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Chen X, Yuan S, Mi L, Long Y, He H. Pannexin1: insight into inflammatory conditions and its potential involvement in multiple organ dysfunction syndrome. Front Immunol 2023; 14:1217366. [PMID: 37711629 PMCID: PMC10498923 DOI: 10.3389/fimmu.2023.1217366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/10/2023] [Indexed: 09/16/2023] Open
Abstract
Sepsis represents a global health concern, and patients with severe sepsis are at risk of experiencing MODS (multiple organ dysfunction syndrome), which is associated with elevated mortality rates and a poorer prognosis. The development of sepsis involves hyperactive inflammation, immune disorder, and disrupted microcirculation. It is crucial to identify targets within these processes to develop therapeutic interventions. One such potential target is Panx1 (pannexin-1), a widely expressed transmembrane protein that facilitates the passage of molecules smaller than 1 KDa, such as ATP. Accumulating evidence has implicated the involvement of Panx1 in sepsis-associated MODS. It attracts immune cells via the purinergic signaling pathway, mediates immune responses via the Panx1-IL-33 axis, promotes immune cell apoptosis, regulates blood flow by modulating VSMCs' and vascular endothelial cells' tension, and disrupts microcirculation by elevating endothelial permeability and promoting microthrombosis. At the level of organs, Panx1 contributes to inflammatory injury in multiple organs. Panx1 primarily exacerbates injury and hinders recovery, making it a potential target for sepsis-induced MODS. While no drugs have been developed explicitly against Panx1, some compounds that inhibit Panx1 hemichannels have been used extensively in experiments. However, given that Panx1's role may vary during different phases of sepsis, more investigations are required before interventions against Panx1 can be applied in clinical. Overall, Panx1 may be a promising target for sepsis-induced MODS. Nevertheless, further research is needed to understand its complex role in different stages of sepsis fully and to develop suitable pharmaceutical interventions for clinical use.
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Affiliation(s)
| | | | | | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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2
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Assessment of left and right ventricular Tei indices in critically ill children with septic shock. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Wencheng H, Zhang W, An Y, Huang L, Luo H. Impact of Pulmonary Arterial Hypertension on Systemic Inflammation, Cardiac Injury and Hemodynamics in Sepsis: A retrospective study from MIMIC-III. Am J Med Sci 2022; 363:311-321. [PMID: 35038420 DOI: 10.1016/j.amjms.2021.12.009] [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: 01/08/2021] [Revised: 08/27/2021] [Accepted: 12/07/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Sepsis and pulmonary arterial hypertension (PAH) may both present in a single patient in the intensive care unit. The impact of PAH on the sepsis process is not well understood. Here we assess the effect of PAH in patients with sepsis from multiple perspectives. METHODS Patients with sepsis with or without PAH underwent propensity score matching according to age, sex and ethnicity. Clinical complications, hemodynamics, and laboratory examinations, including heart injury and inflammation, were compared between the 2 groups. We aimed to model the relationship between the severity of PAH and systemic inflammation levels using linear regression analysis. Factors associated with 28-day and one-year mortality in patients with sepsis with PAH were also analyzed using binary logistic regression. RESULTS A total of 285 pairs of patients with sepsis with or without PAH were included in the analysis. There were no significant differences in the C-reactive protein (CRP), white blood cell (WBC), or lactate levels or neutrophil percentage between the 2 groups, and the mean pulmonary arterial pressure and N-terminal pro b-type natriuretic peptide (NTproBNP) level did not correlate with CRP, WBC or lactate. The cardiac injury indexes were significantly higher in the PAH group. Lower mean arterial pressure was found in patients with PAH. Longer ventilation duration was a risk factor for, while obesity was protective against, both short- and long-term mortality in patients with sepsis with PAH. CONCLUSIONS PAH had little effect on the inflammation profile in sepsis, but it may worsen the sepsis outcome by impairing cardiac function and subsequent hemodynamic stability.
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Affiliation(s)
- He Wencheng
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen Peking University - The Hong Kong University of Science and Technology Medical Center, Shenzhen, Guangdong, China; Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Weixing Zhang
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Youzhong An
- Department of Intensive Care Unit, Peking University People's Hospital, Beijing, China
| | - Lei Huang
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Hua Luo
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China.
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Kemper DAG, Otsuki DA, Maia DRR, Mossoco CDO, Marcasso RA, Cunha LCC, Auler JOC, Fantoni DT. Sildenafil in endotoxin-induced pulmonary hypertension: an experimental study. Braz J Anesthesiol 2021:S0104-0014(21)00239-6. [PMID: 34118261 PMCID: PMC10362450 DOI: 10.1016/j.bjane.2021.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Sepsis and septic shock still represent great challenges in critical care medicine. Sildenafil has been largely used in the treatment of pulmonary arterial hypertension, but its effects in sepsis are unknown. The aim of this study was to investigate the hypothesis that sildenafil can attenuate endotoxin-induced pulmonary hypertension in a porcine model of endotoxemia. METHODS Twenty pigs were randomly assigned to Control group (n = 10), which received saline solution; or to Sildenafil group (n = 10), which received sildenafil orally (100 mg). After 30 minutes, both groups were submitted to endotoxemia with intravenous bacterial lipopolysaccharide endotoxin (LPS) infusion (4 µg.kg-1.h-1) for 180 minutes. We evaluated hemodynamic and oxygenation functions, and also lung histology and plasma cytokine (TNFα, IL-1β, IL6, and IL10) and troponin I response. RESULTS Significant hemodynamic alterations were observed after 30 minutes of LPS continuous infusion, mainly in pulmonary arterial pressure (from Baseline 19 ± 2 mmHg to LPS30 52 ± 4 mmHg, p < 0.05). There was also a significant decrease in PaO2/FiO2 (from Baseline 411 ± 29 to LPS180 334 ± 49, p < 0.05). Pulmonary arterial pressure was significantly lower in the Sildenafil group (35 ± 4 mmHg at LPS30, p < 0.05). The Sildenafil group also presented lower values of systemic arterial pressure. Sildenafil maintained oxygenation with higher PaO2/FiO2 and lower oxygen extraction rate than Control group but had no effect on intrapulmonary shunt. All cytokines and troponin increased after LPS infusion in both groups similarly. CONCLUSION Sildenafil attenuated endotoxin-induced pulmonary hypertension preserving the correct heart function without improving lung lesions or inflammation.
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Affiliation(s)
- Daniella Aparecida Godoi Kemper
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, LIM08 - Laboratório de Anestesiologia, São Paulo, SP, Brazil
| | - Denise Aya Otsuki
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, LIM08 - Laboratório de Anestesiologia, São Paulo, SP, Brazil
| | - Débora Rothstein Ramos Maia
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, LIM08 - Laboratório de Anestesiologia, São Paulo, SP, Brazil
| | - Cristina de Oliveira Mossoco
- Universidade de São Paulo, Faculdade de Medicina Veterinária e Zootecnia, Departamento de Patologia, São Paulo, SP, Brazil
| | | | - Ligia Cristina Câmara Cunha
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | - José Otávio Costa Auler
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, LIM08 - Laboratório de Anestesiologia, São Paulo, SP, Brazil.
| | - Denise Tabacchi Fantoni
- Universidade de São Paulo, Faculdade de Medicina Veterinária e Zootecnia, Departamento de Cirurgia, São Paulo, SP, Brazil
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5
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Manouras A, Johnson J, Lund LH, Nagy AI. Optimizing diastolic pressure gradient assessment. Clin Res Cardiol 2020; 109:1411-1422. [PMID: 32394159 PMCID: PMC7588394 DOI: 10.1007/s00392-020-01641-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/31/2020] [Indexed: 12/25/2022]
Abstract
Aims The diastolic pressure gradient (DPG) has been proposed as a marker pulmonary vascular disease in the setting of left heart failure (HF). However, its diagnostic utility is compromised by the high prevalence of physiologically incompatible negative values (DPGNEG) and the contradictory evidence on its prognostic value. Pressure pulsatility impacts on DPG measurements, thus conceivably, pulmonary artery wedge pressure (PAWP) measurements insusceptible to the oscillatory effect of the V-wave might yield a more reliable DPG assessment. We set out to investigate how the instantaneous PAWP at the trough of the Y-descent (PAWPY) influences the prevalence of DPGNEG and the prognostic value of the resultant DPGY. Methods Hundred and fifty-three consecutive HF patients referred for right heart catheterisation were enrolled prospectively. DPG, as currently recommended, was calculated. Subsequently, PAWPY was measured and the corresponding DPGY was calculated. Results DPGY yielded higher values (median, IQR: 3.2, 0.6–5.7 mmHg) than DPG (median, IQR: 0.9, − 1.7–3.8 mmHg); p < 0.001. Conventional DPG was negative in 45% of the patients whereas DPGY in only 15%. During follow-up (22 ± 14 months) 58 patients have undergone heart-transplantation or died. The predictive ability of DPGY ≥ 6 mmHg for the above defined end-point events was significant [HR 2.1; p = 0.007] and independent of resting mean pulmonary artery pressure (PAPM). In contrast, conventional DPG did not comprise significant prognostic value following adjustment for PAPM. Conclusion Instantaneous pressures at the trough of Y-descent yield significantly fewer DPGNEG than conventional DPG and entail superior prognostic value in HF patients with and without PH. Graphic abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-020-01641-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aristomenis Manouras
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden.,Theme of Heart and Vessels, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Johnson
- Centre for Fetal Medicine Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H Lund
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden.,Theme of Heart and Vessels, Karolinska University Hospital, Stockholm, Sweden
| | - Anikó Ilona Nagy
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden. .,Heart and Vascular Center, Semmelweis University, 68. Városmajor u., Budapest, 1026, Hungary.
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6
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Dalla K, Bech‐Hanssen O, Ricksten S. Impact of norepinephrine on right ventricular afterload and function in septic shock-a strain echocardiography study. Acta Anaesthesiol Scand 2019; 63:1337-1345. [PMID: 31361336 PMCID: PMC7159388 DOI: 10.1111/aas.13454] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 07/06/2019] [Accepted: 07/23/2019] [Indexed: 12/25/2022]
Abstract
Background In this observational study, the effects of norepinephrine‐induced changes in mean arterial pressure (MAP) on right ventricular (RV) systolic function, afterload and pulmonary haemodynamics were studied in septic shock patients. We hypothesised that RV systolic function improves at higher doses of norepinephrine/MAP levels. Methods Eleven patients with septic shock requiring norepinephrine after fluid resuscitation were included <24 hours after ICU arrival. Study enrolment and insertion of a pulmonary artery catheter was performed after written informed consent from the next of kin. Norepinephrine infusion was titrated to target mean arterial pressures (MAP) of 60, 75 and 90 mmHg in a random sequential order. At each target MAP, strain—and conventional echocardiographic—and pulmonary haemodynamic variables were measured. RV afterload was assessed as effective pulmonary arterial elastance, (Epa) and pulmonary vascular resistance index, (PVRI). RV free wall peak strain was the primary end‐point. Results At highest compared to lowest norepinephrine dose/MAP level, RV free wall peak strain increased from −19% to −25% (32%, P = .003), accompanied by increased tricuspid annular plane systolic excursion (22%, P = .01). At the highest norepinephrine dose/MAP, RV end‐diastolic area index (16%, P < .001), central venous pressure (38%, P < .001), stroke volume index (7%, P = .001), mean pulmonary artery pressure (19%, P < .001) and RV stroke work index (15%, P = .045) increased, with no effects on PVRI or Epa. Cardiac index did not change, assessed by thermodilution (P = .079) and echocardiography (P = .054). Conclusions Higher doses of norepinephrine to a target MAP of 90 mm Hg improved RV systolic function while RV afterload was not affected.
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Affiliation(s)
- Keti Dalla
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
| | - Odd Bech‐Hanssen
- Department of Clinical Physiology, Sahlgrenska Academy University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
| | - Sven‐Erik Ricksten
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy University of Gothenburg, Sahlgrenska University Hospital Gothenburg Sweden
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Garcia-Montilla R, Imam F, Miao M, Stinson K, Khan A, Heitner S. Optimal right heart filling pressure in acute respiratory distress syndrome determined by strain echocardiography. Echocardiography 2018. [PMID: 28631361 DOI: 10.1111/echo.13546] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Right ventricular (RV) systolic dysfunction is common in acute respiratory distress syndrome (ARDS). While preload optimization is crucial in its management, dynamic fluid responsiveness indices lack reliability, and there is no consensus on target central venous pressure (CVP). We analyzed the utility of RV free wall longitudinal strain (RVFWS) in the estimation of optimal RV filling pressure in ARDS. METHODS A retrospective cross-sectional analysis of clinical data and echocardiograms of patients with ARDS was performed. Tricuspid annular plane systolic excursion (TAPSE), tricuspid peak systolic velocity (S'), RV fractional area change (RVFAC), RVFWS, CVP, systolic pulmonary artery pressure (SPAP), and left ventricular ejection fraction (LVEF) were measured. RESULTS Fifty-one patients with moderate-severe ARDS were included. There were inverse correlations between CVP and TAPSE, S', RVFAC, RVFWS, and LVEF. The most significant was with RVFWS (r:.74, R2 :.55, P:.00001). Direct correlations with creatinine and lactate were noted. Receiver operating characteristic analysis showed that RVFWS -21% (normal reference value) was associated with CVP: 13 mm Hg (AUC: 0.92, 95% CI: 0.83-1.00). Regression model analysis of CVP, and RVFWS interactions established an RVFWS range from -18% to -24%. RVFWS -24% corresponded to CVP: 11 mm Hg and RVFWS -18% to CVP: 15 mm Hg. Beyond a CVP of 15 mm Hg, biventricular systolic dysfunction rapidly ensues. CONCLUSIONS Our data are the first to show that an RV filling pressure of 13±2 mm Hg-as by CVP-correlates with optimal RV mechanics as evaluated by strain echocardiography in patients with moderate-severe ARDS.
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Affiliation(s)
- Romel Garcia-Montilla
- Department of Trauma Surgery and Surgical Critical Care, Marshfield Clinic, Marshfield, WI, USA.,Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Faryal Imam
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Mi Miao
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kathryn Stinson
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Akram Khan
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Stephen Heitner
- Knight Cardiovascular Institute, Clinical Echocardiography, Oregon Health and Science University, Portland, OR, USA
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Morgan RW, Fitzgerald JC, Weiss SL, Nadkarni VM, Sutton RM, Berg RA. Sepsis-associated in-hospital cardiac arrest: Epidemiology, pathophysiology, and potential therapies. J Crit Care 2017; 40:128-135. [DOI: 10.1016/j.jcrc.2017.03.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/19/2017] [Accepted: 03/29/2017] [Indexed: 12/20/2022]
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Lakomkin N, Sathiyakumar V, Wick B, Shen MS, Jahangir AA, Mir H, Obremskey WT, Dodd AC, Sethi MK. Incidence and predictive risk factors of postoperative sepsis in orthopedic trauma patients. J Orthop Traumatol 2016; 18:151-158. [PMID: 27848054 PMCID: PMC5429254 DOI: 10.1007/s10195-016-0437-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/02/2016] [Indexed: 12/21/2022] Open
Abstract
Background Postoperative sepsis is associated with high mortality and the national costs of septicemia exceed those of any other diagnosis. While numerous studies in the basic orthopedic science literature suggest that traumatic injuries facilitate the development of sepsis, it is currently unclear whether orthopedic trauma patients are at increased risk. The purpose of this study was thus to assess the incidence of sepsis and determine the risk factors that significantly predicted septicemia following orthopedic trauma surgery. Materials and methods 56,336 orthopedic trauma patients treated between 2006 and 2013 were identified in the ACS-NSQIP database. Documentation of postoperative sepsis/septic shock, demographics, surgical variables, and preoperative comorbidities was collected. Chi-squared analyses were used to assess differences in the rates of sepsis between trauma and nontrauma groups. Binary multivariable regressions identified risk factors that significantly predicted the development of postoperative septicemia in orthopedic trauma patients. Results There was a significant difference in the overall rates of both sepsis and septic shock between orthopedic trauma (1.6%) and nontrauma (0.5%) patients (p < 0.001). For orthopedic trauma patients, ventilator use (OR = 15.1, p = 0.002), history of pain at rest (OR = 2.8, p = 0.036), and prior sepsis (OR = 2.6, p < 0.001) were significantly associated with septicemia. Statistically predictive, modifiable comorbidities included hypertension (OR = 2.1, p = 0.003) and the use of corticosteroids (OR = 2.1, p = 0.016). Conclusions There is a significantly greater incidence of postoperative sepsis in the trauma cohort. Clinicians should be aware of these predictive characteristics, may seek to counsel at-risk patients, and should consider addressing modifiable risk factors such as hypertension and corticosteroid use preoperatively. Level of evidence Level III.
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Affiliation(s)
- Nikita Lakomkin
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Vasanth Sathiyakumar
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Brandon Wick
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Michelle S Shen
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - A Alex Jahangir
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Hassan Mir
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - William T Obremskey
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Ashley C Dodd
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Manish K Sethi
- The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN, 37232, USA.
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10
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Nagy AI, Venkateshvaran A, Merkely B, Lund LH, Manouras A. Determinants and prognostic implications of the negative diastolic pulmonary pressure gradient in patients with pulmonary hypertension due to left heart disease. Eur J Heart Fail 2016; 19:88-97. [PMID: 27748008 DOI: 10.1002/ejhf.675] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 08/14/2016] [Accepted: 09/08/2016] [Indexed: 11/11/2022] Open
Abstract
AIMS The diastolic pulmonary pressure gradient (DPG) has recently been introduced as a specific marker of combined pre-capillary pulmonary hypertension (Cpc-PH) in left heart disease (LHD). However, its diagnostic and prognostic superiority compared with traditional haemodynamic indices has been challenged lately. Current recommendations explicitly denote that in the normal heart, DPG values are greater than zero, with DPG ≥7 mmHg indicating Cpc-PH. However, clinicians are perplexed by the frequent observation of DPG <0 mmHg (DPGNEG ), as its physiological explanation and clinical impact are unclear to date. We hypothesized that large V-waves in the pulmonary artery wedge pressure (PAWP) curve yielding asymmetric pressure transmission might account for DPGNEG and undertook this study to clarify the physiological and prognostic implications of DPGNEG . METHODS AND RESULTS Right heart catheterization and echocardiography were performed in 316 patients with LHD due to primary myocardial dysfunction or valvular disease. A total of 256 patients had PH-LHD, of whom 48% demonstrated DPGNEG . The V-wave amplitude inversely correlated with DPG (r = -0.45, P < 0.001) in patients with low pulmonary vascular resistance (PVR), but not in those with elevated PVR (P > 0.05). Patients with large V-waves had negative and lower DPG than those without augmented V-waves (P < 0.001) despite similar PVR (P >0.05). Positive, but normal DPG (0-6 mmHg) carried a worse 2-year prognosis for death and/or heart transplantation than DPGNEG (hazard ratio 2.97; P < 0.05). CONCLUSION Our results advocate against DPGNEG constituting a measurement error. We propose that DPGNEG can partially be ascribed to large V-waves and carries a better prognosis than DPG within the normal positive range.
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Affiliation(s)
- Anikó Ilona Nagy
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ashwin Venkateshvaran
- School for Technology and Health, Royal Institute of Technology, Stockholm, Sweden.,Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Lars H Lund
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Aristomenis Manouras
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Rivers EP, McCord J, Otero R, Jacobsen G, Loomba M. Clinical Utility of B-Type Natriuretic Peptide in Early Severe Sepsis and Septic Shock. J Intensive Care Med 2016; 22:363-73. [DOI: 10.1177/0885066607307523] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
B-type natriuretic peptide (BNP) has diagnostic, therapeutic, and prognostic utility in critically ill patients. For severe sepsis and septic shock patients in particular, similar clinical utility from the most proximal aspects of hospital presentation to the intensive care unit has not been examined. BNP levels were measured at 0, 3, 6, 12, 24, 36, 48, 60, and 72 hours in 252 patients presenting to the emergency department with severe sepsis and septic shock. The clinicians were blinded to the BNP levels. Elevated BNP levels (>100 pg/mL) were seen in 42% and 69% of patients on presentation and at 24 hours, respectively. Elevated BNP ranges (>230 pg/mL) were significantly associated with myocardial dysfunction and severity of global tissue hypoxia. When adjusted for age, gender, history of heart failure, renal function, organ dysfunction, and mean arterial pressure, a BNP greater than 210 pg/mL at 24 hours was the most significant independent indicator of increased mortality: odds ratio 1.061 (1.026-1.097), P < .001, 95% confidence interval. Patients with severe sepsis and septic shock often have elevated BNP levels, which are significantly associated with organ and myocardial dysfunction, global tissue hypoxia, and mortality. Serial BNP levels may be a useful adjunct in the early detection, stratification, treatment, and prognostication of high-risk patients.
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Affiliation(s)
- Emanuel P. Rivers
- Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, Michigan, Department of Surgery, Henry Ford Hospital, Wayne State University, Detroit, Michigan,
| | - James McCord
- Department of Cardiology, Henry Ford Hospital, Wayne State University, Detroit, Michigan
| | - Ronny Otero
- Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, Michigan
| | - Gordon Jacobsen
- Department of Biostatistics and Epidemiology (GJ), Henry Ford Hospital, Wayne State University, Detroit, Michigan
| | - Manisha Loomba
- Department of Anesthesiology, Henry Ford Hospital, Wayne State University Detroit, Michigan
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12
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Courtney Broaddus V, Berthiaume Y, Biondi JW, Matthay MA. Analytic Reviews : Hemodynamic Management of the Adult Respiratory Distress Syndrome. J Intensive Care Med 2016. [DOI: 10.1177/088506668700200404] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemodynamic management is an essential aspect of the care of patients with adult respiratory distress syn drome (ARDS). On the basis of current knowledge, our proposed goals of management are to maximize pe ripheral oxygen delivery while attempting to minimize further lung damage or dysfunction. The major patho physiologic abnormalities of ARDS are an increased lung vascular permeability, right-to-left intrapulmonary shunting, and pulmonary vascular resistance. These abnormalities must be understood to select the proper therapy. Although all patients with ARDS share these abnormalities, they differ in their associated clinical conditions and underlying cardiovascular status. Be cause each ARDS patient may respond differently to therapy, hemodynamic management must be selected empirically with the goal of therapy as a guide. We have considered available therapeutic options including posi tive end-expiratory pressure, volume depletion, volume expansion, vasopressors, and vasodilators. In the future hemodynamic management of patients with ARDS will likely change as better methods of patient assessment and treatment are developed.
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Affiliation(s)
- V. Courtney Broaddus
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, Departments of Medicine and Anesthesia, Yale University School of Medicine, New Haven, CT
| | - Yves Berthiaume
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, Departments of Medicine and Anesthesia, Yale University School of Medicine, New Haven, CT,
| | - James W. Biondi
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, Departments of Medicine and Anesthesia, Yale University School of Medicine, New Haven, CT,
| | - Michael A. Matthay
- University of California, San Francisco, San Francisco, CA 94143., Departments of Medicine and Anesthesia, Yale University School of Medicine, New Haven, CT
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Dixon DD, Trivedi A, Shah SJ. Combined post- and pre-capillary pulmonary hypertension in heart failure with preserved ejection fraction. Heart Fail Rev 2015; 21:285-97. [DOI: 10.1007/s10741-015-9523-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Selby VN, De Marco T. Current Treatment Strategies in Pulmonary Hypertension Associated with Left Heart Disease. CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-015-0075-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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15
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Chatterjee NA, Lewis GD. Characterization of Pulmonary Hypertension in Heart Failure Using the Diastolic Pressure Gradient. JACC-HEART FAILURE 2015; 3:17-21. [DOI: 10.1016/j.jchf.2014.09.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022]
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16
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Tampakakis E, Leary PJ, Selby VN, De Marco T, Cappola TP, Felker GM, Russell SD, Kasper EK, Tedford RJ. The diastolic pulmonary gradient does not predict survival in patients with pulmonary hypertension due to left heart disease. JACC-HEART FAILURE 2014; 3:9-16. [PMID: 25453535 DOI: 10.1016/j.jchf.2014.07.010] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 07/08/2014] [Accepted: 07/28/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study sought to evaluate if diastolic pulmonary gradient (DPG) can predict survival in patients with pulmonary hypertension due to left heart disease (PH-LHD). BACKGROUND Patients with combined post- and pre-capillary PH-LHD have worse prognosis than those with passive pulmonary hypertension. The transpulmonary gradient (TPG) and pulmonary vascular resistance (PVR) have commonly been used to identify high-risk patients. However, these parameters have significant shortcomings and do not always correlate with pulmonary vasculature remodeling. Recently, it has been suggested that DPG may be better a marker, yet its prognostic ability in patients with cardiomyopathy has not been fully assessed. METHODS A retrospective cohort of 1,236 patients evaluated for unexplained cardiomyopathy at Johns Hopkins Hospital was studied. All patients underwent right heart catheterization and were followed until death, cardiac transplantation, or the end of the study period (mean time 4.4 years). The relationships between DPG, TPG, or PVR and survival in subjects with PH-LHD (n = 469) were evaluated with Cox proportional hazards regression and Kaplan-Meier analyses. RESULTS DPG was not significantly associated with mortality (hazard ratio [HR]: 1.02, p = 0.10) in PH-LHD whereas elevated TPG and PVR predicted death (HR: 1.02, p = 0.046; and HR: 1.11, p = 0.002, respectively). Similarly, DPG did not differentiate survivors from non-survivors at any selected cut points including a DPG of 7 mm Hg. CONCLUSIONS In this retrospective study of patients with cardiomyopathy and PH-LHD, an elevated DPG was not associated with worse survival.
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Affiliation(s)
- Emmanouil Tampakakis
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Peter J Leary
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington
| | - Van N Selby
- Division of Cardiology, University of California-San Francisco, San Francisco, California
| | - Teresa De Marco
- Division of Cardiology, University of California-San Francisco, San Francisco, California
| | - Thomas P Cappola
- Penn Cardiovascular Institute, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Stuart D Russell
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Edward K Kasper
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland.
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Ñamendys-Silva SA, Santos-Martínez LE, Pulido T, Rivero-Sigarroa E, Baltazar-Torres JA, Domínguez-Cherit G, Sandoval J. Pulmonary hypertension due to acute respiratory distress syndrome. ACTA ACUST UNITED AC 2014; 47:904-10. [PMID: 25118626 PMCID: PMC4181226 DOI: 10.1590/1414-431x20143316] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 06/02/2014] [Indexed: 01/20/2023]
Abstract
Our aims were to describe the prevalence of pulmonary hypertension in patients with acute respiratory distress syndrome (ARDS), to characterize their hemodynamic cardiopulmonary profiles, and to correlate these parameters with outcome. All consecutive patients over 16 years of age who were in the intensive care unit with a diagnosis of ARDS and an in situ pulmonary artery catheter for hemodynamic monitoring were studied. Pulmonary hypertension was diagnosed when the mean pulmonary artery pressure was >25 mmHg at rest with a pulmonary artery occlusion pressure or left atrial pressure <15 mmHg. During the study period, 30 of 402 critically ill patients (7.46%) who were admitted to the ICU fulfilled the criteria for ARDS. Of the 30 patients with ARDS, 14 met the criteria for pulmonary hypertension, a prevalence of 46.6% (95% CI; 28-66%). The most common cause of ARDS was pneumonia (56.3%). The overall mortality was 36.6% and was similar in patients with and without pulmonary hypertension. Differences in patients' hemodynamic profiles were influenced by the presence of pulmonary hypertension. The levels of positive end-expiratory pressure and peak pressure were higher in patients with pulmonary hypertension, and the PaCO2 was higher in those who died. The level of airway pressure seemed to influence the onset of pulmonary hypertension. Survival was determined by the severity of organ failure at admission to the intensive care unit.
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Affiliation(s)
- S A Ñamendys-Silva
- Departamento de Terapia Intensiva, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - L E Santos-Martínez
- Departamento de Cardioneumología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - T Pulido
- Departamento de Cardioneumología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - E Rivero-Sigarroa
- Departamento de Terapia Intensiva, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J A Baltazar-Torres
- Departamento de Terapia Intensiva, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - G Domínguez-Cherit
- Departamento de Terapia Intensiva, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J Sandoval
- Departamento de Cardioneumología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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Assessment of right ventricular functions in patients with sepsis, severe sepsis and septic shock and its prognostic importance: A tissue Doppler study. J Crit Care 2013; 28:1111.e7-1111.e11. [DOI: 10.1016/j.jcrc.2013.07.059] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 06/29/2013] [Accepted: 07/23/2013] [Indexed: 11/22/2022]
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Prognostic value of the pre-transplant diastolic pulmonary artery pressure-to-pulmonary capillary wedge pressure gradient in cardiac transplant recipients with pulmonary hypertension. J Heart Lung Transplant 2013; 33:289-97. [PMID: 24462554 DOI: 10.1016/j.healun.2013.11.008] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 10/15/2013] [Accepted: 11/20/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although the transpulmonary gradient (TPG) and pulmonary vascular resistance (PVR) are commonly used to differentiate heart failure patients with pulmonary vascular disease from those with passive pulmonary hypertension (PH), elevations in TPG and PVR may not always reflect pre-capillary PH. Recently, it has been suggested an elevated diastolic pulmonary artery pressure-to-pulmonary capillary wedge pressure gradient (DPG) may be a better indicator of pulmonary vascular remodeling, and therefore, may be of added prognostic value in patients with PH being considered for cardiac transplantation. METHODS Using the United Network for Organ Sharing (UNOS) database, we retrospectively reviewed all primary adult (age > 17 years) orthotropic heart transplant recipients between 1998 and 2011. All patients with available pre-transplant hemodynamic data and PH (mean pulmonary artery pressure ≥ 25 mm Hg) were included (n = 16,811). We assessed the prognostic value of DPG on post-transplant survival in patients with PH and an elevated TPG and PVR. RESULTS In patients with PH and a TPG > 12 mm Hg (n = 5,827), there was no difference in survival at up to 5 years post-transplant between high DPG (defined as ≥3, ≥5, ≥7, or ≥10 mm Hg) and low DPG (<3, <5, <7, or <10 mm Hg) groups. Similarly, there was no difference in survival between high and low DPG groups in those with a PVR > 3 Wood units (n = 6,270). Defining an elevated TPG as > 15 mm Hg (n = 3,065) or an elevated PVR > 5 (n = 1,783) yielded similar results. CONCLUSIONS This large analysis investigating the prognostic value of DPG found an elevated DPG had no effect on post-transplant survival in patients with PH and an elevated TPG and PVR.
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Romero-Bermejo FJ, Ruiz-Bailen M, Gil-Cebrian J, Huertos-Ranchal MJ. Sepsis-induced cardiomyopathy. Curr Cardiol Rev 2013; 7:163-83. [PMID: 22758615 PMCID: PMC3263481 DOI: 10.2174/157340311798220494] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Revised: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 01/20/2023] Open
Abstract
Myocardial dysfunction is one of the main predictors of poor outcome in septic patients, with mortality rates next to 70%. During the sepsis-induced myocardial dysfunction, both ventricles can dilate and diminish its ejection fraction, having less response to fluid resuscitation and catecholamines, but typically is assumed to be reversible within 7-10 days. In the last 30 years, It´s being subject of substantial research; however no explanation of its etiopathogenesis or effective treatment have been proved yet. The aim of this manuscript is to review on the most relevant aspects of the sepsis-induced myocardial dysfunction, discuss its clinical presentation, pathophysiology, etiopathogenesis, diagnostic tools and therapeutic strategies proposed in recent years.
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Affiliation(s)
- Francisco J Romero-Bermejo
- Intensive Care Unit, Critical Care and Emergency Department, Puerto Real University Hospital, Cadiz, Spain.
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Adir Y, Humbert M, Sitbon O, Wolf R, Lador F, Jaïs X, Simonneau G, Amir O. Out-of-proportion pulmonary hypertension and heart failure with preserved ejection fraction. Respiration 2012; 85:471-7. [PMID: 22890046 DOI: 10.1159/000339595] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 05/21/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A subset of patients with heart failure with preserved ejection fraction (HFpEF) will have a marked increase in pulmonary artery pressure (PAP). OBJECTIVE To evaluate the clinical and hemodynamic characteristics of these patients in comparison to patients with idiopathic pulmonary arterial hypertension (IPAH). METHODS We reviewed the clinical and hemodynamic data of patients with HFpEF with out-of-proportion pulmonary hypertension (HFpEF-PH) and compared it to the corresponding data of age-matched patients with IPAH. RESULTS Twenty consecutive patients with HFpEF-PH and 20 patients with IPAH were included in the study. The mean age (±SD) was 71.3 ± 7.8 and 70.2 ± 6.7 years, respectively. The majority of the HFpEF-PH patients were postmenopausal females with at least two features of the metabolic syndrome and atrial fibrillation. Although HFpEF-PH patients fulfilled the criteria for out-of-proportion PH, with transpulmonary gradient (TPG) >12 mm Hg, the difference between the diastolic PAP and the pulmonary capillary wedge pressure (PCWP) was significantly lower compared to IPAH (6.3 ± 6.2 vs. 27.5 ± 4.8, p < 0.00001). CONCLUSIONS Our results suggest that a diagnosis of HFpEF-PH should be suspected when severe PH occurs in an elderly postmenopausal female with one or more features of the metabolic syndrome and atrial fibrillation. Interestingly, these patients had significantly lower differences between diastolic PAP and PCWP, suggesting that the increase in TPG is mainly caused by an elevated systolic PAP, possibly as a result of increased pulmonary vascular stiffness, and not pulmonary vascular remodeling.
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Affiliation(s)
- Yochai Adir
- Pulmonary Division, Lady Davis Carmel Medical Center, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Nilsson MCA, Fredén F, Larsson A, Wiklund P, Bergquist M, Hambraeus-Jonzon K. Hypercapnic acidosis transiently weakens hypoxic pulmonary vasoconstriction without affecting endogenous pulmonary nitric oxide production. Intensive Care Med 2012; 38:509-17. [PMID: 22270473 DOI: 10.1007/s00134-012-2482-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 12/06/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE Hypercapnic acidosis often occurs in critically ill patients and during protective mechanical ventilation; however, the effect of hypercapnic acidosis on endogenous nitric oxide (NO) production and hypoxic pulmonary vasoconstriction (HPV) presents conflicting results. The aim of this study is to test the hypothesis that hypercapnic acidosis augments HPV without changing endogenous NO production in both hyperoxic and hypoxic lung regions in pigs. METHODS Sixteen healthy anesthetized pigs were separately ventilated with hypoxic gas to the left lower lobe (LLL) and hyperoxic gas to the rest of the lung. Eight pigs received 10% carbon dioxide (CO(2)) inhalation to both lung regions (hypercapnia group), and eight pigs formed the control group. NO concentration in exhaled air (ENO), nitric oxide synthase (NOS) activity, cyclic guanosine monophosphate (cGMP) in lung tissue, and regional pulmonary blood flow were measured. RESULTS There were no differences between the groups for ENO, Ca(2+)-independent or Ca(2+)-dependent NOS activity, or cGMP in hypoxic or hyperoxic lung regions. Relative perfusion to LLL (Q (LLL)/Q (T)) was reduced similarly in both groups when LLL hypoxia was induced. During the first 90 min of hypercapnia, Q (LLL)/Q (T) increased from 6% (1%) [mean (standard deviation, SD)] to 9% (2%) (p < 0.01), and then decreased to the same level as the control group, where Q (LLL)/Q (T) remained unchanged. Cardiac output increased during hypercapnia (p < 0.01), resulting in increased oxygen delivery (p < 0.01), despite decreased PaO(2) (p < 0.01)(.) CONCLUSIONS Hypercapnic acidosis does not potentiate HPV, but rather transiently weakens HPV, and does not affect endogenous NO production in either hypoxic or hyperoxic lung regions.
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Affiliation(s)
- Manja C A Nilsson
- Department of Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden.
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Abstract
Abstract
Purpose of the review
Non-invasiveness and instantaneous diagnostic capability are prominent features of the use of echocardiography in critical care. Sepsis and septic shock represent complex situations where early hemodynamic assessment and support are among the keys to therapeutic success. In this review, we discuss the range of applications of echocardiography in the management of the septic patient, and propose an echocardiography-based goal-oriented hemodynamic approach to septic shock.
Recent findings
Echocardiography can play a key role in the critical septic patient management, by excluding cardiac causes for sepsis, and mostly by guiding hemodynamic management of those patients in whom sepsis reaches such a severity to jeopardize cardiovascular function. In recent years, there have been both increasing evidence and diffusion of the use of echocardiography as monitoring tool in the patients with hemodynamic compromise. Also thanks to echocardiography, the features of the well-known sepsis-related myocardial dysfunction have been better characterized. Furthermore, many of the recent echocardiographic indices of volume responsiveness have been validated in populations of septic shock patients.
Conclusion
Although not proven yet in terms of patient outcome, echocardiography can be regarded as an ideal monitoring tool in the septic patient, as it allows (a) first line differential diagnosis of shock and early recognition of sepsis-related myocardial dysfunction; (b) detection of pre-existing cardiac pathology, that yields precious information in septic shock management; (c) comprehensive hemodynamic monitoring through a systematic approach based on repeated bedside assessment; (d) integration with other monitoring devices; and (e) screening for cardiac source of sepsis.
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Price LC, Wort SJ, Finney SJ, Marino PS, Brett SJ. Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review. Crit Care 2010; 14:R169. [PMID: 20858239 PMCID: PMC3219266 DOI: 10.1186/cc9264] [Citation(s) in RCA: 206] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 05/30/2010] [Accepted: 09/21/2010] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Pulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by lowering pulmonary vascular resistance (PVR). We therefore provide a detailed update on the management of PH and RV failure in adult critical care. METHODS A systematic review was performed, based on a search of the literature from 1980 to 2010, by using prespecified search terms. Relevant studies were subjected to analysis based on the GRADE method. RESULTS Clinical studies of intensive care management of pulmonary vascular dysfunction were identified, describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators, and mechanical devices. The following GRADE recommendations (evidence level) are made in patients with pulmonary vascular dysfunction: 1) A weak recommendation (very-low-quality evidence) is made that close monitoring of the RV is advised as volume loading may worsen RV performance; 2) A weak recommendation (low-quality evidence) is made that low-dose norepinephrine is an effective pressor in these patients; and that 3) low-dose vasopressin may be useful to manage patients with resistant vasodilatory shock. 4) A weak recommendation (low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular dysfunction. 5) A strong recommendation (moderate-quality evidence) is made that phosphodiesterase type III inhibitors reduce PVR and improve RV function, although hypotension is frequent. 6) A weak recommendation (low-quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance. 7) A strong recommendation (moderate-quality evidence) is made that pulmonary vasodilators reduce PVR and improve RV function, notably in pulmonary vascular dysfunction after cardiac surgery, and that the side-effect profile is reduced by using inhaled rather than systemic agents. 8) A weak recommendation (very-low-quality evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary vascular dysfunction awaiting definitive therapy. CONCLUSIONS This systematic review highlights that although some recommendations can be made to guide the critical care management of pulmonary vascular and right ventricular dysfunction, within the limitations of this review and the GRADE methodology, the quality of the evidence base is generally low, and further high-quality research is needed.
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Affiliation(s)
- Laura C Price
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Stephen J Wort
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Simon J Finney
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Philip S Marino
- Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Stephen J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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Abstract
Acute pulmonary arterial hypertension (PAH), which may complicate the course of many complex disorders, is always underdiagnosed and its treatment frequently begins only after serious complications have developed. Acute PAH is distinctive because they differ in their clinical presentation, diagnostic findings, and response to treatment from chronic PAH. The acute PAH may take either the form of acute onset of chronic PAH or acute PAH or surgery-related PAH. Significant pathophysiologic differences existed between acute and chronic PAH. Therapy of acute PAH should generally be aimed at acutely relieving right ventricular (RV) pressure overload and preventing RV dysfunction. There are three classes of drugs targeting the correction of abnormalities in endothelial dysfunction, which have been approved recently for the treatment of PAH: (1) prostanoids; (2) endothelin receptor antagonists; and (3) phosphodiesterase-5 inhibitors. The efficacy and safety of these compounds have been confirmed in uncontrolled studies in patients with PAH. Intravenous epoprostenol is suggested to serve as the first-line treatment for the most severe patients. In the other situations, the first-line therapy may include bosentan, sildenafil, or a prostacyclin analogue. Recent advances in the management of PAH have markedly improved prognosis.
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Affiliation(s)
- Gan Hui-li
- Cardiac Surgery Department, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Disease, Beijing 100029, China.
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Ilsar R, Bailey BP, Dobbins TA, Celermajer DS. The Relationship Between Pulmonary Artery and Pulmonary Capillary Wedge Pressure for the Diagnosis of Pulmonary Vascular Disease. Heart Lung Circ 2010; 19:38-42. [DOI: 10.1016/j.hlc.2009.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Revised: 08/05/2009] [Accepted: 08/05/2009] [Indexed: 01/22/2023]
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Tsapenko MV, Tsapenko AV, Comfere TB, Mour GK, Mankad SV, Gajic O. Arterial pulmonary hypertension in noncardiac intensive care unit. Vasc Health Risk Manag 2009; 4:1043-60. [PMID: 19183752 PMCID: PMC2605326 DOI: 10.2147/vhrm.s3998] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Pulmonary artery pressure elevation complicates the course of many complex disorders treated in a noncardiac intensive care unit. Acute pulmonary hypertension, however, remains underdiagnosed and its treatment frequently begins only after serious complications have developed. Significant pathophysiologic differences between acute and chronic pulmonary hypertension make current classification and treatment recommendations for chronic pulmonary hypertension barely applicable to acute pulmonary hypertension. In order to clarify the terminology of acute pulmonary hypertension and distinguish it from chronic pulmonary hypertension, we provide a classification of acute pulmonary hypertension according to underlying pathophysiologic mechanisms, clinical features, natural history, and response to treatment. Based on available data, therapy of acute arterial pulmonary hypertension should generally be aimed at acutely relieving right ventricular (RV) pressure overload and preventing RV dysfunction. Cases of severe acute pulmonary hypertension complicated by RV failure and systemic arterial hypotension are real clinical challenges requiring tight hemodynamic monitoring and aggressive treatment including combinations of pulmonary vasodilators, inotropic agents and systemic arterial vasoconstrictors. The choice of vasopressor and inotropes in patients with acute pulmonary hypertension should take into consideration their effects on vascular resistance and cardiac output when used alone or in combinations with other agents, and must be individualized based on patient response.
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Affiliation(s)
- Mykola V Tsapenko
- Division of Pulmonary and Critical Care Medicine, Mayo Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN 55905, USA.
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Price S, Via G, Sloth E, Guarracino F, Breitkreutz R, Catena E, Talmor D. Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound 2008; 6:49. [PMID: 18837986 PMCID: PMC2586628 DOI: 10.1186/1476-7120-6-49] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Accepted: 10/06/2008] [Indexed: 03/06/2023] Open
Abstract
Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described. Obtaining competence in ICU echocardiography may be achieved in different ways - either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level--obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.
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Affiliation(s)
- Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
| | - Gabriele Via
- 1st Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, P.zzale Golgi 2, 27100 Pavia, Italy
| | - Erik Sloth
- Department of Anaesthesiology, Skejby Sygehus, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Fabio Guarracino
- Cardiothoracic Anaesthesia and ICU, Azienda Ospedaliera Pisana, via Paradisa 2, 56124 Pisa, Italy
| | - Raoul Breitkreutz
- Department of Anesthesiology, Intensive Care, and Pain therapy, Hospital of the Johann-Wolfgang-Goethe University, Theodor Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Emanuele Catena
- Department of Cardiothoracic Anesthesia, Azienda Ospedaliera Niguarda Ca'Granda, P.za Osp. Maggiore 3, 20100, Milan, Italy
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, USA
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Morelli A, De Castro S, Teboul JL, Singer M, Rocco M, Conti G, De Luca L, Di Angelantonio E, Orecchioni A, Pandian NG, Pietropaoli P. Effects of levosimendan on systemic and regional hemodynamics in septic myocardial depression. Intensive Care Med 2005; 31:638-44. [PMID: 15812624 DOI: 10.1007/s00134-005-2619-z] [Citation(s) in RCA: 215] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Accepted: 03/04/2005] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Calcium desensitization plays an important part in the pathophysiology of septic myocardial depression. We postulated that levosimendan, a new calcium sensitizer, would be beneficial in sepsis-induced cardiac dysfunction. DESIGN AND SETTING Prospective, randomized, controlled study in two university hospital intensive care units. PATIENTS AND PARTICIPANTS Twenty-eight patients with persisting left ventricular dysfunction related to septic shock after 48 h of conventional treatment including dobutamine (5 microg/kg per minute). INTERVENTIONS After 48 h of conventional treatment patients were randomized to receive a 24-h infusion of either levosimendan (0.2 microg/kg per minute, n=15) or dobutamine (5 microg/kg per minute, n=13). MEASUREMENTS AND RESULTS Data from right heart catheterization, echocardiography, gastric tonometry, laser-Doppler flowmetry, and lactate concentrations and creatinine clearance were obtained before and after the 24-h drug infusion. Dobutamine did not change systemic or regional hemodynamic variables. By contrast, at the same mean arterial pressure levosimendan decreased pulmonary artery occlusion pressure and increased cardiac index. Levosimendan decreased left ventricular end-diastolic volume and increased left ventricular ejection fraction. Levosimendan increased gastric mucosal flow, creatinine clearance, and urinary output while it decreased lactate concentrations. CONCLUSIONS These findings show that levosimendan improves systemic hemodynamics and regional perfusion in patients with septic cardiac dysfunction under conditions where administration of 5 microg/kg dobutamine per minute is no longer efficacious. Accordingly, our results suggest that levosimendan can be an alternative to the strategy of increasing the dose of dobutamine under such conditions.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, University of Rome La Sapienza, Rome, Italy.
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Abstract
The present review will cover the mechanisms of release and the potential pathophysiological role of different natriuretic peptides in critically ill patients. By focusing on the cardiovascular system, possible implications of natriuretic peptides for diagnosis and treatment will be presented. In critical illness such as sepsis, trauma or major surgery, systemic hypotension and an intrinsic myocardial dysfunction occur. Impairment of the cardiovascular system contributes to poor prognosis in severe human sepsis. Natriuretic peptides have emerged as valuable marker substances to detect left ventricular dysfunction in congestive heart failure of different origins. Increased plasma levels of circulating natriuretic peptides, atrial natriuretic peptide, N-terminal pro-atrial natriuretic peptide, brain natriuretic peptide and its N-terminal moiety N-terminal pro-brain natriuretic peptide have also been found in critically ill patients. All of these peptides have been reported to reflect left ventricular dysfunction in these patients. The increased wall stress of the cardiac atria and ventricles is followed by the release of these natriuretic peptides. Furthermore, the release of atrial natriuretic peptide and brain natriuretic peptide might be triggered by members of the IL-6-related family and endotoxin in the critically ill. Apart from the vasoactive actions of circulating natriuretic peptides and their broad effects on the renal system, anti-ischemic properties and immunological functions have been reported for atrial natriuretic peptide. The early onset and rapid reversibility of left ventricular impairment in patients with good prognosis associated with a remarkably augmented plasma concentration of circulating natriuretic peptides suggest a possible role of these hormones in the monitoring of therapy success and the estimation of prognosis in the critically ill.
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Affiliation(s)
- Rochus Witthaut
- Medizinische Klinik III, Klinikum Kroellwitz, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany.
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Konrad D, Oldner A, Rossi P, Wanecek M, Rudehill A, Weitzberg E. Differentiated and dose-related cardiovascular effects of a dual endothelin receptor antagonist in endotoxin shock. Crit Care Med 2004; 32:1192-9. [PMID: 15190972 DOI: 10.1097/01.ccm.0000126262.23422.f0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effects of endothelin receptor antagonism on cardiac performance in endotoxin shock. DESIGN Prospective, experimental study. SETTING A university-affiliated research institution. SUBJECTS Domestic anesthetized landrace pigs. INTERVENTIONS Thirty-seven pigs were anesthetized and subjected to echocardiography, coronary sinus catheterization, and monitoring of central and regional hemodynamics in order to assess cardiac performance. All animals received endotoxin for 5 hrs. Twenty pigs served as endotoxin controls. Tezosentan, a dual endothelin-A and -B receptor antagonist, was administered during established endotoxemic shock. Seven pigs received an infusion of tezosentan of 1 mg x kg(-1) x hr(-1) (tezo1), and an additional ten pigs received a higher dose of 10 mg x kg(-1) x hr(-1) (tezo10). MEASUREMENTS AND MAIN RESULTS Endotoxemia evoked a state of shock with pulmonary hypertension and metabolic acidosis. A decrease in stroke volume and coronary perfusion pressure as well as an increase in troponin I was also noted. Tezosentan administration resulted in a significant increase in cardiac index, stroke volume index, left ventricular stroke work index, and left ventricular end-diastolic area index. Decreases in systemic and pulmonary vascular resistance indexes were also evident after intervention. This was achieved without changes in heart rate or systemic arterial or pulmonary artery occlusion pressures in tezo, animals compared with controls. In addition, metabolic variables were improved by tezosentan. These effects were sustained only in the tezo, group. In the higher dosage, tezosentan resulted in a deterioration of cardiac performance and 50% mortality rate. The endotoxin-induced increase in troponin I was attenuated in the tezo, group compared with controls. CONCLUSIONS In this porcine model of volume-resuscitated, endotoxemic shock, endothelin-receptor blockade with tezosentan improved cardiac performance. However, the effect was not sustained with higher doses of tezosentan, possibly due to reduced coronary perfusion pressure. These findings show differentiated, dose-dependent effects by dual endothelin receptor blockade on endotoxin-induced cardiovascular dysfunction.
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Affiliation(s)
- David Konrad
- Department of Surgical Sciences, Section for Anaesthesiology and Intensive Care, Karolinska Institute, Stockholm, Sweden
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Fischer LG, Aken HV, Bürkle H. Management of pulmonary hypertension: physiological and pharmacological considerations for anesthesiologists. Anesth Analg 2003; 96:1603-1616. [PMID: 12760982 DOI: 10.1213/01.ane.0000062523.67426.0b] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lars G Fischer
- Department of Anesthesiology and Intensive Care, Universita[Combining Diaeresis]tsklinikum Mu[Combining Diaeresis]nster, Mu[Combining Diaeresis]nster, Germany
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35
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Abstract
The nature of myocardial dysfunction during sepsis and septic shock has been investigated for more than half a century. This review traces the evolution of scientific thought regarding this phenomenon during this period with particular emphasis on the current understanding of both the clinical manifestations and the molecular/cellular basis of septic myocardial dysfunction in critically ill patients. Current data suggest, contrary to older literature, that patients with septic shock develop a hyperdynamic circulatory state after fluid resuscitation and maintain this hyperdynamic circulatory state until death or recovery. Overt myocardial depression, as manifested by decreased cardiac output, is decidedly uncommon, even in the preterminal phase. Nonetheless, myocardial depression, as evidenced by biventricular dilation and depression of the ejection fraction, can be demonstrated in most patients with septic shock by using either radionuclide cineangiography or echocardiography. Depression is reversible over the course of 7 to 10 days in survivors. Available evidence suggests that myocardial hypoperfusion is not responsible for septic myocardial depression, because examination of humans with septic shock demonstrates increased myocardial perfusion, and animal models of septic shock appear to maintain myocardial high-energy phosphates. A circulating factor or factors, including the cytokines tumor necrosis factor alpha and interleukin-1beta, appear to have a significant role in the phenomenon. In addition, septic myocardial depression appears to be mediated in part through combinations of nitric oxide-dependent and -independent alterations of basal and catecholamine-stimulated cardiac myocyte contractility.
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Affiliation(s)
- Sreenandh Krishnagopalan
- Section of Critical Care Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA
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36
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Abstract
An understanding of the pathogenesis of ARDS is essential for choosing management strategies and developing new treatments. The key mediators involved in the inflammatory and fibroproliferative responses are reviewed and the mechanisms which regulate these responses are highlighted.
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Abstract
Myocardial dysfunction frequently accompanies severe sepsis and septic shock. Whereas myocardial depression was previously considered a preterminal event, it is now clear that cardiac dysfunction as evidenced by biventricular dilatation and reduced ejection fraction is present in most patients with severe sepsis and septic shock. Myocardial depression exists despite a fluid resuscitation-dependent hyperdynamic state that typically persists in septic shock patients until death or recovery. Cardiac function usually recovers within 7-10 days in survivors. Myocardial dysfunction does not appear to be due to myocardial hypoperfusion but due to circulating depressant factors, including the cytokines tumor necrosis factor alpha and IL-1beta. At a cellular level, reduced myocardial contractility seems to be induced by both nitric oxide-dependent and nitric oxide-independent mechanisms. The present paper reviews both the clinical manifestations and the molecular/cellular mechanisms of sepsis-induced myocardial depression.
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Affiliation(s)
- Olivier Court
- Fellow, Section of Critical Care Medicine, Health Sciences Center, University of Manitoba, Winnipeg, Canada
| | - Aseem Kumar
- Assistant Professor of Medicine, Section of Critical Care Medicine, Rush–Presbyterian–St Luke's Medical Center, Chicago, IL, USA
| | - Joseph E Parrillo
- Director, Division of Cardiovascular Diseases and CCM, Cooper Hospital, Camden, NJ, USA
| | - Anand Kumar
- Assistant Professor of Medicine, Section of Critical Care Medicine, Health Sciences Center, University of Manitoba, Winnipeg, Canada
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38
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Abstract
Severe sepsis and septic shock are relatively common problems in intensive care. The mortality in septic shock is still high, and the main causes of death are multiple organ failure and refractory hypotension. Impaired tissue perfusion due to hypovolemia, disturbed vasoregulation and myocardial dysfunction contribute to the multiple organ dysfunction. Treatment of hemodynamics in septic shock consists of appropriate fluid therapy guided by invasive monitoring combined with vasoactive drugs aiming to correct hypotension and inappropriately low cardiac output. The drug of choice for low vascular resistance is norepinephrine, while insufficient myocardial contractility is commonly treated with dobutamine. The use of norepinephrine seems to be associated with better prognosis as compared to results from the use of dopamine or epinephrine. In septic shock, vasopressin levels are low, and therefore, vasopressin has been advocated as a vasopressor. Its effectiveness and safety have not yet been documented, and so far it is regarded as an experimental treatment Recent data support the use of corticosteroid, at least in some of the patients with septic shock. Also, activated protein C, a drug with anti-inflammatory and antithrombotic properties, decreases mortality in patients with septic shock.
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Affiliation(s)
- Esko Ruokonen
- Department of Intensive Care, Kuopio University Hospital, PO Box 1777, FI-70210 Kuopio, Finland.
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39
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Kumar A, Krieger A, Symeoneides S, Kumar A, Parrillo JE. Myocardial dysfunction in septic shock: Part II. Role of cytokines and nitric oxide. J Cardiothorac Vasc Anesth 2001; 15:485-511. [PMID: 11505357 DOI: 10.1053/jcan.2001.25003] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- A Kumar
- Division of Cardiovascular Diseases and Critical Care Medicine, Department of Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612, USA
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40
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Kumar A, Haery C, Parrillo JE. Myocardial dysfunction in septic shock: Part I. Clinical manifestation of cardiovascular dysfunction. J Cardiothorac Vasc Anesth 2001; 15:364-76. [PMID: 11426372 DOI: 10.1053/jcan.2001.22317] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- A Kumar
- Division of Cardiovascular Diseases and Critical Care Medicine, Department of Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612, USA
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41
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Abstract
The pulmonary artery catheter is an invasive hemodynamic monitor that can provide diagnostic information in situations where history and physical examination are inconclusive. Assisting the physician in therapeutic decisions has added to its clinical value. Understanding the information it provides and making thoughtful therapeutic decisions lie at the core of its use. Despite its use, the PA catheter has been the center of great controversy. Clearly the paucity of prospective randomized trials proving its efficacy is alarming. The inability of physicians to interpret the provided data properly is also unacceptable. Although instituting a moratorium on its use may be extreme, limiting its use to approved indications seems more appropriate. In the future, ready availability of other less invasive methods such as echocardiography may allow clinicians to become less reliant on the PA catheter. Until then, clinicians would be served best by comprehending the intricacies and the limitations of this sophisticated instrument.
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Affiliation(s)
- K Cruz
- Section of Cardiology, Rush-St. Luke's Medical Center, 1725 W. Harrison Street, Chicago, IL 60612, USA
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42
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Abstract
In the time it has taken medicine to develop the techniques to describe the circulatory changes of severe infections, both pattern and process have been profoundly influenced by the use of intravenous fluids, vasopressors, antibiotics, steroids, mechanical ventilation and haemoflltration. Constant features of severe sepsis include a reduction in peripheral vascular tone on both the arterial and venous sides of the circulation, a defect in oxygen utilisation resulting in lactic acidosis, and varying degrees of myocardial dysfunction. These events have a temporal progression, the precise pattern observed depending on the tempo of the infection, the influence of therapeutic manoeuvres, the age and comorbidities of the patient, and the time the observations are made in the course of events. Early sepsis is accompanied by a decrease in systemic vascular resistance and a metabolic acidosis. The clinical picture includes fever, tachycardia, tachypnoea, respiratory alkalosis and an increased cardiac output with warm, dry peripheries and a bounding pulse. Advanced sepsis involves varying degrees of venous and myocardial contractile failure, and is characterised by progressive acidaemia, respiratory failure and marked sympathetic adrenergic activation. In the absence of vigorous fluid resuscitation, the cardiac output is decreased and the patients are cold, clammy peripherally shut down, and frequently confused, obtunded or comatose. In infections with a silent primary focus (predominantly involving Gram-negative organisms), this stage is frequently the first to attract the attention of attending staff. Late sepsis is characterised by profound acidaemia, vascular hypo-responsiveness, multiple organ failure and death.
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Affiliation(s)
- I M MacKenzie
- Nuffield Department of Anaesthetics, Radcliffe Infirmary, Oxford OX3 9DU, UK.
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43
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McIntyre RC, Pulido EJ, Bensard DD, Shames BD, Abraham E. Thirty years of clinical trials in acute respiratory distress syndrome. Crit Care Med 2000; 28:3314-31. [PMID: 11008997 DOI: 10.1097/00003246-200009000-00034] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To systematically review clinical trials in acute respiratory distress syndrome (ARDS). DATA SOURCES Computerized bibliographic search of published research and citation review of relevant articles. STUDY SELECTION All clinical trials of therapies for ARDS were reviewed. Therapies that have been compared in prospective, randomized trials were the focus of this analysis. DATA EXTRACTION Data on population, interventions, and outcomes were obtained by review. Studies were graded for quality of scientific evidence. MAIN RESULTS Lung protective ventilator strategy is supported by improved outcome in a single large, prospective trial and a second smaller trial. Other therapies for ARDS, including noninvasive positive pressure ventilation, inverse ratio ventilation, fluid restriction, inhaled nitric oxide, almitrine, prostacyclin, liquid ventilation, surfactant, and immune-modulating therapies, cannot be recommended at this time. Results of small trials using corticosteroids in late ARDS support the need for confirmatory large clinical trials. CONCLUSIONS Lung protective ventilator strategy is the first therapy found to improve outcome in ARDS. Trials of prone ventilation and fluid restriction in ARDS and corticosteroids in late ARDS support the need for large, prospective, randomized trials.
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Affiliation(s)
- R C McIntyre
- Department of Pediatric Surgery, The Children's Hospital, University of Colorado Health Sciences Center, Denver, USA
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44
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Abstract
Over the last decade, it has become clear that myocardial depression, like vascular dysfunction, is typical of human septic shock. Human septic myocardial depression is characterized by reversible biventricular dilatation, decreased ejection fraction, and decreased response to fluid resuscitation and catecholamine stimulation (in the presence of overall hyperdynamic circulation). A circulating myocardial depressant substance, not myocardial hypoperfusion, is responsible for this phenomenon. This substance has been shown to represent low concentrations of TNF-alpha and IL-1 beta acting in synergy on the myocardium through mechanisms that include NO and cGMP generation. Despite major advances in our understanding of the hemodynamics and pathogenesis of cardiac dysfunction in sepsis, successful attempts to modulate these mechanisms to improve clinical outcomes in human trials have not been demonstrated to date. For the moment, the therapeutic approach to the patient with cardiac dysfunction in distributive or septic shock must be primarily aimed at reestablishing adequate organ perfusion and oxygen delivery by vigorous fluid resuscitation and vasopressor or inotropic support. In the long term, however, only continued research regarding the cellular mechanisms of organ dysfunction, including septic myocardial depression, will lead to successful therapeutic strategies. These strategies will likely involve direct manipulation of intracellular signaling processes that lead to organ dysfunction as manifested by septic myocardial dysfunction and septic shock.
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Affiliation(s)
- A Kumar
- Section of Critical Care Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA.
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45
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Snapper JR, Thabes JS, Lefferts PL, Lu W. Role of endothelin in endotoxin-induced sustained pulmonary hypertension in sheep. Am J Respir Crit Care Med 1998; 157:81-8. [PMID: 9445282 DOI: 10.1164/ajrccm.157.1.95-05117] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BMS182874, an endothelin receptor antagonist, blocks the effects of exogenously administered endothelins in chronically instrumented awake sheep. A possible role for endothelin in endotoxin-induced pulmonary hypertension in sheep was investigated by studying animals given intravenous endotoxin with and without pretreatment with BMS182874. BMS182874 administration alone caused a reduction in pulmonary artery pressure (P[PA]) and systemic arterial pressure (P[SA]). Endotoxin alone caused an acute, nearly threefold increase in P(PA) which was followed, from 2-5 h after endotoxin, by a sustained but less severe increase in P(PA). These changes were accompanied by a threefold increase in lung lymph flow and dramatic increases in plasma and lung lymph thromboxane B2 concentrations. Pretreatment with BMS182874 significantly attenuated the early endotoxin-induced acute increase in P(PA) and completely blocked the late sustained pulmonary hypertension (p < 0.05), while having no affect on the increases in thromboxane levels. BMS182874 shifts the dose response curve for U46619, a prostaglandin H2 analogue, to the right. BMS182874, in addition to functioning as an endothelium receptor antagonist, appears to counteract the action of thromboxane at the receptor level. We theorize that BMS182874 attenuates the early endotoxin-induced pulmonary hypertension by counteracting the effects of thromboxane, since previous studies demonstrated that the early acute rise in P(PA) is caused by thromboxane. The late sustained pulmonary hypertension of endotoxemia, on the other hand, appears to be mediated by endothelin.
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Affiliation(s)
- J R Snapper
- Center for Lung Research, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-2650, USA
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46
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Kunimoto F, Arai K, Isa Y, Koyano T, Kadoi Y, Saito S, Goto F. A comparative study of the vasodilator effects of prostaglandin E1 in patients with pulmonary hypertension after mitral valve replacement and with adult respiratory distress syndrome. Anesth Analg 1997; 85:507-13. [PMID: 9296401 DOI: 10.1097/00000539-199709000-00006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED To determine whether the vasodilator effects of prostaglandin E1 (PGE1) differ according to the etiology and pathophysiology of pulmonary hypertension, we studied 30 patients with pulmonary hypertension after mitral valve replacement (MVR) (n = 16) or with the adult respiratory distress syndrome (ARDS) (n = 14). PGE1 was administered to decrease the mean pulmonary artery pressure to below 30 mm Hg in both groups. Cardiac index and oxygen delivery tended to increase, whereas mean systemic artery pressure, mean pulmonary artery pressure, systemic vascular resistance index (SVRI), and pulmonary vascular resistance index (PVRI) significantly decreased in both groups. A vasodilatory index was defined in this study to allow evaluation of vasodilation relative to PGE1 dose: systemic vasodilatory index (VIs) = SVRI change/PGE1 dose; and pulmonary vasodilatory index (VIp) = PVRI change/PGE1 dose. The VIp was similar in both groups, but the VIs was significantly greater in the ARDS group compared with the MVR group (13.3 +/- 7.8 vs 4.8 +/- 5.1, P < 0.01). A good correlation was found between the pretreatment intrapulmonary shunt fraction (Qs/Qt [%]) value and PGE1 extraction rate in the lung (r = 0.60), and between the pretreatment Qs/Qt value and PGE1 concentration in the radial artery (r = 0.65) in an additional 15 patients. We conclude that the vasodilator effects of PGE1 on the pulmonary circulation are similar in the two groups, whereas the vasodilator effects on the systemic circulation are significantly greater in the ARDS group and that significant reduction in VIs in the ARDS group was associated with decreased PGE1 extraction in the lung. IMPLICATIONS Pulmonary hypertension after mitral valve replacement, or with adult respiratory distress syndrome, is a major medical problem. The authors found that administration of prostaglandin E1 significantly dilated the pulmonary circulation with a concomitant decrease in pulmonary artery pressure. Because the systemic vasodilatory effect was greater in the adult respiratory distress syndrome group, the authors concluded that prostaglandin E1 concentrations in the systemic circulation depend on the severity of lung injury.
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Affiliation(s)
- F Kunimoto
- Intensive Care Unit, Gunma University Hospital, Maebashi, Japan.
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47
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Kunimoto F, Arai K, Isa Y, Koyano T, Kadoi Y, Saito S, Goto F. A Comparative Study of the Vasodilator Effects of Prostaglandin E1 in Patients with Pulmonary Hypertension After Mitral Valve Replacement and with Adult Respiratory Distress Syndrome. Anesth Analg 1997. [DOI: 10.1213/00000539-199709000-00006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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48
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Sheridan BC, McIntyre RC, Moore EE, Meldrum DR, Agrafojo J, Fullerton DA. Neutrophils mediate pulmonary vasomotor dysfunction in endotoxin-induced acute lung injury. THE JOURNAL OF TRAUMA 1997; 42:391-6; discussion 396-7. [PMID: 9095105 DOI: 10.1097/00005373-199703000-00005] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The major hemodynamic feature of endotoxin (ETX)-induced acute lung injury is pulmonary hypertension secondary to increased pulmonary vascular resistance. Endotoxin causes dysfunction of pulmonary vasorelaxation, which is associated with increased lung neutrophil accumulation. We hypothesized that neutrophils mediate the dysfunction of cGMP-mediated pulmonary vasorelaxation in acute lung injury. In a rat model of ETX-induced lung injury, our purpose was to determine the effect of neutrophil depletion on the following mechanisms of pulmonary vasomotor control: endothelium-dependent cGMP-mediated relaxation (response to acetylcholine) and endothelium-independent relaxation (response to sodium nitroprusside). METHODS Rats were studied 6 hours after ETX (20 mg/kg). Neutropenia (< 75 neutrophils/microL) was induced with anti-neutrophil serum 24 hours before ETX. Saline injected rats were controls. Dose-response curves to acetylcholine and sodium nitroprusside were generated in isolated pulmonary artery rings preconstricted with phenylephrine (n = 10 rings/5 rats per group). Lungs were harvested (n = 4 rats/group) and lung neutrophil accumulation was assessed with a myeloperoxidase assay. RESULTS Endothelium-dependent and -independent cGMP-mediated pulmonary vasorelaxation was dysfunctional in ETX-induced ALI. Neutrophil depletion prevented lung neutrophil accumulation and attenuated pulmonary vasomotor dysfunction after endotoxin. CONCLUSIONS These data suggest that neutrophils contribute to pulmonary endothelium and smooth muscle dysfunction in acute lung injury induced by endotoxemia.
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Affiliation(s)
- B C Sheridan
- Department of Surgery, University of Colorado, Denver, USA
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49
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Abstract
Cardiac dysfunction is common in sepsis and septic shock. An understanding of this pathophysiology is crucial in treatment of this disorder. This article reviews the numerous studies of septic shock in humans that focus on cardiovascular physiology, briefly addresses the possible etiology, and concludes with therapeutic implications.
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Affiliation(s)
- E Bunnell
- Department of Medicine, Rush Medical College of Rush University, Chicago, Illinois, USA
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50
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Fullerton DA, Hahn AR, McIntyre RC. Mechanistic imbalance of pulmonary vasomotor control in progressive lung injury. Surgery 1996; 119:98-103. [PMID: 8560394 DOI: 10.1016/s0039-6060(96)80220-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pulmonary hypertension is the major hemodynamic feature of progressive lung injury. We hypothesized that the mechanisms of pulmonary vasorelaxation become progressively impaired in progressive lung injury. The purpose of this study was to examine the following mechanisms of pulmonary vasorelaxation in a rat model of monocrotaline-induced progressive lung injury: endothelial-dependent cyclic guanosine monophosphate-mediated relaxation (response to acetylcholine), endothelial-independent cyclic guanosine monophosphate-mediated relaxation (response to nitroprusside), beta-adrenergic cyclic adenosine monophosphate-mediated relaxation (response to isoproterenol), and hypoxic pulmonary vasoconstriction. METHODS Rats were studied 2, 7, and 14 days after monocrotaline injection (100 mg/kg intraperitoneally). Pulmonary vasomotor control mechanisms were studied in isolated pulmonary artery rings. Controls were studied 14 days after saline injection. Statistical analysis was by ANOVA; p < 0.05 was considered significant. RESULTS A progressive impairment of pulmonary vasorelaxation was observed. By 14 days after monocrotaline injection acetylcholine produced only 25% +/- 5% relaxation versus 95% +/- 5% in controls (p < 0.05), nitroprusside produced 46% +/- 5% relaxation versus 100% in controls (p < 0.05), and isoproterenol produced only 18% +/- 5% relaxation versus 94% +/- 4% in controls (p < 0.05). At the same time hypoxic pulmonary vasoconstriction became progressively exaggerated. CONCLUSIONS Progressive dysfunction of pulmonary vasomotor control may contribute to the pulmonary hypertension seen in progressive lung injury.
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Affiliation(s)
- D A Fullerton
- Department of Surgery, University of Colorado, Denver, USA
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