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Clarkin-Breslin RC, Brainard BM. Point-of-care and traditional erythrocyte sedimentation rate, point-of-care rheometry, and cell-free DNA concentration in dogs with or without systemic inflammation. J Vet Diagn Invest 2024; 36:177-186. [PMID: 38372154 DOI: 10.1177/10406387241226971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024] Open
Abstract
RBC aggregation and deformability characteristics are altered by inflammatory, microcirculatory, and hemorheologic disease. These changes can be indirectly evaluated using the erythrocyte sedimentation rate (ESR). Newer point-of-care devices employ syllectometry to evaluate RBC rheology, which can give information beyond the ESR. We evaluated 2 point-of-care rheometers (iSED and MIZAR; Alcor Scientific) in 52 dogs presented to a university teaching hospital. Whole blood samples were analyzed for correlation between the ESR using the Westergren (ESRw) method (measured at 1 h and 24 h) and the predicted ESR using iSED. Plasma fibrinogen and cell-free DNA concentrations were also measured as probable markers of inflammation. The iSED-predicted ESR was positively correlated to the ESRw method at 1 h (r = 0.74; p < 0.001) and 24 h (r = 0.62; p < 0.001). Comparing dogs with or without inflammation (defined as plasma fibrinogen concentration >3.5 g/L [350 mg/dL]), significant differences were seen in the MIZAR parameters of base point, amplitude, integral, and half-time. Median cell-free DNA concentrations were higher in the group of dogs with inflammation (117 [range: 51-266] ng/mL vs. 82.7 [range: 19-206] ng/mL; p = 0.024). The iSED-predicted ESR is a good predictor of the ESRw and was obtained more rapidly. Rheometric parameters measured by MIZAR may be useful in detecting inflammation and monitoring secondary morphologic and functional changes in canine RBCs.
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Affiliation(s)
- Rachel C Clarkin-Breslin
- Department of Small Animal Medicine and Surgery, University of Georgia Veterinary Teaching Hospital, Athens, GA, USA
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, University of Georgia Veterinary Teaching Hospital, Athens, GA, USA
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Dal-Pizzol F, Ritter C, Cassol-Jr OJ, Rezin GT, Petronilho F, Zugno AI, Quevedo J, Streck EL. Oxidative Mechanisms of Brain Dysfunction During Sepsis. Neurochem Res 2009; 35:1-12. [DOI: 10.1007/s11064-009-0043-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 07/31/2009] [Indexed: 12/16/2022]
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Weiss DJ, Kristensen A, Papenfuss N, McClay CB. Quantitative evaluation of echinocytes in the dog. Vet Clin Pathol 2003; 19:114-118. [PMID: 12684948 DOI: 10.1111/j.1939-165x.1990.tb00556.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Echinocytes were evaluated quantitatively in both healthy and sick dogs and compared with red blood cell (RBC) morphology on Wright's-stained blood smears. Of 68 samples submitted from sick dogs, 32 had high echinocyte numbers. Two diseases, glomerulonephritis and lymphosarcoma, accounted for 15 of the 32 cases. In only four instances were echinocytes reported from blood smear evaluation and not found to be high by quantitative studies. We conclude that nonartifactual echinocytosis occurs in the dog and that it may be associated with specific diseases.
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Affiliation(s)
- Douglas J. Weiss
- Department of Veterinary Pathobiology, College of Veterinary Medicine, University of Minnesota, St. Paul, MN 55108
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Papadopoulos MC, Davies DC, Moss RF, Tighe D, Bennett ED. Pathophysiology of septic encephalopathy: a review. Crit Care Med 2000; 28:3019-24. [PMID: 10966289 DOI: 10.1097/00003246-200008000-00057] [Citation(s) in RCA: 217] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Encephalopathy is a common complication of sepsis. This review describes the different pathologic mechanisms that may be involved in its etiology. DATA SOURCES The studies described here were derived from the database PubMed (http:¿¿www.nlm.nih.gov) and from references identified in the bibliographies of pertinent articles and books. The citations are largely confined to English language articles between 1966 and 1998. Older publications were used if they were of historical significance. STUDY SELECTION All investigations in which any aspect of septic encephalopathy was reported were included. This selection encompasses clinical, animal, and in vitro cell culture work. DATA EXTRACTION The literature cited was published in peer-reviewed clinical or basic science journals or in books. DATA SYNTHESIS Contradictions between the results of published studies are discussed. CONCLUSIONS The most immediate and serious complication of septic encephalopathy is impaired consciousness, for which the patient may require ventilation. The etiology of septic encephalopathy involves reduced cerebral blood flow and oxygen extraction by the brain, cerebral edema, and disruption of the blood-brain barrier that may arise from the action of inflammatory mediators on the cerebrovascular endothelium, abnormal neurotransmitter composition of the reticular activating system, impaired astrocyte function, and neuronal degeneration. Currently, there is no treatment.
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Affiliation(s)
- M C Papadopoulos
- Department of Anaesthetics and Intensive Care Medicine, St. George's Hospital Medical School, London, UK
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Millar CG, Thiemermann C. Intrarenal haemodynamics and renal dysfunction in endotoxaemia: effects of nitric oxide synthase inhibition. Br J Pharmacol 1997; 121:1824-30. [PMID: 9283724 PMCID: PMC1564887 DOI: 10.1038/sj.bjp.0701335] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
1. This study investigated the effects of low dose endotoxin (lipopolysaccharide, LPS) on (i) systemic haemodynamics, (ii) renal blood flow (RBF), (iii) renal cortical and medullary perfusion and (iv) renal function in the anaesthetized rat. We have also investigated the effects of nitric oxide (NO) synthase (NOS) inhibition with NG-methyl-L-arginine (L-NMMA) on the alterations in systemic and renal haemodynamics and renal function caused by endotoxin. 2. Infusion of low dose LPS (1 mg kg-1 over 30 min, n = 6) caused a late fall in mean arterial blood pressure (MAP, at 5 and 6 h after LPS), but did not cause an early (at 1-4 h after LPS) hypotension. The pressor effect of noradrenaline (NA, 1 microgram kg-1, i.v.) was significantly reduced at 1 to 6 h after LPS (vascular hyporeactivity). Infusion of L-NMMA (50 micrograms kg-1 min-1 commencing 60 min before LPS and continued throughout the experiment, n = 7) abolished the delayed hypotension and significantly attenuated the vascular hyporeactivity to NA (at 2-6 h). 3. Infusion of LPS (1 mg kg-1 over 30 min, n = 6) caused a rapid (within 2 h) decline in renal function (measured by inulin clearance) in the absence of a significant fall in MAP or renal blood flow (RBF). L-NMMA (n = 7) attenuated the impairment in renal function caused by LPS so that the inulin clearance in LPS-rats treated with L-NMMA was significantly greater than in LPS-rats treated with vehicle (control) at 3-6 h after infusion of LPS. 4. Endotoxaemia also caused a significant reduction in renal cortical, but not medullary perfusion (measured as Laser Doppler flux). Infusion of L-NMMA caused a significant further fall in cortical perfusion and a significant fall in medullary perfusion in the absence of changes in RBF. 5. Infusion of LPS resulted in a progressive increase in the plasma levels of nitrite/nitrate (an indicator of the formation of NO), so that the plasma concentration of nitrite/nitrate was significantly higher than baseline at 150 to 330 min after LPS. Infusion of L-NMMA attenuated the rise in the plasma concentration of nitrite/nitrate (at 270 and 330 min, P < 0.05) caused by LPS. 6. Thus, the renal dysfunction caused by injection of low dose of endotoxin in the rat occurs in the absence of significant falls in blood pressure or total renal blood flow. Inhibition of NOS activity with L-NMMA attenuates the renal dysfunction caused by endotoxin (without improving intrarenal haemodynamics), suggesting that an overproduction of NO may contribute to the development of renal injury and dysfunction by causing direct cytotoxic effects.
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Affiliation(s)
- C G Millar
- William Harvey Research Institute, St. Bartholomew's and the Royal London School of Medicine and Dentistry
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Wang P, Ba ZF, Chaudry IH. Pentoxifylline maintains hepatocellular function and improves cardiac performance during early sepsis. THE JOURNAL OF TRAUMA 1997; 42:429-35; discussion 435-6. [PMID: 9095110 DOI: 10.1097/00005373-199703000-00010] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Although pentoxifylline (PTX) produces various beneficial effects after endotoxemia, it remains unknown whether this agent attenuates the depressed hepatocellular function and improves heart performance during early sepsis. The aim of this study, therefore, was to determine whether PTX maintains hepatocellular function and improves cardiac function during the early hyperdynamic stages of polymicrobial sepsis. DESIGN, MATERIALS, AND METHODS Rats were subjected to sepsis by cecal ligation and puncture (CLP). At 1 hour after CLP, PTX (50 mg/kg body weight), or an equal volume of saline, was infused intravenously over 30 minutes. At 2 or 5 hours after CLP (i.e., early hyperdynamic stages of sepsis), hepatocellular function was assessed by in vivo indocyanine green clearance. Cardiac output was determined by dye dilution. Left ventricular performance parameters such as maximal rates of left ventricular pressure rise and fall (+/-dP/dtmax), ventricular peak systemic pressure, etc., were determined using a heart performance analyzer. RESULTS The results indicate that hepatocellular function was significantly depressed at 2 and 5 hours after CLP. Administration of PTX, however, maintained hepatocellular function to sham levels. Although cardiac output increased after CLP with or without PTX treatment, this agent markedly improved cardiac performance as evidenced by significantly higher + dP/dtmax and ventricular peak systemic pressure as well as other heart performance parameters. CONCLUSIONS Pentoxifylline appears to be a useful adjunct for maintaining hepatocellular function and improving cardiac performance during the early hyperdynamic stages of polymicrobial sepsis.
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Affiliation(s)
- P Wang
- Center for Surgical Research, Brown University School of Medicine, Providence, Rhode Island, USA
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Abstract
OBJECTIVE An overview of the importance of understanding mechanisms occurring in the microcirculation during septic and endotoxic shock. The thesis of the paper is to place emphasis on this important vascular network to ultimately benefit the patient. DATA SOURCES Early descriptions of vascular reactions to endotoxin which suggest that the microcirculation is a major site of attack during shock. More recent studies were sought out and examined as to their possible impacts on the microcirculation. STUDY SELECTION Early comprehensive studies concerning vascular reactions in the microcirculation during shock were selected. Subsequent studies identified from the mainstream scientific medical literature describe the actions of blood, cells, and the emerging significant role of the vascular endothelium among other factors. A consensus view is identified, pointing to the causes of a malfunctioning microcirculation during shock. DATA EXTRACTION Data gathered from reports in the mainstream, well-established basic and clinical literature, from reviews and forum reports, from studies by well-established investigators, and from more recent reports of excellent quality. DATA SYNTHESIS The microcirculation undergoes massive alterations during sepsis/septic shock. There are numerous changes, including slowing of capillary blood flow due to depressed perfusion pressure as a result of systemic pressure reduction and local arteriolar constriction. Observations suggest that the microcirculation is shut off early in severe sepsis, allowing the effects of hypoperfusion and attacks by microorganisms to prevail in their destructive capabilities. Widespread capillary dilation may ultimately occur. However, with blood flow diverted through some arteriovenous channels, important areas of capillary exchange are bypassed. Decreased capillary blood flow during shock results from failure to allow normal passage of cellular elements, including erythrocytes and neutrophils. This defect occurs, in part, because of decreased perfusion pressure, decreased deformability of red and white cells, constricted arterioles, circulating obstructive fragments (including hemoglobin), and plugging of microvessels with "sludge." Other factors are adherence of cells to capillary and venular epithelial membranes creating increased resistance to flow, loss of fluid through abnormal transcapillary exchange, differential vascular resistance changes between various beds (e.g., intestinal vs. muscle), and the relative absence of regulatory neurohumoral control of small vessel segments of the circulation. During sepsis/septic shock, endothelial cells are reported to modulate vascular tone, control local blood flow, influence the rate of leakage of fluids and plasma proteins into tissues, modulate the accumulation and extravasation of white cells into tissues, and influence white cell activation. As a result of the predominance of many destructive factors, a subsequent round of tissue damage may occur. Because of prolonged capillary vascular stasis, deficient flow, and factors released from injured cells, the microcirculation becomes a trap for uncontrolled bacterial growth enhanced by sustained hypoxemia, acidosis and toxemia. These events may combine to contribute to the loss of normal cell integrity and death of the host. CONCLUSIONS The purpose of this review is to draw the readers' attention to the growing list of adverse factors occurring in the microcirculation during sepsis/septic shock. A further aim is to point to the realization of the complexity of factors which may contribute to the importance of a well-functioning microcirculation.
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Affiliation(s)
- L B Hinshaw
- Oklahoma Medical Research Foundation, Oklahoma City, 73104, USA
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Holzheimer RG, Molloy RG, O'Riordain DS, Mendez MV, Curley P, Collins K, Nestor M, Saporoschetz IB, Mannick JA, Rodrick ML. Long-term immunotherapeutic intervention with pentoxifylline in a mouse model of thermal injury and infection. THE JOURNAL OF TRAUMA 1995; 38:757-62. [PMID: 7760405 DOI: 10.1097/00005373-199505000-00014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Major thermal or traumatic injury often results in abnormalities of immune function, and these abnormalities contribute to the increased susceptibility to infection observed in these patients. Abnormalities of T-cell function, including decreased proliferation and secretion of cytokines are observed following major injury and, conversely, there is markedly increased monokine production. Thus, therapy of this syndrome might logically be aimed at modulating the immune system to upregulate T-cell function and downregulate monocyte hyperactivation. Pentoxifylline (PTX), a methylxanthine derivative, has been shown to be therapeutically effective in several animal models. The purpose of this study was to evaluate PTX and its effect on cytokine production in a mouse model of thermal injury and to study its effect on survival after septic challenge. The results show that PTX therapy after injury can restore T-cell production of IL-2 and downregulate the hyperactive macrophage secretion of proinflammatory cytokines. However, improvement in survival resulting from this therapy following thermal injury and septic challenge depends on timing of dosage.
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Affiliation(s)
- R G Holzheimer
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA 02115, USA
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Lam C, Tyml K, Martin C, Sibbald W. Microvascular perfusion is impaired in a rat model of normotensive sepsis. J Clin Invest 1994; 94:2077-83. [PMID: 7962554 PMCID: PMC294647 DOI: 10.1172/jci117562] [Citation(s) in RCA: 273] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
We hypothesized that normotensive sepsis affects the ability of the microcirculation to appropriately regulate microregional red blood cell (RBC) flux. An extensor digitorum longus muscle preparation for intravital study was used to compare the distribution of RBC flux and the functional hyperemic response in SHAM rats and rats made septic by cecal ligation and perforation (CLP). Using intravital microscopy, we found that sepsis was associated with a 36% reduction in perfused capillary density (from 35.3 +/- 1.5 to 22.5 +/- 1.0 capillaries/mm of test line) and a 265% increase in stopped-flow capillaries (from 0.9 +/- 0.2 to 3.3 +/- 0.4 capillaries/mm); the spatial distribution of perfused capillaries was also 72% more heterogeneous. Mean intercapillary distance (ICD) increased 30% (from 25.7 +/- 0.8 to 33.5 +/- 1.6 microns), and the proportion of capillary pairs with intercapillary distances > 33.8 microns (the 75th percentile of ICDSHAM) was greater with sepsis. Mean capillary RBC velocity increased 17% in CLP rats (391 vs 333 microns/s). Laser Doppler flowmetry was used to assess the functional hyperemic response of the extensor digitorum longus muscle before and after a period of maximal twitch contraction designed to increase oxygen demand. RBC flux was 36% lower in the CLP rats at rest. After contraction, RBC flux increased in both SHAM and CLP rats; however, the relative increase was less in the CLP group. We concluded that sepsis affects the ability of the skeletal muscle microcirculation to appropriately distribute RBC flux and to respond to increases in oxygen need.
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Affiliation(s)
- C Lam
- A. C. Burton Vascular Biology Laboratory, Victoria Hospital Research Institute, London, Canada
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Sigurdsson GH, Youssef H. Effects of pentoxifylline on hemodynamics, gas exchange and multiple organ platelet sequestration in experimental endotoxic shock. Acta Anaesthesiol Scand 1993; 37:396-403. [PMID: 8322569 DOI: 10.1111/j.1399-6576.1993.tb03736.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In an intensive care setting we studied the effects of pentoxifylline on hemodynamics, gas-exchange and platelet sequestration in multiple organs in three groups of sheep exposed to endotoxin shock (n = 7 in each). Group P-E was given pentoxifylline before and group E-P after E. coli endotoxin infusion, while group E received normal saline (controls). The endotoxin infusion caused a three-fold increase in pulmonary artery pressure (PAP) and a significant decrease in mean arterial pressure (25-30%; MAP), respiratory compliance (CT; 60%) and arterial oxygen tension (65-70%; Pao2) in all groups after 30 min. After 4 h MAP had improved significantly in the pretreated animals (group P-E) and arterial pH, Pao2 and CT improved in both pentoxifylline-treated groups compared with the controls. On the other hand, the effects of endotoxin on PAP and cardiac index were not significantly influenced by pentoxifylline treatment. In addition, there was a pronounced platelet sequestration in the lungs and in the liver in groups E and E-P during the 4 h study, but in the pretreated group (group P-E) the changes were significantly less marked (P < 0.01). The wet-to-dry weight ratios of the lungs were significantly lower in both pentoxifylline-treated groups compared with the controls (P < 0.01). It was concluded that pentoxifylline modified the effects of endotoxin on hemodynamics, gas exchange and platelet sequestration in the lungs and liver in sheep when it was given prior to endotoxin. However, when it was given after hemodynamic and respiratory signs of shock had appeared, the effects were more moderate.
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Affiliation(s)
- G H Sigurdsson
- Department of Anaesthesia and Intensive Care, University of Berne, Switzerland
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Ogata M, Matsumoto T, Kamochi M, Yoshida SI, Mizuguchi Y, Shigematsu A. Protective effects of a leukotriene inhibitor and a leukotriene antagonist on endotoxin-induced mortality in carrageenan-pretreated mice. Infect Immun 1992; 60:2432-7. [PMID: 1587610 PMCID: PMC257177 DOI: 10.1128/iai.60.6.2432-2437.1992] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The leukotrienes and tumor necrosis factor (TNF) play an important role in the pathophysiology of septic shock, in which hypotension, leukopenia, thrombocytopenia, and hemoconcentration are observed. This study was performed to examine the effects of a 5-lipoxygenase inhibitor (AA-861), a selective leukotriene receptor antagonist (ONO-1078), and a cyclooxygenase inhibitor (indomethacin) on endotoxin-induced mortality and TNF production in mice. Mice were injected intraperitoneally with carrageenan (5 mg per mouse), which we previously reported as an effective priming agent for lipopolysaccharide (LPS)-induced TNF production and mortality (M. Ogata, S. Yoshida, M. Kamochi, A. Shigematsu, and Y. Mizuguchi, Infect. Immun. 59:679-683, 1991). The indicated doses of AA-861, ONO-1078, indomethacin, or controls were administrated subcutaneously 30 min before LPS (50 micrograms per mouse) provocation. The mortality of mice was significantly decreased by pretreatment with AA-861 (P less than 0.001) or ONO-1078 (P less than 0.01) but not by pretreatment with indomethacin. The 50% lethal dose of LPS in the mice treated with dimethyl sulfoxide or ethanol was 32 or 33 micrograms, respectively, and it increased to 83 micrograms with AA-861 or 59 micrograms with ONO-1078, respectively. Neither AA-861 nor ONO-1078 suppressed LPS-induced TNF production in sera. Treatment with AA-861 significantly decreased the leukopenia and thrombocytopenia, and ONO-1078 significantly decreased the hemoconcentration and thrombocytopenia. The role of endogenous TNF was also examined in the carrageenan-pretreated mice. Treatment with 2 x 10(5) U of rabbit anti TNF-alpha antibody intravenously 2 h before LPS challenge significantly suppressed the LPS-induced TNF activity and decreased the mortality. Therefore, both leukotrienes and TNF play important roles in endotoxin-induced shock and mortality.
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Affiliation(s)
- M Ogata
- Department of Anesthesiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Kato T, Hayashi K, Takamizawa K, Tsushima N. A selective thromboxane synthetase inhibitor, OKY-046, fails to improve blood rheology in endotoxin-shocked rabbits. J Anesth 1991; 5:247-54. [PMID: 15278626 DOI: 10.1007/s0054010050247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/1990] [Accepted: 12/03/1990] [Indexed: 10/26/2022]
Abstract
Effects of a selective thromboxane synthetase inhibitor, (E)-3-[4-(1-imidazolylmethyl)phenyl]-2-propenoic acid hydrochloride monohydrate (OKY-046), were studied hemorheologically in endotoxin shocked-rabbits. The animals were intravenously administrated with 0.1 mg of endotoxin 3 times at intervals of 3 days. At 7 days after the last endotoxin injection, endotoxin (0.2 mg.kg(-1)) was intravenously administrated to induce a shock. OKY-046 (30 mg.kg(-1)) was administrated after hypotension was developed by the endotoxin treatment and, then, it was continuously injected at 0.03 mg.kg(-1).min(-1). Blood pressure remained unchanged and hypotensive was maintained during the treatment with OKY-046. Blood was sampled from the femoral artery 15 (before the administration of OKY-046), 45, and 120 minutes after the final administration of endotoxin. Pa(O)(2) increased, and Pa(CO)(2), arterial pH, and base excess (BE) decreased during the endotoxin shock. The decrease of pH and BE was prevented by the administration of OKY-046. In the endotoxin-shocked animals, hematocrit, whole blood viscosity, erythrocyte deformability, plasma fluidity, and the ratio of hematocrit to whole blood viscosity showed no significant differences between the OKY-046 treated animals and non-treated ones. These data show that a selective thromboxane synthetase inhibitor (OKY-046) does not improve the blood rheology during endotoxin shock, although it seems to prevent the acidosis in some extent.
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Affiliation(s)
- T Kato
- Department of Anesthesiology, Toyokawa City Hospital, Toyokawa, Japan
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