Oxidative stress status: possible guideline for clinical management of critically ill patients

BACKGROUND

Critical care medicine has developed in the last few years into a separate scientific discipline and studies related to the outcome after intensive care usually suggest a long hospital stay that becomes cost prohibitive. The majority of problems (death) amongst critically ill patients requiring critical care involve sepsis, inflammation, tissue damage-oxidative stress, oxygen tension PO2, lipid peroxidation. The present investigation involves monitoring of serum levels of MDA, SOD as a possible guideline for severity of clinical situations in critically ill patients.

METHODS

Fifty critically ill heterogeneous patients requiring intensive care in the ICU of IKDRC were selected as subjects with ages varying from 17 to 75 years. Serum levels of MDA (ng/ml), SOD (U/ml) were determined right from admission to discharge due to improvement / DAMA / death. MDA and SOD were estimated according to the methods of Buege and Aust et al. (1978), Nandi and Chatterji (1988).

RESULTS

Critically ill patients irrespective of the disease process indicated significantly very high serum levels of MDA and low levels of SOD at the time of admission (13.28+/-4.26 ng/ml, 3.80+/-2.60 U/ml, respectively) according to the severity of the prevalent clinical situation. The pattern of serum levels of MDA and SOD according to subsequent clinical performance did indicate a decreasing trend of MDA (oxidant) and fluctuating trend of SOD (antioxidant enzyme except in those who inevitably succumbed to death in spite of adequate clinical management.

CONCLUSIONS

The results of the present study have amply revealed the utility and relevance of monitoring oxidative stress in critically ill patients as biochemical markers, cost-effectiveness and role in decision making (withdrawal/continuation of different support modalities) as deemed fit.

Stress and women

Stress-tension-pain occur more often in health disorders of women than anywhere in the entire spectrum of human illness. No where is the effect of rapid change more apparent than in the changing role of today's women who are subjected to pressures from all sides. Now a days women virtually take part occupy positions, in day to day activities similar to their male counterparts. An outline of conceptual consideration, biochemical overview of stress and intricacies of coping mechanisms are delineated from the point of view of stress situations in female (during reproductive life span) peculiar to them only viz menarche, menstrual cycle, pregnancy-eventualities of pregnancy-labour-delivery, purperium, postpartum psychosis, abortions-induced, spontaneous, menopause. Lipid profile and oxidative stress status as biochemical responses in these stresses were investigated. As expected observed maximal/minimal biochemical responses well correlated with peak time and at termination of stress. Present day emphasis is on menstrual regulation by intake of oral contraceptive to improve health if women prefer not to bleed every month and hormone replacement therapy for elderly women to improve post menopausal quality of life and avoiding menstrual problems at the same time.

Iodinated contrast media induced oxidative stress status in patients undergoing urography

BACKGROUND

The present investigation is an extension of our earlier work on oxidative stress in a number of clinical situations and awareness of potential toxicity of contrast media. It was of interest to understand the relative safety (in terms of balance between oxidants/antioxidants) of the usage of iodinated contrast media in urography.

METHODS

Alterations in serum levels of oxidant lipid peroxidation and product malondialdehyde (MDA) and components of anti-oxidant have been studied in 125 patients (with renal calculus disease) to undergo intravenous urographic procedure before and 3 hours following intravenous administration of Trivideo-400 (Iothalmate Sodium 40 ml: 18 gm Iodine) and results of serum levels of MDA (nmol/ml), SOD (mu/ml), Vit-C and Vit-E (mg/dl) were also compared with 135 appropriately age matched controls.

RESULTS

The salient features of present investigation indicated definite pattern viz. Significant rise in serum levels of oxidant MDA (4.35 +/- 2.05) and fall in SOD (3.04 +/- 1.04), Vit-C (0.55 +/- 0.17), Vit-E (0.67 +/- 0.20) in patients at pre-IVU stage in comparison with those of controls viz MDA (4.35 +/- 2.05), SOD (3.77 +/- 1.55), Vit-C (0.71 +/- 0.25) and Vit-E (0.80 +/- 0.30). There occurred further elevation in serum levels of MDA (5.28 +/- 2.48) and fall in SOD (3.07 +/- 0.97), Vit-C (0.52 +/- 0.16), Vit-E (0.66 +/- 0.19) showing no significant alterations 3 hours following intravenous IVU procedure.

CONCLUSIONS

It is concluded that contrast media induced changes did remain within tolerable physiological limits and no significant changes in anti-oxidant components Vit-E and SOD were suggestive of relative safety of iodinated contrast media usage.

Effect of renal transplantation (surgical stress) on serum levels of oxidants and reducing system

BACKGROUND

This study attempts to understand the correlation (if any) between surgical stress of renal transplantation and serum levels of pro-oxidant/antioxidants.

METHODS

Twenty-four ESRD patients having undergone transplant surgery followed from day-1 to day-10 postsurgery were investigated for serum levels of MDA, SOD, Vit. C and E. The drug regimen received was immunosuppressant, H2 blockers and antihypertensives as per the situation.

RESULTS

The typical observations indicated elevated serum levels of MDA from preoperative stage reaching peak value 24 hrs after surgery followed by a steady fall and achieving minima on the 10th day. As regards antioxidants enzyme SOD, Vit. C, Vit. E were low from pretransplant day reaching minima 24 hours postoperatively and returning to normal from 7th day.

CONCLUSIONS

The present investigation has amply shown a typical imbalance between pro-oxidant/antioxidants from pretransplant day up to 24 hrs and there after returning to normal level from 7th day suggestive to desired recovery and surgical stress not a limiting factor in way of health progress renal transplant. Dietary intake of Vit. C and E in mega doses can be a good therapeutic measure.

Oxidative stress status in children with nephrotic syndrome

In continuation of our work on human stress situation and present day awareness of the role of free radical toxicity in a variety of clinical conditions, oxidative stress status (in terms of serum levels of MDA, scavenging enzyme SOD, vitamins: C and E) has been studied in 45 pediatric patients with nephrotic syndrome (further classified as steroid: responders, frequent/ infrequent relapsers, dependents). The results have been compared with 42 appropriately age healthy children as controls. The salient features of the present study centre around typical observations viz significantly increased levels of MDA (7.92 +/- 2.24 nmol/ml), decreased levels of SOD (1.36 +/- 1.01 U/ml), vitamin C (0.49 +/- 0.17 mg/dl) and vitamin E (0.52 +/- 0.19 mg/dl) in children with nephrotic syndrome as a whole when compared with healthy controls [MDA (4.40 +/- 1.31 nmol/ml), SOD (3.04 +/- 1.83 U/ml), vitamin C (0.60 +/- 0.26 mg/dl) and vitamin E (0.68 +/- 0.25 mg/dl) respectively]. An almost similar trend was encountered in different groups as classified. However, maximum fluctuations were observed in steroid dependents. The present observations appear to be suggestive of alternative guidelines to clinicians in the absence of conventional renal biopsy as the procedure. It is felt that children with nephrotic syndrome should regularly take vitamins C and E from the health point of view.

Serum lipoperoxide levels in surgical stress of abdominal hysterectomy

In continuation of our studies on stress situations in female reproductive life span, serum lipid peroxide levels in terms of malondialdehyde (nmol/ml) have been determined in females [(n = 40) (aged between 35-40 years)] to undergo total abdominal hysterectomy (due to dysfunctional uterine bleeding). There occurred a statistically significant though within physiological limits, progressive rise in serum lipid peroxide levels right from preoperative stage 3.51, per operatively 3.56 to a maximum of 4.10 postoperative stage I with a tendency of fall at postoperative stage II 3.94 in comparison with self control on admission 2.97. It is suggestive of the balancing and protective role of scavenging enzyme system like superoxide dismutase also backed by improvement in health status of abdominal hysterectomy patients in terms of ambulation, free intake of food and behavioural positive attitude within 24 hours following operation presumably due to relief from stress of DUB. It is felt from the results of the present investigation that patients undergoing abdominal hysterectomy were free from free radical toxicity.

Serum lipoperoxides in induced and spontaneous abortions

Abortion, primarily as a measure of population control, certainly continues to be an emotional, frustrating and stressful event. In continuation of our work on stressful situations in the female life span and biochemical parameters, serum lipid peroxide levels in terms of malondialdehyde (nmol/ml) have been determined in females undergoing abortion [suction curettage (n = 30), Emcredil-induced abortion (n = 30) and spontaneous abortion (n = 40)] and were compared with appropriate gestational controls. Irrespective of the type of abortion, the serum lipid peroxide levels before abortion [mean malondialdehyde concentrations (nmol/ml): suction curettage 2.67, Emcredil-induced abortion 3.22, and spontaneous abortion 3.49] were found to be significantly elevated in comparison with those after abortion (suction curettage 1.91, Emcredil 1.97 and spontaneous abortion 1.95), indicating a maximum at peak time of stress and a minimum at the end of stress. The levels of serum lipid peroxide encountered before abortion were found to be significantly elevated in case of Emcredil-induced abortion and spontaneous abortion when compared with controls (second trimester mean levels 1.82 and first trimester 2.4) whereas the levels before suction curettage were found to be nonsignificant in comparison with controls, indicating a lesser degree of stress. It is felt that monitoring of serum lipid peroxide levels in serum and tissues (placenta), backed by scavenging enzyme superoxide dismutase, can be more helpful for corroborating safety and the risk of free radical toxicity in pregnancy and abortion.

Serum immunoglobulin status of psychiatric in-patients

In view of the fact that substantial evidence today links psyche, brain, stress and immune system, the serum immunoglobulin (viz. IgG, IgA, IgM) levels in 40 patients with psychiatric disorders (viz. Schizophrenia, Affective disorder and generalized Anxiety disorders) have been investigated. With the exception of IgA, all psychiatric patients had significantly elevated IgG, IgM levels (p less than 0.001) when compared with healthy controls. Surprisingly these immunoglobulin levels irrespective of prevalent psychiatric disorder were almost similar to those of the hospitalized surgical patients pre-operatively (preferable controls), suggestive of no direct linear causal relationship between the psychiatric disorder and serum immunoglobulin levels. Factors affecting immunoglobulins have been discussed. Considering a probable viral association in Schizophrenia it is felt that simultaneous monitoring of viruses (affecting the nervous system) in the form of antigen/antibodies may be more informative.

Serum lipoperoxide levels in pregnancy induced hypertension

With present day awareness of role and toxicity of lipid peroxides, serum levels of lipoperoxides have been investigated in forty pregnancy induced hypertension (PIH) subjects, before and after antihypertensive drug therapy, using full term normotensive patients as control. PIH subjects demonstrated highly significant elevated serum levels of lipoperoxides (mean 3.60 nmol/ml) in comparison (mean 2.15 nmol/ml) with full term normotensive subjects. At post-partum PIH subjects following antihypertensive drug therapy and becoming normotensive showed highly significant fall in serum lipoperoxide (mean level 2.27 nmol/ml). Full term normotensive subjects at post-partum also demonstrated the same pattern. However, observed levels of serum lipoperoxide in PIH subjects at post-partum even after becoming normotensive following treatment were found to be significantly elevated when compared with those of full term normotensives at post-partum (mean level 1.94 nmol/ml). It is felt that monitoring of serum lipoperoxide level can serve as one of the useful parameters in PIH subjects.

[Levels of serum lipids during abortion induced by a hypertonic saline solution]

Studies were carried out on serum lipid levels in 30 women in good health who were pregnant for the first time with a pregnancy of between 15 and 20 weeks duration, who had the pregnancies terminated by the use of a hypertonic saline solution. They showed a rise only in the cholesterol level (5.83 mmol/l +/- 0.17) in the phase of actively aborting (a period of maximum stress) as compared with a level of cholesterol in the pre-abortion phase (4.93 mmol/l +/- 0.17). Between 12 and 15 hours after the termination the cholesterol level dropped sharply as did the levels of phospho-lipids and triglycerides. The levels became of the order of 4.1 mmol/l +/- 0.25, 2.73 mmol/l +/- 0.097 and 1.03 mmol/l +/- 0.06 respectively according to the phase the termination was in. The levels of serum lipids after the termination were, surprisingly, almost the same as those in non-pregnant women. The poor rise in serum lipids during termination induced by hypertonic saline solution shows that probably labour was of low intensity.

Effect of menstrual stress on serum lipid levels

The effect of menstrual stress on serum lipid levels has been investigated in 28 healthy unmarried student nurses aged between 19 and 25 years, with histories of regular 26-30 day menstrual cycles. There were definite and similar patterns of changes in serum cholesterol, phospholipids and triglycerides during different phases of the menstrual cycle.

Effect of preoperative stress on serum cholesterol level in humans

Effect of preoperative stress on serum cholesterol level in 65 patients of different age groups in a surgical ward, has been studied. In all age groups, statistically significant rise of cholesterol in serum preoperatively was notices as compared with serum cholesterol level at the time of discharge from hospital. The preoperative rise of cholesterol varied from 39 to 56.9% in this series. These findings support previous reports of the effect of mental tension on serum cholesterol level.