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Vintrych P, Al-Obeidallah M, Horák J, Chvojka J, Valešová L, Nalos L, Jarkovská D, Matějovič M, Štengl M. Modeling sepsis, with a special focus on large animal models of porcine peritonitis and bacteremia. Front Physiol 2023; 13:1094199. [PMID: 36703923 PMCID: PMC9871395 DOI: 10.3389/fphys.2022.1094199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023] Open
Abstract
Infectious diseases, which often result in deadly sepsis or septic shock, represent a major global health problem. For understanding the pathophysiology of sepsis and developing new treatment strategies, reliable and clinically relevant animal models of the disease are necessary. In this review, two large animal (porcine) models of sepsis induced by either peritonitis or bacteremia are introduced and their strong and weak points are discussed in the context of clinical relevance and other animal models of sepsis, with a special focus on cardiovascular and immune systems, experimental design, and monitoring. Especially for testing new therapeutic strategies, the large animal (porcine) models represent a more clinically relevant alternative to small animal models, and the findings obtained in small animal (transgenic) models should be verified in these clinically relevant large animal models before translation to the clinical level.
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Affiliation(s)
- Pavel Vintrych
- Department of Cardiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Mahmoud Al-Obeidallah
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Jan Horák
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Jiří Chvojka
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Lenka Valešová
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Lukáš Nalos
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Dagmar Jarkovská
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Martin Matějovič
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Milan Štengl
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,*Correspondence: Milan Štengl,
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2
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Abstract
Endotoxaemia is an inflammatory condition which happens due to the presence of outer cell wall layer of Gram-negative bacteria in blood circulation, containing lipopolysaccharide commonly known as endotoxin. This condition causes high mortality in affected animals and sheep are highly susceptible in this regard. Several researchers have emphasised the therapeutic regimens of endotoxaemia and its sequels in sheep. Furthermore, sheep are among the most commonly used animal species in experimental studies on endotoxaemia, and for the past five decades, ovine models have been employed to evaluate different aspects of endotoxaemia. Currently, there are several studies on experimentally induced endotoxaemia in sheep, and information regarding novel therapeutic protocols in this species contributes to better understanding and treating the condition. This review aims to specifically introduce various treatment methods of endotoxaemia in sheep.
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Affiliation(s)
- A. Chalmeh
- Department of Clinical Sciences, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
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Brinkworth JF, Valizadegan N. Sepsis and the evolution of human increased sensitivity to lipopolysaccharide. Evol Anthropol 2021; 30:141-157. [PMID: 33689211 DOI: 10.1002/evan.21887] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/29/2020] [Accepted: 01/30/2021] [Indexed: 01/03/2023]
Abstract
Among mammals, humans are exquisitely sensitive to lipopolysaccharide (LPS), an environmentally pervasive bacterial cell membrane component. Very small doses of LPS trigger powerful immune responses in humans and can even initiate symptoms of sepsis. Close evolutionary relatives such as African and Asian monkeys require doses that are an order of magnitude higher to do the same. Why humans have evolved such an energetically expensive antimicrobial strategy is a question that biological anthropologists are positioned to help address. Here we compare LPS sensitivity in primate/mammalian models and propose that human high sensitivity to LPS is adaptive, linked to multiple immune tactics against pathogens, and part of multi-faceted anti-microbial strategy that strongly overlaps with that of other mammals. We support a notion that LPS sensitivity in humans has been driven by microorganisms that constitutively live on us, and has been informed by human behavioral changes over our species' evolution (e.g., meat eating, agricultural practices, and smoking).
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Affiliation(s)
- Jessica F Brinkworth
- Evolutionary Immunology and Genomics Laboratory, Department of Anthropology, University of Illinois Urbana-Champaign, Urbana, Illinois, USA.,Carl R Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA.,Department of Animal Biology, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Negin Valizadegan
- Evolutionary Immunology and Genomics Laboratory, Department of Anthropology, University of Illinois Urbana-Champaign, Urbana, Illinois, USA.,Carl R Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
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4
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Abstract
OBJECTIVES Fluid bolus therapy is the initial recommended treatment for acute circulatory failure in sepsis, yet it is unknown whether this has the intended effect of increasing cardiac index. We aimed to describe the effect of fluid bolus therapy on cardiac index in children with sepsis. DESIGN A prospective observational cohort study. SETTING The Emergency Department of The Royal Children's Hospital, Melbourne, VIC, Australia. PATIENTS A convenience sample of children meeting international consensus criteria for sepsis with acute circulatory failure. INTERVENTION Treating clinician decision to administer fluid bolus therapy. MEASUREMENTS AND MAIN RESULTS Transthoracic echocardiography was recorded immediately before, 5 minutes after, and 60 minutes after fluid bolus therapy. Cardiac index was calculated by a pediatric cardiologist blinded to the timing of the echocardiogram. Cardiac index was calculated for 49 fluid boluses in 41 children. The median change in cardiac index 5 minutes after a fluid bolus therapy was +18.0% (interquartile range, 8.6-28.1%) and after 60 minutes was -6.0% (interquartile range, -15.2% to 3.0%) relative to baseline. Thirty-one of 49 fluid boluses (63%) resulted in an increase in cardiac index of greater than 10% at 5 minutes, and these participants were considered fluid responsive. This was sustained in four of 31 (14%) at 60 minutes. No association between change in cardiac index at 5 or 60 minutes and age, baseline mean arterial blood pressure, fluid bolus volume, and prior volume of fluid bolus therapy was found on linear regression. CONCLUSIONS Fluid bolus therapy for pediatric sepsis is associated with a transient increase in cardiac index. Fluid responsiveness is variable and, when present, not sustained. The efficacy of fluid bolus therapy for achieving a sustained increase in cardiac index in children with sepsis is limited.
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Hill TL, Lascelles BDX, Blikslager AT. Effect of sucralfate on gastric permeability in an ex vivo model of stress-related mucosal disease in dogs. J Vet Intern Med 2018; 32:670-678. [PMID: 29460464 PMCID: PMC5866966 DOI: 10.1111/jvim.15076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 11/19/2017] [Accepted: 01/22/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Sucralfate is a gastroprotectant with no known systemic effects. The efficacy of sucralfate for prevention and treatment of stress-related mucosal diseases (SRMD) in dogs is unknown. HYPOTHESIS/OBJECTIVES To develop a canine ex vivo model of SRMD and to determine the effect of sucralfate on mucosal barrier function in this model. ANIMALS Gastric antral mucosa was collected immediately postmortem from 29 random-source apparently healthy dogs euthanized at a local animal control facility. METHODS Randomized experimental trial. Sucralfate (100 mg/mL) was applied to ex vivo canine gastric mucosa concurrent with and after acid injury. Barrier function was assessed by measurement of transepithelial electrical resistance (TER) and radiolabeled mannitol flux. RESULTS Application of acidified Ringers solution to the mucosal side of gastric antrum caused a reduction in gastric barrier function, and washout of acidified Ringers solution allowed recovery of barrier function (TER: 34.0 ± 2.8% of control at maximum injury, 71.3 ± 5.5% at recovery, P < .001). Sucralfate application at the time of injury or after injury significantly hastened recovery of barrier function (TER: 118.0 ± 15.2% of control at maximum injury, P < .001 and 111.0 ± 15.5% at recovery, P = .35). CONCLUSIONS AND CLINICAL IMPORTANCE Sucralfate appeared effective at restoring defects in gastric barrier function induced by acid and accelerating repair of tissues subjected to acid in this model, suggesting that sucralfate could have utility for the treatment and prevention of SRMD in dogs.
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Affiliation(s)
- Tracy L. Hill
- Department of Small Animal Medicine and Surgery, College of Veterinary MedicineUniversity of GeorgiaAthensGeorgia
| | - B. Duncan X. Lascelles
- Department of Clinical Sciences, College of Veterinary MedicineNorth Carolina State UniversityRaleighNorth Carolina
- Center for Pain Research and InnovationUNC School of DentistryChapel HillNorth Carolina
- Department of Anesthesiology, Center for Translational Pain ResearchDuke UniversityDurhamNorth Carolina
| | - Anthony T. Blikslager
- Department of Clinical Sciences, College of Veterinary MedicineNorth Carolina State UniversityRaleighNorth Carolina
- Center for Gastrointestinal Biology and Disease, Large Animal Models CoreNorth Carolina State UniversityRaleighNorth Carolina
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6
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Byrne L, Obonyo NG, Diab S, Dunster K, Passmore M, Boon AC, Hoe LS, Hay K, Van Haren F, Tung JP, Cullen L, Shekar K, Maitland K, Fraser JF. An Ovine Model of Hyperdynamic Endotoxemia and Vital Organ Metabolism. Shock 2018; 49:99-107. [PMID: 28520696 PMCID: PMC7004818 DOI: 10.1097/shk.0000000000000904] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Animal models of endotoxemia are frequently used to understand the pathophysiology of sepsis and test new therapies. However, important differences exist between commonly used experimental models of endotoxemia and clinical sepsis. Animal models of endotoxemia frequently produce hypodynamic shock in contrast to clinical hyperdynamic shock. This difference may exaggerate the importance of hypoperfusion as a causative factor in organ dysfunction. This study sought to develop an ovine model of hyperdynamic endotoxemia and assess if there is evidence of impaired oxidative metabolism in the vital organs. METHODS Eight sheep had microdialysis catheters implanted into the brain, heart, liver, kidney, and arterial circulation. Shock was induced with a 4 h escalating dose infusion of endotoxin. After 3 h vasopressor support was initiated with noradrenaline and vasopressin. Animals were monitored for 12 h after endotoxemia. Blood samples were recovered for hemoglobin, white blood cell count, creatinine, and proinflammatory cytokines (IL-1Beta, IL-6, and IL-8). RESULTS The endotoxin infusion was successful in producing distributive shock with the mean arterial pressure decreasing from 84.5 ± 12.8 mm Hg to 49 ± 8.03 mm Hg (P < 0.001). Cardiac index remained within the normal range decreasing from 3.33 ± 0.56 L/min/m to 2.89l ± 0.36 L/min/m (P = 0.0845). Lactate/pyruvate ratios were not significantly abnormal in the heart, brain, kidney, or arterial circulation. Liver microdialysis samples demonstrated persistently high lactate/pyruvate ratios (mean 37.9 ± 3.3). CONCLUSIONS An escalating dose endotoxin infusion was successful in producing hyperdynamic shock. There was evidence of impaired oxidative metabolism in the liver suggesting impaired splanchnic perfusion. This may be a modifiable factor in the progression to multiple organ dysfunction and death.
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Affiliation(s)
- Liam Byrne
- The Critical Care Research Group, Chermside, Brisbane, Australia
- Australian National University, Canberra, ACT, Australia
- The Canberra Hospital Yamba Dr, Garran, ACT, Australia
| | | | - Sara Diab
- The Critical Care Research Group, Chermside, Brisbane, Australia
| | - Kimble Dunster
- The Critical Care Research Group, Chermside, Brisbane, Australia
- Queensland University of Technology, Brisbane City, Australia
| | - Margaret Passmore
- The Critical Care Research Group, Chermside, Brisbane, Australia
- University of Queensland, St Lucia, Australia
| | - Ai Ching Boon
- The Critical Care Research Group, Chermside, Brisbane, Australia
- University of Queensland, St Lucia, Australia
| | - Louise See Hoe
- The Critical Care Research Group, Chermside, Brisbane, Australia
- University of Queensland, St Lucia, Australia
| | - Karen Hay
- QIMR Berghofer Medical Research Institute, Herston, Brisbane, Australia
| | - Frank Van Haren
- Australian National University, Canberra, ACT, Australia
- The Canberra Hospital Yamba Dr, Garran, ACT, Australia
| | - John-Paul Tung
- The Critical Care Research Group, Chermside, Brisbane, Australia
- Australian Red Cross Blood Service, Kelvin Grove, Brisbane, Australia
| | - Louise Cullen
- Queensland University of Technology, Brisbane City, Australia
- The Emergency Department Royal Brisbane Women and Children’s Hospital Brisbane, Australia
| | - Kiran Shekar
- The Critical Care Research Group, Chermside, Brisbane, Australia
- The Adult Intensive Care, The Prince Charles Hospital, Chermside, Brisbane, Australia
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College London, United Kingdom
| | - John F. Fraser
- The Critical Care Research Group, Chermside, Brisbane, Australia
- University of Queensland, St Lucia, Australia
- The Adult Intensive Care, The Prince Charles Hospital, Chermside, Brisbane, Australia
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7
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An X, Zhang H, Sun Y, Ma X. The microcirculatory failure could not weaken the increase of systematic oxygen extraction rate in septic shock: An observational study in canine models. Clin Hemorheol Microcirc 2017; 63:267-79. [PMID: 26639767 DOI: 10.3233/ch-152022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECT This study aimed at exploring what level of the microcirculation alteration could weaken the decrease of ScvO2 (or the increase of O2ER) and further result in an abnormally elevated ScvO2. METHODS Beagles were randomly assigned into control (n = 5) and shock group (n = 5). The canines in shock group were intravenously injected with live E. coli (3.5×108 cfu/kg), and the ones in control group were injected with sterile saline. The experiment continued to the animals' death or for a maximum of 24 hours. Hemodynamic parameters, blood gas and inflammatory cytokines level were collected. Microcirculatory parameters were assessed with Sidestream Dark Field (SDF) imaging. The correlation between the microcirculation and oxygen metabolism or inflammatory cytokine, meanwhile the correlation between the oxygen metabolism and inflammatory cytokine was assessed. RESULTS E. coli infusion induced hypodynamic shock. The correlation between microcirculation and oxygen metabolism or inflammatory cytokine, and The correlation between the oxygen metabolism and inflammatory cytokine (O2ER vs. MFI: r = -0.700, P < 0.01; O2ER vs. PVD: r = -0.677, P < 0.01; O2ER vs. PPV: r = -0.538, P < 0.01; MFI vs. IL-6: r = -0.780, P < 0.01; PPV vs. IL-6: r = -0.621, P < 0.01; MFI vs. TNF-α: r = -0.636, P < 0.01; PPV vs. TNF-α: r = -0.561, P < 0.01) were observed. CONCLUSIONS The increase of O2ER cannot be weakened by the microcirculatory failure.
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8
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Byrne L, Van Haren F. Fluid resuscitation in human sepsis: Time to rewrite history? Ann Intensive Care 2017; 7:4. [PMID: 28050897 PMCID: PMC5209309 DOI: 10.1186/s13613-016-0231-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/20/2016] [Indexed: 01/01/2023] Open
Abstract
Fluid resuscitation continues to be recommended as the first-line resuscitative therapy for all patients with severe sepsis and septic shock. The current acceptance of the therapy is based in part on long history and familiarity with its use in the resuscitation of other forms of shock, as well as on an incomplete and incorrect understanding of the pathophysiology of sepsis. Recently, the safety of intravenous fluids in patients with sepsis has been called into question with both prospective and observational data suggesting improved outcomes with less fluid or no fluid. The current evidence for the continued use of fluid resuscitation for sepsis remains contentious with no prospective evidence demonstrating benefit to fluid resuscitation as a therapy in isolation. This article reviews the historical and physiological rationale for the introduction of fluid resuscitation as treatment for sepsis and highlights a number of significant concerns based on current experimental and clinical evidence. The research agenda should focus on the development of hyperdynamic animal sepsis models which more closely mimic human sepsis and on experimental and clinical studies designed to evaluate minimal or no fluid strategies in the resuscitation phase of sepsis.
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Affiliation(s)
- Liam Byrne
- Australian National University Medical School, Canberra, Australia. .,Intensive Care Unit, The Canberra Hospital, Canberra, Australia.
| | - Frank Van Haren
- Australian National University Medical School, Canberra, Australia.,Intensive Care Unit, The Canberra Hospital, Canberra, Australia
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9
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Assuncao MSCD, Corrêa TD, Bravim BDA, Silva E. How to choose the therapeutic goals to improve tissue perfusion in septic shock. ACTA ACUST UNITED AC 2015; 13:441-7. [PMID: 26313438 PMCID: PMC4943794 DOI: 10.1590/s1679-45082015rw3148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 03/14/2015] [Indexed: 12/30/2022]
Abstract
The early recognition and treatment of severe sepsis and septic shock is the key to a successful outcome. The longer the delay in starting treatment, the worse the prognosis due to persistent tissue hypoperfusion and consequent development and worsening of organ dysfunction. One of the main mechanisms responsible for the development of cellular dysfunction is tissue hypoxia. The adjustments necessary for adequate tissue blood flow and therefore of oxygen supply to metabolic demand according to the assessment of the cardiac index and oxygen extraction rate should be performed during resuscitation period, especially in high complexity patients. New technologies, easily handled at the bedside, and new studies that directly assess the impact of macro-hemodynamic parameter optimization on microcirculation and in the clinical outcome of septic patients, are needed.
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Affiliation(s)
| | | | | | - Eliézer Silva
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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10
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Hypertonic saline solution reduces mesenteric microcirculatory dysfunctions and bacterial translocation in a rat model of strangulated small bowel obstruction. Shock 2014; 40:35-44. [PMID: 23644577 DOI: 10.1097/shk.0b013e318299d3fa] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We examined the effects of hypertonic saline (HS) on inflammatory, metabolic variables, and bacterial translocation (BT) in rats submitted to intestinal obstruction and ischemia (IO). Male Wistar rats were submitted to IO and treated, 2 h thereafter, with lactated Ringer's (LR) (4 mL/kg per 5 min, i.v.) or HS (7.5% NaCl, 4 mL/kg per 5 min, i.v.). Twenty-four hours after IO, rats were also submitted to enterectomy/enteroanastomosis to resection of necrotized small bowel. Leukocyte-endothelial interactions were investigated by intravital microscopy and the expression of P-selectin and intercellular adhesion molecule 1 by immunohistochemistry. Bacterial cultures of mesenteric lymph nodes, liver, spleen, and blood were used to evaluate BT. Levels of chemokines (cytokine-induced neutrophil chemoattractants 1 and 2), insulin, and corticosterone were determined by enzyme-linked immunosorbent assay. Intestinal histology, serum urea and creatinine levels, and hepatic enzymes activities were performed to evaluate local and remote damage. Relative to IO and LR-treated rats, which exhibited increases in the number of rolling (1.5-fold), adhered (3.5-fold) and migrated (9.0-fold) leukocytes, and increased expression of P-selectin (3-fold) and intercellular adhesion molecule 1 (3-fold) on mesenteric microcirculation, treatment with HS followed by enterectomy reduced leukocyte-endothelial interactions and expression of both adhesion molecules to values attained in sham rats. Serum chemokines were normalized after treatment with both solutions followed by enterectomy. Hypertonic saline-treated rats demonstrated a significant reduction in BT to 50% in liver and spleen samples and bacteremia (14%), compared with 82% of BT in liver and spleen samples of IO and LR-treated rats and bacteremia (57%). Local intestinal damage was attenuated, and renal and hepatic function preserved by treatment with HS followed by enterectomy. Survival rate increased to 86% up to 15 days. Data presented suggest that HS solution followed by enterectomy reduces mesenteric microcirculatory dysfunctions and BT, attenuating local and remote damage in a model of strangulated small bowel obstruction.
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Hypertonic fluid administration in patients with septic shock: a prospective randomized controlled pilot study. Shock 2012; 37:268-75. [PMID: 22089205 DOI: 10.1097/shk.0b013e31823f152f] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We assessed the short-term effects of hypertonic fluid versus isotonic fluid administration in patients with septic shock. This was a double-blind, prospective randomized controlled trial in a 15-bed intensive care unit. Twenty-four patients with septic shock were randomized to receive 250 mL 7.2% NaCl/6% hydroxyethyl starch (HT group) or 500 mL 6% hydroxyethyl starch (IT group). Hemodynamic measurements included mean arterial blood pressure (MAP), central venous pressure, stroke volume index, stroke volume variation, intrathoracic blood volume index, gastric tonometry, and sublingual microcirculatory flow as assessed by sidestream dark field imaging. Systolic tissue Doppler imaging velocities of the medial mitral annulus were measured using echocardiography to assess left ventricular contractility. Log transformation of the ratio MAP divided by the norepinephrine infusion rate (log MAP/NE) quantified the combined effect on both parameters. Compared with the IT group, hypertonic solution treatment resulted in an improvement in log MAP/NE (P = 0.008), as well as an increase in systolic tissue Doppler imaging velocities (P = 0.03) and stroke volume index (P = 0.017). No differences between the groups were found for preload parameters (central venous pressure, stroke volume variation, intrathoracic blood volume index) or for afterload parameters (systemic vascular resistance index, MAP). Hypertonic solution treatment decreased the need for ongoing fluid resuscitation (P = 0.046). No differences between groups were observed regarding tonometry or the sublingual microvascular variables. In patients with septic shock, hypertonic fluid administration did not promote gastrointestinal mucosal perfusion or sublingual microcirculatory blood flow in comparison to isotonic fluid. Independent of changes in preload or afterload, hypertonic fluid administration improved the cardiac contractility and vascular tone compared with isotonic fluid. The need for ongoing fluid resuscitation was also reduced.
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12
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Seller-Pérez G, Herrera-Gutiérrez ME, Aragón-González C, Granados MM, Dominguez JM, Navarrete R, Quesada-García G, Morgaz J, Gómez-Villamandos R. Bladder mucosal CO2 compared with gastric mucosal CO2 as a marker for low perfusion states in septic shock. ScientificWorldJournal 2012; 2012:360378. [PMID: 22593678 PMCID: PMC3349138 DOI: 10.1100/2012/360378] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 11/02/2011] [Indexed: 11/17/2022] Open
Abstract
Recent reports indicate the possible role of bladder CO(2) as a marker of low perfusion states. To test this hypothesis, shock was induced in six beagle dogs with 1 mg/kg of E. coli lipopolysaccharide, gastric CO(2) (CO(2)-G) was measured with a continuous monitor, and a pulmonary catheter was inserted in the bladder to measure CO(2) (CO(2)-B). Levels of CO(2)-B were found to be lower than those of CO(2)-G, with a mean difference of 36.8 mmHg (P < 0.001), and correlation between both measurements was poor (r(2) = 0.16). Even when the correlation between CO(2)-G and ΔCO(2)-G was narrow (r(2) = 0.86), this was not the case for the relationship between CO(2)-B and ΔCO(2)-B (r(2) = 0.29). Finally, the correlation between CO(2)-G and base deficit was good (r(2) = 0.45), which was not the case with the CO(2)-B correlation (r(2) = 0.03). In our experience, bladder CO(2) does not correlate to hemodynamic parameters and does not substitute gastric CO(2) for detection of low perfusion states.
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Affiliation(s)
- Gemma Seller-Pérez
- Intensive Care Medicine, University Hospital Carlos Haya, 29010 Málaga, Spain
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13
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Assadi A, Desebbe O, Rimmelé T, Florence A, Goudable J, Chassard D, Allaouchiche B. Small-volume hypertonic saline/pentastarch improves ileal mucosal microcirculation in experimental peritonitis. Infect Dis Rep 2012; 4:e22. [PMID: 24470929 PMCID: PMC3892658 DOI: 10.4081/idr.2012.e22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 01/08/2012] [Indexed: 11/23/2022] Open
Abstract
We compared the effects of hypertonic saline 7.2%/6% hydroxyethyl starch (HSS-HES) and isotonic saline 0.9%/6% hydroxyethyl starch (ISS-HES) on ileal microcirculatory blood flow (MBF) at the initial phase of septic shock. Pigs were anesthetized and mechanically ventilated. Catheters were inserted into right atrium, pulmonary artery, carotid artery, and portal vein for hemodynamic measurements and for blood sampling. Ileal mucosal and muscularis MBF was continuously measured by laser Doppler flowmetry (LDF). Septic shock was obtained 240 min after induction of fecal peritonitis; then animals were randomized to receive 10 mL.kg(-1) during 10 min of either HSS-HES or ISS-HES. Systemic and microcirculatory blood flow as well as systemic metabolism were assessed. Fecal peritonitis promoted a hypodynamic septic shock, with significant reduction of mean arterial pressure (MAP) and cardiac index (CI). Ileal mucosal MBF (-34%) and ileal muscularis MBF (-54%) significantly diminished from baseline. Contrary to ISS-HES group, mucosal MBF significantly augmented after HSS-HES (+192% at min 150 post-shock) despite low blood pressure. There was weak correlation with CI (r(2)= 0.2, P=0.01) . Muscularis MBF didn't change. HSS-HES-treated animals had a significantly higher osmolarity and sodium concentration than ISS-HES group. Other variables did not change. Small-volume resuscitation with HSS-HES, but not ISS-HES, improved ileal microcirculatory impairment in experimental peritonitis model of septic shock even when MAP was low. This beneficial microcirculatory effect could be valuable in the management of early severe sepsis.
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Affiliation(s)
- Abdelnasser Assadi
- Inserm ERI 22, Agressions vasculaires-Réponses tissulaires, Claude Bernard University-Lyon 1
| | - Olivier Desebbe
- Inserm ERI 22, Agressions vasculaires-Réponses tissulaires, Claude Bernard University-Lyon 1; ; Department of Anesthesiology and Intensive Care, Louis Pradel Hospital
| | - Thomas Rimmelé
- Inserm ERI 22, Agressions vasculaires-Réponses tissulaires, Claude Bernard University-Lyon 1; ; Department of Anesthesiology and Intensive Care, Edouard Herriot Hospital
| | - Arnal Florence
- Inserm ERI 22, Agressions vasculaires-Réponses tissulaires, Claude Bernard University-Lyon 1
| | - Joëlle Goudable
- Laboratory of Biochemistry, Edouard Herriot hospital, Lyon, France
| | | | - Bernard Allaouchiche
- Inserm ERI 22, Agressions vasculaires-Réponses tissulaires, Claude Bernard University-Lyon 1; ; Department of Anesthesiology and Intensive Care, Edouard Herriot Hospital
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14
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Should We Monitor ScVO(2) in Critically Ill Patients? Cardiol Res Pract 2011; 2012:370697. [PMID: 21941671 PMCID: PMC3177360 DOI: 10.1155/2012/370697] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 07/08/2011] [Accepted: 07/25/2011] [Indexed: 01/20/2023] Open
Abstract
Hemodynamic monitoring has become a real challenge in the intensive care unit. As an integrative parameter for oxygen supply/demand, venous oxygen saturation (SvO2) provided by pulmonary artery catheterization is one of the most popular parameters to assess the adequacy of cardiac output. However, technical limitations and potential iatrogenic complications constitute important limits for a widespread use. Regular central venous catheters coupled with a fiberoptic lumen for central venous oxygen saturation (ScvO2) monitoring have been proposed as a surrogate for SvO2 monitoring. The purpose of the present article is to review the physiological backgrounds of circulation, the pathophysiology of circulatory failure and subsequent venous oxygen saturation alterations, and finally the merits and the limits of the use of ScvO2 in different clinical situations.
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Butler AL, Campbell VL. Assessment of oxygen transport and utilization in dogs with naturally occurring sepsis. J Am Vet Med Assoc 2010; 237:167-73. [DOI: 10.2460/javma.237.2.167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fluid replacement with hypertonic or isotonic solutions guided by mixed venous oxygen saturation in experimental hypodynamic sepsis. ACTA ACUST UNITED AC 2010; 67:1205-12. [PMID: 20009668 DOI: 10.1097/ta.0b013e31818b2567] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Splanchnic perfusion is prone to early injury and persists despite normalization of global hemodynamic variables in sepsis. Volume replacement guided by oxygen derived variables has been recommended in the management of septic patients. Our hypothesis was that a hypertonic isoncotic solution would improve the benefits of crystalloids replacement guided by mixed venous oxygen saturation. METHODS Seventeen anesthetized and mechanically ventilated mongrel dogs received an intravenous infusion of live E. coli in 30 minutes. They were then randomized into three groups: control group (n = 3) bacterial infusion without treatment; normal saline (n = 7), initial fluid replacement with 32 mL/kg of normal saline during 20 minutes; hypertonic solution (n = 7), initial fluid replacement with 4 mL/kg of hypertonic solution during 5 minutes. After 30 and 60 minutes, additional boluses of normal saline were administered when mixed venous oxygen saturation remained below 70%. Mean arterial pressure, cardiac output; regional blood flows, systemic and regional oxygen-derived variables, and lactate levels were assessed. Animals were observed for 90 minutes and then killed. Hystopathological analysis including apoptosis detection using terminal deoxynucleotidil transferase mediated dUTP-biotin nick end labeling was performed. RESULTS A hypodynamic septic shock was observed after bacterial infusion. Both the fluid-treated groups presented similar transient benefits in systemic and regional variables. A greater degree of gut epithelial cells apoptosis was observed in normal saline-treated animals. CONCLUSIONS Although normalization of mixed venous oxygen saturation was not associated with restoration of markers of splanchnic or other systemic perfusion variables, the initial fluid savings with hypertonic saline and its latter effect on gut apoptosis may be of interest in sepsis management.
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Reis MB, del Pilar Gallardo Garrido A, Cruz Junior RJ, Ribeiro EA, Rocha e Silva M, Poli de Figueiredo LF. Early Restoration of Cocaine-Induced Splanchnic Hypoperfusion in Anesthetized Dogs. J INVEST SURG 2009; 20:291-9. [DOI: 10.1080/08941930701598800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Zanoni FL, Benabou S, Greco KV, Moreno ACR, Cruz JWMC, Filgueira FP, Martinez MB, Figueiredo LFPD, Silva MRE, Sannomiya P. Mesenteric microcirculatory dysfunctions and translocation of indigenous bacteria in a rat model of strangulated small bowel obstruction. Clinics (Sao Paulo) 2009; 64:911-9. [PMID: 19759886 PMCID: PMC2745135 DOI: 10.1590/s1807-59322009000900013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 06/11/2009] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Bacterial translocation has been shown to occur in critically ill patients after extensive trauma, shock, sepsis, or thermal injury. The present study investigates mesenteric microcirculatory dysfunctions, the bacterial translocation phenomenon, and hemodynamic/metabolic disturbances in a rat model of intestinal obstruction and ischemia. METHODS Anesthetized (pentobarbital 50 mg/kg, i.p.) male Wistar rats (250-350 g) were submitted to intestinal obstruction or laparotomy without intestinal obstruction (Sham) and were evaluated 24 hours later. Bacterial translocation was assessed by bacterial culture of the mesenteric lymph nodes (MLN), liver, spleen, and blood. Leukocyte-endothelial interactions in the mesenteric microcirculation were assessed by intravital microscopy, and P-selectin and intercellular adhesion molecule (ICAM)-1 expressions were quantified by immunohistochemistry. Hematocrit, blood gases, lactate, glucose, white blood cells, serum urea, creatinine, bilirubin, and hepatic enzymes were measured. RESULTS About 86% of intestinal obstruction rats presented positive cultures for E. coli in samples of the mesenteric lymph nodes, liver, and spleen, and 57% had positive hemocultures. In comparison to the Sham rats, intestinal obstruction induced neutrophilia and increased the number of rolling (approximately 2-fold), adherent (approximately 5-fold), and migrated leukocytes (approximately 11-fold); this increase was accompanied by an increased expression of P-selectin (approximately 2-fold) and intercellular adhesion molecule-1 (approximately 2-fold) in the mesenteric microcirculation. Intestinal obstruction rats exhibited decreased PaCO2, alkalosis, hyperlactatemia, and hyperglycemia, and increased blood potassium, hepatic enzyme activity, serum urea, creatinine, and bilirubin. A high mortality rate was observed after intestinal obstruction (83% at 72 h vs. 0% in Sham rats). CONCLUSION Intestinal obstruction and ischemia in rats is a relevant model for the in vivo study of mesenteric microcirculatory dysfunction and the occurrence of bacterial translocation. This model parallels the events implicated in multiple organ dysfunction (MOD) and death.
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Affiliation(s)
- Fernando Luiz Zanoni
- Heart Institute (InCor), LIM 11, University of São Paulo Medical School, São Paulo/SP, Brazil.
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Silva E, Passos RDH, Ferri MB, de Figueiredo LFP. Sepsis: from bench to bedside. Clinics (Sao Paulo) 2008; 63:109-20. [PMID: 18297215 PMCID: PMC2664172 DOI: 10.1590/s1807-59322008000100019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Accepted: 09/14/2007] [Indexed: 01/04/2023] Open
Abstract
Sepsis is a syndrome related to severe infections. It is defined as the systemic host response to microorganisms in previously sterile tissues and is characterized by end-organ dysfunction away from the primary site of infection. The normal host response to infection is complex and aims to identify and control pathogen invasion, as well as to start immediate tissue repair. Both the cellular and humoral immune systems are activated, giving rise to both anti-inflammatory and proinflammatory responses. The chain of events that leads to sepsis is derived from the exacerbation of these mechanisms, promoting massive liberation of mediators and the progression of multiple organ dysfunction. Despite increasing knowledge about the pathophysiological pathways and processes involved in sepsis, morbidity and mortality remain unacceptably high. A large number of immunomodulatory agents have been studied in experimental and clinical settings in an attempt to find an efficacious anti-inflammatory drug that reduces mortality. Even though preclinical results had been promising, the vast majority of these trials actually showed little success in reducing the overwhelmingly high mortality rate of septic shock patients as compared with that of other critically ill intensive care unit patients. Clinical management usually begins with prompt recognition, determination of the probable infection site, early administration of antibiotics, and resuscitation protocols based on "early-goal" directed therapy. In this review, we address the research efforts that have been targeting risk factor identification, including genetics, pathophysiological mechanisms and strategies to recognize and treat these patients as early as possible.
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Affiliation(s)
- Eliézer Silva
- Research Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil.
| | - Rogério Da Hora Passos
- Research Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil.
| | - Maurício Beller Ferri
- Research Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil.
| | - Luiz Francisco Poli de Figueiredo
- Research Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil.
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Assadi A, Desebbe O, Kaminski C, Rimmelé T, Bénatir F, Goudable J, Chassard D, Allaouchiche B. Effects of sodium nitroprusside on splanchnic microcirculation in a resuscitated porcine model of septic shock. Br J Anaesth 2008; 100:55-65. [DOI: 10.1093/bja/aem278] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Nakagawa NK, Jukemura J, Aikawa P, Nogueira RA, Poli-de-Figueiredo LF, Sannomiya P. In vivo observation of mesenteric leukocyte-endothelial interactions after cecal ligation/puncture and surgical sepsis source control. Clinics (Sao Paulo) 2007; 62:321-6. [PMID: 17589674 DOI: 10.1590/s1807-59322007000300018] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Accepted: 12/20/2006] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Cecal ligation and puncture (CLP) has been used as a useful model for the induction of polymicrobial sepsis. Necrotic tissue resection and peritoneal lavage (REL) are the surgical procedures for controlling perforated appendicitis. The aim of this study was to evaluate leukocyte-endothelial interactions in the rat mesentery in vivo after CLP and REL. METHODS Thirty-seven male Wistar rats (250-300 g) underwent laparotomy and were randomly assigned to the following groups: 1) SHAM; 2) CLP: animals submitted to CLP, 3) CLP+REL: animals submitted to CLP and REL. Mesenteric leukocyte-endothelial interactions were studied by intravital microscopy assessed once in each animal (3-5 postcapillary venules, 15-25 microm diameter) 24 hours after intervention. Follow-up was performed in all animals; this included analysis of glycemia, lactate, hematocrit, white blood cell count as well as a functional score that was the sum of scoring on the following parameters: alertness, mobility, piloerection, diarrhea, encrusted eyes, and dirty nose and tail. RESULTS None of the animals showed significant changes in body weight (265 +/- 20 g) or in hematocrit levels (46% +/- 2%) during the experimental protocol. Compared to SHAM animals, CLP animals showed an increased number of rolling (2x), adherent, and migrating leukocytes (7x) in the mesenteric microcirculation, an increase in blood glucose (136 +/- 8 mg/dL), lactate (3.58 +/- 0.94 mmol/L), white cell count (23,570 +/- 4,991 cells/mm(3)) and functional alterations (score 11 +/- 1), characterized by impaired alertness and mobility, and presence of piloerection, diarrhea, encrusted eyes, and dirty nose and tail. The REL procedure normalized the number of rolling, adherent, and migrated leukocytes in the mesentery; glycemia; lactate; and white blood cell count. The REL procedure also improved the functional score (7 +/- 1). CONCLUSION Local and systemic inflammation was induced by CLP, while REL completely overcame the inflammatory process.
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Affiliation(s)
- Naomi K Nakagawa
- Research Division, Heart Institute, InCor, University of Sao Paulo School of Medicine, São Paulo, SP, Brazil.
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Lagoa CE, Bartels J, Baratt A, Tseng G, Clermont G, Fink MP, Billiar TR, Vodovotz Y. The role of initial trauma in the host's response to injury and hemorrhage: insights from a correlation of mathematical simulations and hepatic transcriptomic analysis. Shock 2007; 26:592-600. [PMID: 17117135 DOI: 10.1097/01.shk.0000232272.03602.0a] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Trauma and hemorrhagic shock (HS) elicit severe physiological disturbances that predispose the victims to subsequent organ dysfunction and death. The general lack of effective therapeutic options for these patients is mainly due to the complex interplay of interacting inflammatory and physiological elements working at multiple levels. Systems biology has emerged as a new paradigm that allows the study of large portions of physiological networks simultaneously. Seeking a better understanding of the interplay among known inflammatory pathways, we constructed a mathematical model encompassing the dynamics of the acute inflammatory response that incorporates the intertwined effects of inflammation and global tissue damage. The model was calibrated using data from C57Bl/6 mice subjected to endotoxemia, sham operation (i.e., surgical trauma induced by cannulation [ST]) or ST + HS+ resuscitation (ST-HS-R). An in silico simulation, made at whole-organism level, suggested that similar pathways of different magnitudes were operant as the degree of total body damage increased. We sought to validate this hypothesis by subjecting mice to HS and comparing the models predictions to circulating markers of inflammation and tissue injury as well as the global transcriptomic response of the liver. C57Bl/6 mice were subjected to ST or ST-HS (without resuscitation). Liver gene expression was assessed using an Affymetrix DNA microarray (GeneChip Mouse Expression Set 430A, Affymetrix, Santa Clara, CA), which contains 22,621 probe sets and effectively interrogates 12,341 mouse genes. The microarray data sets were subjected to hierarchical clustering and pathway analysis. In agreement with model predictions, circulating levels of inflammation/tissue injury markers and the microarray analysis both demonstrated that ST alone accounts for a substantial proportion of the observed phenotypic and genetic/molecular changes versus untreated animals. The addition of HS further increased the magnitude of gene expression, but relatively few additional genes were recruited. Mathematical simulations and DNA microarrays, both systems biology tools, may provide valuable insight into the complex global physiological interactions that occur in response to trauma and hemorrhagic shock.
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Affiliation(s)
- Claudio E Lagoa
- Department of Surgery, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Garrido ADPG, Cruz RJ, de Figueiredo LFP, e Silva MR. Small volume of hypertonic saline as the initial fluid replacement in experimental hypodynamic sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R62. [PMID: 16613615 PMCID: PMC1550924 DOI: 10.1186/cc4901] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2006] [Revised: 02/28/2006] [Accepted: 03/17/2006] [Indexed: 01/13/2023]
Abstract
INTRODUCTION We conducted the present study to examine the effects of hypertonic saline solution (7.5%) on cardiovascular function and splanchnic perfusion in experimental sepsis. METHODS Anesthetized and mechanically ventilated mongrel dogs received an intravenous infusion of live Escherichia coli over 30 minutes. After 30 minutes, they were randomized to receive lactated Ringer's solution 32 ml/kg (LR; n = 7) over 30 minutes or 7.5% hypertonic saline solution 4 ml/kg (HS; n = 8) over 5 minutes. They were observed without additional interventions for 120 minutes. Cardiac output (CO), mean arterial pressure (MAP), portal and renal blood flow (PBF and RBF, respectively), gastric partial pressure of CO2 (pCO2; gas tonometry), blood gases and lactate levels were assessed. RESULTS E. coli infusion promoted significant reductions in CO, MAP, PBF and RBF (approximately 45%, 12%, 45% and 25%, respectively) accompanied by an increase in lactate levels and systemic and mesenteric oxygen extraction (sO2ER and mO2ER). Widening of venous-arterial (approximately 15 mmHg), portal-arterial (approximately 18 mmHg) and gastric mucosal-arterial (approximately 55 mmHg) pCO2 gradients were also observed. LR and HS infusion transiently improved systemic and regional blood flow. However, HS infusion was associated with a significant and sustained reduction of systemic (18 +/- 2.6 versus 38 +/- 5.9%) and mesenteric oxygen extraction (18.5 +/- 1.9 versus 36.5 +/- 5.4%), without worsening other perfusional markers. CONCLUSION A large volume of LR or a small volume of HS promoted similar transient hemodynamic benefits in this sepsis model. However, a single bolus of HS did promote sustained reduction of systemic and mesenteric oxygen extraction, suggesting that hypertonic saline solution could be used as a salutary intervention during fluid resuscitation in septic patients.
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Affiliation(s)
| | - Ruy Jorge Cruz
- Research Division, Heart Institute (InCor), University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | | | - Maurício Rocha e Silva
- Research Division, Heart Institute (InCor), University of Sao Paulo School of Medicine, Sao Paulo, Brazil
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Rahal L, Garrido AG, Cruz RJ, Rocha e Silva M, Poli-de-Figueiredo LF. Systemic and regional hemodynamic effects of enalaprilat infusion in experimental normotensive sepsis. Braz J Med Biol Res 2006; 39:1205-15. [PMID: 16981048 DOI: 10.1590/s0100-879x2006000900008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Accepted: 06/28/2006] [Indexed: 11/21/2022] Open
Abstract
Angiotensin-converting enzyme inhibitors have been shown to improve splanchnic perfusion in distinct shock states. We hypothesized that enalaprilat potentiates the benefits of early fluid resuscitation in severe experimental sepsis, particularly in the splanchnic region. Anesthetized and mechanically ventilated mongrel dogs received an intravenous infusion of live Escherichia coli over a period of 30 min. Thereafter, two interventions were performed: fluid infusion (normal saline, 32 mL/kg over 30 min) and enalaprilat infusion (0.02 mg kg(-1) min(-1) for 60 min) in randomized groups. The following groups were studied: controls (fluid infusion, N = 4), E1 (enalaprilat infusion followed by fluid infusion, N = 5) and E2 (fluid infusion followed by enalaprilat infusion, N = 5). All animals were observed for a 120 min after bacterial infusion. Mean arterial pressure, cardiac output (CO), portal vein blood flow (PVBF), systemic and regional oxygen-derived variables, and lactate levels were measured. Rapid and progressive reductions in CO and PVBF were induced by the infusion of live bacteria, while minor changes were observed in mean arterial pressure. Systemic and regional territories showed a significant increase in oxygen extraction and lactate levels. Widening venous-arterial and portal-arterial pCO2 gradients were also detected. Fluid replacement promoted transient benefits in CO and PVBF. Enalaprilat after fluid resuscitation did not affect systemic or regional hemodynamic variables. We conclude that in this model of normotensive sepsis inhibition of angiotensin-converting enzyme did not interfere with the course of systemic or regional hemodynamic and oxygen-derived variables.
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Affiliation(s)
- L Rahal
- Divisão de Experimentação, Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Cruz RJ, Yada-Langui MM, Garrido AG, Figueiredo LFPD, Rocha e Silva M. [Early effects of 7.5% hypertonic saline solution on splanchnic perfusion after hemorrhagic shock]. Acta Cir Bras 2006; 21:106-12. [PMID: 16583064 DOI: 10.1590/s0102-86502006000200010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate the effects of SSH resuscitation on systemic and splanchnic hemodynamic variables in an experimental model of controlled hemorrhagic shock. METHODS Ten mongrel dogs were bled (20 ml/min) to a target mean arterial pressure (MAP) of 40+/-5 mmHg. After 30 minutes of shock, animals received SSH infused in 5-minute and they were observed for 60 minutes thereafter. Systemic hemodynamics were evaluated through a Swan-Ganz and arterial catheters while gastrointestinal tract perfusion by a catheter inside the portal vein, an ultrasonic flowprobe around portal vein blood flow (PVBF) and a gastric tonometer. Splanchnic oxygen delivery and consumption, intramucosal pH and veno-arterial, portal-arterial and mucosal-arterial pCO2-gradients (D(ap-a)pCO2, D(vp-a)pCO2 e D(t-a)pCO2, respectively) were assessed. RESULTS Hemorrhage (29.8+/-2.4 ml/Kg) induced significant decreases in MAP (125+/-6 to 42+/-1 mmHg), in CO (1.9+/-0.2 to 0.6+/-0.1 L/min), and PVBF (504+/-73 to 126+/-12 ml/min) while significant increases were detected in D(ap-a)pCO2 (5.3+/-0.8 to 19.9+/-1.6 mmHg) D(vp-a)pCO2 (5.4+/-1.4 to 22.6+/-2.1 mmHg) and D(t-a)pCO2 (6.1+/-1.1 to 43.8+/-7.5 mmHg). SSH infusion promoted only partial benefits in systemic and splanchnic blood flows. Reduced pCO2 gradients but fewer effects in D(t-a)pCO2 were observed. CONCLUSION The SSH infusion promoted partial systemic and splanchnic hemodynamic benefits. Those benefits were especially poor at the splanchnic microcirculation, as evaluated by D(t-a)pCO2. In addition, systemic and regional oxygen-derived variables do not reflect the regional microcirculation disturbances. Gastrointestinal tonometry clearly represents a useful tool for monitoring splanchnic perfusion in patients in hemodynamic shock.
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Affiliation(s)
- Ruy Jorge Cruz
- Serviço de Fisiologia Aplicada, Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, Brazil.
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Abstract
The best strategy for volume therapy has been the focus of debate and there are still no unique accepted guidelines. There is increasing evidence that some plasma substitutes possess additional effects on organ perfusion, microcirculation, tissue oxygenation, inflammation, endothelial activation, capillary leakage, and tissue edema that are beyond their volume replacing properties. Whether the different plasma substitutes differ with regard this additional effects was reviewed. The additional effects of plasma substitutes have mostly been studied experimentally or in animals, much less results are available in humans. The results are not uniform ranging from beneficial to even detrimental effects of a certain volume replacement strategy. Some important results from the literature are not reflected in the actual recommendations for treating volume deficits in the critically ill: although crystalloids have been shown to have considerable negative effects on microcirculation, organ perfusion, tissue oxygenation, and endothelial integrity, they are still often recommended as first choice volume replacement strategy. In several experimental studies hypertonic solutions have been shown to have various beneficial effects, they have not been, however, translated into humans. In future, the choice of the ideal volume replacement regimen should not only be focused on its volume restoring properties, but additional effects (e.g. on organ perfusion on, tissue oxygenation, inflammation, endothelial activation, capillary leakage) should also be taken into account when treating hypovolemia in the critically ill.
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Affiliation(s)
- Joachim Boldt
- Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Bremserstrasse 79, D-67063 Ludwigshafen, Germany.
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Cruz RJ, Correia CJ, Poli-de-Figueiredo LF, Rocha-e-Silva M. [Initial evaluation of systemic and regional pCO2 gradients as markers of mesenteric hypoperfusion]. ARQUIVOS DE GASTROENTEROLOGIA 2006; 43:59-65. [PMID: 16699621 DOI: 10.1590/s0004-28032006000100015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
BACKGROUND Mesenteric ischemia is a life-threatening emergency with a mortality rates still ranging between 60% and 100%. AIM To evaluate the systemic and regional pCO2 gradients changes induced by mesenteric ischemia-reperfusion injury. In addition, we sought to determine if other systemic marker of splanchnic hypoperfusion could detect the initial changes in intestinal mucosal microcirculation after superior mesenteric artery occlusion. METHODS Seven pentobarbital anesthetized mongrel dogs (20.6 +/- 1.1 kg) were subjected to superior mesenteric artery occlusion for 45 minutes, and followed for an additional 120 minutes. Systemic hemodynamic was evaluated through a Swan-Ganz and arterial catheters, while gastrointestinal tract perfusion by superior mesenteric vein and jejunal serosal blood flows (ultrasonic flowprobe). Intestinal oxygen delivery, extraction and consumption (DO2intest, ERO2intest and VO2intest, respectively), intramucosal pH (gas tonometry), and mesenteric-arterial and mucosal arterial pCO2 gradients (D(vm-a)pCO2 and D(t-a)pCO2, respectively) were calculated. RESULTS Superior mesenteric artery occlusion was not associated with significant changes on systemic hemodynamics parameters. A significant increase of D(vm-a)pCO2 (1.7 +/- 0.5 to 5.7 +/- 1.8 mm Hg) and D(t-a)pCO2 (8.2 +/- 4.8 to 48.7 +/- 4.6 mm Hg) were detected. During the reperfusion period a significant decrease on DO2intest (67.7 +/- 9.9 to 38.8 +/- 5.3 mL/min) and a compensatory increase on ERO2intest from 5.0 +/- 1.1% to 12.4 +/- 2.7% was observed. CONCLUSION We conclude that gas tonometry can detect the mesenteric blood flow disturbances sooner than other analyzed parameters. Additionally, we demonstrated that changes on systemic or regional pCO2 gradients are not able to detect the magnitude of intestinal mucosal blood flow reduction after mesenteric ischemia-reperfusion injury.
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Affiliation(s)
- Ruy J Cruz
- Serviço de Fisiologia Aplicada, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP.
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Garrido AG, Poli de Figueiredo LF, Cruz RJ, Silva E, Rocha E Silva M. Short-lasting systemic and regional benefits of early crystalloid infusion after intravenous inoculation of dogs with live Escherichia coli. Braz J Med Biol Res 2005; 38:873-84. [PMID: 15933781 DOI: 10.1590/s0100-879x2005000600009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We investigated the systemic and regional hemodynamic effects of early crystalloid infusion in an experimental model of septic shock induced by intravenous inoculation with live Escherichia coli. Anesthetized dogs received an intravenous infusion of 1.2 x 10(10) cfu/kg live E. coli in 30 min. After 30 min of observation, they were randomized to controls (no fluids; N = 7), or fluid resuscitation with lactated Ringer's solution, 16 ml/kg (N = 7) or 32 ml/kg (N = 7) over 30 min and followed for 120 min. Cardiac index, portal blood flow, mean arterial pressure, systemic and regional oxygen-derived variables, blood lactate, and gastric PCO2 were assessed. Rapid and progressive cardiovascular deterioration with reduction in cardiac output, mean arterial pressure and portal blood flow (approximately 50, approximately 25 and approximately 70%, respectively) was induced by the live bacteria challenge. Systemic and regional territories showed significant increases in oxygen extraction and in lactate levels. Significant increases in venous-arterial (approximately 9.6 mmHg), portal-arterial (approximately 12.1 mmHg) and gastric mucosal-arterial (approximately 18.4 mmHg) PCO2 gradients were also observed. Early fluid replacement, especially with 32 ml/kg volumes of crystalloids, promoted only partial and transient benefits such as increases of approximately 76% in cardiac index, of approximately 50% in portal vein blood flow and decreases in venous-arterial, portal-arterial, gastric mucosal-arterial PCO2 gradients (7.2 +/- 1.0, 7.2 +/- 1.3 and 9.7 +/- 2.5 mmHg, respectively). The fluid infusion promoted only modest and transient benefits, unable to restore the systemic and regional perfusional and metabolic changes in this hypodynamic septic shock model.
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Affiliation(s)
- A G Garrido
- Serviço de Fisiologia aplicada, InCor, Hospital das Clínicas, Universidade de São Paulo, SP, Brasil
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O'Brien JM, Ali NA, Abraham E. Year in review in Critical Care, 2004: sepsis and multi-organ failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:409-13. [PMID: 16137392 PMCID: PMC1269453 DOI: 10.1186/cc3728] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- James M O'Brien
- Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Medical Center, Columbus, Ohio, USA.
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Anel R, Kumar A. Human endotoxemia and human sepsis: limits to the model. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:151-2. [PMID: 15774069 PMCID: PMC1175943 DOI: 10.1186/cc3501] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Sepsis remains the most common cause of death in intensive care units of the developed world. Accurate models of this disease syndrome are crucial for to the understanding of the complex pathophysiology of this disorder. The administration of a small dose of lipopolysaccharide to healthy volunteers is one such model of spontaneous human sepsis. Although this human endotoxemia model appears to be reasonably effective in mimicking early biochemical, metabolic, hematologic and cardiovascular septic responses in septic shock, the ability to mimic other aspects of human sepsis is open to question. The current study demonstrates that human experimental endotoxemia fails to generate evidence of increased vascular permeability within the relatively short time frame of the study.
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Affiliation(s)
- Ramon Anel
- Assistant Professor, Section of Critical Care Medicine, Section of Nephrology, University of North Dakota, Grand Forks, North Dakota, USA
| | - Anand Kumar
- Associate Professor, Section of Critical Care Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Canada, and University of Medicine and Dentistry, UMDNJ, Camden, New Jersey, USA
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Dubin A, Murias G, Maskin B, Pozo MO, Sottile JP, Barán M, Edul VSK, Canales HS, Badie JC, Etcheverry G, Estenssoro E. Increased blood flow prevents intramucosal acidosis in sheep endotoxemia: a controlled study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:R66-73. [PMID: 15774052 PMCID: PMC1175914 DOI: 10.1186/cc3021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2004] [Revised: 11/21/2004] [Accepted: 11/22/2004] [Indexed: 01/20/2023]
Abstract
Introduction Increased intramucosal–arterial carbon dioxide tension (PCO2) difference (ΔPCO2) is common in experimental endotoxemia. However, its meaning remains controversial because it has been ascribed to hypoperfusion of intestinal villi or to cytopathic hypoxia. Our hypothesis was that increased blood flow could prevent the increase in ΔPCO2. Methods In 19 anesthetized and mechanically ventilated sheep, we measured cardiac output, superior mesenteric blood flow, lactate, gases, hemoglobin and oxygen saturations in arterial, mixed venous and mesenteric venous blood, and ileal intramucosal PCO2 by saline tonometry. Intestinal oxygen transport and consumption were calculated. After basal measurements, sheep were assigned to the following groups, for 120 min: (1) sham (n = 6), (2) normal blood flow (n = 7) and (3) increased blood flow (n = 6). Escherichia coli lipopolysaccharide (5 μg/kg) was injected in the last two groups. Saline solution was used to maintain blood flood at basal levels in the sham and normal blood flow groups, or to increase it to about 50% of basal in the increased blood flow group. Results In the normal blood flow group, systemic and intestinal oxygen transport and consumption were preserved, but ΔPCO2 increased (basal versus 120 min endotoxemia, 7 ± 4 versus 19 ± 4 mmHg; P < 0.001) and metabolic acidosis with a high anion gap ensued (arterial pH 7.39 versus 7.35; anion gap 15 ± 3 versus 18 ± 2 mmol/l; P < 0.001 for both). Increased blood flow prevented the elevation in ΔPCO2 (5 ± 7 versus 9 ± 6 mmHg; P = not significant). However, anion-gap metabolic acidosis was deeper (7.42 versus 7.25; 16 ± 3 versus 22 ± 3 mmol/l; P < 0.001 for both). Conclusions In this model of endotoxemia, intramucosal acidosis was corrected by increased blood flow and so might follow tissue hypoperfusion. In contrast, anion-gap metabolic acidosis was left uncorrected and even worsened with aggressive volume expansion. These results point to different mechanisms generating both alterations.
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Affiliation(s)
- Arnaldo Dubin
- Medical Director, Intensive Care Unit, Sanatorio Otamendi y Miroli, Buenos Aires Argentina
| | - Gastón Murias
- Staff Physician, Intensive Care Unit, Clinicas Bazterrica y Santa Isabel, Buenos Aires, Argentina
| | - Bernardo Maskin
- Medical Director, Intensive Care Unit, Hospital Posadas, Buenos Aires, Argentina
| | - Mario O Pozo
- Staff Physician, Intensive Care Unit, Clinicas Bazterrica y Santa Isabel, Buenos Aires, Argentina
| | - Juan P Sottile
- Research Fellow, Cátedra de Farmacología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Argentina
| | - Marcelo Barán
- Medical Director, Renal Transplantation Unit, CRAI Sur, CUCAIBA, Argentina
| | - Vanina S Kanoore Edul
- Research Fellow, Cátedra de Farmacología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Argentina
| | - Héctor S Canales
- Staff Physician, Intensive Care Unit, Hospital San Martin de la Plata, Argentina
| | - Julio C Badie
- Research Fellow, Cátedra de Farmacología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Argentina
| | - Graciela Etcheverry
- Staff Physician, Clinical Chemistry Laboratory, Hospital San Martin de La Plata, Argentina
| | - Elisa Estenssoro
- Medical Director, Intensive Care Unit, Hospital San Martin de la Plata, Argentina
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