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He B, Wang X, Shi L, Cheng H, Zhao L. Meta-analysis of initial natriuretic peptides in the setting of sepsis-induced myocardial dysfunction. Biomark Med 2024; 18:145-155. [PMID: 38380989 DOI: 10.2217/bmm-2023-0605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Aim: To investigate the association of initial brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) with the detection of sepsis-induced myocardial dysfunction (SIMD) in the setting of Sepsis 3.0. Methods: Three databases were searched to analyze initial BNP and NT-proBNP levels between SIMD and non-SIMD groups. Results: Eighteen studies were included, most of which defined SIMD based on echocardiography. The SIMD group exhibited higher initial BNP and NT-proBNP levels in blood. NT-proBNP higher than a certain cutoff value (>3000 pg/ml) was an independent risk factor for SIMD and its accuracy for SIMD diagnosis was moderate (pooled area under the curve: 0.81). Conclusion: Initial blood BNP and NT-proBNP levels are useful to assist in the detection of SIMD and further studies are warranted to determine the SIMD definition.
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Affiliation(s)
- Boyong He
- Emergency Department, Tianjin Fourth Central Hospital, Tianjin, 300140, China
| | - Xin Wang
- Emergency Department, Tianjin Fourth Central Hospital, Tianjin, 300140, China
| | - Liguo Shi
- Emergency Department, Tianjin Fourth Central Hospital, Tianjin, 300140, China
| | - Hongbin Cheng
- Emergency Department, Tianjin Fourth Central Hospital, Tianjin, 300140, China
| | - Luyi Zhao
- Emergency Department, Tianjin Fourth Central Hospital, Tianjin, 300140, China
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2
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Shah NM, Charani E, Ming D, Cheah FC, Johnson MR. Antimicrobial stewardship and targeted therapies in the changing landscape of maternal sepsis. JOURNAL OF INTENSIVE MEDICINE 2024; 4:46-61. [PMID: 38263965 PMCID: PMC10800776 DOI: 10.1016/j.jointm.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 01/25/2024]
Abstract
Pregnant and postnatal women are a high-risk population particularly prone to rapid progression to sepsis with significant morbidity and mortality worldwide. Moreover, severe maternal infections can have a serious detrimental impact on neonates with almost 1 million neonatal deaths annually attributed to maternal infection or sepsis. In this review we discuss the susceptibility of pregnant women and their specific physiological and immunological adaptations that contribute to their vulnerability to sepsis, the implications for the neonate, as well as the issues with antimicrobial stewardship and the challenges this poses when attempting to reach a balance between clinical care and urgent treatment. Finally, we review advancements in the development of pregnancy-specific diagnostic and therapeutic approaches and how these can be used to optimize the care of pregnant women and neonates.
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Affiliation(s)
- Nishel M Shah
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Esmita Charani
- Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Damien Ming
- Department of Infectious Diseases, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Fook-Choe Cheah
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Mark R Johnson
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
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3
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Chaikijurajai T, Rincon-Choles H, Tang WHW. Natriuretic peptide testing strategies in heart failure: A 2023 update. Adv Clin Chem 2023; 118:155-203. [PMID: 38280805 DOI: 10.1016/bs.acc.2023.11.005] [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: 01/29/2024]
Abstract
Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP), have been recommended as standard biomarkers for diagnosing heart failure (HF), and one of the strongest risk predictors for mortality and HF hospitalization regardless of ejection fraction (EF) and etiology of HF. BNP is an active neurohormone opposing renin-angiotensin-aldosterone and sympathetic nervous system overactivated in HF, whereas NT-proBNP is an inactive prohormone released from cardiomyocytes in response to wall stress. Despite substantial advances in the development of guideline-directed medical therapy (GDMT) for HF with reduced EF, studies demonstrating direct benefits of NP-guided chronic HF therapy on mortality, HF hospitalization, and GDMT optimization have yielded conflicting results. However, accumulating evidence shows that achieving prespecified BNP or NT-proBNP target over time is significantly associated with favorable outcomes, suggesting that benefits of serially measured NPs may be limited to particular groups of HF patients, such as those with extreme levels of baseline BNP or NT-proBNP, which could represent severe phenotypes of HF associated with natriuretic peptide resistance or cardiorenal syndrome. Over the past decade, clinical utilization of BNP and NT-proBNP has been expanded, especially using serial NP measurements for guiding HF therapy, optimizing GDMT and identifying at-risk patients with HF phenotypes who may be minimally symptomatic or asymptomatic.
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Affiliation(s)
- Thanat Chaikijurajai
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States; Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Hernan Rincon-Choles
- Department of Nephrology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, United States
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States.
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4
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Hong H, Kim J, Min H, Kim YW, Kim TY. Association of B-Type Natriuretic Peptide Level with Clinical Outcome in Out-of-Hospital Cardiac Arrest in Emergency Department Patients. Diagnostics (Basel) 2023; 13:2522. [PMID: 37568885 PMCID: PMC10417783 DOI: 10.3390/diagnostics13152522] [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: 05/04/2023] [Revised: 06/16/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVES B-type natriuretic peptide (BNP) is used for outcome assessment of various diseases. We designed this study to investigate whether BNP, which has been proven useful in the risk stratification of sudden cardiac arrest (SCA) of cardiac etiology, can also prove to be a valuable prognostic tool for SCA also included with non-cardiac etiology. In this study, we aim to investigate the relationship between measured BNP levels and clinical outcomes in SCA, regardless of the cause of SCA. METHODS This retrospective multicenter observational study was performed in two tertiary university hospitals and one general hospital between January 2015 and December 2020. The total number of SCA patients was 1625. The patients with out-of-hospital cardiac arrest over 19 years old and acquired laboratory data, including BNP at emergency department (ED) arrival, were included. BNP was measured during advanced Cardiovascular Life Support (ACLS). The exclusion criteria were age under 18 years, traumatic arrest, and without BNP. RESULTS The median BNP was 171.8 (range; 5-5000) pg/mL in the return of Spontaneous Circulation (ROSC), higher than No-ROSC (p = 0.007). The median BNP concentration was 99.7 (range; 5-3040.68) pg/mL in the survival to discharge, which was significantly lower than the death group (p = 0.012). The odds ratio of survival to discharge decreased proportionally to the BNP level. The odds ratio of neurologic outcome was not correlated with the BNP level. CONCLUSION In patients with SCA of all origins, low BNP concentration measured during ACLS correlated with an increased ratio of survival to discharge. However, BNP measured during ACLS was not found to be an independent factor.
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Affiliation(s)
- Heejin Hong
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, 27, Dongguk-ro, Ilsandong-gu, Goyang 10326, Republic of Korea
| | - Jihyun Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, 27, Dongguk-ro, Ilsandong-gu, Goyang 10326, Republic of Korea
| | - Hana Min
- Department of Emergency Medicine, National Health Insurance Service Ilsan Hospital, 100, Ilsan-ro, Ilsandong-gu, Goyang 10444, Republic of Korea
| | - Yong Won Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, 27, Dongguk-ro, Ilsandong-gu, Goyang 10326, Republic of Korea
| | - Tae-Youn Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, 27, Dongguk-ro, Ilsandong-gu, Goyang 10326, Republic of Korea
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Biomarkers of sepsis in pigs, horses and cattle: from acute phase proteins to procalcitonin. Anim Health Res Rev 2022; 23:82-99. [PMID: 35795920 DOI: 10.1017/s1466252322000019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Sepsis is a complex clinical syndrome triggered by an inflammatory host response to an infection. It is usually complicated to detect and diagnose, and has severe consequences in human and veterinary health, especially when treatment is not started early. Therefore, efforts to detect sepsis accurately are needed. In addition, its proper diagnosis could reduce the misuse of antibiotics, which is essential fighting against antimicrobial resistance. This case is a particular issue in farm animals, as antibiotics have been traditionally given massively, but now they are becoming increasingly restricted. When sepsis is suspected in animals, the most frequently used biomarkers are acute phase proteins such as C-reactive protein, serum amyloid A and haptoglobin, but their concentrations can increase in other inflammatory conditions. In human patients, the most promising biomarkers to detect sepsis are currently procalcitonin and presepsin, and there is a wide range of other biomarkers under study. However, there is little information on the application of these biomarkers in veterinary species. This review aims to describe the general concepts of sepsis and the current knowledge about the biomarkers of sepsis in pigs, horses, and cattle and to discuss possible advances in the field.
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6
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Sakane K, Kanzaki Y, Hoshiga M. Reply to "Clinical Significance of B-type Natriuretic Peptide in Patient with Acute Decompensated Heart Failure". Int J Cardiol 2021; 330:146. [PMID: 33581178 DOI: 10.1016/j.ijcard.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Kazushi Sakane
- Department of Cardiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan
| | - Yumiko Kanzaki
- Department of Cardiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan.
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan
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Alataby H, Nfonoyim J, Diaz K, Al-Tkrit A, Akhter S, David S, Leelaruban V, Gay-Simon KS, Maharaj V, Colet B, Hanna C, Gomez CA. The Levels of Lactate, Troponin, and N-Terminal Pro-B-Type Natriuretic Peptide Are Predictors of Mortality in Patients with Sepsis and Septic Shock: A Retrospective Cohort Study. Med Sci Monit Basic Res 2021; 27:e927834. [PMID: 33518698 PMCID: PMC7863562 DOI: 10.12659/msmbr.927834] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Serum lactate, troponin, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) have been proposed to be useful prognostic indicators in patients with sepsis and septic shock. This study aimed to evaluate the predictive ability of these biomarkers and assess how their prognostic utility may be improved by using them in combination. Material/Methods A retrospective review of the medical records of 1242 patients with sepsis and septic shock who were admitted to the Richmond University Medical Center between June 1, 2018, and June 1, 2019, was carried out; 427 patients met the study criteria and were included in the study. The primary outcome measures included 30-day mortality, APACHE II scores, length of hospital stay, and admission to the Medical Intensive Care Unit (MICU). Results High levels of lactate (>4 mmol/L), troponin (>0.45 ng/mL), and NT-proBNP (>8000 pg/mL) were independent predictors of 30-day mortality, with an adjusted odds ratio of mortality being 3.19 times, 2.13 times, and 2.5 times higher, respectively, compared with corresponding reference groups, at 95% confidence intervals. Elevated levels of lactate, troponin, and NT-proBNP were associated with 9.12 points, 7.70 points, and 8.88 points in higher APACHE II scores, respectively. Only elevated troponin levels were predictive of a longer length of hospital stay. In contrast, elevated lactate and troponin were associated with an increased chance of admission to the MICU. Conclusions Elevated levels of serum lactate, troponin, and NT-proBNP are independent predictors of mortality and higher APACHE II scores in patients with sepsis and septic shock.
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Affiliation(s)
- Harith Alataby
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Jay Nfonoyim
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA.,Department of Pulmonary and Critical Care, Richmond University Medical Center, Staten Island, NY, USA
| | - Keith Diaz
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA.,Department of Pulmonary and Critical Care, Richmond University Medical Center, Staten Island, NY, USA
| | - Amna Al-Tkrit
- Department of Clinical Research, Richmond University Medical Center, Staten Island, NY, USA
| | - Shahnaz Akhter
- Department of Clinical Research, Richmond University Medical Center, Staten Island, NY, USA
| | - Sharoon David
- Department of Clinical Research, Richmond University Medical Center, Staten Island, NY, USA
| | | | - Kara S Gay-Simon
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Vedatta Maharaj
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Bruce Colet
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Cherry Hanna
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Cheryl-Ann Gomez
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA
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BEYDİLLİ Y, GÖKÇE Hİ. Investigations of Cardiac Functions and Organ Damages in Neonatal Calves with Suscepted Sepsis. MEHMET AKIF ERSOY ÜNIVERSITESI VETERINER FAKÜLTESI DERGISI 2020. [DOI: 10.24880/maeuvfd.815632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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9
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Hoffman M, Kyriazis ID, Lucchese AM, de Lucia C, Piedepalumbo M, Bauer M, Schulze PC, Bonios MJ, Koch WJ, Drosatos K. Myocardial Strain and Cardiac Output are Preferable Measurements for Cardiac Dysfunction and Can Predict Mortality in Septic Mice. J Am Heart Assoc 2020; 8:e012260. [PMID: 31112430 PMCID: PMC6585345 DOI: 10.1161/jaha.119.012260] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Sepsis is the overwhelming host response to infection leading to shock and multiple organ dysfunction. Cardiovascular complications greatly increase sepsis‐associated mortality. Although murine models are routinely used for preclinical studies, the benefit of using genetically engineered mice in sepsis is countered by discrepancies between human and mouse sepsis pathophysiology. Therefore, recent guidelines have called for standardization of preclinical methods to document organ dysfunction. We investigated the course of cardiac dysfunction and myocardial load in different mouse models of sepsis to identify the optimal measurements for early systolic and diastolic dysfunction. Methods and Results We performed speckle‐tracking echocardiography and assessed blood pressure, plasma inflammatory cytokines, lactate, B‐type natriuretic peptide, and survival in mouse models of endotoxemia or polymicrobial infection (cecal ligation and puncture, [CLP]) of moderate and high severity. We observed that myocardial strain and cardiac output were consistently impaired early in both sepsis models. Suppression of cardiac output was associated with systolic dysfunction in endotoxemia or combined systolic dysfunction and reduced preload in the CLP model. We found that cardiac output at 2 hours post‐CLP is a negative prognostic indicator with high sensitivity and specificity that predicts mortality at 48 hours. Using a known antibiotic (ertapenem) treatment, we confirmed that this approach can document recovery. Conclusions We propose a non‐invasive approach for assessment of cardiac function in sepsis and myocardial strain and strain rate as preferable measures for monitoring cardiovascular function in sepsis mouse models. We further show that the magnitude of cardiac output suppression 2 hours post‐CLP can be used to predict mortality.
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Affiliation(s)
- Matthew Hoffman
- 1 Center for Translational Medicine and Department of Pharmacology Lewis Katz School of Medicine Temple University Philadelphia PA
| | - Ioannis D Kyriazis
- 1 Center for Translational Medicine and Department of Pharmacology Lewis Katz School of Medicine Temple University Philadelphia PA
| | - Anna M Lucchese
- 1 Center for Translational Medicine and Department of Pharmacology Lewis Katz School of Medicine Temple University Philadelphia PA
| | - Claudio de Lucia
- 1 Center for Translational Medicine and Department of Pharmacology Lewis Katz School of Medicine Temple University Philadelphia PA
| | - Michela Piedepalumbo
- 1 Center for Translational Medicine and Department of Pharmacology Lewis Katz School of Medicine Temple University Philadelphia PA.,2 Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences University of Campania "Luigi Vanvitelli" Naples Italy
| | - Michael Bauer
- 3 Department for Anesthesiology and Intensive Care Medicine Friedrich-Schiller-University Jena Germany
| | - P Christian Schulze
- 4 Division of Cardiology, Angiology, Intensive Medical Care and Pneumology Department of Internal Medicine I University Hospital Jena Germany
| | - Michael J Bonios
- 5 Heart Failure and Transplant Unit Onassis Cardiac Surgery Center Athens Greece
| | - Walter J Koch
- 1 Center for Translational Medicine and Department of Pharmacology Lewis Katz School of Medicine Temple University Philadelphia PA
| | - Konstantinos Drosatos
- 1 Center for Translational Medicine and Department of Pharmacology Lewis Katz School of Medicine Temple University Philadelphia PA
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10
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Saeed Z, Greer O, Shah NM. Is the Host Viral Response and the Immunogenicity of Vaccines Altered in Pregnancy? Antibodies (Basel) 2020; 9:E38. [PMID: 32759839 PMCID: PMC7551810 DOI: 10.3390/antib9030038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/06/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022] Open
Abstract
The intricacy of the maternal immune system arises from its ability to prevent a maternal immune response against a semi-allogenic fetus, while protecting the mother against harmful pathogens. However, these immunological adaptations may also make pregnant women vulnerable to developing adverse complications from respiratory viral infections. While the influenza and SARS pandemics support this theory, there is less certainty regarding the clinical impact of SARS-CoV-2 in pregnancy. In the current COVID-19 pandemic, vaccine development is key to public preventative strategies. Whilst most viral vaccines are able to induce a seroprotective antibody response, in some high-risk individuals this may not correlate with clinical protection. Some studies have shown that factors such as age, gender, and chronic illnesses can reduce their effectiveness and in this review, we discuss how pregnancy may affect the efficacy and immunogenicity of vaccines. We present literature to support the hypothesis that pregnant women are more susceptible to respiratory viral infections and may not respond to vaccines as effectively. In particular, we focus on the clinical implications of important respiratory viral infections such as influenza during pregnancy, and the pregnancy induced alterations in important leukocytes such as TFH, cTFH and B cells, which play an important role in generating long-lasting and high-affinity antibodies. Finally, we review how this may affect the efficacy of vaccines against influenza in pregnancy and highlight areas that require further research.
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Affiliation(s)
| | | | - Nishel Mohan Shah
- Academic Department of Obstetrics & Gynaecology, Imperial College London, Level 3, Chelsea & Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK; (Z.S.); (O.G.)
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11
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Darwish OS, Mahayni A, Kataria S, Zuniga E, Zhang L, Amin A. Diagnosis of Acute Heart Failure Using Inferior Vena Cava Ultrasound: Systematic Review and Meta-analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1367-1378. [PMID: 31985108 DOI: 10.1002/jum.15231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 12/12/2019] [Accepted: 01/03/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The utility of bedside inferior vena cava (IVC) ultrasound (US) in the diagnosis of heart failure (HF) is unclear. The aim of this study was to determine whether IVC parameters in patients with acute heart failure (AHF) are statistically different from those without HF. METHODS The MEDLINE database of English-language publications from 1966 to August 2018 was searched. Retrospective and prospective studies that included either IVC expiratory diameter (IVCexp ) or IVC collapsibility index (IVC-CI) values were collected in patients with and without HF. to determine whether there was a statistical difference in the IVC parameters between these groups. RESULTS A total of 27 articles with a total of 1472 patients with AHF were included. The standard mean differences for the IVCexp and IVC-CI for the control group versus the AHF group were found to be statistically significant (P < .0001). The combined mean IVCexp values were 15.11 mm (95% confidence interval [CI], 14.19-16.02 mm) for the control group and 20.26 mm (95% CI, 14.82-25.71 mm) for the AHF group. The combined mean IVC-CI values were 61.6% (95% CI, 48.4%-74.7%) for the control group and 30.5% (95% CI, 26.4%-34.6%) for the AHF group. CONCLUSIONS Bedside IVC US showed that a statistically significant difference existed in the IVC parameters between patients with and without AHF. Based on mean calculations, an IVCexp of greater than 2.0 cm and an IVC-CI of less than 30% are reasonable cutoffs to suggest that a patient with acute dyspnea is more likely to have AHF than a non-AHF condition. Given the high degree of heterogeneity across the studies and the high risk of bias, larger randomized studies are warranted to explore the use of IVC US in patients with HF.
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Affiliation(s)
- Omar S Darwish
- University of California Irvine Medical Center, Orange, California, USA
| | - Abdullah Mahayni
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Eric Zuniga
- University of California Medical School, Irvine, California, USA
| | - Lishi Zhang
- University of California, Irvine, California, USA
| | - Alpesh Amin
- University of California, Irvine, California, USA
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12
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Hoffman M, Kyriazis ID, Dimitriou A, Mishra SK, Koch WJ, Drosatos K. B-type natriuretic peptide is upregulated by c-Jun N-terminal kinase and contributes to septic hypotension. JCI Insight 2020; 5:133675. [PMID: 32324169 PMCID: PMC7205432 DOI: 10.1172/jci.insight.133675] [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: 09/19/2019] [Accepted: 03/18/2020] [Indexed: 02/06/2023] Open
Abstract
B-type natriuretic peptide (BNP) is secreted by ventricular cardiomyocytes in response to various types of cardiac stress and has been used as a heart failure marker. In septic patients, increased BNP suggests poor prognosis; however, no causal link has been established. Among various effects, BNP decreases systemic vascular resistance and increases natriuresis that leads to lower blood pressure. We previously observed that JNK inhibition corrects cardiac dysfunction and suppresses cardiac BNP mRNA in endotoxemia. In this study, we investigated the transcriptional mechanism that regulates BNP expression and the involvement of plasma BNP in causing septic hypotension. Our in vitro and in vivo findings confirmed that activation of JNK signaling increases BNP expression in sepsis via direct binding of c-Jun in activating protein–1 (AP-1) regulatory elements of the Nppb promoter. Accordingly, genetic ablation of BNP, as well as treatment with a potentially novel neutralizing anti-BNP monoclonal antibody (19B3) or suppression of its expression via administration of JNK inhibitor SP600125 improved cardiac output, stabilized blood pressure, and improved survival in mice with polymicrobial sepsis. Therefore, inhibition of JNK signaling or BNP in sepsis appears to stabilize blood pressure and improve survival.
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Affiliation(s)
- Matthew Hoffman
- Center for Translational Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ioannis D Kyriazis
- Center for Translational Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alexandra Dimitriou
- Center for Translational Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Santosh K Mishra
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Walter J Koch
- Center for Translational Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Konstantinos Drosatos
- Center for Translational Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA.,Center for Metabolic Disease Research, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
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13
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Pandompatam G, Kashani K, Vallabhajosyula S. The role of natriuretic peptides in the management, outcomes and prognosis of sepsis and septic shock. Rev Bras Ter Intensiva 2019; 31:368-378. [PMID: 31618357 PMCID: PMC7005946 DOI: 10.5935/0103-507x.20190060] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 05/25/2019] [Indexed: 11/30/2022] Open
Abstract
Sepsis continues to be a leading public health burden in the United States and worldwide. With the increasing use of advanced laboratory technology, there is a renewed interest in the use of biomarkers in sepsis to aid in more precise and targeted decision-making. Natriuretic peptides have been increasingly recognized to play a role outside of heart failure. They are commonly elevated among critically ill patients in the setting of cardiopulmonary dysfunction and may play a role in identifying patients with sepsis and septic shock. There are limited data on the role of these biomarkers in the diagnosis, management, outcomes and prognosis of septic patients. This review seeks to describe the role of natriuretic peptides in fluid resuscitation, diagnosis of ventricular dysfunction and outcomes and the prognosis of patients with sepsis. B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) have been noted to be associated with left ventricular systolic and diastolic and right ventricular dysfunction in patients with septic cardiomyopathy. BNP/NT-proBNP may predict fluid responsiveness, and trends of these peptides may play a role in fluid resuscitation. Despite suggestions of a correlation with mortality, the role of BNP in mortality outcomes and prognosis during sepsis needs further evaluation.
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Affiliation(s)
- Govind Pandompatam
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic - Rochester, Minnesota, United States
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic - Rochester, Minnesota, United States
| | - Saraschandra Vallabhajosyula
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic - Rochester, Minnesota, United States.,Department of Cardiovascular Medicine, Mayo Clinic - Rochester, Minnesota, United States
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Transfusion-Associated Circulatory Overload and Transfusion-Related Acute Lung Injury. Hematol Oncol Clin North Am 2019; 33:767-779. [DOI: 10.1016/j.hoc.2019.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lautz AJ, Zingarelli B. Age-Dependent Myocardial Dysfunction in Critically Ill Patients: Role of Mitochondrial Dysfunction. Int J Mol Sci 2019; 20:ijms20143523. [PMID: 31323783 PMCID: PMC6679204 DOI: 10.3390/ijms20143523] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/11/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
Abstract
Myocardial dysfunction is common in septic shock and post-cardiac arrest but manifests differently in pediatric and adult patients. By conventional echocardiographic parameters, biventricular systolic dysfunction is more prevalent in children with septic shock, though strain imaging reveals that myocardial injury may be more common in adults than previously thought. In contrast, diastolic dysfunction in general and post-arrest myocardial systolic dysfunction appear to be more widespread in the adult population. A growing body of evidence suggests that mitochondrial dysfunction mediates myocardial depression in critical illness; alterations in mitochondrial electron transport system function, bioenergetic production, oxidative and nitrosative stress, uncoupling, mitochondrial permeability transition, fusion, fission, biogenesis, and autophagy all may play key pathophysiologic roles. In this review we summarize the epidemiologic and clinical phenotypes of myocardial dysfunction in septic shock and post-cardiac arrest and the multifaceted manifestations of mitochondrial injury in these disease processes. Since neonatal and pediatric-specific data for mitochondrial dysfunction remain sparse, conclusive age-dependent differences are not clear; instead, we highlight what evidence exists and identify gaps in knowledge to guide future research. Finally, since focal ischemic injury (with or without reperfusion) leading to myocardial infarction is predominantly an atherosclerotic disease of the elderly, this review focuses specifically on septic shock and global ischemia-reperfusion injury occurring after resuscitation from cardiac arrest.
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Affiliation(s)
- Andrew J Lautz
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Basilia Zingarelli
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.
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Kakoullis L, Giannopoulou E, Papachristodoulou E, Pantzaris ND, Karamouzos V, Kounis NG, Koniari I, Velissaris D. The utility of brain natriuretic peptides in septic shock as markers for mortality and cardiac dysfunction: A systematic review. Int J Clin Pract 2019; 73:e13374. [PMID: 31111653 DOI: 10.1111/ijcp.13374] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/01/2019] [Accepted: 05/16/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To conduct a systematic review evaluating the utility of brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) as biomarkers in adult patients with septic shock. MATERIALS AND METHODS Pubmed/Medline databases were searched from inception to November 2018 using the search terms: (septic[Title/Abstract] AND shock[Title/Abstract]) AND bnp[Title/Abstract]) and (septic[Title/Abstract]) AND shock[Title/Abstract]) AND natriuretic[Title/Abstract]). No restriction was applied regarding date of publication. Comparative observational studies evaluating BNP and NT-proBNP in patients with septic shock aged ≥18 years were eligible for inclusion. Bibliographies from the extracted articles were also reviewed to identify additional relevant publications. RESULTS In total, 46 studies met all eligibility criteria and were included. A strong body of literature has demonstrated that in patients with septic shock, increased values of BNP and NT-proBNP are associated with increased mortality. An increase from baseline BNP values has also been associated with increased mortality, whereas decreases from baseline values are not related to worse outcome. Brain natriuretic peptides have also been associated with cardiac dysfunction in patients with sepsis. Moreover, BNP values have been found to be significantly elevated in septic shock, regardless of cardiac dysfunction, and have been used to distinguish between septic and cardiogenic shock. Furthermore, BNP and NT-proBNP are significantly increased in patients with septic shock, compared to patients with sepsis and severe sepsis. CONCLUSIONS BNP and NT-proBNP appear to be reliable predictors of outcome in septic shock.
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Affiliation(s)
- Loukas Kakoullis
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
- Department of Internal Medicine, Nicosia General Hospital, Nicosia, Cyprus
| | - Eleni Giannopoulou
- Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Eleni Papachristodoulou
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
- Department of Internal Medicine, Nicosia General Hospital, Nicosia, Cyprus
| | | | | | - Nicholas G Kounis
- Department of Cardiology, University Hospital of Patras, Patras, Greece
| | - Ioanna Koniari
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
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Bai YL, Hu BL, Wen HC, Zhang YL, Zhu JJ. Prognostic value of plasma brain natriuretic peptide value for patientswith sepsis: A meta-analysis. J Crit Care 2018; 48:145-152. [DOI: 10.1016/j.jcrc.2018.08.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 08/21/2018] [Accepted: 08/28/2018] [Indexed: 11/26/2022]
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Roles of Procalcitonin and N-Terminal Pro-B-Type Natriuretic Peptide in Predicting Catheter-Related Bloodstream Infection in Severe Burn Injury Patients. DISEASE MARKERS 2018; 2018:5607932. [PMID: 30595763 PMCID: PMC6282120 DOI: 10.1155/2018/5607932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/08/2018] [Accepted: 10/31/2018] [Indexed: 11/17/2022]
Abstract
Objective To investigate the characteristics of early catheter-related bloodstream infection (CRBSI) in severe burn injury patients induced by a massive aluminum dust explosion. Methods Sixty-eight severe burn injury patients experienced a massive dust explosion in Kunshan were included in this study. Patients received central venous catheter placement, arterial catheterization to monitor blood pressure and PiCCO cardiac monitoring, tracheostomy, mechanical ventilation, analgesics and sedation treatment, and fluid resuscitation. Clinical data including age, gender, burn surface area, fluid intake and output, urine temperature, and APACHE II score information were collected from each patient. Ultrasound screening was performed to exclude heart failure, which may lead to the change of NT-proBNP. When CRBSI was suspected, 10 ml central venous blood and peripheral arterial blood were sent for testing. For patients with suspected CRBSI, the level of PCT and NT-proBNP were monitored every day until the infection was controlled. Results Among the 68 patients, 29 showed CRBSI. The most common pathogenic bacteria of CRBSI were A. baumannii (39.8%), P. aeruginosa (26.4%), and K. pneumoniae (13.7%). Procalcitonin (PCT) (2.98 ng/ml) and NT-proBNP (355 pg/ml) were significantly associated with CRBSI results. The sensitivity of PCT, NT-proBNP, WBC, and CRP was 94.2%, 89.7%, 88.3%, and 90.5%, respectively (P < 0.05). The area under curve (AUC) of PCT combined with NT-proBNP for prediction of CRBSI was 0.981, and the sensitivity and specificity was 0.812 and 0.857, respectively. Conclusion PCT and NT-proBNP combination improves the diagnosis of CRBSI. PCT and NT-proBNP may be alternative candidates for potential prediction of CRBSI in patients with severe injury.
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Nguyen HB, Jaehne AK, Jayaprakash N, Semler MW, Hegab S, Yataco AC, Tatem G, Salem D, Moore S, Boka K, Gill JK, Gardner-Gray J, Pflaum J, Domecq JP, Hurst G, Belsky JB, Fowkes R, Elkin RB, Simpson SQ, Falk JL, Singer DJ, Rivers EP. Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE. Crit Care 2016; 20:160. [PMID: 27364620 PMCID: PMC4929762 DOI: 10.1186/s13054-016-1288-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.
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Affiliation(s)
- H. Bryant Nguyen
- />Department of Medicine, Pulmonary and Critical Care Medicine, Loma Linda University, Loma Linda, CA USA
- />Department of Emergency Medicine, Loma Linda University, Loma Linda, CA USA
| | - Anja Kathrin Jaehne
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Quality Assurance, Aspirus Hospital, Iron River, MI USA
| | - Namita Jayaprakash
- />Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN USA
| | - Matthew W. Semler
- />Department of Medicine, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN USA
| | - Sara Hegab
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Angel Coz Yataco
- />Department of Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, Lexington, KY USA
| | - Geneva Tatem
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Dhafer Salem
- />Department of Internal Medicine, Mercy Hospital Medical Center, Chicago, IL USA
| | - Steven Moore
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Kamran Boka
- />Department of Internal Medicine, Division of Critical Care Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jasreen Kaur Gill
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jayna Gardner-Gray
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jacqueline Pflaum
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Juan Pablo Domecq
- />Department of Internal Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />CONEVID, Conocimiento y Evidencia Research Unit, Universidad Peruana Cayetano Heredia, Lima, PERU
| | - Gina Hurst
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Justin B. Belsky
- />Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond Fowkes
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Ronald B. Elkin
- />Pulmonary and Critical Care Medicine, California Pacific Medical Center, San Francisco, CA USA
| | - Steven Q. Simpson
- />Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, Kansas USA
| | - Jay L. Falk
- />Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida USA
- />University of Central Florida College of Medicine, Orlando, Florida USA
- />University of Florida College of Medicine, Orlando, Florida USA
- />University of South Florida College of Medicine, Orlando, Florida USA
- />Florida State University College of Medicine, Orlando, Florida USA
| | - Daniel J. Singer
- />Department of Surgery, Division of Surgical Critical Care, Icahn School of Medicine, Mount Sinai Hospital,, New York, NY USA
| | - Emanuel P. Rivers
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Surgery, Henry Ford Hospital, Wayne State University, Detroit, MI USA
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Meng JB, Hu MH, Lai ZZ, Ji CL, Xu XJ, Zhang G, Tian S. Levosimendan Versus Dobutamine in Myocardial Injury Patients with Septic Shock: A Randomized Controlled Trial. Med Sci Monit 2016; 22:1486-96. [PMID: 27138236 PMCID: PMC4861009 DOI: 10.12659/msm.898457] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND We aimed to investigate the effect of levosimendan on biomarkers of myocardial injury and systemic hemodynamics in patients with septic shock. MATERIAL AND METHODS After achieving normovolemia and a mean arterial pressure of at least 65 mmHg, 38 septic shock patients with low cardiac output (left ventricular ejective fraction), LEVF £45%) were randomly divided into two groups: levosimendan dobutamine. Patients in the levosimendan and dobutamine groups were maintained with intravenous infusion of levosimendan (0.2 μg/kg/minute) and dobutamine (5 μg/kg/minute) for 24 hours respectively. During treatment we monitored hemodynamics and LVEF, and measured levels of heart-type fatty acid binding protein (HFABP), troponin I (TNI), and brain natriuretic peptide(BNP). In addition, the length of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, and 28-day mortality were compared between the two groups. RESULTS The levosimendan group and the dobutamine group were well matched with respect to age (years, 55.4 ± 1 7.5 versus 50.2 ± 13.6) and gender (males, 68.4% versus 57.9%). Levosimendan-treated patients had higher stroke volume index (SVI), cardiac index (CI), LVEF, and left ventricular stroke work index (LVSWI), and lower extravascular lung water index (EVLWI) compared to dobutamine-treated patients (p<0.05). HFABP, TNI, and BNP in the levosimendan group were less than in the dobutamine group (p<0.05). There was no difference in the mechanical ventilation time, length of stay in ICU and hospital, and 28-day mortality between the two groups. CONCLUSIONS Compared with dobutamine, levosimendan reduces biomarkers of myocardial injury and improves systemic hemodynamics in patients with septic shock. However, it does not reduce the days on mechanical ventilation, length of stay in ICU and hospital, or 28-day mortality.
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Affiliation(s)
- Jianb-biao Meng
- Department of Intensive Care Unit, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China (mainland)
| | - Ma-hong Hu
- Department of Intensive Care Unit, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China (mainland)
| | - Zhi-zhen Lai
- Department of Intensive Care Unit, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China (mainland)
| | - Chun-lian Ji
- Department of Intensive Care Unit, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China (mainland)
| | - Xiu-juan Xu
- Department of Intensive Care Unit, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China (mainland)
| | - Geng Zhang
- Department of Intensive Care Unit, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China (mainland)
| | - Shuyuan Tian
- Department of Ultrasonography, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China (mainland)
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Abstract
PURPOSE Few studies on plasma glucagon levels in patients with sepsis have been performed. We aimed to assess clinical value of glucagon levels in comparison with clinical parameters and severity scores in patients with severe sepsis or septic shock. METHODS A total of 112 patients who were admitted to intensive care unit with severe sepsis or septic shock were included. Plasma levels of glucagon on days 0, 1, 3, and 7 were serially measured in 112 patients with severe sepsis or septic shock. RESULTS Compared with survivors, patients who died within 28 days had significantly higher glucagon levels on every day of examination. Glucagon levels were positively correlated with and Acute Physiology and Chronic Health Evaluation II score (day 0, r = 0.288, P < 0.01) and Sequential Organ Failure Assessment (day 0, r = 0.482, P< 0.01; day 1, r = 0.588, P < 0.01; day 3, r = 0.480, P < 0.01; day 7, r = 0.454, P < 0.01). Receiver operating characteristic analysis showed that the area under the curve of glucagon levels to predict 28-day survival was 0.65 (95% confidence interval [CI], 0.55-0.75; P = 0.005), similar to the Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores. Multivariate analysis revealed that glucagon levels of greater than 70 pg/mL (hazard ratio, 1.85; 95% CI, 1.03-3.29) and chronic liver disease (hazard ratio, 1.97; 95% CI, 1.02-3.79) were associated with mortality. CONCLUSIONS Glucagon levels might reflect disease severity and clinical outcomes in patients with severe sepsis or septic shock.
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Liu Z, Chen J, Liu Y, Si X, Jiang Z, Zhang X, Guan X. A simple bioscore improves diagnostic accuracy of sepsis after surgery. J Surg Res 2015; 200:290-7. [PMID: 26255225 DOI: 10.1016/j.jss.2015.07.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 06/27/2015] [Accepted: 07/09/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Rapid and accurate prediction for sepsis remains a challenge in surgical intensive care units. Detection of individual biomarkers is often of marginal usefulness, and several biomarkers are difficult to measure in the clinical setting. The aim of this study was to evaluate the diagnostic and prognostic performance of three routine biomarkers, procalcitonin (PCT), B-type natriuretic peptide (BNP), and lymphocyte percentage, as individual or in combination for sepsis in surgical critically ill patients. MATERIALS AND METHODS Circulating PCT, BNP, and lymphocyte percentage were measured in surgical patients on admission to the intensive care unit. A bioscore system combining these biomarkers was constructed. All studied variables were analyzed according to the diagnosis and clinical outcomes of sepsis. RESULTS A total of 320 consecutive patients were included in the analysis. One hundred fifty-six patients presented with sepsis. In the patients with sepsis, levels of PCT and BNP increased and lymphocyte percentage decreased. For individual biomarkers, PCT achieved the best area under the curve for the diagnosis of sepsis, whereas the diagnostic performance of the bioscore was better than that of each individual biomarker (area under the curve, 0.914 [95% confidence interval, 0.862-0.951]). Levels of BNP and bioscore increased in nonsurvivors in the entire cohort, but the accuracy of these two variables for mortality prediction was lower than that shown by Acute Physiology and Chronic Health Evaluation II score. Furthermore, bioscore failed to predict outcomes in septic patients. CONCLUSIONS A simple bioscore combining PCT together with BNP and lymphocyte percentage improves the diagnostic accuracy for sepsis in surgical critically ill patients but fails to predict outcomes in surgical patients with sepsis.
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Affiliation(s)
- Zimeng Liu
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Juan Chen
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yongjun Liu
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiang Si
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhiyi Jiang
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xuyu Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Xiangdong Guan
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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Prognostic value of B-type natriuretic peptide with the sequential organ failure assessment score in septic shock. Am J Med Sci 2015; 349:287-91. [PMID: 25651369 DOI: 10.1097/maj.0000000000000422] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the prognostic value of B-type natriuretic peptide (BNP) in combination with the sequential organ failure assessment (SOFA) score in patients with septic shock at the time of emergency department (ED). METHODS Study subjects included all consecutive patients with septic shock who were treated with resuscitation bundle therapy between January 2010 and July 2012. SOFA scores and BNP were measured at ED recognition. The primary outcome was 28-day mortality. The area under the receiver operating characteristic curve was used to compare the predictive ability of SOFA score alone and in combination with BNP. RESULTS A total of 290 patients with septic shock admitted to ED were included. The BNP and SOFA score were higher in nonsurvival group compared with survival group (1,156.0 versus 469.1 pg/mL, P < 0.01; 9.9 versus 8.0, P < 0.01). In the receiver operating characteristic curves for predicting 28-day mortality, the area under the curves of SOFA score combined with BNP was 0.728 (95% confidence interval [CI]: 0.658-0.798) and SOFA score alone was 0.682 (95% CI: 0.610-0.755). Although the predictive ability of SOFA with BNP was statistically higher than that of SOFA alone (P = 0.02), it could not increase prognostic accuracy clinically significantly. SOFA with BNP was an independent predictor of 28-day mortality (odds ratio: 1.40, 95% CI: 1.15-1.71). CONCLUSIONS The combination of SOFA with BNP at the time of ED presentation may provide superior prognostic accuracy to the patients with septic shock. However, further studies need to validate the prognostic usefulness of SOFA with BNP.
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Nayer J, Aggarwal P, Galwankar S. Utility of point-of-care testing of natriuretic peptides (brain natriuretic peptide and n-terminal pro-brain natriuretic peptide) in the emergency department. Int J Crit Illn Inj Sci 2014; 4:209-15. [PMID: 25337482 PMCID: PMC4200546 DOI: 10.4103/2229-5151.141406] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Rapid and accurate diagnosis of a patient with an acute disease is a challenge for emergency physicians. Natriuretic peptides have emerged as important tools for diagnosis, risk stratification and therapeutic decision making for some categories of emergency patients. Brain natriuretic peptide (BNP) is a member of a four natriuretic peptides family that shares a common 17-peptide ring structure. Atrial natriuretic peptide, C-natriuretic peptide (CNP), and D-type natriuretic peptide are the other natriuretic peptide, which share the same common 17-peptide ring structure. The N-terminal fragment of pro-BNP, N-terminal pro-brain natriuretic peptide (NT-proBNP) consists of 76 amino acids, which is biologically inert, while the active component BNP contains 32 amino acids. BNP and NT-proBNP are secreted in the plasma in equimolar quantities and are frequently used in the diagnosis of congestive heart failure, and distinguishing between patients with dyspnea of cardiac or pulmonary origin. Both natriuretic peptides have also been evaluated for use in the assessment and management of several other conditions including sepsis, cirrhosis of liver and renal failure. However, one should remember that the values of natriuretic peptides are affected by age and weight of the patients, and presence of several comorbidities such as chronic renal failure, type 2 diabetes mellitus, anemia, pulmonary embolism, and acute coronary syndrome. Values of these peptides also vary depending on the type of test used. The performance characteristics of these natriuretic peptides vary depending on the patients on whom they are used. Therefore determination of reference values for these peptides represents a challenge.
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Affiliation(s)
- Jamshed Nayer
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sagar Galwankar
- Department of Emergency Medicine, University of South Florida and Winter Haven Hospital, Florida, USA
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Diagnostic Performance of Brain Natriuretic Peptide in Patients Suspected to Sepsis. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2013. [DOI: 10.5812/archcid.19310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Omar AS, Ur Rahman M, Dhatt GS, Salami GO, Abuhasna S. Dynamics of brain natriuretic peptide in critically ill patients with severe sepsis and septic shock. Saudi J Anaesth 2013; 7:270-6. [PMID: 24015129 PMCID: PMC3757799 DOI: 10.4103/1658-354x.115347] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Purpose: Changes of B-type natriuretic peptide (BNP) in sepsis and its utility in predicting intensive care unit outcomes remains a conflicting issue. To investigate the changes in plasma levels of BNP in patients with severe sepsis/septic shock and to study the association of BNP levels with the severity of the disease and prognosis of those patients. Methods: Thirty patients with severe sepsis or septic shock were enrolled in our study. BNP measurements and echocardiography were carried out on admission and on 4th and 7th days. Blood concentrations of BNP were measured by commercially available assays (Abbott methods). In-hospital mortality and length of stay were recorded multivariate analyses adjusted for acute physiology and chronic health evaluation score II (APACHE II score) was used for mortality prediction. Results: Twenty patients admitted with the diagnosis of severe sepsis and 10 patients with septic shock. The in-hospital mortality was 23.3% (7 patients). Admission BNP was significantly higher in the non-survivors 1123±236.08 versus 592.7±347.1 (P<0.001). By doing multivariate logestic regression, the predicatable variables for mortality was APACHE II score, BNP, and then EF. Conclusion: BNP concentrations were increased in patients with severe sepsis or septic shock and poor outcome was associated with high BNP levels; thus, it may serve as a useful laboratory marker to predict survival in these patients.
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Affiliation(s)
- Amr S Omar
- Department of Critical Care Medicine, Beni Suef University, Egypt
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Jeong EG, Nam HS, Lee SM, An WS, Kim SE, Son YK. Role of B-type natriuretic peptide as a marker of mortality in acute kidney injury patients treated with continuous renal replacement therapy. Ren Fail 2013; 35:1216-22. [PMID: 23924312 DOI: 10.3109/0886022x.2013.823870] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Acute kidney injury (AKI) treated with continuous renal replacement therapy (CRRT) is associated with poor outcome. Plasma B-type natriuretic peptide (BNP) is a biomarker related to fluid volume overload, and is elevated in AKI patients. The purpose of the study was to assess whether BNP levels at the time of starting CRRT could be used as a predictor of mortality in patients with AKI receiving CRRT. METHODS We conducted a prospective observational cohort study enrolling 149 patients with AKI receiving CRRT. The primary outcome was mortality during CRRT. RESULTS The median BNP level of 84 (56.3%) patients who expired was significantly higher than that of those who survived (1812.5 vs. 475.0 pg/mL; p = 0.01). Receiver operating characteristic curves demonstrated BNP levels as a predictor of mortality during CRRT with an area under the curve of 0.77 (p = 0.000), and the optimal threshold for BNP was 1054 pg/mL. Patients with BNP levels above 1054 pg/mL had a significantly higher mortality (76.6 vs. 34.7%; p = 0.01). CONCLUSION Elevated BNP level is associated with mortality in patients with AKI receiving CRRT.
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Affiliation(s)
- Eu Gene Jeong
- Department of Internal Medicine, Dong-A University College of Medicine , Busan , Korea
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Mirjafari H, Welsh P, Verstappen SMM, Wilson P, Marshall T, Edlin H, Bunn D, Chipping J, Lunt M, Symmons DPM, Sattar N, Bruce IN. N-terminal pro-brain-type natriuretic peptide (NT-pro-BNP) and mortality risk in early inflammatory polyarthritis: results from the Norfolk Arthritis Registry (NOAR). Ann Rheum Dis 2013; 73:684-90. [PMID: 23511225 PMCID: PMC3963600 DOI: 10.1136/annrheumdis-2012-202848] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background We measured N-terminal pro-brain natriuretic peptide (NT-pro-BNP), a marker of cardiac dysfunction, in an inception cohort with early inflammatory polyarthritis (IP) and assessed its association with disease phenotype, cardiovascular disease (CVD), all-cause and CVD related mortality. Methods Subjects with early IP were recruited to the Norfolk Arthritis Register from January 2000 to December 2008 and followed up to death or until March 2010 including any data from the national death register. The associations of baseline NT-pro-BNP with IP related factors and CVD were assessed by linear regression. Cox proportional hazards models examined the independent association of baseline NT-pro-BNP with all-cause and CVD mortality. Results We studied 960 early IP subjects; 163 (17%) had prior CVD. 373 (39%) patients had a baseline NT-pro-BNP levels ≥100 pg/ml. NT-pro-BNP was associated with age, female gender, HAQ score, CRP, current smoking, history of hypertension, prior CVD and the presence of carotid plaque. 92 (10%) IP subjects died including 31 (3%) from CVD. In an age and gender adjusted analysis, having a raised NT-pro-BNP level (≥100 pg/ml) was associated with both all-cause and CVD mortality (adjusted HR (95% CI) 2.36 (1.42 to 3.94) and 3.40 (1.28 to 9.03), respectively). These findings were robust to adjustment for conventional CVD risk factors and prevalent CVD. Conclusions In early IP patients, elevated NT-pro-BNP is related to HAQ and CRP and predicts all-cause and CVD mortality independently of conventional CVD risk factors. Further study is required to identify whether NT-pro-BNP may be clinically useful in targeting intensive interventions to IP patients at greatest risk of CVD.
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Affiliation(s)
- Hoda Mirjafari
- Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, , Manchester, UK
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Wang F, Wu Y, Tang L, Zhu W, Chen F, Xu T, Bo L, Li J, Deng X. Brain natriuretic peptide for prediction of mortality in patients with sepsis: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R74. [PMID: 22559153 PMCID: PMC3580616 DOI: 10.1186/cc11331] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Accepted: 05/06/2012] [Indexed: 01/28/2023]
Abstract
Introduction Early identification of septic patients at high risk of dying remains a challenge. The prognostic role of brain natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) in septic patients remains controversial. The purpose of this systematic review and meta-analysis was to investigate the value of elevated BNP or NT-proBNP in predicting mortality in septic patients. Methods PubMed, Embase and the Cochrane Central Register of Controlled Trials were searched (up to February 18, 2011). Studies were included if they had prospectively collected data on all-cause mortality in adult septic patients with either plasma BNP or NT-proBNP measurement. Studies that failed to construct a 2 × 2 table of results were excluded. Two authors independently determined the validity of included studies and extracted data. Results 12 studies with a total of 1,865 patients were included. Elevated natriuretic peptides were significantly associated with increased risk of mortality (odds ratio (OR) 8.65, 95% confidence interval (CI) 4.94 to 15.13, P < 0.00001). The association was consistent for BNP (OR 10.44, 95% CI 4.99 to 21.58, P < 0.00001) and NT-proBNP (OR 6.62, 95% CI 2.68 to 16.34, P < 0.0001). The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 79% (95% CI 75 to 83), 60% (95% CI 57 to 62), 2.27 (95% CI 1.83 to 2.81) and 0.32 (95% CI 0.22 to 0.46), respectively. Conclusions Our results suggested that an elevated BNP or NT-proBNP level may prove to be a powerful predictor of mortality in septic patients. Future larger and more adequately powered prospective studies are warranted to clarify the assay standardization, the optimal cut-off, and the prognostic value of BNPs in conjunction with other biomarkers.
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Myocardial dysfunction in sepsis: a large, unsolved puzzle. Crit Care Res Pract 2012; 2012:896430. [PMID: 22482045 PMCID: PMC3312225 DOI: 10.1155/2012/896430] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 12/14/2011] [Accepted: 01/04/2012] [Indexed: 12/12/2022] Open
Abstract
Sepsis has high incidence and mortality rates around the world. The role of cardiac depression in myocardial dysfunction during sepsis remains to be elucidated. This review attempts to summarize our understanding of the anatomical, histopathological, and pathophysiological mechanisms behind cardiac dysfunction. Biomarkers to detect cardiac depression have been used to recognize developing problems, but the actual impact of these tools remains unclear.
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Bayram I, Erbey F, Erdem S, Tanyeli A. Brain natriuretic peptide levels in pediatric cancer patients with febrile neutropenia. Pediatr Hematol Oncol 2011; 28:294-8. [PMID: 21413834 DOI: 10.3109/08880018.2010.548849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Brain natriuretic peptide (BNP) is considered as a prognostic marker in patients with sepsis, but no data are available on BNP in pediatric cancer patients with febrile neutropenia (FN). Twenty-five pediatric cancer patients with FN were included in this study. Serum BNP level was measured. The mean BNP level was 330.8 ± 765.3 pg/mL (5.9-3806 pg/mL). BNP levels of 12 patients were found over the normal level. High BNP levels were related to some conditions of the patients, and these were statistically significant (P < .05). These conditions were required erythrocyte suspension, had pneumonia, time stayed in hospital, and neutropenia time. When regression test was done, required erythrocyte suspension for anemia and had pneumonia were found to be statistically significant. In conclusion, this is one of the first studies on BNP levels in pediatric cancer patients with FN. However, further studies with large sample sizes are needed to confirm the results and provide new data about this issue.
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Affiliation(s)
- Ibrahim Bayram
- Department of Pediatric Oncology, Cukurova University Medical Faculty, Adana, Turkey
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Turner KL, Moore LJ, Todd SR, Sucher JF, Jones SA, McKinley BA, Valdivia A, Sailors RM, Moore FA. Identification of cardiac dysfunction in sepsis with B-type natriuretic peptide. J Am Coll Surg 2011; 213:139-46; discussion 146-7. [PMID: 21514182 DOI: 10.1016/j.jamcollsurg.2011.03.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 03/15/2011] [Accepted: 03/18/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND B-type natriuretic peptide (BNP) is secreted in response to myocardial stretch and has been used clinically to assess volume overload and predict death in congestive heart failure. More recently, BNP elevation has been demonstrated with septic shock and is predictive of death. How BNP levels relate to cardiac function in sepsis remains to be established. STUDY DESIGN Retrospective review of prospectively gathered sepsis database from a surgical ICU in a tertiary academic hospital. Initial BNP levels, patient demographics, baseline central venous pressure levels, and in-hospital mortality were obtained. Transthoracic echocardiography was performed during initial resuscitation per protocol. RESULTS During 24 months ending in September 2009, two hundred and thirty-one patients (59 ± 3 years of age, 43% male) were treated for sepsis. Baseline BNP increased with initial sepsis severity (ie, sepsis vs severe sepsis vs septic shock, by ANOVA; p < 0.05) and was higher in those who died vs those who lived (by Fisher's exact test; p < 0.05). Of these patients, 153 (66%) had early echocardiography. Low ejection fraction (<50%) was associated with higher BNP (by Fisher's exact test; p < 0.05) and patients with low ejection fraction had a higher mortality (39% vs 20%; odds ratio = 3.03). We found no correlation between baseline central venous pressure (12.7 ± 6.10 mmHg) and BNP (526.5 ± 82.10 pg/mL) (by Spearman's ρ, R(s) = .001) for the entire sepsis population. CONCLUSIONS In surgical sepsis patients, BNP increases with sepsis severity and is associated with early systolic dysfunction, which in turn is associated with death. Monitoring BNP in early sepsis to identify occult systolic dysfunction might prompt earlier use of inotropic agents.
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Affiliation(s)
- Krista L Turner
- Department of Surgery, The Methodist Hospital, Weill Cornell Medical College, 6550 Fannin St, Smith Tower 1661, Houston, TX 77030, USA.
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Chelazzi C, Villa G, De Gaudio AR. Cardiorenal syndromes and sepsis. Int J Nephrol 2011; 2011:652967. [PMID: 21603105 PMCID: PMC3097051 DOI: 10.4061/2011/652967] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 01/25/2011] [Accepted: 01/28/2011] [Indexed: 12/15/2022] Open
Abstract
The cardiorenal syndrome is a clinical and pathophysiological entity defined as the concomitant presence of renal and cardiovascular dysfunction. In patients with severe sepsis and septic shock, acute cardiovascular, and renal derangements are common, that is, the septic cardiorenal syndrome. The aim of this paper is to describe the pathophysiology and clinical features of septic cardiorenal syndrome in light of the actual clinical and experimental evidence. In particular, the importance of systemic and intrarenal endothelial dysfunction, alterations of kidney perfusion, and myocardial function, organ “crosstalk” and ubiquitous inflammatory injury have been extensively reviewed in light of their role in cardiorenal syndrome etiology. Treatment includes early and targeted optimization of hemodynamics to reverse systemic hypotension and restore urinary output. In case of persistent renal impairment, renal replacement therapy may be used to remove cytokines and restore renal function.
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Affiliation(s)
- C Chelazzi
- Section of Anesthesiology and Intensive Care, Department of Critical Care, University of Florence, Padiglione Cliniche Chirurgiche, Viale Morgagni 85, 50134 Florence, Italy
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Thygesen K, Mair J, Mueller C, Huber K, Weber M, Plebani M, Hasin Y, Biasucci LM, Giannitsis E, Lindahl B, Koenig W, Tubaro M, Collinson P, Katus H, Galvani M, Venge P, Alpert JS, Hamm C, Jaffe AS. Recommendations for the use of natriuretic peptides in acute cardiac care: a position statement from the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Eur Heart J 2011; 33:2001-6. [PMID: 21292681 DOI: 10.1093/eurheartj/ehq509] [Citation(s) in RCA: 189] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kristian Thygesen
- Department of Medicine and Cardiology, Aarhus University Hospital, Tage-Hansens Gade 2, Aarhus C DK-8000, Denmark.
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Perman SM, Chang AM, Hollander JE, Gaieski DF, Trzeciak S, Birkhahn R, Otero R, Osborn TM, Moretti E, Nguyen HB, Gunnerson KJ, Milzman D, Goyal M, Cairns CB, Ngo L, Rivers EP, Shapiro NI. Relationship between B-type natriuretic peptide and adverse outcome in patients with clinical evidence of sepsis presenting to the emergency department. Acad Emerg Med 2011; 18:219-22. [PMID: 21314784 DOI: 10.1111/j.1553-2712.2010.00968.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Myocardial dysfunction is an important aspect of sepsis pathophysiology. B-type natriuretic peptide (BNP) is a neurohormone released from the ventricles in response to myocardial stretch and volume overload. The authors hypothesized that an elevated BNP in patients presenting to the emergency department (ED) with suspected sepsis are at increased risk for development of adverse events. METHODS This was a prospective, observational, multicenter cohort study in 10 EDs. Patients were eligible if they were older than 18 years, had two or more systemic inflammatory response syndrome (SIRS) criteria, and had suspected infection or a serum lactate level > 2.5 mmol/L. Patients were excluded if they were pregnant, had do-not-attempt-resuscitation status, sustained a cardiac arrest prior to hospital arrival, had known chronic renal insufficiency, or were on dialysis. BNP levels were obtained at arrival. The primary outcome was a composite of severe sepsis, septic shock within 72 hours, or in-hospital mortality. RESULTS There were 825 patients enrolled (mean ± standard deviation [SD] age = 53.5 ± 19.6 years; 51% were female and 37% were African American). The area under the curve (AUC) for BNP to predict the triple composite outcome was 0.69, and the optimal cut-point of BNP was 49 pg/mL. Patients with a BNP > 49 pg/mL had a greater mortality rate (11.6% vs. 2.1%; p = 0.0001), a greater risk of development of severe sepsis (67.7% vs. 36.8%; p = 0.0001) and septic shock (51.7% vs. 26.4%; p = 0.0001), and a higher rate of the triple composite outcome (69% vs. 37%; unadjusted odds ratio [OR] = 1.9, 95% confidence interval [CI] = 1.6 to 2.1; p < 0.001). The sensitivity was 63% (95% CI = 58% to 67%), specificity was 69% (95% CI = 65% to 73%), negative predictive value (NPV) was 63% (95% CI = 58% to 67%), and positive predictive value (PPV) was 69% (95% CI = 65% to 74%). In multivariate modeling, after adjusting for age, sex, heart rate, white blood cell count, and creatinine, an elevated BNP was associated with increased odds of having the composite outcome. The outcome was similar in the subset of patients who did not have severe sepsis or septic shock upon arrival. CONCLUSIONS In patients who present to the ED with SIRS criteria and suspected infection, an elevated BNP is associated with a worse prognosis but has limited diagnostic utility.
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Hämäläinen S, Juutilainen A, Kuittinen T, Nousiainen T, Matinlauri I, Pulkki K, Koivula I, Jantunen E. Serum amino-terminal pro-brain natriuretic peptide in hematological patients with neutropenic fever: a prospective comparison with C-reactive protein. Leuk Lymphoma 2010; 51:1040-6. [PMID: 20470220 DOI: 10.3109/10428191003743478] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Serum amino-terminal pro-brain natriuretic peptide (NT-proBNP) is considered as a prognostic marker in patients with severe sepsis or septic shock, but no data are available on NT-proBNP kinetics in hematological patients with neutropenic fever. Altogether 70 hematological patients with neutropenic fever were included in this prospective study. NT-proBNP and C-reactive protein (CRP) were determined at the beginning of the neutropenic fever (d0) and then daily up to 3-4 days. The median NT-proBNP (interquartile range) increased from 127 (57-393) ng/L on d0 to 542 (194-1385) ng/L on d4. The increment of CRP was from 35 (17-61) mg/L on d0 to 109 (56-109) mg/L on d2. Neither serial NT-proBNP nor CRP predicted development of severe sepsis, but NT-proBNP was significantly higher in patients with previous cardiovascular disease than in those without. NT-proBNP seemed to reflect cardiac distress, but it did not help to predict the development of severe sepsis in this patient group.
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Affiliation(s)
- Sari Hämäläinen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland.
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Hartemink KJ, Twisk JWR, Groeneveld ABJ. High circulating N-terminal pro-B-type natriuretic peptide is associated with greater systolic cardiac dysfunction and nonresponsiveness to fluids in septic vs nonseptic critically ill patients. J Crit Care 2010; 26:108.e1-8. [PMID: 20646903 DOI: 10.1016/j.jcrc.2010.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 03/20/2010] [Accepted: 05/02/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE It is still unclear whether circulating levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) reflect cardiac filling and function in the critically ill patient, particularly during sepsis and a proinflammatory response that may induce NT-proBNP release from the heart. MATERIALS AND METHODS We prospectively evaluated the value of NT-proBNP as a marker of cardiac loading, function, and response to fluid loading in 18 septic and 68 nonseptic, critically ill patients in the intensive care unit of a university medical center. Transpulmonary thermal dilution and pressure measurements were done, and plasma NT-proBNP was determined before and after colloid fluid loading. RESULTS Compared with nonseptic patients, NT-proBNP plasma levels were higher and systolic cardiac function indices were lower in patients with sepsis than those without sepsis. N-terminal pro-B-type natriuretic peptide best related, from all hemodynamic parameters before and after fluid loading, to systolic cardiac function (rather than diastolic filling) variables, independently of confounders such as renal dysfunction (judged from serum creatinine). In addition, a high NT-proBNP (>3467 pg/mL) predicted absence of fluid responsiveness in sepsis only. CONCLUSIONS Our data suggest that an increased circulating NT-proBNP plasma level is an independent marker of greater systolic cardiac dysfunction, irrespective of filling status, and is a better predictor of fluid nonresponsiveness in septic vs nonseptic, critically ill patients.
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Affiliation(s)
- Koen J Hartemink
- Department of Intensive Care and the Institute for Cardiovascular Research, VU University Medical Center, 1081 HV Amsterdam, The Netherlands.
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Pierrakos C, Vincent JL. Sepsis biomarkers: a review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R15. [PMID: 20144219 PMCID: PMC2875530 DOI: 10.1186/cc8872] [Citation(s) in RCA: 839] [Impact Index Per Article: 59.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 12/28/2009] [Accepted: 02/09/2010] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Biomarkers can be useful for identifying or ruling out sepsis, identifying patients who may benefit from specific therapies or assessing the response to therapy. METHODS We used an electronic search of the PubMed database using the key words "sepsis" and "biomarker" to identify clinical and experimental studies which evaluated a biomarker in sepsis. RESULTS The search retrieved 3370 references covering 178 different biomarkers. CONCLUSIONS Many biomarkers have been evaluated for use in sepsis. Most of the biomarkers had been tested clinically, primarily as prognostic markers in sepsis; relatively few have been used for diagnosis. None has sufficient specificity or sensitivity to be routinely employed in clinical practice. PCT and CRP have been most widely used, but even these have limited ability to distinguish sepsis from other inflammatory conditions or to predict outcome.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, route de Lennik 808, 1070 Brussels, Belgium.
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Abstract
PURPOSE OF REVIEW Severe sepsis and septic shock are among the most important causes of morbidity and mortality in patients admitted to the intensive care unit. The purpose of this review is to review current understanding of sepsis-induced cardiac dysfunction and discuss pertinent findings regarding its clinical presentation, underlying mechanisms of disease, and therapy. RECENT FINDINGS Cardiac dysfunction in sepsis is characterized by decreased contractility, impaired ventricular response to fluid therapy, and in some patients ventricular dilatation. Current data support a complex underlying physiopathology with a host of potential pathways leading to myocardial depression. Circulating factors such as cytokines (TNF-alpha, IL-1beta), lysozyme c, endothelin-1 have direct inhibitory actions on myocyte contractility. Nitric oxide has a complex role in sepsis-induced cardiac dysfunction. Current data suggest a combination of deleterious and positive effects on the myocardium determined by the specific type of nitric oxide expressed. Recent studies have shown that mitochondrial dysfunction and apoptosis also play a role in the development of sepsis-induced cardiac dysfunction. Current treatment for sepsis-induced cardiac dysfunction is based on appropriate treatment for the infectious focus (antibiotics and source control) and hemodynamic support (fluids, vasopressors, and inotropes). SUMMARY Cardiac dysfunction is common in patients with severe sepsis and septic shock. Current understanding of the underlying mechanisms responsible is rapidly evolving and future novel therapeutic targets may be soon available. Present therapy for sepsis-induced cardiac dysfunction is based on treatment of underlying sepsis with antibiotics and hemodynamic support.
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Reel B, Oishi PE, Hsu JH, Gildengorin G, Matthay MA, Fineman JR, Flori H. Early elevations in B-type natriuretic peptide levels are associated with poor clinical outcomes in pediatric acute lung injury. Pediatr Pulmonol 2009; 44:1118-24. [PMID: 19830720 PMCID: PMC4427345 DOI: 10.1002/ppul.21111] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To determine B-type natriuretic peptide (BNP) levels in infants and children with acute lung injury (ALI), and to investigate associations between BNP levels and clinical outcome. DESIGN Prospective observational study. SUBJECTS After informed consent, plasma was collected from 48 pediatric patients on day 1 of ALI. METHODOLOGY Plasma BNP levels were measured by immunoassay on day 1 of ALI in 48 pediatric patients. Associations between BNP levels and outcome were determined. RESULTS The mean PaO(2)/FiO(2) at the onset of ALI was 155 (+/-74) and BNP values ranged from 5 to 2,060 pg/ml with a mean of 109 (+/-311). BNP levels were inversely correlated with ventilator-free days (Spearman rho -0.30, P = 0.04), and positively correlated with exhaled tidal volume (Spearman rho 0.44, P = 0.02). BNP levels were higher in patients receiving inotropic support (n = 12) than patients not receiving inotropic support (n = 33, P = 0.02). BNP levels were correlated with PRISM III scores (Spearman rho 0.55, P < 0.001) and PELOD scores (Spearman rho 0.4, P = 0.006). Mortality for the cohort was 15%. BNP levels were higher in non-survivors (n = 7) than survivors (n = 41, P = 0.055). CONCLUSIONS BNP levels are elevated in children with ALI/ARDS early in the disease course, and increased levels are associated with worse clinical outcome.
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Affiliation(s)
- Bhupinder Reel
- Department of Pediatrics, University of California, San Francisco, California, USA
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Chen Y, Li C. Prognostic significance of brain natriuretic peptide obtained in the ED in patients with SIRS or sepsis. Am J Emerg Med 2009; 27:701-6. [DOI: 10.1016/j.ajem.2009.02.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 01/23/2009] [Accepted: 02/03/2009] [Indexed: 11/26/2022] Open
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Abstract
Key links in the chain of survival for the management of severe sepsis and septic shock are early identification and comprehensive resuscitation of high-risk patients. Multiple studies have shown that the first 6 hours of early sepsis management are especially important from a diagnostic, pathogenic, and therapeutic perspective, and that steps taken during this period can have a significant impact on outcome. The recognition of this critical time period and the robust outcome benefit realized in previous studies provides the rationale for adopting early resuscitation as a distinct intervention. Sepsis joins trauma, stroke, and acute myocardial infarction in having "golden hours," representing a critical opportunity early on in the course of disease for actions that offer the most benefit.
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Christenson RH. What is the value of B-type natriuretic peptide testing for diagnosis, prognosis or monitoring of critically ill adult patients in intensive care? Clin Chem Lab Med 2009; 46:1524-32. [PMID: 18847367 DOI: 10.1515/cclm.2008.294] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND B-natriuretic peptide (BNP) and aminoterminal proBNP (NT-proBNP) are clinically useful for the diagnosis of decompensated heart failure and for prognosis in heart failure and acute coronary syndromes. Clinical use of these biomarkers in critically ill patients being treated in intensive care is not well established. METHODS This is a narrative review of evidence identified searching MEDLINE with the strategy [(BNP OR NT-proBNP) AND (critical illness AND intensive care)]. Seven primary reports and two narrative reviews were retrieved. For completeness, literature from each of the following searches was reviewed: [(BNP OR NT-proBNP) AND (critical illness)] and [(BNP OR NT-proBNP) AND (intensive care)]. RESULTS Primary literature used BNP and NT-proBNP for diagnosis, prognosis and monitoring. For diagnosis of acute lung injury in unselected intensive care patients and for diagnosis of heart failure in trauma patients, the biomarkers had low sensitivity and are of modest use. BNP and NT-proBNP were found to have a significant ability to prognosticate adverse outcomes in critically ill patients. A single paper examined the use of BNP as a non-invasive replacement for pulmonary capillary wedge pressure, finding little value. The impact of renal insufficiency on the markers was noted as a confounder in most studies. In the secondary searches, some preliminary data suggested a possible role for the natriuretic peptides in exclusion of a cardiac cause for certain conditions among intensive care unit (ICU) patients. However, the general findings were that the performance of BNP and NT-proBNP is unimpressive among ICU patients. CONCLUSIONS Currently, utilization of BNP and NT-proBNP does not appear to provide much useful information or have a substantial role in the care of critically ill patients in intensive care.
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Affiliation(s)
- Robert H Christenson
- Department of Pathology and Medical and Research Technology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Collinson PO. Natriuretic peptide determinations in critical care medicine: part of routine clinical practice or research test only? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:105. [PMID: 19183435 PMCID: PMC2688097 DOI: 10.1186/cc7133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Measurement of N-terminal pro-B-type natriuretic peptide has been shown a good rule-out test for cardiac dysfunction in patients in the intensive care unit. The peptide measurement should not be used as a replacement for other forms of monitoring, and performs best as a diagnostic test when interpreted together with other clinical findings and investigations. At a cutoff value similar to that found in other clinical studies in acute decompensated heart failure, measurement of N-terminal pro-B-type natriuretic peptide offers an additional tool for diagnostic assessment of patients presenting to the intensive care physician.
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Affiliation(s)
- Paul O Collinson
- Department of Chemical Pathology, St George's Hospital and Medical School, London, UK.
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Rady MY. B-type natriuretic peptide and sepsis: it is not just the heart. J Intensive Care Med 2007; 22:386-8. [PMID: 18048879 DOI: 10.1177/0885066607307659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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