Activated macrophages decrease rat cardiac myocyte contractility: importance of ICAM-1-dependent adhesion

Macrophages are found in the heart as part of the inflammatory response. To determine whether macrophages could contribute to myocardial dysfunction, rat ventricular myocytes were isolated and cocultured with elicited peritoneal macrophages in media containing tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta, or endotoxin for 4 h. Cardiac myocytes were electrically stimulated, and fractional shortening was determined using videomicroscopy. When myocytes alone or myocytes in coculture with macrophages separated by a membrane were challenged with TNF-alpha, lipopolysaccharide, or IL-1, fractional shortening did not decrease. When macrophages were allowed to contact myocytes, fractional shortening decreased from 20. 1 +/- 0.9% in unchallenged macrophage-myocyte cocultures to 15.5 +/- 0.9, 16.3 +/- 0.8, and 15.8 +/- 0.6% when challenged for 4 h with TNF-alpha, endotoxin, or IL-1beta, respectively (P < 0.05). Myocytes had a mean adherence of 4.2 +/- 0.2 macrophages after TNF-alpha challenge compared with 2.6 +/- 0.3 for controls (P < 0.05). The number of adherent macrophages was associated with the decrease in fractional shortening. Anti-intercellular adhesion molecule-1 (ICAM-1) reduced macrophage adherence and prevented the decrease in fractional shortening. This decrease was also prevented by desferoxamine, superoxide dismutase, and nitro-L-arginine methyl ester. This suggests that activated macrophages adhere to myocytes via ICAM-1, and adherent macrophages decrease their contractile function via TNF-alpha, oxygen free radicals, and nitric oxide.

Nitric oxide reduces the sequestration of polymorphonuclear leukocytes in lung by changing deformability and CD18 expression

Nitric oxide (NO) influences polymorphonuclear leukocytes (PMN)-endothelial cell interactions. The aim of this study was to evaluate this effect in the lung and investigate this mechanism. PMN sequestration in the lung was evaluated in vivo after the infusion of complement fragments. Rabbits (n = 9) that inhaled 40 ppm of NO were compared with control rabbits (n = 9) over a 2-h period following infusion of complement fragments. Circulating PMN counts immediately decreased after infusion of complement fragments in both groups followed by a recovery to baseline. This recovery was maintained in the NO-treated group compared with the control rabbits (p < 0.05). NO reduced PMN sequestration in the lung measured by both arteriovenous PMN difference across the lung (p < 0.01) and the myeloperoxidase (MPO) content of the lung tissue (p < 0.01). NO had no effect on the complement fragments-induced PMN release from the bone marrow. In vitro studies showed that NO partially inhibited F-actin assembly (p < 0.01) reduced the change in deformability (p < 0.05) and inhibited CD18 upregulation (p < 0.05) but had no effect on the L-selectin shedding of PMN stimulated by complement fragments. We conclude that NO reduces the sequestration of activated PMN by reducing deformability change via inhibition of F-actin assembly and inhibiting the upregulation of CD18.

Leukocyte activation does not mediate myocardial leukocyte retention during endotoxemia in rabbits

Our goal was to determine whether coronary leukocyte retention after endotoxin infusion was due primarily to leukocyte activation. Leukocytes were activated by infusion of endotoxin into 12 blood donor rabbits. Separately, 12 isolated rabbit hearts were perfused with blood from an endotoxemic support rabbit to expose coronary endothelium to an inflammatory stimulus. During an infusion of 20 ml of donor blood into the isolated heart, the coronary transit time of leukocytes was determined by deconvolution of multiple measurements of injectate and collected leukocyte concentrations. With no leukocyte activation or inflammatory stimulation of endothelium, leukocyte transit time was 9.2 +/- 3.5 s, and 11.6 +/- 4.1 x 10(6) leukocytes were retained in the coronary circulation. Leukocyte activation alone did not alter transit time (9.8 +/- 3.2 s) or retention (9.3 +/- 4.6 x 10(6) leukocytes). Inflammatory stimulation of endothelium with and without leukocyte activation increased transit time (18.0 +/- 3.6 and 18.9 +/- 3.8 s, respectively; P < 0. 05) and retention (24.8 +/- 8.4 and 25.3 +/- 6.8 x 10(6) leukocytes, respectively; P < 0.05) to the same extent. Differential counts showed that neutrophils (but not lymphocytes) were slowed and retained. Inflammatory stimulation of endothelium caused coronary capillary endothelial swelling and pseudopod formation. Thus increased coronary neutrophil transit time and retention are due to structural changes of coronary endothelial cells or other effects of the inflammatory response occurring within coronary capillaries, not only due to activation of leukocytes.

Effect of crystalloid administration on oxygen extraction in endotoxemic pigs

We asked whether crystalloid administration improves tissue oxygen extraction in endotoxicosis. Four groups of anesthetized pigs (n = 8/group) received either normal saline infusion or no saline and either endotoxin or no endotoxin. We measured whole body (WB) and gut oxygen delivery and consumption during hemorrhage to determine the critical oxygen extraction ratio (ERO2 crit). Just after onset of ischemia (critical oxygen delivery rate), gut was removed for determination of area fraction of interstitial edema and capillary hematocrit. Radiolabeled microspheres were used to determine erythrocyte transit time for the gut. Endotoxin decreased WB ERO2 crit (0.82 +/- 0.06 to 0.55 +/- 0.08, P < 0.05) and gut ERO2 crit (0.77 +/- 0.07 to 0.52 +/- 0.06, P < 0.05). Unexpectedly, saline administration also decreased WB ERO2 crit (0.82 +/- 0.06 to 0.62 +/- 0.08, P < 0.05) and gut ERO2 crit (0.77 +/- 0.07 to 0.67 +/- 0.06, P < 0.05) in nonendotoxin pigs. Saline administration increased the area fraction of interstitial space (P < 0.05) and resulted in arterial hemodilution (P < 0.05) but not capillary hemodilution (P > 0.05). Saline increased the relative dispersion of erythrocyte transit times from 0.33 +/- 0.08 to 0.72 +/- 0.53 (P < 0.05). Thus saline administration impairs tissue oxygen extraction possibly by increasing interstitial edema or increasing heterogeneity of microvascular erythrocyte transit times.

Small bowel tonometry is more accurate than gastric tonometry in detecting gut ischemia

Gastric tonometer PCO2 measurement may help identify gut ischemia in critically ill patients but is frequently associated with large measurement errors. We tested the hypothesis that small bowel tonometer PCO2 measurement yields more accurate information. In 10 anesthetized, mechanically ventilated pigs subject to progressive hemorrhage, we measured gut oxygen delivery and consumption. We also measured tonometer PCO2 minus arterial PCO2 (DeltaPCO2) and calculated the corresponding intracellular pH from tonometers placed in the stomach and jejunum. We found that the correlation coefficient (r2) for biphasic gut oxygen delivery-DeltaPCO2 relationships was 0.29 +/- 0.52 for the gastric tonometer vs. 0.76 +/- 0.25 for the small bowel tonometer (P < 0.05). In addition, the critical gastric tonometer DeltaPCO2 was excessively high and variable (62.9 +/- 39.6) compared with the critical small bowel tonometer DeltaPCO2 (17.0 +/- 15.0, P < 0.01). Small bowel tonometer PCO2 was closely correlated with superior mesenteric vein PCO2 (r2 = 0.81, P < 0.001), whereas gastric tonometer PCO2 was not (r2 = -0.13, P = not significant). We conclude that measurement of gastric tonometer PCO2 yields excessively noisy and inaccurate data on the onset of gut anaerobic metabolism in hemorrhagic shock. Small bowel tonometer PCO2 is less noisy and, as a result, is superior in detecting gut hypoperfusion and the onset of anaerobic metabolism.

L-2-Oxothiazolidine-4-carboxylic acid prevents endotoxin-induced cardiac dysfunction

We tested the hypothesis that treatment with the glutathione repleting agent, L-2-oxothiazolidine-4-carboxylic acid (OTZ), could prevent endotoxin-induced ventricular dysfunction. Rabbits were treated with OTZ 2.4 g/kg (10% solution subcutaneously), or an equal volume and osmolality of saline, 24 h prior to, and again (intravenously) just prior to, infusion of 1 mg/kg E. coli endotoxin (or vehicle control). Ventricular contractility was measured in isolated hearts perfused by support rabbits. Contractility did not change in control groups (Saline/Control [n = 7] or OTZ/Control [n = 7]) over 6 h. However, Emax decreased in the Saline/Endotoxin group (-16.1 +/- 4.5% from baseline, n = 7, p < 0.05) and this was prevented by pretreatment with OTZ in the OTZ/ Endotoxin group (+6.3 +/- 4.1%, n = 7, p < 0.05 by analysis of variance). To better understand the mechanism of this effect we measured myocardial glutathione concentration and found it to be greater in OTZ/Endotoxin animals (104 +/- 4 ng/g) than in the Saline/Endotoxin animals (80 +/- 3 ng/g, p < 0.05). OTZ did not appreciably alter the endotoxin-induced increase in serum concentration of tumor necrosis factor (TNF) or the endotoxin-induced increase in myocardial leukocyte content. We conclude that oxygen radicals contribute to the early decrease in left ventricular contractility after endotoxin infusion and this decrease may be prevented by OTZ.

Oxygen uptake during peritoneal ventilation in a porcine model of hypoxemia

OBJECTIVES

Peritoneal ventilation (PV) can greatly increase PaO2 in hypoxemic rabbits. We tested the hypothesis that the peritoneum can provide a gas exchange surface for oxygen uptake in larger animals that, like humans, have a smaller relative peritoneal surface area and corresponding blood flow.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

University research laboratory.

INTERVENTIONS

In six anesthetized pigs, a modified endotracheal tube (9.0-inner diameter) was inserted into the peritoneal cavity, and the peritoneal cavity was ventilated with oxygen in helium in gas phase. Measurements of peritoneal oxygen uptake and mixed venous oxygen saturation were made over 30 mins of: a) baseline FiO2 0.20, no PV; b) FiO2 0.20, PV; c) FiO2 0.20, PV, dopamine 5 microg/kg/min; d) baseline FiO2 0.15, no PV; e) FiO2 0.15, PV; and f) FiO2 0.15, PV, dopamine 5 microg/kg/min.

MEASUREMENTS AND MAIN RESULTS

Mixed venous oxygen saturation was 61% at the baseline FiO2 of 0.20 and 33% at an FiO2 of 0.15 and did not increase significantly from baseline with PV or with dopamine at either FiO2. Peritoneal oxygen uptake, measured with a waterseal spirometer, was 9.1+/-3.1 (SD) and 11.9+/-3.0 mL/min when lung FiO2 was 0.20 and 0.15, respectively, and 9.7+/-2.8 and 12.2+/-2.7 mL/min when FiO2 was 0.20 and 0.15 and dopamine was infused, respectively.

CONCLUSION

Peritoneal ventilation does not result in clinically significant oxygen uptake or alter mixed venous oxygen saturation in a porcine model of hypoxemia.

Assessment of three methods to reduce the influence of mathematical coupling on oxygen consumption and delivery relationships

STUDY OBJECTIVES

To determine if oxygen consumption/oxygen delivery (VO2/DO2) relationships derived using calorimetry (which are not influenced by shared measurement error) agreed with those obtained using the pulmonary artery (PA) catheter alone. To evaluate three strategies to reduce the influence of shared measurement error to determine if agreement between the two methods could be improved.

METHODS

Twenty-seven patients were studied following coronary artery bypass surgery. Calorimetric VO2, six thermodilution cardiac outputs (COs), and arterial and mixed venous oxygen content measurements were made at baseline and were repeated 30 min following dobutamine administrations of 3 microg/kg/min and 5 microg/kg/min.

RESULTS

Dobutamine produced a dose-dependent increase in DO2, from 378+/-65 mL/min/m2 to 446+/-78 mL/min/m2 (p<0.01) and in both PA catheter and calorimetric-derived VO2, from 104+/-18 mL/min/Mi2 to 114+/-22 mL/min/m2 (p<0.05) and from 117+/-15 mL/min/m2 to 126+/-19 mL/min/m2 (p<0.01), respectively. Agreement was poor (bias=12%, SD=21%) between the calorimetric and PA catheter methods of determining VO2/DO2 slope. When three CO measurements were used to calculate VO2, and three separate CO measurements were used to calculate DO2, the level of agreement between the two methods improved (bias=2%, SD=15%). Increasing the number of COs resulted in a similar improvement in the level of agreement between the two methods. Weighting the slope to the observed change in DO2 was the best method to improve the level of agreement (bias=2%, SD=6% for three COs).

CONCLUSIONS

To reduce the influence of shared measurement error, the best strategy to improve the measurement of VO2/DO2 slope is to maximize the change in DO2 (optimally over 100 mL/min/m2).

Venous gas embolism--a comparison of carbon dioxide and helium in pigs

PURPOSE

The use of helium for insufflation during laparoscopic surgery avoids hypercarbia and acidosis associated with absorbed CO2, but the effects of helium gas embolism are unknown. We compared the effects of CO2 with He gas embolism on survival, haemodynamic variables, oxygenation, and ventilation in pigs.

METHODS

Anaesthetized juvenile pigs were given progressively larger boluses of either CO2 (n = 5) or He (n = 4) into the right atrium. Measurements of haemodynamic variables, oxygenation, and PETCO2 were made before and after each gas injection.

RESULTS

All animals survived injection of 300 ml CO2 while no animal survived more than 120 ml He (P < 0.01). Mean arterial pressure decreased more after 60 ml He (99 +/- 14 to 44 +/- 20 mmHg) than after 60 ml CO2 (110 +/- 12 to 88 +/- 14 mmHg, P < 0.001). Cardiac output did not change at any injection volume. The PETCO2 decreased more after 60 ml He (30 +/- 2 to 3 +/- 6 mmHg) than after 60 ml CO2 (35 +/- 3 to 30 +/- 3 mmHg, P < 0.001). Only the He group showed a decrease in PaO2 (190 +/- 51 to 68 +/- 22 mmHg at 60 ml, P < 0.05).

CONCLUSION

Helium gas embolism has a greater deleterious effect than CO2 gas embolism on survival, MAP, PETCO2, and PaO2. These different effects of gas embolism should be recognized when considering the use of helium or other insoluble gases for abdominal laparoscopic insufflation.

Elevated levels of macrophage inflammatory protein 2 in severe murine peritonitis increase neutrophil recruitment and mortality

We hypothesized that chemokines may play important roles in a cecal ligation and puncture (CLP) model of septic peritonitis in CD-1 mice. Concentrations of C-X-C (macrophage inflammatory protein 2 [MIP-2] and ENA-78) and C-C (MIP-1alpha and JE) chemokines were measured (by enzyme-linked immunosorbent assay) in serum, peritoneal lavage fluid, lung, and liver at 4, 8, 24, 48, and 96 h after CLP. Significant elevations in all measured chemokines occurred in peritoneal fluid after CLP (P < 0.05). MIP-2, in particular, increased dramatically (>400-fold, P < 0.001) in peritoneal fluid, serum, and to a lesser extent lung and liver (P < 0.05). Increased MIP-2 was correlated with severity of sepsis (P < 0.001). To determine the significance of this finding, mice were passively immunized prior to CLP with polyclonal antibody to MIP-2, which decreased mortality from 85 to 38% at 96 h (P < 0.01). To further understand the mechanism of the effect of MIP-2, additional measurements demonstrated that anti-MIP-2 prior to CLP decreased the percent neutrophils in peritoneal fluid (55% +/- 12%, compared with 82% +/- 10% in controls), but no significant changes in tumor necrosis factor alpha, interleukin-6, or interleukin-10 occurred. MIP-2 contributes to the inflammatory response and overall mortality in this model of severe septic peritonitis, possibly by increasing recruitment of neutrophils, which clear bacteria but may also injure the host.

Leukocytes and decreased left-ventricular contractility during endotoxemia in rabbits

We hypothesized that leukocytes contribute to decreased myocardial contractility following endotoxin infusion. To test this hypothesis, we administered endotoxin (1 mg/kg intravenously) to intact, anesthetized rabbits whose arterial blood perfused two isolated hearts at a constant pressure (75 mm Hg). One heart was perfused with blood passed through a leukocyte filter, whereas the other received unfiltered blood. Contractility of both hearts was measured every 30 min for 6 h, using the slope of the end-systolic pressure-volume relationship (Emax) and the maximum rate of change of intraventricular pressure (dP/dt(max)). In the unfiltered hearts at 6 h, Emax decreased to 81 +/- 6% (mean +/- SEM) of baseline (p < 0.05). In the hearts perfused with leukocyte-filtered blood there was no change in Emax. Similarly, dP/dt(max) decreased 74 +/- 9% of baseline in the hearts receiving unfiltered blood (p < 0.05) but did not decrease in the hearts receiving leukocyte-filtered blood. The leukocyte filter significantly reduced the number of neutrophils in perfusing blood (p < 0.01), decreased the number of neutrophils in the heart by 77% (p < 0.01), and decreased myocardial morphometric changes (p < 0.05). A 55 +/- 18% reduction in neutrophil L-selectin expression after endotoxin infusion (p < 0.01) suggests that the neutrophils were significantly activated. We conclude that leukocytes, notably activated neutrophils, may contribute to decreased myocardial contractility during septic shock.

Small hemodynamic effect of typical rapid volume infusions in critically ill patients

OBJECTIVES

To determine what volumes are commonly used for rapid volume infusions in critically ill patients admitted to the intensive care unit (ICU) for > 12 hrs; and to determine the effectiveness of a typical rapid volume infusion in producing hemodynamic change and increasing left ventricular end-diastolic volume.

DESIGN

A prospective survey of clinical practice (part 1) and a prospective clinical investigation (part 2).

SETTING

Two hospital ICUs (11 and six beds) of which one is university affiliated.

PATIENTS

Critically ill patients admitted to the ICU for > 12 hrs.

INTERVENTIONS

Infusion of 500 mL of normal saline over 5 to 10 mins.

MEASUREMENTS AND MAIN RESULTS

For 1 month, we recorded the volume and composition of all volume infusions given as a rapid bolus in patients admitted to the ICU for > 12 hrs. We then measured the effected the median rapid volume infusion in a subset of 13 patients by measuring hemodynamics (using arterial and pulmonary artery flotation catheters) and left ventricular end-diastolic area (using transgastric short-axis views from transesophageal echocardiograms). During 470 patient days, 159 rapid volume infusions were administered. The average rapid volume infusion administered was 390 +/- 160 mL (median 500; interquartile range 250 to 500). Crystalloid solutions were used for two thirds of the rapid volume infusions and colloid solutions were used for one third of the rapid volume infusions. The rapid volume infusion of 500 mL of saline did not significantly increase mean arterial pressure (78.0 +/- 11.9 to 79.3 +/- 14.6 mm Hg), cardiac index (4.3 +/- 1.7 to 4.6 +/- 1.8 L/min/m2), right atrial pressure (11.1 +/- 3.8 to 12.4 +/- 3.3 mm Hg), left ventricular end-diastolic area (8.6 +/- 1.7 to 9.1 +/- 1.8 cm2/m2), or left ventricular end-systolic area (3.5 +/- 1.5 to 3.6 +/- 1.5 cm2/m2). Pulmonary artery occlusion pressure increased slightly but significantly from 12.9 +/- 3.4 to 14.7 +/- 3.3 mm Hg (p < .05).

CONCLUSIONS

After patients are admitted to the ICU for > 12 hrs, rapid volume infusions are common therapeutic interventions but the rapid volume infusions are typically small. The effect of a typical rapid volume infusion on hemodynamics and left ventricular areas in these patients is surprisingly small.

Platelet-activating factor antagonism improves ventricular contractility in endotoxemia

OBJECTIVES

Endotoxin stimulates platelet-activating factor production and also causes a decrease in myocardial contractility within a few hours in animal models of sepsis. Platelet-activating factor by itself decreases left ventricular contractility. We investigated whether platelet-activating factor contributes substantially to the decrease in left ventricular contractility seen in sepsis.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

University research laboratory.

SUBJECTS

Twenty-two juvenile, cross-bred pigs.

INTERVENTIONS

Anesthetized pigs were pretreated with a platelet-activating factor receptor antagonist (L-659,989) or vehicle (control), and then treated with endotoxin or saline (control). Hemodynamics and left ventricular pressures (Millar catheter) and volumes (conductance catheter) were measured. Left ventricular contractility was assessed using the slope, or maximum elastance (Emax), of the end-systolic pressure-volume relationship.

MEASUREMENTS AND MAIN RESULTS

In the control/endotoxin group, 4 hrs after endotoxin administration, Emax had decreased by 41 +/- 4% (p < .05) and mean arterial pressure had decreased by 32 +/- 3% (p < .05). In the L-659,989/endotoxin group, the decreases in Emax (26 +/- 2%, p < .05) and mean arterial pressure (16 +/- 7%) were significantly attenuated compared with the control/endotoxin group (p < .05).

CONCLUSIONS

We conclude that platelet-activating factor plays a modest but statistically significant role in the early decrease in left ventricular contractility after endotoxin administration. Inhibition of platelet-activating factor during sepsis might be beneficial for left ventricular mechanics and hemodynamics.

Myocardial anaerobic metabolism occurs at a critical coronary venous PO2 in pigs

We tested the hypothesis that the onset of myocardial anaerobic metabolism is fundamentally different from the whole body and other organs, where the onset of anaerobic metabolism occurs at a critical oxygen extraction ratio--not at a critical venous PO2. We measured oxygen saturation and PO2 of arterial and coronary venous blood at the onset of global myocardial anaerobic metabolism during progressive hypoxic hypoxia (n = 7) compared with carbon monoxide hypoxia (n = 7), which left-shifted the oxygen-hemoglobin dissociation curve. The onset of global myocardial anaerobic metabolism was defined by decreased myocardial lactate consumption and left ventricular contractility. Coronary venous PO2 was no different during hypoxic hypoxia and carbon monoxide hypoxia at equivalent arterial oxygen saturations, particularly at the onset of myocardial anaerobic metabolism (PO2 17.0 +/- 1.7 torr versus 15.9 +/- 2.2 torr, p = NS). However, the myocardial oxygen extraction ratio was significantly greater during hypoxic hypoxia than during carbon monoxide hypoxia at the onset of myocardial anaerobic metabolism (0.88 +/- 0.02 versus 0.65 +/- 0.04, p < 0.01). Thus, in contrast to the whole body where the onset of anaerobic metabolism occurs at a critical oxygen extraction ratio, the onset of myocardial anaerobic metabolism occurs at a critical coronary venous PO2.

Balance of inflammatory cytokines related to severity and mortality of murine sepsis

We tested the hypothesis that, during sepsis, the balance of pro- and anti-inflammatory cytokines is related to severity and survival. Cecal ligation and puncture (CLP) with a large (18-gauge)-, intermediate (21-gauge)-, or small (26-gauge)-diameter needle, or sham laparotomy, was performed on outbred CD-1 mice. Concentrations of tumor necrosis factor alpha (TNF-alpha), interleukin-6 (IL-6), and the anti-inflammatory cytokine IL-10 were measured (by enzyme-linked immunosorbent assay) in serum, peritoneal lavage fluid, and liver and lung samples at 4, 8, 24, 48, and 96 h. As the diameter of the CLP needle decreased, the mortality rate decreased (at 48 h: large, 80%; intermediate, 40%; small, 20%; P < 0.05), the TNF-alpha and IL-6 concentrations decreased, and the time-to-peak TNF-alpha expression increased. In contrast, IL-10 concentration increased compared with baseline (serum at 24 h: large, 2.3-fold +/- 1.6-fold; intermediate, 2.0-fold +/- 0.5-fold; small, 49.9-fold +/- 8.3-fold; P < 0.05). Administration of IL-10 (5 microg, intraperitoneal) prior to CLP decreased mortality (P < 0.001). Administration of polyclonal anti-IL-10 serum prior to CLP (0.5 ml intraperitoneal) had the opposite effect and increased mortality (P < 0.001) and TNF-alpha, IL-6, and TNF-alpha mRNA expression compared with controls. Thus, severe sepsis is associated with a largely unopposed inflammatory response, and a largely unopposed inflammatory response (with anti-IL-10) results in severe sepsis and death. Less severe sepsis is associated with greater anti-inflammatory mediator expression, and greater anti-inflammatory mediator expression (with IL-10) results in less severe sepsis. Thus, the balance of inflammatory mediators is related to the severity and mortality of murine sepsis.

Comparison of transesophageal echocardiographic, fick, and thermodilution cardiac output in critically ill patients

PURPOSE

Recent observations have highlighted errors in the thermodilution technique of measuring cardiac output. Thus, cardiac output measurements using transesophageal echocardiography and the Fick method were compared with simultaneous thermodilution measurements.

METHODS

In 13 mechanically ventilated critically ill patients, cardiac output was determined simultaneously using (1) transesophageal echocardiography (COTEE, (2) the Fick method (COFICK, and (3) thermodilution (COTD immediately before and after a rapid infusion of 500 mL of saline. Left ventricular end-diastolic and end-systolic areas were measured using the transesophageal echocardiographic transgastric short axis view, and COTEE was calculated from the corresponding volumes. Absolute cardiac output values and the changes from before to after saline infusion (delta CO) were compared using analysis of variance, linear regression, and the Bland and Altman method.

RESULTS

There were no significant differences between COTEE (8.0 +/- 3.4), COFICK (8.4 +/- 3.3), and COTD (8.3 +/- 3.0) or between delta COTEE, delta COFICK, and delta COTD using analysis of variance. However, correlations between COTEE and COTD (r2 = 0.46; P < .00001), COFICK and COTD (r2 = 0.46; P < .0001), and COTEE and COFICK (r2 = 0.42; P < .0001) were only moderately good. Using the method of Bland and Altman, the mean difference (+/-2 standard deviations) between COTEE and COTD was 0.3 +/- 4.3 L/min, between COFICK and COTD was -1.0 +/- 3.8 L/min, and between COTEE and COFICK was 0.6 +/- 5.6 L/min, whereas the difference between delta COTEE and delta COTD was 0% +/- 26%, between delta COFICK and delta COTD was 9% +/- 46%, and between delta COTEE and delta COFICK was 8% +/- 39%.

CONCLUSIONS

There are substantial differences in cardiac output as measured by these three methods, best demonstrated using the method of Bland and Altman. The variability of cardiac output and its derivatives (eg, oxygen delivery) should be borne in mind when making clinical decisions on individual patients.

Heterogeneity of oxygen delivery impairs oxygen extraction by peripheral tissues: theory

The hypothesis that the distribution of oxygen demand in relation to oxygen supply (dO2/qO2) effects oxygen extraction in peripheral tissues was tested. By using a simple theoretical model, realistic biphasic oxygen consumption-delivery relationships were predicted from dO2/qO2 distributions. Increasing width (relative dispersion) of the dO2/qO2 distribution, indicating mismatch between oxygen demand and supply, nonlinearly decreased the critical oxygen extraction ratio (calculated by using dual-line regression). Skewed dO2/qO2 distributions had a lesser effect. Incomplete oxygen uptake, due to diffusion limitation or other causes of physiological arteriovenous shunt, linearly decreased the critical oxygen extraction ratio. Approximate dO2/qO2 distributions were then estimated from previously reported capillary transit-time distributions. Critical oxygen extraction ratios predicted from these estimated dO2/qO2 distributions match reported values. This theoretical approach also predicts the decrease in the critical oxygen extraction ratio in porcine gut after endotoxin infusion in the companion paper (M. F. Humer, P. T. Phang, B. P. Friesen, M. F. Allard, C. M. Goddard, and K. R. Walley. J. Appl. Physiol. 81: 895-904, 1996). Much as pulmonary ventilation-perfusion relationships account for pulmonary gas exchange, dO2/qO2 distributions quantitatively account for measured tissue oxygen extraction and predict novel features of the relationship between heterogeneity and oxygen extraction.

Heterogeneity of gut capillary transit times and impaired gut oxygen extraction in endotoxemic pigs

We tested the hypothesis that endotoxin increases the heterogeneity of gut capillary transit times and impairs oxygen extraction. The gut critical oxygen extraction ratio was determined by measuring multiple oxygen delivery-consumption points during progressive phlebotomy in eight control and eight endotoxin-infused anesthetized pigs. In multiple 1- to 2-g samples of small bowel, we measured blood volume (radiolabeled red blood cells) and flow (radiolabeled 15-microns microspheres) before and after critical oxygen extraction. Red blood cell transit time (= volume/flow) multiplied by morphologically determined capillary/total blood volume gave capillary transit time. During hemorrhage, capillary/total blood volume did not change in the endotoxin group (0.5 +/- 4.5%) but increased in the control group (17.6 +/- 2.5%; P < 0.05) due to a decrease in total gut blood volume. Flow decreased significantly in the endotoxin group (36 +/- 10%; P < 0.05) but not in the control group (12 +/- 10%). Capillary transit-time heterogeneity increased in the endotoxin group (12.3 +/- 4.9%) compared with the control group (-5.8 +/- 7.4%; P < 0.05), predicting a critical oxygen extraction ratio 0.14 lower in the endotoxin group than in the control group (K. R. Walley. J. Appl. Physiol. 81: 885-894, 1996). This matches the measured difference (endotoxin group, 0.60 +/- 0.04; control group, 0.74 +/- 0.03; P < 0.05). Increased heterogeneity of capillary transit times may be an important cause of impaired oxygen extraction.

Nitric oxide synthase inhibition partially prevents decreased LV contractility during endotoxemia

Decreased contractility of myocytes after cytokine exposure can be prevented by nitric oxide synthase inhibition. Whether this is true in an intact animal model of sepsis is unknown. Anesthetized pigs were pretreated with saline or a nitric oxide synthase inhibitor, N omega-nitro-L-arginine, and then treated with saline or endotoxin. We measured hemodynamics and left ventricular pressures (Millar catheter) and volumes (conductance catheter). Left ventricular contractility was assessed using the slope (E(max)) of the end-systolic pressure-volume relationship. Four hours after endotoxin infusion, E(max) had decreased by 44 +/- 5% (P < 0.05) and mean arterial pressure had decreased by 30 +/- 10% (P < 0.05). Pretreatment with N omega-nitro-L-arginine significantly reduced the decrease in E(max) to 28 +/- 3% (P < 0.05) and prevented the decrease in mean arterial pressure. However, it also raised pulmonary arterial pressure. We conclude that nitric oxide contributes to the early decrease in left ventricular contractility after endotoxin in the intact animal. However, the vascular effects of nitric oxide synthase inhibition increase right and left ventricular afterloads, which were detrimental to cardiac function.

Decreased left ventricular contractility during porcine endotoxemia is not prevented by ibuprofen

OBJECTIVE

We investigated whether ibuprofen could prevent early decrease in left ventricular contractility that occurs during porcine endotoxemia.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

University research laboratory.

SUBJECTS

Adolescent crossbred pigs (n = 28).

INTERVENTIONS

Anesthetized pigs were instrumented to measure hemodynamics and left ventricular pressures (using a Millar catheter) and volumes (using a conductance catheter). Pigs were then treated in four groups, according to pretreatment using ibuprofen (15 mg/kg) or saline and subsequent treatment using endotoxin (0111:B4, 50 microg/kg) or saline.

MEASUREMENTS AND MAIN RESULTS

Measurements of hemodynamics and left ventricular pressures and volumes were repeated after pretreatment with ibuprofen (or saline in controls), and at hourly intervals for 4 hrs after the start of endotoxin or control saline infusions. Left ventricular contractility was primarily assessed using the slope of the end-systolic pressure-volume relationship. Data were analyzed, using a repeated-measures analysis of variance. The slope of the end-systolic pressure-volume relationship was decreased at 4 hrs by 41 +/- 9% in the saline/endotoxin group (p < .05) and by 36 +/- 14% in the ibuprofen/endotoxin group (p < .05), so that ibuprofen pretreatment had no significant effect on the decrease in left ventricular contractility. Mean arterial pressure decreased in the saline/endotoxin group by 23 +/- 12% at 1 hr (p < .05) and by 35 +/- 12% (p < .05) at 4 hrs. Ibuprofen significantly reduced the decrease in mean arterial pressure (2 +/- 6% increased at 1 hr, and 17 +/- 12% decreased at 4 hrs, both p<.05 compared with saline/endotoxin). Cardiac output increased by 25% (p < .05) in the first hour, but then decreased to be slightly (NS) below baseline at 4 hrs in both endotoxin groups. Mean pulmonary arterial pressure was increased in the saline/endotoxin group by 154 +/- 52% (p < .05) at 30 mins and by 118 +/- 40% (p < .05) at 4 hrs. Ibuprofen prevented the very acute increase in pulmonary arterial pressure (increased by 11 +/- 33% at 30 mins, p < .05 compared with saline/endotoxin) and significantly reduced the pulmonary hypertension at 4 hrs (increased by 70 +/- 25%, p < .05 compared with both baseline and saline/endotoxin).

CONCLUSIONS

We conclude that products of the cyclooxygenase pathway do not play a major role in the early decrease in left ventricular contractility after endotoxin. However, ibuprofen may have a role in reducing the other cardiovascular effects of sepsis.

Myocardial morphometric changes related to decreased contractility after endotoxin

Decreased ventricular contractility during sepsis lasts much longer than the half-lives of inflammatory mediators that have been suggested to be myocardial depressant factors. Our hypothesis is that blood-borne factors may also cause myocardial structural changes, including damage and death of myocytes, associated with decreased ventricular contractility. We tested this hypothesis in an isolated rabbit heart perfused by a support rabbit. Support rabbits received 1 mg/kg endotoxin i.v. over 30 min (endotoxin group, n = 7) or vehicle (control group, n = 6). The slope of the end-systolic pressure-volume relationship, Emax, was used to measure contractility of the isolated heart. Five hours after endotoxin infusion, Emax decreased by 17 +/- 7% (P < 0.03) compared with 0 +/- 2% in the control group. Quantitative morphometric analysis of isolated hearts from the endotoxin group demonstrated an increased volume fraction of myocardial capillaries occupied by leukocytes (15.7 +/- 3.5 vs. 3.0 +/- 0.7% in the control group, P < 0.05), structurally abnormal myocytes (7.6 +/- 3.6 vs. 0.8 +/- 0.4%, P < 0.05), and interstitial edema (23.2 +/- 5.2 vs. 14.3 +/- 2.1%, P < 0.05). We conclude that blood-borne factors cause myocardial structural changes that may contribute to decreased ventricular contractility and may explain the prolonged decrease in ventricular contractility during sepsis.

Prolonged leukocyte transit time in coronary microcirculation of endotoxemic pigs

We quantified the timing and extent of leukocyte retention by the coronary microcirculation in a pig model of hyperdynamic sepsis in three ways. First, the transmyocardial leukocyte gradient was determined as coronary blood flow (calibrated ultrasonic flow probe) multiplied by the difference between leukocyte counts in the aorta and coronary sinus. Measurements were taken at 1-min intervals for 30 min and then at 3-min intervals for 45 min in anesthetized pigs exposed to either endotoxin (50 micrograms/kg iv over 30 min) (n = 7) or vehicle (n = 7). Second, postmortem morphometric analysis was used to quantitate the number and location of retained myocardial leukocytes. Finally, myocardial capillary transit time of leukocytes was calculated from the above measures. In the endotoxin group 2.1 +/- 0.8 x 10(9) leukocytes/100 g wet wt were retained in the coronary circulation, primarily in capillaries. This resulted in 111 +/- 37 (P < 0.05) times as many leukocytes in the coronary microcirculation than predicted from the arterial leukocyte concentration. Myocardial capillary transit time of leukocytes was prolonged to 39.1 +/- 20.6 s (P < 0.05) in the endotoxin group versus 5.0 +/- 1.4 s in the control group. We conclude that, after endotoxin infusion in a pig model of hyperdynamic sepsis, myocardial leukocyte transit is slowed, leading to the retention of large numbers of leukocytes in the coronary microcirculation.

Different effects of histamine H1 and H2 stimulation on left ventricular contractility in pigs

Histamine decreases ventricular contractility in some settings but increases it in others. To better understand these apparently discrepant results, we measured hemodynamics and left ventricular pressure (Millar catheter) and volume (ultrasonic crystals) in atrially paced, alpha- and beta-antagonist-treated pigs. Histamine was infused (0.5-10 micrograms.kg-1.min-1) before and after H2-antagonist (ranitidine) pretreatment. Changes in left ventricular contractile function were measured as shift of the end-systolic pressure-volume relationship (delta ESPVR) at a pressure of 100 mmHg. We found that at low doses (0.5 and 1 micrograms.kg-1.min-1), histamine significantly decreased delta ESPVR (-1.1 +/- 1.4 ml, P < 0.05) after H2-antagonist pretreatment. At doses above 1 micrograms.kg-1.min-1, histamine increased contractility in a dose-response fashion [maximum effect: 5.1 +/- 3.3 ml, dose resulting in 50% effect (ED50): 0.75 +/- 1.79 micrograms.kg-1.min-1] that was best described using a Hill coefficient of 2. Ranitidine increased the ED50 by approximately one order of magnitude (0.75 +/- 1.79 to 9.50 +/- 2.60 micrograms.kg-1.min-1, P < 0.05). We conclude that in vivo, at higher doses, histamine increases left ventricular contractility via H2-receptor stimulation, whereas at low doses histamine decreases left ventricular contractility, probably via H1-receptor stimulation.

Myocardial oxygen extraction ratio is decreased during endotoxemia in pigs

Why the myocardial oxygen extraction ratio (ERm) is decreased during septic shock in humans is unknown. Therefore, we calculated ERm in 15 anesthetized pigs by measuring arterial and coronary venous oxygen content. We measured myocardial lactate flux, myocardial contractility, and global myocardial blood flow and its distribution. After baseline measurements, animals received either saline (n = 6) or 50 micrograms/kg of endotoxin (n = 9). Measurements were repeated for 4 h. After endotoxin, ERm decreased from 67 +/- 12% at baseline to 36 +/- 10% (P < 0.01) at 1 h and 54 +/- 10% (P < 0.05) at 4 h, associated with an increased myocardial blood flow that was heterogeneous. Neither myocardial oxygen nor lactate consumption decreased in the endotoxin group, and changes in left ventricular contractility were not correlated with changes in ERm. We conclude that the decrease in ERm after endotoxin infusion is due to both increased blood flow and mismatching between myocardial oxygen delivery and demand. Impaired myocardial oxygen extraction capacity during sepsis did not cause global myocardial tissue hypoxia.