NHS Trust and St George's University of London, London, United Kingdom
| | - Anselmo Gil Cano
- Department of Intensive Care Medicine, St. George's Healthcare NHS Trust and St George's University of London, London, United Kingdom
| | - Antonio Messina
- Department of Intensive Care Medicine, St. George's Healthcare NHS Trust and St George's University of London, London, United Kingdom
| | - Andrew Rhodes
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rozzano, Italy
| | - Maurizio Cecconi
- Department of Intensive Care Medicine, St. George's Healthcare NHS Trust and St George's University of London, London, United Kingdom.,Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rozzano, Italy
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Guijo Gonzalez P, Gracia Romero MA, Gil Cano A, Garcia Rojo M, Cecconi M, Monge Garcia IM. Hemodynamic resuscitation with fluids bolus and norepinephrine increases severity of lung damage in an experimental model of septic shock. Med Intensiva 2020; 45:S0210-5691(20)30178-9. [PMID: 32718740 DOI: 10.1016/j.medin.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/23/2020] [Accepted: 05/18/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Hemodynamic resuscitation is considered a cornerstone of the initial treatment of septic shock. However, there is growing concern about its side effects. Our objective was to assess the relationship between fluid administration and norepinephrine infusion and the development of lung injury. DESIGN Randomized in vivo study in rabbits. SETTING University animal research laboratory. PATIENTS Eighteen New Zealand rabbits. Control group (SHAM, n=6), Sepsis group with or without hemodynamic resuscitation (ETX-R, n=6; ETX-NR, n=6). INTERVENTIONS Sepsis was induced by intravenous lipopolysaccharide administration and animals were followed-up for 4h. Hemodynamic resuscitation with Ringer lactate (20mL·kg-1) was administered and later norepinephrine was initiated 3h after sepsis induction. At the end, the left lung was excised. MAIN VARIABLES OF INTEREST An indwelling arterial catheter and an esophageal Doppler were placed. Lung mechanics were monitored with side stream spirometry. Lung damage was analyzed by histopathological examination. RESULTS The SHAM group did not show hemodynamic or respiratory changes. Lipopolysaccharide administration aimed an increase in cardiac output and arterial hypotension. In the ETX-NR group, animals remained hypotensive until the end of the experiment. Resuscitation with fluids and norepinephrine reversed arterial hypotension. Compared to the ETX-NR group, the remaining lung of the ETX-R group showed greater accumulation of neutrophils and reactive type-II pneumocytes, thicker alveolar wall, alveolar hemorrhage and non-aerated pulmonary areas. Lung injury score was larger in the ETX-R group. CONCLUSIONS In our experimental study, following a strategy with bolus fluids and late norepinephrine used in the early phase of endotoxic septic shock has a negative influence on the development of lung injury.
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Affiliation(s)
- P Guijo Gonzalez
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain; Research Group in Critical Disorders (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Critical Care Department, Hospital del Mar, Barcelona, Spain.
| | - M A Gracia Romero
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
| | - A Gil Cano
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
| | - M Garcia Rojo
- Derpartment of Pathology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - M Cecconi
- Department of Anaesthesia and Intensive Care, IRCCS Instituto Clínico Humanitas, Humanitas University, Milan, Italy
| | - I M Monge Garcia
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
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Left ventricular systolic function evaluated by strain echocardiography and relationship with mortality in patients with severe sepsis or septic shock: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:183. [PMID: 30075792 PMCID: PMC6091069 DOI: 10.1186/s13054-018-2113-y] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/03/2018] [Indexed: 01/25/2023]
Abstract
Background Sepsis-induced myocardial dysfunction is associated with poor outcomes, but traditional measurements of systolic function such as left ventricular ejection fraction (LVEF) do not directly correlate with prognosis. Global longitudinal strain (GLS) utilizing speckle-tracking echocardiography (STE) could be a better marker of intrinsic left ventricular (LV) function, reflecting myocardial deformation rather than displacement and volume changes. We sought to investigate the prognostic value of GLS in patients with sepsis and/or septic shock. Methods We conducted a systematic review (PubMed and Embase up to 26 October 2017) and meta-analysis to investigate the association between GLS and mortality at longest follow up in patients with severe sepsis and/or septic shock. In the primary analysis, we included studies reporting transthoracic echocardiography data on GLS according to mortality. A secondary analysis evaluated the association between LVEF and mortality including data from studies reporting GLS. Results We included eight studies in the primary analysis with a total of 794 patients (survival 68%, n = 540). We found a significant association between worse LV function and GLS values and mortality: standard mean difference (SMD) − 0.26; 95% confidence interval (CI) − 0.47, − 0.04; p = 0.02 (low heterogeneity, I2 = 43%). No significant association was found between LVEF and mortality in the same population of patients (eight studies; SMD, 0.02; 95% CI − 0.14, 0.17; p = 0.83; no heterogeneity, I2 = 3%). Conclusions Worse GLS (less negative) values are associated with higher mortality in patients with severe sepsis or septic shock, while such association is not valid for LVEF. More critical care research is warranted to confirm the better ability of STE in demonstrating underlying intrinsic myocardial disease compared to LVEF. Electronic supplementary material The online version of this article (10.1186/s13054-018-2113-y) contains supplementary material, which is available to authorized users.
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Abstract
Hemodynamic instability as a clinical state represents either a perfusion failure with clinical manifestations of circulatory shock or heart failure or 1 or more out-of-threshold hemodynamic monitoring values, which may not necessarily be pathologic. Different types of causes of circulatory shock require different types of treatment modalities, making these distinctions important. Diagnostic approaches or therapies based on data derived from hemodynamic monitoring assume that specific patterns of derangements reflect specific disease processes, which respond to appropriate interventions. Hemodynamic monitoring at the bedside improves patient outcomes when used to make treatment decisions at the right time for patients experiencing hemodynamic instability.
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Affiliation(s)
- Eliezer L Bose
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 336 Victoria Hall, 3500 Victoria Street, Pittsburgh, PA 15261, USA
| | - Marilyn Hravnak
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, 336 Victoria Building, Pittsburgh, PA 15261, USA.
| | - Michael R Pinsky
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Datta G, Gupta H, Zhang Z, Mayakonda P, Anantharamaiah G, White CR. HDL Mimetic Peptide Administration Improves Left Ventricular Filling and Cardiac output in Lipopolysaccharide-Treated Rats. JOURNAL OF CLINICAL & EXPERIMENTAL CARDIOLOGY 2011; 2:1000172. [PMID: 23227448 PMCID: PMC3514969 DOI: 10.4172/2155-9880.1000172] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIMS: Cardiac dysfunction is a complication of sepsis and contributes to morbidity and mortality. Since raising plasma apolipoprotein (apo) A-I and high density lipoprotein (HDL) concentration reduces sepsis complications, we tested the hypothesis that the apoA-I mimetic peptide 4F confers similar protective effects in rats treated with lipopolysaccharide (LPS). METHODS AND RESULTS: Male Sprague-Dawley (SD) rats were randomized to receive saline vehicle (n=13), LPS (10 mg/kg: n=16) or LPS plus 4F (10 mg/kg each: n=13) by intraperitoneal injection. Plasma cytokine and chemokine levels were significantly elevated 24 hrs after LPS administration. Echocardiographic studies revealed changes in cardiac dimensions that resulted in a reduction in left ventricular end-diastolic volume (LVEDV), stroke volume (SV) and cardiac output (CO) 24 hrs after LPS administration. 4F treatment reduced plasma levels of inflammatory mediators and increased LV filling, resulting in improved cardiac performance. Chromatographic separation of lipoproteins from plasma of vehicle, LPS and LPS+4F rats revealed similar profiles. Further analyses showed that LPS treatment reduced the agarose electrophoretic mobility of isolated HDL fractions. HDL-associated proteins were characterized by SDSPAGE and mass spectrometry. ApoA-I and apoA-IV were reduced while apoE content was increased in LPStreated rats. 4F treatment in vivo attenuated changes in HDL-associated apolipoproteins and increased the electrophoretic mobility of the particle. CONCLUSIONS: The ability of 4F to reduce inflammation and improve cardiac performance in LPS-treated rats may be due to its capacity to neutralize endotoxin and prevent adverse changes in HDL composition and function.
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Affiliation(s)
- Geeta Datta
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Himanshu Gupta
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zhenghao Zhang
- Department of Physiology and Biophysics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - G.M. Anantharamaiah
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - C. Roger White
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Physiology and Biophysics, University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
PURPOSE OF REVIEW Myocardial dysfunction in sepsis demonstrates acute reduction in left-ventricular function that is potentially reversible yet also associated with increased mortality. The purpose of this review is to discuss the most recent advances in the current knowledge regarding the pathophysiological mechanisms of septic cardiomyopathy. RECENT FINDINGS There are numerous candidate pathophysiologic mechanisms for the induction of myocardial dysfunction in sepsis. Sarcolemmal and myofibrillar damage to septic rat cardiomyocytes has been observed, and is likely related to oxidative stress. In a septic chimeric murine model, wild-type mice had decreased cardiac function and increased myocardial TNF-α and IL-6 levels whereas TLR-4 knockout mice had attenuated responses to lipopolysaccharide challenge; thus contributing to the increasing evidence for TLR-4's role in the myocardial inflammatory response to lipopolysaccharide. A similar finding regarding endothelial cell NF-κβ signaling inhibition was found using knockout mice. SUMMARY Septic cardiomyopathy is a significant morbid component of severe sepsis and septic shock. Further research into reducing cardiomyocyte damage via oxidative stress, reducing pro-inflammatory responses induced by TLR-4/NF-κβ signaling, decreasing mitochondrial dysfunction, and improving cellular respiration thereby decreasing apoptosis are examples of areas that may be future therapeutic targets.
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Bacterial flagellin triggers cardiac innate immune responses and acute contractile dysfunction. PLoS One 2010; 5:e12687. [PMID: 20856884 PMCID: PMC2938352 DOI: 10.1371/journal.pone.0012687] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 07/26/2010] [Indexed: 11/19/2022] Open
Abstract
Background Myocardial contractile failure in septic shock may develop following direct interactions, within the heart itself, between molecular motifs released by pathogens and their specific receptors, notably those belonging to the toll-like receptor (TLR) family. Here, we determined the ability of bacterial flagellin, the ligand of mammalian TLR5, to trigger myocardial inflammation and contractile dysfunction. Methodology/Principal Findings TLR5 expression was determined in H9c2 cardiac myoblasts, in primary rat cardiomyocytes, and in whole heart extracts from rodents and humans. The ability of flagellin to activate pro-inflammatory signaling pathways (NF-kappaB and MAP kinases) and the expression of inflammatory cytokines was investigated in H9c2 cells, and, in part, in primary cardiomyocytes, as well as in the mouse myocardium in vivo. The influence of flagellin on left ventricular function was evaluated in mice by a conductance pressure-volume catheter. Cardiomyoyctes and intact myocardium disclosed significant TLR5 expression. In vitro, flagellin activated NF-kappaB, MAP kinases, and the transcription of inflammatory genes. In vivo, flagellin induced cardiac activation of NF-kappaB, expression of inflammatory cytokines (TNF alpha, IL-1 beta, IL-6, MIP-2 and MCP-1), and provoked a state of reversible myocardial dysfunction, characterized by cardiac dilation, reduced ejection fraction, and decreased end-systolic elastance. Conclusion/Significance These results are the first to indicate that flagellin has the ability to trigger cardiac innate immune responses and to acutely depress myocardial contractility.
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Jianhui L, Rosenblatt-Velin N, Loukili N, Pacher P, Feihl F, Waeber B, Liaudet L. Endotoxin impairs cardiac hemodynamics by affecting loading conditions but not by reducing cardiac inotropism. Am J Physiol Heart Circ Physiol 2010; 299:H492-501. [PMID: 20525873 PMCID: PMC2930391 DOI: 10.1152/ajpheart.01135.2009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 06/03/2010] [Indexed: 12/25/2022]
Abstract
Acute myocardial dysfunction is a typical manifestation of septic shock. Experimentally, the administration of endotoxin [lipopolysacharride (LPS)] to laboratory animals is frequently used to study such dysfunction. However, a majority of studies used load-dependent indexes of cardiac function [including ejection fraction (EF) and maximal systolic pressure increment (dP/dt(max))], which do not directly explore cardiac inotropism. Therefore, we evaluated the direct effects of LPS on myocardial contractility, using left ventricular (LV) pressure-volume catheters in mice. Male BALB/c mice received an intraperitoneal injection of E. coli LPS (1, 5, 10, or 20 mg/kg). After 2, 6, or 20 h, cardiac function was analyzed in anesthetized, mechanically ventilated mice. All doses of LPS induced a significant drop in LV stroke volume and a trend toward reduced cardiac output after 6 h. Concomitantly, there was a significant decrease of LV preload (LV end-diastolic volume), with no apparent change in LV afterload (evaluated by effective arterial elastance and systemic vascular resistance). Load-dependent indexes of LV function were markedly reduced at 6 h, including EF, stroke work, and dP/dt(max). In contrast, there was no reduction of load-independent indexes of LV contractility, including end-systolic elastance (ejection phase measure of contractility) and the ratio dP/dt(max)/end-diastolic volume (isovolumic phase measure of contractility), the latter showing instead a significant increase after 6 h. All changes were transient, returning to baseline values after 20 h. Therefore, the alterations of cardiac function induced by LPS are entirely due to altered loading conditions, but not to reduced contractility, which may instead be slightly increased.
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Affiliation(s)
- Li Jianhui
- Department of Intensive Care Medicine, and
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Zhejiang University, College of Medicine, Hangzhou, China; and
| | - Nathalie Rosenblatt-Velin
- Division of Clinical Pathophysiology, University Hospital Center and Faculty of Biology and Medicine, Lausanne, Switzerland
| | | | - Pal Pacher
- Laboratory of Physiologic Studies, National Institutes of Health/National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - François Feihl
- Division of Clinical Pathophysiology, University Hospital Center and Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Bernard Waeber
- Division of Clinical Pathophysiology, University Hospital Center and Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Lucas Liaudet
- Department of Intensive Care Medicine, and
- Division of Clinical Pathophysiology, University Hospital Center and Faculty of Biology and Medicine, Lausanne, Switzerland
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11
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Butler AL, Campbell VL. Assessment of oxygen transport and utilization in dogs with naturally occurring sepsis. J Am Vet Med Assoc 2010; 237:167-73. [DOI: 10.2460/javma.237.2.167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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A'roch R, Steendijk P, Oldner A, Weitzberg E, Konrad D, Johansson G, Haney M. Left ventricular mechanical dyssynchrony is load independent at rest and during endotoxaemia in a porcine model. Acta Physiol (Oxf) 2009; 196:375-83. [PMID: 19302073 DOI: 10.1111/j.1748-1716.2009.01962.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM In diseased or injured states, the left ventricle displays higher degrees of mechanical dyssynchrony. We aimed at assessing mechanical dyssynchrony ranges in health related to variation in load as well as during acute endotoxin-induced ventricular injury. METHODS In 16 juvenile anaesthetized pigs, a five-segment conductance catheter was placed in the left ventricle as well as a balloon-tipped catheter in the inferior vena cava. Mechanical dyssynchrony during systole, including dyssynchrony time in per cent during systole and internal flow fraction during systole, were measured at rest and during controlled pre-load reduction sequences, as well as during 3 h of endotoxin infusion (0.25 microg kg(-)1 h(-1)). RESULTS Systolic dyssynchrony and internal flow fraction did not change during the course of acute beat-to-beat pre-load alteration. Endotoxin-produced acute pulmonary hypertension by left ventricular dyssynchrony measures was not changed during the early peak of pulmonary hypertension. Endotoxin ventricular injury led to progressive increases in systolic mechanical segmental dyssynchrony (7.9 +/- 1.2-13.0 +/- 1.3%) and ventricular systolic internal flow fraction (7.1 +/- 2.4-16.6 +/- 2.8%), respectively for baseline and then at hour 3. There was no localization of dyssynchrony changes to segment or region in the ventricular long axis during endotoxin infusion. CONCLUSION These results suggest that systolic mechanical dyssynchrony measures may be load independent in health and during acute global ventricular injury by endotoxin. More study is needed to validate ranges in health and disease for parameters of mechanical dyssynchrony.
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Affiliation(s)
- R A'roch
- Anesthesia and Intensive Care Medicine, University Hospital of Umeå, Umeå, Sweden.
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Abstract
The advent of balanced solutions for i.v. fluid resuscitation and replacement is imminent and will affect any specialty involved in fluid management. Part of the background to their introduction has focused on the non-physiological nature of 'normal' saline solution and the developing science about the potential problems of hyperchloraemic acidosis. This review assesses the physiological significance of hyperchloraemic acidosis and of acidosis in general. It aims to differentiate the effects of the causes of acidosis from the physiological consequences of acidosis. It is intended to provide an assessment of the importance of hyperchloraemic acidosis and thereby the likely benefits of balanced solutions.
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Affiliation(s)
- J M Handy
- Chelsea and Westminster NHS Foundation Trust, Imperial College London, 369 Fulham Road, London SW10 9NH, UK.
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Cariou A, Pinsky MR, Monchi M, Laurent I, Vinsonneau C, Chiche JD, Charpentier J, Dhainaut JF. Is myocardial adrenergic responsiveness depressed in human septic shock? Intensive Care Med 2008; 34:917-22. [PMID: 18259725 DOI: 10.1007/s00134-008-1022-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Accepted: 01/16/2008] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess left ventricular (LV) contractile function and adrenergic responsiveness in septic patients. METHODS We used echocardiographically defined fractional area of contraction (FAC), and LV area to end-systolic arterial pressure estimates of end-systolic elastance (E'es) and its change in response to dobutamine (5 microg/kg/min) in 10 subjects in septic shock admitted to an intensive care unit of an academic medical center. Subjects were studied on admission and again at both 5 days and 8-10 days after admission. RESULTS Three of the 10 subjects died as a result of their acute process, while the others were discharged from hospital. Nine out of 10 subjects required intravenous vasopressor therapy on day 1, while only 1 of 9 subjects required vasopressor support at day 5. LV end-diastolic area (EDA) increased from day 1 to day 5 and days 8-10 (p<0.05), but neither FAC nor E'es was altered by time (EDA 15.7+/-5.8, 21.4+/-5.1, and 19.4+/-5.6 cm2; FAC 0.46+/-0.19, 0.50+/-0.20, and 0.48+/-0.15%; E'es 21.6+/-12.6, 23.2+/-8.5, and 19.2+/-6.3 mmHg/cm2, mean+/-SD, for days 1, 5 and 8-10 respectively). Although dobutamine did not alter E'es on day 1 or day 5, E'es increased in all of the 5 subjects studied on days 8-10 (p<0.05). CONCLUSIONS Adrenergic hyporesponsiveness is present in septic shock and persists for at least 5 days into recovery, resolving by days 8-10 in survivors.
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Affiliation(s)
- Alain Cariou
- Cochin-Saint Vincent de Paul Hospital and Paris Descartes University, Paris, France
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Konrad D, Haney M, Johansson G, Wanecek M, Weitzberg E, Oldner A. Cardiac effects of endothelin receptor antagonism in endotoxemic pigs. Am J Physiol Heart Circ Physiol 2007; 293:H988-96. [PMID: 17400719 DOI: 10.1152/ajpheart.01023.2006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Myocardial depression in sepsis is frequently encountered clinically and contributes to morbidity and mortality. Increased plasma levels of endothelin-1 (ET-1) have been described in septic shock, and previous reports have shown beneficial effects on cardiovascular performance and survival in septic models using ET receptor antagonists. The aim of the current study was to investigate specific cardiac effects of ET receptor antagonism in endotoxicosis. Sixteen domestic pigs were anesthetized and subjected to endotoxin for 5 h. Eight of these pigs were given tezosentan (dual ET receptor antagonist) after 3 h. Cardiac effects were evaluated using the left ventricular (LV) pressure-volume relationship. Endotoxin was not associated with any effects on parameters of LV contractile function [end-systolic elastance (Ees), preload recruitable stroke work (PRSW), powermax/end-diastolic volume (PWRmax/EDV) and dP/d tmax/end-diastolic volume (dP/d tmax/EDV)] but with impairments in isovolumic relaxation (time constant for pressure decay, tau) and mechanical efficiency. Tezosentan administration decreased Ees, PWRmax/EDV, and dP/d tmax/EDV, while improving tau and LV stiffness. Thus, dual ET receptor antagonism was associated with a decline in contractile function but, in contrast, improved diastolic function. Positive hemodynamic effects from ET receptor antagonism in acute endotoxemia may be due to changes in cardiac load and enhanced diastolic function rather than improved contractile function.
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Affiliation(s)
- D Konrad
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
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16
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Tokunaga C, Bateman RM, Boyd J, Wang Y, Russell JA, Walley KR. Albumin resuscitation improves ventricular contractility and myocardial tissue oxygenation in rat endotoxemia. Crit Care Med 2007; 35:1341-7. [PMID: 17414087 DOI: 10.1097/01.ccm.0000260242.77637.57] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Fluid resuscitation to improve delivery of oxygen to vital organs is a principal clinical intervention for septic patients. We previously reported that albumin resuscitation in rat endotoxemia improved contractility in isolated cardiomyocytes, but whether this effect occurs in vivo is unknown. We hypothesized that albumin resuscitation would improve decreased ventricular contractility and myocardial tissue oxygenation in vivo. DESIGN Randomized, controlled, prospective animal study. SETTING University animal laboratory. SUBJECTS Male Sprague-Dawley rats (250-350 g). INTERVENTIONS Rats were randomized into three groups: control with no lipopolysaccharide (n = 8), lipopolysaccharide (10 mg/kg) without albumin resuscitation (n = 8), and lipopolysaccharide with albumin resuscitation (n = 6). Five hours after lipopolysaccharide injection, animals were resuscitated with 10 mL/kg 5% rat albumin in 0.9% saline. Six hours after 10 mL/kg lipopolysaccharide, a pressure-volume conductance catheter (MIKRO-Tip 2.0-Fr, Millar Instruments, Houston, TX) was inserted into the left ventricle to quantify maximum elastance as an index of contractility. Myocardial tissue Po2 was measured using a fiberoptic oxygen probe. MEASUREMENTS AND MAIN RESULTS Maximum elastance decreased after lipopolysaccharide relative to control (47%, from 5.9 +/- 0.8 to 3.1 +/- 0.4 mm Hg/microL, p < .05). Albumin resuscitation prevented the lipopolysaccharide-induced decrease in maximum elastance (7.0 +/- 1.2 mm Hg/microL, p < .05 vs. lipopolysaccharide). Myocardial tissue Po2 was reduced in endotoxemia compared with control (53%, from 10.1 +/- 0.9 to 4.7 +/- 0.6 mm Hg, p < .05), and albumin resuscitation improved the lipopolysaccharide-induced tissue hypoxia toward the control value (9.0 +/- 1.4 mm Hg, p < .05). CONCLUSIONS Albumin resuscitation improved decreased ventricular contractility and myocardial oxygenation in endotoxemic rats. This result suggests that albumin resuscitation may improve ventricular dysfunction by improving myocardial hypoxia.
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Affiliation(s)
- Chiho Tokunaga
- Critical Care Research Laboratories, University of British Columbia, Vancouver, Canada
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17
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Dulu AO, Haupt MT. Fluid therapy continues to be validated in early sepsis: Impact on myocardial depression*. Crit Care Med 2007; 35:1435-6. [PMID: 17446746 DOI: 10.1097/01.ccm.0000262394.20388.cc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Barraud D, Faivre V, Damy T, Welschbillig S, Gayat E, Heymes C, Payen D, Shah AM, Mebazaa A. Levosimendan restores both systolic and diastolic cardiac performance in lipopolysaccharide-treated rabbits: Comparison with dobutamine and milrinone. Crit Care Med 2007; 35:1376-82. [PMID: 17414729 DOI: 10.1097/01.ccm.0000261889.18102.84] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Current treatment strategies for severe septic conditions (i.e., intravenous fluids, vasopressors, and cardiac inotropes) reestablish fluid balance and improve cardiac systole but do not address diastolic dysfunction. Our study aimed to fully characterize both systolic and diastolic abnormalities of sepsis-associated heart failure and to identify treatment that would support full-cycle cardiac improvement. DESIGN Endotoxin-injected rabbits, an animal model of abnormal cardiac function in human sepsis, were used to delineate cardiac abnormalities and to examine effects of drug treatments on heart systolic and diastolic function (n = 30); saline-injected animals served as comparators (n = 17). As treatment, three inotropes commonly used for treatment of cardiac failure were infused for 45 mins in separate animal groups-milrinone, dobutamine, and levosimendan. MEASUREMENTS Variables of left ventricular systolic and diastolic function were assessed with a pressure conductance catheter. Measurements were made before and after endotoxin/saline injection and before and after inotrope treatment. RESULTS Pressure-volume analyses of the left ventricle showed marked impairment in systolic function and in all indices of diastolic function (isovolumic relaxation time constant, left ventricular end-diastolic pressure, and end-diastolic pressure-volume relationship) in endotoxin-treated rabbits. The inotropes, milrinone, dobutamine, and levosimendan, could each partially or completely restore systolic function in the lipopolysaccharide-treated rabbits. However, only levosimendan therapy led to additional beneficial effects on left ventricular relaxation and diastolic function. CONCLUSIONS Cardiac failure in severe sepsis results from impairments in both systolic and diastolic functions. Treatment with the calcium sensitizer levosimendan improved both systolic and diastolic cardiac functions in septic animals, but cyclic adenosine monophosphate-dependent inotropes milrinone and dobutamine only improved systolic function.
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Mathru M, Pollard V, He G, Varma TK, Ahmad M, Prough DS. LEFT VENTRICULAR DIASTOLIC FILLING CHARACTERISTICS ARE NOT IMPAIRED BUT SYSTOLIC PERFORMANCE WAS AUGMENTED IN THE EARLY HOURS OF EXPERIMENTAL ENDOTOXEMIA IN HUMANS. Shock 2006; 25:338-43. [PMID: 16670634 DOI: 10.1097/01.shk.0000209523.05249.27] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study was performed to determine whether endotoxemia causes diastolic cardiac dysfunction. Eleven healthy volunteers, 30 +/- 6 years of age, underwent comprehensive transthoracic echocardiographic assessment including two-dimensional, M-mode transmitral and tissue Doppler of systolic and diastolic function at baseline and at 3 and 5 h after intravenous administration of purified Escherichia coli endotoxin (4 ng/kg). Data were analyzed by analysis of variance; P values of less than 0.05 were considered significant. Endotoxin administration resulted in a hyperdynamic state characterized by decreased mean arterial pressure and significant increase in cardiac index. This was accompanied by increases in several load-dependent systolic performance indices (3 and 5 h). Robust increases in peak systolic blood pressure/end-systolic volume index, one of the relatively load-independent contractility parameter, were also observed at 3 h after endotoxin administration. Transmitral peak early velocity (E), which represents early filling, significantly increased at 3 h after infusion. Late diastolic velocity (A), which represents atrial contraction, significantly increased at 3 and 5 h after infusion. The E/A ratio indicative of delayed relaxation significantly decreased due to increases in A (transmitral) and A (tissue Doppler) at 3 and 5 h after infusion. As expected, endotoxin infusion resulted in a hyperdynamic state associated with increases in systolic function indices including endocardial systolic velocities. The observed decreases in E/A (transmitral) and E/A (tissue Doppler) ratio were primarily due to increases in A and A. Moreover, isovolumic relaxation time and time constant for left ventricular relaxation, a load-independent parameter for ventricular relaxation, remained unchanged at 3 and 5 h after endotoxin infusion. Therefore, our findings are more likely due to enhanced atrial contractility resulting from increased sympathetic activity in response to reduction in left ventricular afterload and not due to altered diastolic filling characteristics.
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Affiliation(s)
- Mali Mathru
- University of Alabama at Birmingham, Birmingham, AL 35249-6810, USA.
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20
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Kumar A, Kumar A, Michael P, Brabant D, Parissenti AM, Ramana CV, Xu X, Parrillo JE. Human serum from patients with septic shock activates transcription factors STAT1, IRF1, and NF-kappaB and induces apoptosis in human cardiac myocytes. J Biol Chem 2005; 280:42619-26. [PMID: 16223733 DOI: 10.1074/jbc.m508416200] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Proinflammatory cytokines have been linked to depression of myocardial contractility in vivo in patients with acute septic shock and in vitro models employing isolated myocytes exposed to serum from such patients. The key pathways involved in mediating this septic organ dysfunction (cell adhesion molecule expression, inducible nitric-oxide synthase induction, and apoptosis) are known to be regulated by transcription factors STAT1, IRF1, and NF-kappaB. Utilizing a model that mimics human disease, we have demonstrated activation of the transcription factors STAT1, IRF1, and NF-kappaB in human fetal myocytes exposed to human septic serum. Both reporter and electrophoretic mobility shift assays demonstrated a 5-19-fold increase in activation of transcription factors STAT1, IRF1, and NF-kappaB in response to incubation with human septic serum. The addition of human septic serum to human fetal myocytes induced apoptosis in human fetal myocytes and activation of the mitogen-activated protein kinase c-Jun NH -terminal kinase and caspase 1 as measured by Western blot. These data suggest that transcription factor activation and early myocyte apoptosis play a mechanistic role in septic myocardial depression and sepsis-induced organ dysfunction.
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Affiliation(s)
- Aseem Kumar
- Department of Chemistry and Biochemistry and the Biomolecular Sciences Programme, Laurentian University, Sudbury, Ontario P3E 2C6, Canada.
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21
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Royse CF, Royse AG. The myocardial and vascular effects of bupivacaine, levobupivacaine, and ropivacaine using pressure volume loops. Anesth Analg 2005; 101:679-687. [PMID: 16115975 DOI: 10.1213/01.ane.0000157123.69327.6a] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ropivacaine and levobupivacaine were developed to reduce the risk of fatal accidental overdose reported with bupivacaine. The myocardial depressant potential of these drugs in sublethal dosage is unknown. Pressure volume loops can be used to separate myocardial from vascular effects. We acquired dose-response curves to incremental infusions in seven anesthetized, open-chest New Zealand white rabbits in each of bupivacaine, levobupivacaine, ropivacaine, and saline control groups. Simultaneous high-fidelity left ventricular pressure and volume data were acquired during caval occlusion with a combined conductance-pressure catheter inserted via an apical stab. Measurements of contractility (V(100)), diastolic function (tau and end-diastolic pressure volume relation), and vascular resistance were performed after each dose increase. Drugs were infused at a ratio of 0.125:0.2 for levobupivacaine and bupivacaine/ropivacaine to simulate clinical usage, with a log(2) (8 step) dose escalation protocol. Over 40 min, the accumulated doses were 2.66/4.25 mg/kg. Levobupivacaine (P = 0.013) and bupivacaine (P = 0.019) significantly impaired contractility at doses exceeding 1.32 mg/kg, whereas ropivacaine was not different from control at 4.25 mg/kg. Bupivacaine reduced ejection fraction (EF) and cardiac index, and increased vascular resistance. Levobupivacaine reduced EF and cardiac index and demonstrated a biphasic vascular response, increasing vascular resistance at larger dosage. Ropivacaine increased vascular resistance and reduced EF without effect on contractility. Mean arterial blood pressure and diastolic function were unchanged for all drugs. Significant decline in contractility from control occurs with bupivacaine and levobupivacaine, but not with ropivacaine, at doses achievable in routine clinical practice.
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Affiliation(s)
- Colin F Royse
- Cardiovascular Therapeutics Unit, Department of Pharmacology, University of Melbourne, Victoria, Australia
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22
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Affiliation(s)
- Richard J Levy
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia 19104, USA.
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23
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Aghajani E, Korvald C, Nordhaug D, Sager G, Revhaug A, Myrmel T. E. Coli Sepsis Induces Profound Mechanoenergetic Inefficiency in the Porcine Left Ventricle. Shock 2004; 21:103-9. [PMID: 14752281 DOI: 10.1097/01.shk.0000105503.75189.17] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Myocardial dysfunction is believed to be a central part of septic multiorgan manifestations. The aim of the present study was to assess whether E. coli sepsis in an in vivo model would induce a dysfunction in the relationship between mechanical work and energy consumption in the left ventricle (LV). Accordingly, we measured hemodynamics, left ventricular pressure-volume area (PVA), and myocardial oxygen consumption (MVo2) in deeply anesthetized pigs. Eight pigs received 2.0 +/- 0.5 x 10(9) E. coli bacteria intravenously, and seven served as controls. Compared with baseline and the control group, no alternations were observed in LV diastolic function or indices of contractility in the septic group. The MVo2-PVA relationship was highly linear in both groups (all r2 = 0.96-0.99). At 5 h, the y-axis intercept of the MVo2-PVA relationship (nonmechanical MVo2) had increased in the sepsis group by 70% compared with baseline (P = 0.004) and by 60% compared with the control group (P = 0.003). Contractile efficiency (the inverse of the MVo2-PVA slope) remained unchanged over time and between groups. The study demonstrates a profound increase in nonmechanical oxygen consumption during E. coli sepsis in the LV.
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Affiliation(s)
- Ebrahim Aghajani
- Surgical Research Laboratory, Institute of Clinical Medicine, University of Tromsø, N-9038 Tromsø, Norway.
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Regulatory Role of Nitric Oxide in the Heart of the Critically Ill Patient. Intensive Care Med 2002. [DOI: 10.1007/978-1-4757-5551-0_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Affiliation(s)
- M J Tobin
- Division of Pulmonary and Critical Care Medicine, Loyola University of Chicago Stritch School of Medicine and Hines Veterans Affairs Hospital, Hines, Illinois 60141, USA.
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26
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Massion PB, Moniotte S, Balligand JL. Nitric oxide: does it play a role in the heart of the critically ill? Curr Opin Crit Care 2001; 7:323-36. [PMID: 11805529 DOI: 10.1097/00075198-200110000-00003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Nitric oxide regulates many aspects of myocardial function, not only in the normal heart but also in ischemic and nonischemic heart failure, septic cardiomyopathy, cardiac allograft rejection, and myocarditis. Accumulating evidence implicates the endogenous production of nitric oxide in the regulation of myocardial contractility, distensibility, heart rate, coronary vasodilation, myocardial oxygen consumption, mitochondrial respiration, and apoptosis. The effects of nitric oxide promote left ventricular mechanical efficiency, ie, appropriate matching between cardiac work and myocardial oxygen consumption. Most of these beneficial effects are attributed to the low physiologic concentrations generated by the constitutive endothelial or neuronal nitric oxide synthase. By contrast, inducible nitric oxide synthase generates larger concentrations of nitric oxide over longer periods of time, leading to mostly detrimental effects. In addition, the recently identified beta3-adrenoceptor mediates a negative inotropic effect through coupling to endothelial nitric oxide synthase and is overexpressed in heart failure. An imbalance between beta 1 and beta2-adrenoceptor and beta3-adrenoceptor, with a prevailing influence of beta3-adrenoceptor, may play a causal role in the pathogenesis of cardiac diseases such as terminal heart failure. Likewise, changes in the expression of endothelial nitric oxide synthase or inducible nitric oxide synthase within the myocardium may alter the delicate balance between the effects of nitric oxide produced by either of these isoforms. New treatments such as selective inducible nitric oxide synthase blockade, endothelial nitric oxide synthase promoting therapies, and selective beta3-adrenoceptor modulators may offer promising new therapeutic approaches to optimize the care of critically ill patients according to their stage and specific underlying disease process.
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Affiliation(s)
- P B Massion
- Department of Internal Medicine, Unit of Pharmacology and Therapeutics, Université catholique de Louvain, Brussels, Belgium
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