Sepsis-induced myocardial dysfunction

The apelinergic system: a perspective on challenges and opportunities in cardiovascular and metabolic disorders

The apelinergic pathway has been generating increasing interest in the past few years for its potential as a therapeutic target in several conditions associated with the cardiovascular and metabolic systems. Indeed, preclinical and, more recently, clinical evidence both point to this G protein-coupled receptor as a target of interest in the treatment of not only cardiovascular disorders such as heart failure, pulmonary arterial hypertension, atherosclerosis, or septic shock, but also of additional conditions such as water retention/hyponatremic disorders, type 2 diabetes, and preeclampsia. While it is a peculiar system with its two classes of endogenous ligand, the apelins and Elabela, its intricacies are a matter of continuing investigation to finely pinpoint its potential and how it enables crosstalk between the vasculature and organ systems of interest. In this perspective article, we first review the current knowledge on the role of the apelinergic pathway in the above systems, as well as the associated therapeutic indications and existing pharmacological tools. We also offer a perspective on the challenges and potential ahead to advance the apelinergic system as a target for therapeutic intervention in several key areas.

MicroRNAs in Inflammatory Heart Diseases and Sepsis-Induced Cardiac Dysfunction: A Potential Scope for the Future?

Background: MicroRNAs (miRNAs) are small, single-stranded RNA sequences that regulate gene expression on a post-transcriptional level. In the last few decades, various trials have investigated the diagnostic and therapeutic potential of miRNAs in several disease entities. Here, we provide a review of the available evidence on miRNAs in inflammatory heart diseases (myocarditis, endocarditis, and pericarditis) and sepsis-induced cardiac dysfunction. Methods: Systematic database research using the PubMed and Medline databases was conducted between July and September 2019 using predefined search terms. The whole review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: In total, 131 studies were screened, 96 abstracts were read, and 69 studies were included in the review. Discussion: In the future, circulating miRNAs could serve as biomarkers for diagnosis and disease monitoring in the context of inflammatory heart diseases and sepsis-induced cardiac dysfunction. Considering the promising results of different animal models, certain miRNAs could also emerge as novel therapeutic approaches in this setting.

Hemodynamic profiles following digoxin use in patients with sepsis in the ICU

PURPOSE

To explore the impact of digoxin on hemodynamic parameters in patients with sepsis and tachycardia admitted to the intensive care unit.

MATERIALS AND METHODS

Retrospective review of adult patients admitted to the medical and mixed ICU at Mayo Clinic Rochester, Minnesota from March 2008 to February 2018, initiated on digoxin within 24 h of ICU stay. Hemodynamic parameters were reviewed before digoxin administration and at 6, 12 and 24 h after. Adverse events including new onset conduction abnormalities or arrhythmias during the first 48 h after digoxin administration were reviewed by a critical care cardiologist.

RESULTS

Study included 180 patients. We observed significant decrease in heart rate from 124 (115-138) beats/min 1 h before digoxin to 101 (87-117) 6 h after digoxin and 94 (84-112) 12 h after (p < .01). Median systolic blood pressure increased from 100 (91-112) mm Hg 1 h before to 110 (100-122) (p < .01) and 111 (103-124) at 6 and 12 h respectively after digoxin.

CONCLUSIONS

Early digoxin administration in patients with sepsis and tachycardia is uncommon but associated with improvements of hemodynamic parameters. These preliminary results will help formulate future hypotheses for focused trials on utility, efficacy and safety of digoxin in sepsis.

Alleviation of sepsis‑induced cardiac dysfunction by overexpression of Sestrin2 is associated with inhibition of p‑S6K and activation of the p‑AMPK pathway

Sepsis-induced myocardial injury is one of the manifestations of multiple organ dysfunction in sepsis. The aim of the present study was to determine the mechanism of alleviation of lipopolysaccharide (LPS)-induced injury on cardiomyocytes by Sestrin2. A sepsis model using LPS injection was constructed in Sprague-Dawley (SD) rats, and after 6, 12 and 24 h, rat blood was collected and cardiac troponin T (CTnT) levels were determined using ELISA. Heart specimens were excised, tumor necrosis factor-α (TNF-α) and interleukin 6 (IL-6) levels were detected by ELISA, malondialdehyde (MDA) levels were estimated using colorimetric analysis, and phosphorylated (p)-S6K and p-AMP-activated protein kinase (AMPK) levels were determined by western blot analysis. In the septic rats, phenomenon of myocardial fiber rupture, interstitial edema and inflammatory cell infiltration were observed under light microscope. Following LPS injection, CTnT in serum and MDA in myocardial homogenate were increased time-dependently. TNF-α and IL-6 levels were significantly increased, with a peak at 6 h. p-S6K levels were adaptively downregulated, and levels of p-AMPK and Sestrin2 were adaptively upregulated by LPS. In LPS-injured H9c2 cells, Sestrin2 overexpression attenuated the LPS-mediated inhibitory effects on cell viability, suppressed LPS-mediated increase in CTnT, TNF-α, IL-6 and MDA levels, as well as attenuated p-S6K levels and elevated p-AMPK and Sestrin2 levels. Sestrin2 interference showed the opposite effect. Sestrin2 promoted cell viability and inhibited the inflammatory responses of LPS-injured myocardial cells. The phenomena may be associated with inhibition of p-S6K and activation of the p-AMPK pathway.

Preclinical septic shock research: why we need an animal ICU

Animal experiments are widely used in preclinical medical research with the goal of disease modeling and exploration of novel therapeutic approaches. In the context of sepsis and septic shock, the translation into clinical practice has been disappointing. Classical animal models of septic shock usually involve one-sex-one-age animal models, mostly in mice or rats, contrasting with the heterogeneous population of septic shock patients. Many other factors limit the reliability of preclinical models and may contribute to preclinical research failure in critical care, including the host specificity of several pathogens, the fact that laboratory animals are raised in pathogen-free facilities and that organ support techniques are either absent or minimal. Advanced animal models have been developed with the aim of improving the clinical translatability of experimental findings. So-called animal ICUs refer to the preclinical investigation of adult or even aged animals of either sex, using—in case of rats and mice—miniaturized equipment allowing for reproducing an ICU environment at a small animal scale and integrating chronic comorbidities to more closely reflect the clinical conditions studied. Strength and limitations of preclinical animal models designed to decipher the mechanisms involved in septic cardiomyopathy are discussed. This article reviews the current status and the challenges of setting up an animal ICU.

Effect of Shenfu injection on lipopolysaccharide (LPS)-induced septic shock in rabbits

ETHNOPHARMACOLOGICAL RELEVANCE

Shenfu injection is a popular Chinese herbal formula that has been widely used in the treatment of shock in China.

AIM OF THE STUDY

To investigate the effect of Shenfu injection on lipopolysaccharide (LPS)-induced septic shock in rabbits.

MATERIALS AND METHODS

We established a septic shock model in rabbits by administering an intravenous injection of 0.6 mg/kg LPS to anesthetized rabbit, and 15 min after LPS challenge, the rabbits were intravenously administered the Shenfu injection. In these in vivo experiments, the jugular vein of the rabbits was cannulated for LPS and drug administration, and the right common carotid artery was cannulated to record the mean arterial pressure (MAP) over a 6-h period. In addition, various serum biochemical parameters, including lactate dehydrogenase (LDH), aspartate aminotransferase (AST), glutamate transaminase (ALT), creatinine (Cre), and urea nitrogen (Urea), were measured at 0, 3, and 6 h. Serum LPS levels at 6 h were determined by the test kit. And histological changes in the heart, liver and kidney tissues were observed by HE staining. Furthermore, some related small molecules in the heart tissues were detected by MALDI-TOF-MSI.

RESULTS

We found that Shenfu injection can increase the MAP, decrease the serum LPS, LDH and AST levels, and improve the tissue morphology of the heart, liver and kidney in rabbits with LPS-induced septic shock. In addition, Shenfu injection can increase the contents of ATP and taurine while reducing the content of AMP in the heart tissue during septic shock.

CONCLUSIONS

These results indicate that Shenfu injection exerts a protective effect on LPS-induced septic shock in rabbits.

Adiponectin attenuates lipopolysaccharide-induced cell injury of H9c2 cells by regulating AMPK pathway

Adiponectin, an adipokine synthesized and secreted majorly by adipose tissue, is reported to exert cardioprotective properties via anti-inflammation and antiapoptosis. Lipopolysaccharide (LPS) is a common inflammation and apoptosis inducer of cardiomyocytes. However, few studies have reported the roles of adiponectin on LPS-induced inflammation as well as apoptosis of H9c2 cells, and the possible mechanisms of these effects. In the present study, we found that adiponectin significantly relieved LPS-induced cytotoxicity including decreased viability and elevated LDH release, inhibited LPS-triggered inflammation, which is evidenced by increases in release of TNF-α, IL-1β as well as IL-6, and attenuated the enhanced rates of apoptotic cells as well as increased caspase-3 activity caused by LPS in H9c2 cells. In addition, our data demonstrated that adiponectin upregulated AMP-activated protein kinase (AMPK) activation of H9c2 cells with or without LPS administration. Moreover, we found that blocking AMPK pathway by compound c attenuated the protective effects of adiponectin against the cytotoxicity, inflammatory response, and apoptosis of H9c2 cells resulted from LPS. Our observations bring novel insights for understanding the mediatory role of AMPK pathway implicated in the protective effects of adiponectin against LPS-induced cardiotoxicity.

Oxygen Delivery and Oxygen Consumption in Pediatric Fluid Refractory Septic Shock During the First 42 h of Therapy and Their Relationship to 28-Day Outcome

Background: In septic shock, both oxygen delivery (DO₂) and oxygen consumption (VO₂) are dysfunctional. The current therapeutic regimens are geared to normalize global oxygen delivery (DO₂) to tissues via goal directed therapies but mortality remains high at 10-20%. Methods: We studied cardiac index (CI), systemic vascular resistance index (SVRI), central venous oxygen saturation (ScvO2), central venous pressure (CVP), peripheral oxygen saturation (SpO2), mean blood pressure (MBP), body temperature, blood lactate, base excess and hemoglobin concentration (Hb) in a cohort of children admitted in "fluid-refractory" severe septic shock to pediatric intensive care, over 4.5-years. We calculated their 6 h global oxygen delivery (DO2) and global oxygen consumption (VO2) over the first 42 h and looked at factors associated with VO2/DO2 ratio (i.e., global oxygen extraction, gO2ER) and 28-day mortality. Results: Sixty-two children mean age (SD) 7.19 (5.44) years were studied. Fifty-seven (93%) children were sedated and mechanically ventilated and all received adrenaline or noradrenaline or both and added milrinone in 6 (9.6%). At 28 days, 9 (14.5%) were dead. The global oxygen extraction ratio (gO2ER) was consistently lower amongst the survivors and independently predicted mortality (ROC AUC = 0.75). A lactate level of 4 mmol/l or above, when associated with a concurrent metabolic acidosis predicted mortality with a sensitivity of 100% (95% CI 90.5-100) and a specificity of 67.7% (95% CI 62.2-72.9). A gO2ER of 0.48 or above on admission to the PICU was associated with death with a 66.7% sensitivity (95%CI 29.9-92.5) and 90.5% specificity (95%CI 79.3-96.8). A global O2ER of >0.48 combined with a concurrent blood lactate >4.0 mmol/l at any time within the first 42 h of therapy predicted death with a sensitivity of 63.9% (95% CI, 46.2-79.1) and specificity of 97.8% (95% CI, 95.7-99.0). A radar plot identified MBP-CVP difference, and CI as additional goals of therapy that may offer a survival benefit. Conclusions: Global O2ER of >0.48 with a concurrent blood lactate >4.0 mmol/l in children with metabolic acidosis was an independent factor associated with death in fluid resistant septic shock. Trends of gO2ER seem useful to recognize survivors and non-survivors early in the illness.