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Liang C, Pan S, Wu W, Chen F, Zhang C, Zhou C, Gao Y, Ruan X, Quan S, Zhao Q, Pan J. Glucocorticoid therapy for sepsis in the AI era: a survey on current and future approaches. Comput Struct Biotechnol J 2024; 24:292-305. [PMID: 38681133 PMCID: PMC11047203 DOI: 10.1016/j.csbj.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 05/01/2024] Open
Abstract
Sepsis, a life-threatening medical condition, manifests as new or worsening organ failures due to a dysregulated host response to infection. Many patients with sepsis have manifested a hyperinflammatory phenotype leading to the identification of inflammatory modulation by corticosteroids as a key treatment modality. However, the optimal use of corticosteroids in sepsis treatment remains a contentious subject, necessitating a deeper understanding of their physiological and pharmacological effects. Our study conducts a comprehensive review of randomized controlled trials (RCTs) focusing on traditional corticosteroid treatment in sepsis, alongside an analysis of evolving clinical guidelines. Additionally, we explore the emerging role of artificial intelligence (AI) in medicine, particularly in diagnosing, prognosticating, and treating sepsis. AI's advanced data processing capabilities reveal new avenues for enhancing corticosteroid therapeutic strategies in sepsis. The integration of AI in sepsis treatment has the potential to address existing gaps in knowledge, especially in the application of corticosteroids. Our findings suggest that combining corticosteroid therapy with AI-driven insights could lead to more personalized and effective sepsis treatments. This approach holds promise for improving clinical outcomes and presents a significant advancement in the management of this complex and often fatal condition.
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Affiliation(s)
- Chenglong Liang
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Wenzhou Medical University, Wenzhou 325000, China
- School of Nursing, Wenzhou Medical University, Wenzhou 325000, China
| | - Shuo Pan
- Wenzhou Medical University, Wenzhou 325000, China
| | - Wei Wu
- School of Computer Science and Software Engineering, University of Science and Technology Liaoning, Anshan 114051, China
| | - Fanxuan Chen
- Wenzhou Medical University, Wenzhou 325000, China
- School of Biomedical Engineering, School of Ophthalmology and Optometry, Eye Hospital, Wenzhou Medical University, Wenzhou 325000, China
| | - Chengxi Zhang
- School of Materials Science and Engineering, Shandong Jianzhu University, Jinan 250101, China
| | - Chen Zhou
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yifan Gao
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Xiangyuan Ruan
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Shichao Quan
- Department of Big Data in Health Science, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Qi Zhao
- School of Computer Science and Software Engineering, University of Science and Technology Liaoning, Anshan 114051, China
| | - Jingye Pan
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou 325000, China
- Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou 325000, China
- Zhejiang Engineering Research Center for Hospital Emergency and Process Digitization, Wenzhou 325000, China
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2
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Lu H. Inflammatory liver diseases and susceptibility to sepsis. Clin Sci (Lond) 2024; 138:435-487. [PMID: 38571396 DOI: 10.1042/cs20230522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 01/09/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024]
Abstract
Patients with inflammatory liver diseases, particularly alcohol-associated liver disease and metabolic dysfunction-associated fatty liver disease (MAFLD), have higher incidence of infections and mortality rate due to sepsis. The current focus in the development of drugs for MAFLD is the resolution of non-alcoholic steatohepatitis and prevention of progression to cirrhosis. In patients with cirrhosis or alcoholic hepatitis, sepsis is a major cause of death. As the metabolic center and a key immune tissue, liver is the guardian, modifier, and target of sepsis. Septic patients with liver dysfunction have the highest mortality rate compared with other organ dysfunctions. In addition to maintaining metabolic homeostasis, the liver produces and secretes hepatokines and acute phase proteins (APPs) essential in tissue protection, immunomodulation, and coagulation. Inflammatory liver diseases cause profound metabolic disorder and impairment of energy metabolism, liver regeneration, and production/secretion of APPs and hepatokines. Herein, the author reviews the roles of (1) disorders in the metabolism of glucose, fatty acids, ketone bodies, and amino acids as well as the clearance of ammonia and lactate in the pathogenesis of inflammatory liver diseases and sepsis; (2) cytokines/chemokines in inflammatory liver diseases and sepsis; (3) APPs and hepatokines in the protection against tissue injury and infections; and (4) major nuclear receptors/signaling pathways underlying the metabolic disorders and tissue injuries as well as the major drug targets for inflammatory liver diseases and sepsis. Approaches that focus on the liver dysfunction and regeneration will not only treat inflammatory liver diseases but also prevent the development of severe infections and sepsis.
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Affiliation(s)
- Hong Lu
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, U.S.A
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3
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Vine J, Berlin N, Moskowitz A, Berg KM, Liu X, Balaji L, Donnino MW, Grossestreuer AV. Corticosteroids to Reduce Inflammation in Severe Pancreatitis (CRISP) protocol and statistical analysis plan: a prospective, multicentre, double-blind, randomized, placebo controlled clinical trial. Contemp Clin Trials 2024; 139:107486. [PMID: 38431131 PMCID: PMC11131038 DOI: 10.1016/j.cct.2024.107486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 01/29/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Acute pancreatitis is a common disease which, in its severe form, is associated with significant morbidity and mortality. Currently, there is no specific therapy known to attenuate organ failure in severe pancreatitis and treatment consists primarily of supportive care. Corticosteroids have been shown to be beneficial in disease processes associated with systemic inflammation and could potentially improve outcomes in severe acute pancreatitis. METHODS The Corticosteroids to Reduce Inflammation in Severe Pancreatitis (CRISP) trial is a multi-centre, double-blind, randomized, placebo-controlled clinical trial that aims to determine the impact of corticosteroids versus placebo on organ injury in patients with severe acute pancreatitis. Patients are randomized to receive 100 mg of hydrocortisone parenterally versus matching placebo every 8 h for 3 days. Clinical and laboratory data are collected at the time of study enrollment, at 24, 48 and 72 h. The primary end-point for the trial is the difference in 72-h change in the Sequential Organ Failure Assessment (SOFA) score between hydrocortisone and placebo groups. Additional key secondary outcomes include ventilator free days and 28-day mortality. DISCUSSION This study will add to the evidence base in the treatment of severe acute pancreatitis. The results will inform clinical practice and future studies in the field. Trial registration number The trial is registered on clinicaltrials.gov (NCT05160506). It was posted on December 16th, 2021. The study protocol was approved by the Beth Israel Deaconess Medical Center Committee on Clinical Investigation (CCI) (protocol 2021 P-000803).
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Affiliation(s)
- Jacob Vine
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Noa Berlin
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA, USA
| | - Ari Moskowitz
- Division of Critical Care Medicine, Montefiore Medical Center, the Bronx, NY, USA; Bronx Center for Critical Care Outcomes and Resuscitation Research, the Bronx, New York, NY, USA
| | - Katherine M Berg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Xiaowen Liu
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Lakshman Balaji
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Anne V Grossestreuer
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA.
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Wang Y, Guo D, Winkler R, Lei X, Wang X, Messina J, Luo J, Lu H. Development of novel liver-targeting glucocorticoid prodrugs. MEDICINE IN DRUG DISCOVERY 2024; 21:100172. [PMID: 38390434 PMCID: PMC10883687 DOI: 10.1016/j.medidd.2023.100172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Background Glucocorticoids (GCs) are widely used in the treatment of inflammatory liver diseases and sepsis, but GC's various side effects on extrahepatic tissues limit their clinical benefits. Liver-targeting GC therapy may have multiple advantages over systemic GC therapy. The purpose of this study was to develop novel liver-targeting GC prodrugs as improved treatment for inflammatory liver diseases and sepsis. Methods A hydrophilic linker or an ultra-hydrophilic zwitterionic linker carboxylic betaine (CB) was used to bridge cholic acid (CA) and dexamethasone (DEX) to generate transporter-dependent liver-targeting GC prodrugs CA-DEX and the highly hydrophilic CA-CB-DEX. The efficacy of liver-targeting DEX prodrugs and DEX were determined in primary human hepatocytes (PHH), macrophages, human whole blood, and/or mice with sepsis induced by cecal ligation and puncture. Results CA-DEX was moderately water soluble, whereas CA-CB-DEX was highly water soluble. CA-CB-DEX and CA-DEX displayed highly transporter-dependent activities in reporter assays. Data mining found marked dysregulation of many GR-target genes important for lipid catabolism, cytoprotection, and inflammation in patients with severe alcoholic hepatitis. These key GR-target genes were similarly and rapidly (within 6 h) induced or down-regulated by CA-CB-DEX and DEX in PHH. CA-CB-DEX had much weaker inhibitory effects than DEX on endotoxin-induced cytokines in mouse macrophages and human whole blood. In contrast, CA-CB-DEX exerted more potent anti-inflammatory effects than DEX in livers of septic mice. Conclusions CA-CB-DEX demonstrated good hepatocyte-selectivity in vitro and better anti-inflammatory effects in vivo. Further test of CA-CB-DEX as a novel liver-targeting GC prodrug for inflammatory liver diseases and sepsis is warranted.
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Affiliation(s)
- Yazheng Wang
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Dandan Guo
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Rebecca Winkler
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Xiaohong Lei
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Xiaojing Wang
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Jennifer Messina
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Juntao Luo
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Hong Lu
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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Srivastava V, Singh S. Organ support in sepsis: A panoramic view from infection to death. Med J Armed Forces India 2024; 80:4-9. [PMID: 38239603 PMCID: PMC10793238 DOI: 10.1016/j.mjafi.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/10/2023] [Indexed: 01/22/2024] Open
Abstract
Despite significant advancements in medical research, sepsis persists as a leading cause of mortality in intensive care units (ICUs). Sepsis intricately contributes to organ failure, amplifying both morbidity and mortality. In these instances, a comprehensive comprehension of the physiology of each organ is imperative for accurate diagnosis and effective management. Within the context of an ICU clinical scenario, a meticulous evaluation and monitoring of six pivotal organ systems cardiovascular, renal, respiratory, neurological, hematological, and hepatic are essential. The primary objective in managing sepsis-induced organ failure is the early detection and intervention, encompassing timely administration of antibiotics, identification and control of the infection source, and implementation of supportive therapy. Despite the extensive body of medical literature, there is a conspicuous absence of evidence-based multi-organ management strategies for such patients. The intricate interplay between organs, commonly referred to as organ crosstalk, presents a formidable challenge in navigating the complexities of sepsis management.
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Affiliation(s)
| | - Shalendra Singh
- Senior Advisor (Anaesthesia) & Neuroanaesthesiologist, Command Hospital (Northern Commmand), Udhampur, India
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Ilias I, Vassiliou AG, Keskinidou C, Vrettou CS, Orfanos S, Kotanidou A, Dimopoulou I. Changes in Cortisol Secretion and Corticosteroid Receptors in COVID-19 and Non COVID-19 Critically Ill Patients with Sepsis/Septic Shock and Scope for Treatment. Biomedicines 2023; 11:1801. [PMID: 37509441 PMCID: PMC10376106 DOI: 10.3390/biomedicines11071801] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/16/2023] [Accepted: 06/22/2023] [Indexed: 07/30/2023] Open
Abstract
Sepsis is associated with dysregulated cortisol secretion, leading to abnormal levels of cortisol in the blood. In the early stages of the condition, cortisol levels are typically elevated due to increased secretion from the adrenal glands. However, as the disease progresses, cortisol levels may decline due to impaired adrenal function, leading to relative adrenal insufficiency. The latter is thought to be caused by a combination of factors, including impaired adrenal function, decreased production of corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) by the hypothalamus and pituitary gland, and increased breakdown of cortisol. The dysregulation of cortisol secretion in sepsis is thought to contribute to the pathophysiology of the disease by impairing the body's ability to mount an appropriate inflammatory response. Given the dysregulation of cortisol secretion and corticosteroid receptors in sepsis, there has been considerable interest in the use of steroids as a treatment. However, clinical trials have yielded mixed results and corticosteroid use in sepsis remains controversial. In this review, we will discuss the changes in cortisol secretion and corticosteroid receptors in critically ill patients with sepsis/septic shock. We will also make special note of COVID-19 patients, who presented a recent challenge for ICU management, and explore the scope for corticosteroid administration in both COVID-19 and non-COVID-19 septic patients.
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Affiliation(s)
- Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, GR-11521 Athens, Greece
| | - Alice G Vassiliou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Chrysi Keskinidou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Charikleia S Vrettou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Stylianos Orfanos
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Ioanna Dimopoulou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
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7
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Saleem N, Kulkarni A, Snow TAC, Ambler G, Singer M, Arulkumaran N. Effect of Corticosteroids on Mortality and Clinical Cure in Community-Acquired Pneumonia: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Control Trials. Chest 2023; 163:484-497. [PMID: 36087797 PMCID: PMC10808071 DOI: 10.1016/j.chest.2022.08.2229] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 07/07/2022] [Accepted: 08/27/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality. Corticosteroids may be a beneficial adjunct in the treatment of bacterial pneumonia. RESEARCH QUESTION Is there any benefit of corticosteroid therapy in the management of bacterial CAP among patients requiring hospitalization? STUDY DESIGN AND METHODS PubMed, Cochrane Library, and Embase were searched to identify randomized controlled trials assessing the use of systemic corticosteroids compared with standard care in the management of CAP. A systematic review, meta-analysis, and Trial Sequential Analysis (TSA) were performed. The primary outcome was all-cause mortality. Secondary outcomes included ICU admission, mechanical ventilation, treatment failure, readmission, and adverse events. Data are presented as risk ratio (RR) with 95% CI, P value, heterogeneity (I2), and TSA-adjusted CIs. RESULTS Sixteen trials met the eligibility criteria. All-cause mortality (16 studies [3,842 patients]; RR, 0.85 [95% CI, 0.67-1.07]; P = .17; I2 = 14%; TSA-adjusted CI, 0.61-1.09), ICU admission (six studies [2,619 patients]; RR, 0.66 [95% CI, 0.45-0.97]; P = .04; I2 = 0%; TSA-adjusted CI, 0.37-1.12), treatment failure (six studies [2,093 patients]; RR, 0.78 [95% CI, 0.37-1.67]; P = .52; I2 = 68%; TSA-adjusted CI, 0.02-25.5), and the incidence of adverse events (six studies [2,487 patients]; RR, 1.10 [95% CI, 0.97-1.25]; P = .14; I2 = 53%; TSA-adjusted CI, 0.82-2.41) were similar between patients receiving corticosteroids and patients assigned to the control group. The need for mechanical ventilation (eight studies [1,457 patients]; RR, 0.51 [95% CI, 0.33-0.77]; P = .001; I2 = 0%; TSA-adjusted CI, 0.20-0.85) was lower among patients receiving corticosteroids compared with those receiving standard care. However, corticosteroid use may be associated with higher rates of hospital readmission (five studies [2,853 patients]; RR, 1.20 [95% CI, 1.05-1.38]; P = .008; I2 = 0%; TSA-adjusted CI, 0.89-1.98). INTERPRETATION Corticosteroid therapy is associated with a lower incidence of progression to requiring mechanical ventilation among patients hospitalized with CAP. No association was found between corticosteroid therapy and mortality, treatment failure, or adverse events. TRIAL REGISTRY PROSPERO; No.: CRD42021279359; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Naveed Saleem
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, England
| | - Adarsh Kulkarni
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, England
| | - Timothy Arthur Chandos Snow
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, England
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, England
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, England
| | - Nishkantha Arulkumaran
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, England.
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Pérez Vela JL, Llanos Jorge C, Duerto Álvarez J, Jiménez Rivera JJ. Clinical management of postcardiotomy shock in adults. Med Intensiva 2022; 46:312-325. [PMID: 35570187 DOI: 10.1016/j.medine.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/14/2021] [Accepted: 08/21/2021] [Indexed: 06/15/2023]
Abstract
Postcardiotomy cardiogenic shock represents the most serious expression of low cardiac output syndrome after cardiac surgery. Although infrequent, it is a relevant condition due to its specific and complex pathophysiology and important morbidity-mortality. The diagnosis requires a high index of suspicion and multimodal hemodynamic monitoring, where echocardiography and the pulmonary arterial catheter play a main role. Early and multidisciplinary management should focus on the management of postoperative or mechanical complications and the optimization of determinants of cardiac output through fluid therapy or diuretic treatments, inotropic drugs and vasopressors/vasodilators and, in the absence of a response, early mechanical circulatory support. The aim of this paper is to review and update the pathophysiology, diagnosis and management of postcardiotomy cardiogenic shock.
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Affiliation(s)
- J L Pérez Vela
- Servicio de Medicina Intensiva, Hospital Universitario Doce de Octubre, Madrid, Spain.
| | - C Llanos Jorge
- Servicio de Medicina Intensiva, Hospital Quirónsalud Tenerife, Santa Cruz de Tenerife, Spain
| | - J Duerto Álvarez
- Servicio de Medicina Intensiva, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - J J Jiménez Rivera
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
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Recchia A, Cascella M, Altamura S, Borrelli F, De Nittis N, Dibenedetto E, Labonia M, Pavone G, Del Gaudio A. Early Diagnosis and Antibiotic Treatment Combined with Multicomponent Hemodynamic Support for Addressing a Severe Case of Lemierre's Syndrome. Antibiotics (Basel) 2021; 10:antibiotics10121526. [PMID: 34943737 PMCID: PMC8698451 DOI: 10.3390/antibiotics10121526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/14/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022] Open
Abstract
A 20-year-old man was admitted to the intensive care unit for septic shock due to Lemierre’s syndrome. It is a rare syndrome that manifests as an upper respiratory infection, although systemic involvement, severe coagulopathy, and multi-organ failure can dangerously complicate the clinical picture. In this syndrome, sepsis-related neuroendocrine dysregulation and microcirculation impairment can have a rapid deleterious progression. Consequently, proper diagnosis, early source control, and appropriate antibiotics administration are mandatory to improve the prognosis. The intensive treatment is aimed at limiting organ damage through hemodynamic optimization. Remarkably, in septic shock due to Lemierre’s syndrome, hemodynamic optimization can be achieved through the synergic effect of norepinephrine, argipressin, and hydrocortisone.
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Affiliation(s)
- Andreaserena Recchia
- Anesthesia and Intensive Care 2, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy; (S.A.); (F.B.); (N.D.N.); (E.D.); (G.P.); (A.D.G.)
- Correspondence: (A.R.); (M.C.); Tel.: +39-0882-4107-03 (A.R.)
| | - Marco Cascella
- Anesthesia and Pain Medicine Istituto Nazionale Tumori-IRCCS, Fondazione G. Pascale, 80100 Napoli, Italy
- Correspondence: (A.R.); (M.C.); Tel.: +39-0882-4107-03 (A.R.)
| | - Sabrina Altamura
- Anesthesia and Intensive Care 2, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy; (S.A.); (F.B.); (N.D.N.); (E.D.); (G.P.); (A.D.G.)
| | - Felice Borrelli
- Anesthesia and Intensive Care 2, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy; (S.A.); (F.B.); (N.D.N.); (E.D.); (G.P.); (A.D.G.)
| | - Nazario De Nittis
- Anesthesia and Intensive Care 2, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy; (S.A.); (F.B.); (N.D.N.); (E.D.); (G.P.); (A.D.G.)
| | - Elisabetta Dibenedetto
- Anesthesia and Intensive Care 2, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy; (S.A.); (F.B.); (N.D.N.); (E.D.); (G.P.); (A.D.G.)
| | - Maria Labonia
- Microbiology and Virology, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy;
| | - Giovanna Pavone
- Anesthesia and Intensive Care 2, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy; (S.A.); (F.B.); (N.D.N.); (E.D.); (G.P.); (A.D.G.)
| | - Alfredo Del Gaudio
- Anesthesia and Intensive Care 2, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy; (S.A.); (F.B.); (N.D.N.); (E.D.); (G.P.); (A.D.G.)
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Sato R, Hasegawa D, Prasitlumkum N, Ueoka M, Nishida K, Takahashi K, Nasu M, Dugar S. Effect of IV High-Dose Vitamin C on Mortality in Patients With Sepsis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2021; 49:2121-2130. [PMID: 34495877 DOI: 10.1097/ccm.0000000000005263] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials to investigate whether IV high-dose vitamin C improves the short-term mortality of patients with sepsis. DESIGN This study is a systematic review and meta-analysis of randomized controlled trials. We searched EMBASE, the Cochrane Central Register of Controlled Trials, and MEDLINE for randomized controlled trials that met inclusion criteria. The protocol was registered at the University hospital Medical Information Network Clinical Trials Registry (UMIN000040528). All analyses were presented with the use of random-effects models. The primary outcome was short-term mortality defined as 28-day, 30-day, or in-hospital mortality. PATIENTS Two authors independently evaluated the following eligibility criteria: 1) randomized controlled trial, 2) patients with sepsis aged ≥18 years, and 3) received intravenous high-dose vitamin C in addition to standard of care, or standard of care alone. Then, two authors independently extracted the selected patient and study characteristics and outcomes from studies that met above eligibility criteria. MEASUREMENTS AND MAIN RESULTS Eleven randomized controlled trials (n = 1,737 patients) were included in this meta-analysis. High-dose IV vitamin C was not associated with a significantly lower short-term mortality (risk ratio, 0.88; 95% CI, 0.73-1.06; p = 0.18; I2 = 29%) but was associated with a significantly shorter duration of vasopressor use (standardized mean difference, -0.35; 95% CI, -0.63 to -0.07; p < 0.01; I2 = 80%) and a significantly greater decline in the Sequential Organ Failure Assessment score at 72-96 hours (standardized mean difference, -0.20; 95% CI, -0.32 to -0.08; p < 0.01; I2 = 16%). One study reported significant association with hypernatremia, but adverse effects were rare, and high-dose vitamin C is deemed relatively safe. CONCLUSIONS In this meta-analysis, the use of IV high-dose vitamin C in patients with sepsis was not associated with lower short-term mortality although it was associated with significantly shorter duration of vasopressor use and greater decline in the Sequential Organ Failure Assessment score at 72-96 hours.
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Affiliation(s)
- Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Narut Prasitlumkum
- Department of Cardiology, University of California Riverside School of Medicine, Riverside, CA
| | - Miki Ueoka
- Department of Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI
| | - Kazuki Nishida
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Aichi, Japan
- Department of Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Michitaka Nasu
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
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11
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Pérez Vela J, Llanos Jorge C, Duerto Álvarez J, Jiménez Rivera J. Manejo clínico del shock poscardiotomía en pacientes adultos. Med Intensiva 2021. [DOI: 10.1016/j.medin.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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New Evidence of Potential Benefits of Dexamethasone and Added on Therapy of Fludrocortisone on Clinical Outcomes of Corticosteroid in Sepsis Patients: A Systematic Review and Meta-Analysis. J Pers Med 2021; 11:jpm11060544. [PMID: 34208300 PMCID: PMC8231131 DOI: 10.3390/jpm11060544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022] Open
Abstract
The aim of this study is to investigate clinical outcomes of corticosteroid treatment in patients with sepsis or septic shock. An electronic keyword searches of PubMed, EMBASE, and Google Scholar were conducted per PRISMA guidelines. The pooled analyses on the corticosteroid impact on mortality, adverse events, and clinical outcomes were performed. Subgroup analyses on the clinical outcomes in relation to corticosteroid dose, duration, and agents were performed. Pooled analyses of 21 randomized control trials revealed substantially reduced mortality (RR 0.93, 95% CI 0.88-0.99, p = 0.02) and length of stay in intensive care unit (SMD -1.66, 95% CI -1.91--1.40, p < 0.00001) without increased risks of adverse events (RR 1.04, 95% CI 0.96-1.12, p = 0.38). No significant improvements of other clinical outcomes were observed. Subgroup analyses demonstrated substantially reduced mortality with short-term (≤7 days) low-dose (<400 mg/day) corticosteroid treatment (RR 0.91, 95% CI 0.87-0.95, p < 0.0001). Moreover, dexamethasone (RR 0.40, 95% CI 0.20-0.81, p = 0.01) and combined hydrocortisone and fludrocortisone treatment (RR 0.89, 95% CI 0.84-0.94, p < 0.00001) provided substantial reduction of mortality whereas hydrocortisone alone did not reduce the mortality risk in sepsis patients. Thus, further controlled studies on the clinical outcomes of potential corticosteroid options on sepsis-related clinical outcomes are warranted.
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13
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Assessing the Course of Organ Dysfunction Using Joint Longitudinal and Time-to-Event Modeling in the Vasopressin and Septic Shock Trial. Crit Care Explor 2020; 2:e0104. [PMID: 32426746 PMCID: PMC7188432 DOI: 10.1097/cce.0000000000000104] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Supplemental Digital Content is available in the text. Non-mortality septic shock outcomes (e.g., Sequential Organ Failure Assessment score) are important clinical endpoints in pivotal sepsis trials. However, comparisons of observed longitudinal non-mortality outcomes between study groups can be biased if death is unequal between study groups or is associated with an intervention (i.e., informative censoring). We compared the effects of vasopressin versus norepinephrine on the Sequential Organ Failure Assessment score in the Vasopressin and Septic Shock Trial to illustrate the use of joint modeling to help minimize potential bias from informative censoring.
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14
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Wu J, Huang M, Wang Q, Ma Y, Jiang L. Effects and safety of separate low-dose hydrocortisone use in patients with septic shock: A meta-analysis. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907919833205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: The aim of this study was to explore the effects and safety of low-dose hydrocortisone in patients with septic shock. Methods: The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched from database inception until 1 August 2018. Two reviewers performed literature selection, data extraction, and quality evaluation independently. Results: Twelve randomized controlled trials were included in this meta-analysis. The combined results showed that low-dose hydrocortisone use had no survival benefit in patients with septic shock (relative risk = 1.09; 95% confidence interval = 0.88–1.05; P = 0.37). But low-dose hydrocortisone use was useful for shock reverse (relative risk = 1.09; 95% confidence interval = 1.00–1.19; P = 0.04) and in shortening the time of vasopressor support (weighted mean difference = −1.79, 95% confidence interval = −2.05 to −1.52; P < 0.00001). In addition, use of low-dose hydrocortisone was associated with a higher risk of hyperglycemia (relative risk = 1.21; 95% confidence interval = 1.04–1.40; P = 0.01) and hypernatremia (relative risk = 6.34; 95% confidence interval = 1.19–33.81; P = 0.03). There was no significant improvement of intensive care unit mortality (relative risk = 1.11; 95% confidence interval = 0.93–1.33; P = 0.23) or hospital mortality (relative risk = 1.08; 95% confidence interval = 0.94–1.24; P = 0.29), length of intensive care unit (weighted mean difference = −1.84; 95% confidence interval = −5.80 to 2.11; P = 0.36) or length of hospital (weighted mean difference = 0.11; 95% confidence interval = −2.06 to 2.29; P = 0.98), and time of mechanical support (weighted mean difference = −0.69; 95% confidence interval = −1.76 to −0.38; P = 0.20) with the use of low-dose hydrocortisone. There was no significant difference in secondary infection (relative risk = 1.04; 95% confidence interval = 0.91–1.18; P = 0.57), recurrence of shock (relative risk = 1.47; 95% confidence interval = 0.64–3.39; P = 0.36), and gastrointestinal bleeding (relative risk = 1.41; 95% confidence interval = 0.89–2.22; P = 0.14) with the use of low-dose hydrocortisone. Conclusion: Although there was no effect of low-dose hydrocortisone on survival of patients with septic shock, it is associated with a higher rate of shock reversal and shortening duration of vasopressor support; thus, low-dose hydrocortisone may be an alternative drug in septic shock patients who are refractory to fluid resuscitation and vasopressors.
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Affiliation(s)
- Jing Wu
- Department of Emergency Medicine, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Man Huang
- Department of Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - QianWen Wang
- Department of Emergency Medicine, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Emergency Medicine, Zhejiang University, Hangzhou, China
| | - Yuefeng Ma
- Department of Emergency Medicine, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Libing Jiang
- Department of Emergency Medicine, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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15
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Ortoleva J, Shapeton A, Vanneman M, Dalia AA. Vasoplegia During Cardiopulmonary Bypass: Current Literature and Rescue Therapy Options. J Cardiothorac Vasc Anesth 2019; 34:2766-2775. [PMID: 31917073 DOI: 10.1053/j.jvca.2019.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/11/2022]
Abstract
Vasoplegia syndrome in the cardiac surgical intensive care unit and postoperative period has been an area of interest to clinicians because of its prevalence and effects on morbidity and mortality. However, there is a paucity of evidence regarding the treatment of vasoplegia syndrome during cardiopulmonary bypass (on-CPB VS). This review aims to detail the incidence, outcomes, and possible treatment options for patients who develop vasoplegia during bypass. The pharmacologic rescue agents discussed are used in cases in which vasoplegia during CPB is refractory to standard catecholamine agents, such as norepinephrine, epinephrine, and phenylephrine. Methods to improve vasoplegia during CPB can be both pharmacologic and nonpharmacologic. In particular, optimization of CPB parameters plays an important nonpharmacologic role in vasoplegia during CPB. Pharmacologic agents that have been demonstrated as being effective in vasoplegia include vasopressin, terlipressin, methylene blue, hydroxocobalamin, angiotensin II (Giapreza), vitamin C, flurbiprofen (Ropion), and hydrocortisone. Although these agents have not been specifically evaluated for vasoplegia during CPB, they have shown signs of effectiveness for vasoplegia postoperatively to varying degrees. Understanding the evidence for, dosing, and side effects of these agents is crucial for cardiac anesthesiologists when treating vasoplegia during CPB bypass.
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Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Alexander Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA
| | - Mathew Vanneman
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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16
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Pourmand A, Whiteside T, Yamane D, Rashed A, Mazer-Amirshahi M. The controversial role of corticosteroids in septic shock. Am J Emerg Med 2019; 37:1353-1361. [PMID: 31056383 DOI: 10.1016/j.ajem.2019.04.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/13/2019] [Accepted: 04/25/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Several clinical trials and literature reviews have been conducted to evaluate the impact of corticosteroids on the physiological markers and clinical outcomes of patients in septic shock. While the findings have been somewhat contradictory, there is evidence of moderate benefit from the administration of low-dose corticosteroids to patients in septic shock. In this review, we discuss recent studies evaluating the impact of corticosteroids on morbidity and mortality in septic shock and explore future directions to fully elucidate when and how the administration of corticosteroid therapies can be beneficial. METHODS A literature review was performed using the Mesh database of PubMed with the term "septic shock" and subheadings "therapeutic use", "drug therapy", "pharmacology", and "therapy" followed by the addition of "steroid". Filters were added to restrict the search to 18+ age, English and human studies, and articles published within the last 10 years. One hundred sixty-five articles were examined and twenty-five were deemed relevant to this review. RESULTS The twenty-five articles reviewed here provide conflicting evidence as to the usefulness of corticosteroid treatments during septic shock. Several showed improved physiological outcomes, including rates of organ failure, need for life supporting interventions, adverse effects, inflammatory markers, and perfusion during the course of septic shock, as well as decreased mortality for a statistically significant number of patients. CONCLUSIONS There remains a need for improved therapy for patients in septic shock. Corticosteroids have shown some potential in improving mortality rates and clinical markers. Additional studies are needed to determine the optimal role of corticosteroids in septic shock.
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Affiliation(s)
- Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Tess Whiteside
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - David Yamane
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Amir Rashed
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, United States; Georgetown University School of Medicine, Washington, DC, United States
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17
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Brettner F, Chappell D, Nebelsiek T, Hauer D, Schelling G, Becker BF, Rehm M, Weis F. Preinterventional hydrocortisone sustains the endothelial glycocalyx in cardiac surgery. Clin Hemorheol Microcirc 2019; 71:59-70. [DOI: 10.3233/ch-180384] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Florian Brettner
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
- Walter-Brendel Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, Martinsried, Germany
| | - Daniel Chappell
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Tim Nebelsiek
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Daniela Hauer
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Gustav Schelling
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Bernhard F. Becker
- Walter-Brendel Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, Martinsried, Germany
| | - Markus Rehm
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Florian Weis
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Fürstenfeldbruck, Fürstenfeldbruck, Germany
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18
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Lyu QQ, Chen QH, Zheng RQ, Yu JQ, Gu XH. Effect of Low-Dose Hydrocortisone Therapy in Adult Patients With Septic Shock: A Meta-Analysis With Trial Sequential Analysis of Randomized Controlled Trials. J Intensive Care Med 2018; 35:971-983. [PMID: 30270720 DOI: 10.1177/0885066618803062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The efficacy of low-dose hydrocortisone therapy in the management of septic shock remains controversial in critical care for many years. Hence, we performed this meta-analysis of randomized controlled trials (RCTs) with trial sequential analysis (TSA) to evaluate its effect on clinical outcome among adult patients with septic shock. METHODS We identified relevant RCTs published from inception to March 7, 2018 comparing low-dose hydrocortisone with placebo or no intervention in adults admitted to the intensive care unit (ICU) for septic shock. Meta-analyses were performed for the primary and secondary outcomes. The risk of bias was assessed using the Cochrane Collaboration's instrument. Trial sequential analysis was used to pool the results from the included studies for the primary outcomes. RESULTS Thirteen studies were retrieved by our literature search strategy. There were no significant differences in 28-day mortality (odds ratio [OR] = 0.90, 95% confidence interval [CI] = 0.81-1.00; P = .05) and hospital mortality (OR = 0.91, 95% CI = 0.82-1.02; P = .09) between the 2 groups, which were confirmed by TSA. However, there was a significant improvement in shock reversal in the hydrocortisone group (OR = 1.33, 95% CI = 1.02-1.72; P = .03). Furthermore, subgroup analyses revealed that hydrocortisone plus fludrocortisone statistically reduced the rate of 28-day mortality (OR = 0.79, 95% CI = 0.64-0.97; P = .03), ICU mortality (OR = 0.77, 95% CI = 0.63-0.95; P = .02), and hospital mortality (OR = 0.77, 95% CI = 0.63-0.95; P = .01) in comparison with the placebo, the results were also confirmed by TSA. CONCLUSION Among adult patients with septic shock, the use of low-dose hydrocortisone compared with control did not confer overall survival benefits, albeit improving shock reversal rate. The benefit of reducing 28-day mortality, ICU mortality, and hospital mortality was observed in combination use of hydrocortisone and fludrocortisone.
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Affiliation(s)
- Qing-Quan Lyu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, People's Republic of China
| | - Qi-Hong Chen
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, People's Republic of China
| | - Rui-Qiang Zheng
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, People's Republic of China
| | - Jiang-Quan Yu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, People's Republic of China
| | - Xiao-Hua Gu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, People's Republic of China
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Exposure to Stress-Dose Steroids and Lethal Septic Shock After In-Hospital Cardiac Arrest: Individual Patient Data Reanalysis of Two Prior Randomized Clinical Trials that Evaluated the Vasopressin-Steroids-Epinephrine Combination Versus Epinephrine Alone. Cardiovasc Drugs Ther 2018; 32:339-351. [PMID: 30084038 DOI: 10.1007/s10557-018-6811-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE Low-dose steroids may reduce the mortality of severely ill patients with septic shock. We sought to determine whether exposure to stress-dose steroids during and/or after cardiopulmonary resuscitation is associated with reduced risk of death due to postresuscitation septic shock. METHODS We analyzed pooled, individual patient data from two prior, randomized clinical trials (RCTs). RCTs evaluated vasopressin, steroids, and epinephrine (VSE) during resuscitation and stress-dose steroids after resuscitation in vasopressor-requiring, in-hospital cardiac arrest. In the second RCT, 15 control group patients received open-label, stress-dose steroids. Patients with postresuscitation shock were assigned to a Steroids (n = 118) or No Steroids (n = 73) group according to an "as-treated" principle. We used cumulative incidence competing risks Cox regression to determine cause-specific hazard ratios (CSHRs) for pre-specified predictors of lethal septic shock (primary outcome). In sensitivity analyses, data were analyzed according to the intention-to-treat (ITT) principle (VSE group, n = 103; control group, n = 88). RESULTS Lethal septic shock was less likely in Steroids versus No Steroids group, CSHR, 0.40, 95% confidence interval (CI), 0.20-0.82; p = 0.012. ITT analysis yielded similar results: VSE versus Control, CSHR, 0.44, 95% CI, 0.23-0.87; p = 0.019. Adjustment for significant, between-group baseline differences in composite cardiac arrest causes such as "hypotension and/or myocardial ischemia" did not appreciably affect the aforementioned CSHRs. CONCLUSIONS In this reanalysis, exposure to stress-dose steroids (primarily in the context of a combined VSE intervention) was associated with lower risk of postresuscitation lethal septic shock.
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Neuroendocrine Derangements in Early Septic Shock: Pharmacotherapy for Relative Adrenal and Vasopressin Insufficiency. Shock 2018; 48:284-293. [PMID: 28296657 DOI: 10.1097/shk.0000000000000864] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Septic shock is a leading cause of mortality in intensive care units throughout the world. While this disease state represents a highly complex pathophysiology involving numerous organ systems, the early approach to care includes adequate hemodynamic support traditionally achieved via infusions of vasoactive medications after adequate fluid resuscitation. Relative adrenal and vasopressin deficiencies are a common feature of septic shock that contribute to impaired hemodynamics. Hydrocortisone and vasopressin are endocrine system hormone analogues that target the acute neuroendocrine imbalance associated with septic shock. This clinically focused annotated review describes the pathophysiological mechanisms behind their use and explores the potential clinical roles of early administration and synergy when combined.
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Martino EA, Baiardo Redaelli M, Sardo S, Lembo R, Giordano VF, Winterton D, Ruggeri L, Hajjar LA, Zangrillo A, Landoni G. Steroids and Survival in Critically Ill Adult Patients: A Meta-analysis of 135 Randomized Trials. J Cardiothorac Vasc Anesth 2018; 32:2252-2260. [PMID: 29793761 DOI: 10.1053/j.jvca.2018.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Corticosteroids have important effects on intermediate outcomes in critically ill patients, but their effect on survival is unknown. The objective of this meta-analysis was to analyze the effect on mortality of corticosteroids in critical and perioperative settings. DESIGN A meta-analysis of randomized trials. SETTING PubMed, Embase, BioMed Central, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched to February 1, 2018, for randomized trials comparing corticosteroids with placebo or standard care. PARTICIPANTS Critically ill or surgical adult patients. INTERVENTIONS Corticosteroids compared with placebo or standard care. MEASUREMENTS AND MAIN RESULTS A total of 44,553 patients from 135 studies were included. Overall, mortality in the corticosteroid group and in the control group were similar (16% v 16%; p = 0.9). Subanalyses identified a beneficial effect of corticosteroids on survival in patients with respiratory system diseases (9% v 13%; p < 0.001) and bacterial meningitis (28% v 32%; p= 0.04), and a detrimental effect on survival in patients with traumatic brain injury (22% v 19%; p < 0.001). No differences in mortality were found in patients with cardiac diseases (7% v 6%; p = 0.7), in patients undergoing cardiac surgery (2.8% v 3.2% p = 0.14), and when treatment duration or patient age were considered. CONCLUSIONS This meta-analysis documents the safety of corticosteroids in the overall critically ill population with the notable exception of brain injury patients, a setting where the authors confirmed their detrimental effect on survival. A possible beneficial effect of corticosteroids on survival was found among patients with respiratory diseases and in patients with bacterial meningitis.
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Affiliation(s)
- Enrico A Martino
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Salvatore Sardo
- Department of Medical Sciences "M. Aresu," University of Cagliari, Cagliari, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Vito F Giordano
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Winterton
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludhmilla A Hajjar
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Lv QQ, Gu XH, Chen QH, Yu JQ, Zheng RQ. Early initiation of low-dose hydrocortisone treatment for septic shock in adults: A randomized clinical trial. Am J Emerg Med 2017; 35:1810-1814. [DOI: 10.1016/j.ajem.2017.06.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/01/2017] [Accepted: 06/04/2017] [Indexed: 01/31/2023] Open
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23
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Plassais J, Venet F, Cazalis MA, Le Quang D, Pachot A, Monneret G, Tissot S, Textoris J. Transcriptome modulation by hydrocortisone in severe burn shock: ancillary analysis of a prospective randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017. [PMID: 28623938 PMCID: PMC5473974 DOI: 10.1186/s13054-017-1743-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Despite shortening vasopressor use in shock, hydrocortisone administration remains controversial, with potential harm to the immune system. Few studies have assessed the impact of hydrocortisone on the transcriptional response in shock, and we are lacking data on burn shock. Our objective was to assess the hydrocortisone-induced transcriptional modulation in severe burn shock, particularly modulation of the immune response. Methods We collected whole blood samples during a randomized controlled trial assessing the efficacy of hydrocortisone administration in burn shock. Using whole genome microarrays, we first compared burn patients (n = 32) from the placebo group to healthy volunteers to describe the transcriptional modulation induced by burn shock over the first week. Then we compared burn patients randomized for either hydrocortisone administration or placebo, to assess hydrocortisone-induced modulation. Results Study groups were similar in terms of severity and major outcomes, but shock duration was significantly reduced in the hydrocortisone group. Many genes (n = 1687) were differentially expressed between burn patients and healthy volunteers, with 85% of them exhibiting a profound and persistent modulation over seven days. Interestingly, we showed that hydrocortisone enhanced the shock-associated repression of adaptive, but also innate immunity. Conclusions We found that the initial host response to burn shock encompasses wide and persistent modulation of gene expression, with profound modulation of pathways associated with metabolism and immunity. Importantly, hydrocortisone administration may worsen the immunosuppression associated with severe injury. These data should be taken into account in the risk ratio of hydrocortisone administration in patients with inflammatory shock. Trial registration ClinicalTrials.gov, NCT00149123. Registered on 6 September 2005. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1743-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonathan Plassais
- EA7426, Université Claude Bernard Lyon 1, Hospices Civils de Lyon, bioMérieux ; "Pathophysiology of injury induced immunosuppression (PI3)", hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France
| | - Fabienne Venet
- EA7426, Université Claude Bernard Lyon 1, Hospices Civils de Lyon, bioMérieux ; "Pathophysiology of injury induced immunosuppression (PI3)", hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France.,Hospices Civils de Lyon, Immunology laboratory, hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France
| | - Marie-Angélique Cazalis
- EA7426, Université Claude Bernard Lyon 1, Hospices Civils de Lyon, bioMérieux ; "Pathophysiology of injury induced immunosuppression (PI3)", hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France
| | - Diane Le Quang
- Hospices Civils de Lyon, Burn ICU, Anesthesia and Critical Care Medicine department, hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France
| | - Alexandre Pachot
- EA7426, Université Claude Bernard Lyon 1, Hospices Civils de Lyon, bioMérieux ; "Pathophysiology of injury induced immunosuppression (PI3)", hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France
| | - Guillaume Monneret
- EA7426, Université Claude Bernard Lyon 1, Hospices Civils de Lyon, bioMérieux ; "Pathophysiology of injury induced immunosuppression (PI3)", hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France.,Hospices Civils de Lyon, Immunology laboratory, hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France
| | - Sylvie Tissot
- Hospices Civils de Lyon, Burn ICU, Anesthesia and Critical Care Medicine department, hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France
| | - Julien Textoris
- EA7426, Université Claude Bernard Lyon 1, Hospices Civils de Lyon, bioMérieux ; "Pathophysiology of injury induced immunosuppression (PI3)", hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France. .,Hospices Civils de Lyon, Burn ICU, Anesthesia and Critical Care Medicine department, hôpital E. Herriot, 5 place d'Arsonval, 69437, Lyon, France.
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Pierrakos C, Velissaris D, Felleiter P, Antonelli M, Vanhems P, Sakr Y, Vincent JL. Increased mortality in critically ill patients with mild or moderate hyperbilirubinemia. J Crit Care 2017; 40:31-35. [PMID: 28314169 DOI: 10.1016/j.jcrc.2017.01.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 12/11/2016] [Accepted: 01/22/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE Increased bilirubin concentrations may be related to outcome, but this has not been well studied. We evaluated the relationship between total serum bilirubin levels and outcome in critically ill patients. MATERIALS AND METHODS Data were analyzed from adult critically ill patients included in a 1-day international prevalence study after excluding those with an obvious underlying cause of hyperbilirubinemia. RESULTS Serum bilirubin concentrations were >1 mg/dL in 2803 (31%) of 8973 patients, and these patients had higher mortality rates than patients with lower bilirubin concentrations (30% vs 21%, P<.01). For serum bilirubin values of 1.1-6 mg/dL, there was a linear increase in crude mortality (R2=0.96), with the highest hospital mortality (42%) in patients with bilirubin concentrations between 3.7 and 6.0 mg/dL. There was no further increase in the mortality rates for patients with bilirubin concentrations >6 mg/dL. A serum bilirubin concentration >1 mg/dL was an independent risk factor for mortality in multilevel analysis. CONCLUSIONS Hyperbilirubinemia without a recognized cause was common and independently associated with increased mortality. There was a linear correlation of mortality with bilirubin concentration for values between 1 and 6 mg/dL but not for higher values.
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Affiliation(s)
| | | | - Peter Felleiter
- Intensive Care Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Philippe Vanhems
- Hospices Civils de Lyon, Service d'Hygiène, Epidémiologie et Prévention, Unité Epidémiologie et Biomarqueurs de l'Infection, Lyon, France
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Abstract
Sepsis and septic shock are characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. The liver has a central role during sepsis, and is essential to the regulation of immune defence during systemic infections by mechanisms such as bacterial clearance, acute-phase protein or cytokine production and metabolic adaptation to inflammation. However, the liver is also a target for sepsis-related injury, including hypoxic hepatitis due to ischaemia and shock, cholestasis due to altered bile metabolism, hepatocellular injury due to drug toxicity or overwhelming inflammation, as well as distinct pathologies such as secondary sclerosing cholangitis in critically ill patients. Hence, hepatic dysfunction substantially impairs the prognosis of sepsis and serves as a powerful independent predictor of mortality in the intensive care unit. Sepsis is particularly problematic in patients with liver cirrhosis (who experience increased bacterial translocation from the gut and impaired microbial defence) as it can trigger acute-on-chronic liver failure - a syndrome with high short-term mortality. Here, we review the importance of the liver as a guardian, modifier and target of sepsis, the factors that contribute to sepsis in patients with liver cirrhosis and new therapeutic strategies.
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Honore PM, Jacobs R, De Waele E, Hendrickx I, Spapen HD. Vasopressin versus noradrenaline as initial therapy in septic shock. Is vasopressin-related renal protection doomed to "vanish" in the haze? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:S47. [PMID: 27868015 PMCID: PMC5104637 DOI: 10.21037/atm.2016.10.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/18/2016] [Indexed: 09/20/2023]
Affiliation(s)
- Patrick M Honore
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rita Jacobs
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elisabeth De Waele
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Inne Hendrickx
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herbert D Spapen
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Abstract
Abstract
Muscle weakness is common in the surgical intensive care unit (ICU). Low muscle mass at ICU admission is a significant predictor of adverse outcomes. The consequences of ICU-acquired muscle weakness depend on the underlying mechanism. Temporary drug-induced weakness when properly managed may not affect outcome. Severe perioperative acquired weakness that is associated with adverse outcomes (prolonged mechanical ventilation, increases in ICU length of stay, and mortality) occurs with persistent (time frame: days) activation of protein degradation pathways, decreases in the drive to the skeletal muscle, and impaired muscular homeostasis. ICU-acquired muscle weakness can be prevented by early treatment of the underlying disease, goal-directed therapy, restrictive use of immobilizing medications, optimal nutrition, activating ventilatory modes, early rehabilitation, and preventive drug therapy. In this article, the authors review the nosology, epidemiology, diagnosis, and prevention of ICU-acquired weakness in surgical ICU patients.
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Abstract
OBJECTIVE Cortisol clearance is reduced in sepsis and may contribute to the development of impaired adrenocortical function that is thought to contribute to the pathophysiology of critical illness-related corticosteroid insufficiency. We sought to assess adrenocortical function using computer-assisted numerical modeling methodology to characterize and compare maximal cortisol secretion rate and free cortisol half-life in septic shock, sepsis, and healthy control subjects. DESIGN Post hoc analysis of previously published total cortisol, free cortisol, corticosteroid-binding globulin, and albumin concentration data. SETTING Single academic medical center. PATIENTS Subjects included septic shock (n = 45), sepsis (n = 25), and healthy controls (n = 10). INTERVENTIONS I.v. cosyntropin (250 μg). MEASUREMENTS AND MAIN RESULTS Solutions for maximal cortisol secretion rate and free cortisol half-life were obtained by least squares solution of simultaneous, nonlinear differential equations that account for free cortisol appearance and elimination as well as reversible binding to corticosteroid-binding globulin and albumin. Maximal cortisol secretion rate was significantly greater in septic shock (0.83 nM/s [0.44, 1.58 nM/s] reported as median [lower quartile, upper quartile]) compared with sepsis (0.51 nM/s [0.36, 0.62 nM/s]; p = 0.007) and controls (0.49 nM/s [0.42, 0.62 nM/s]; p = 0.04). The variance of maximal cortisol secretion rate in septic shock was also greater than that of sepsis or control groups (F test, p < 0.001). Free cortisol half-life was significantly increased in septic shock (4.6 min [2.2, 6.3 min]) and sepsis (3.0 min [2.3, 4.8 min] when compared with controls (2.0 min [1.2, 2.6 min]) (both p < 0.004). CONCLUSIONS Results obtained by numerical modeling are consistent with comparable measures obtained by the gold standard stable isotope dilution method. Septic shock is associated with generally not only higher levels but also greater variance of maximal cortisol secretion rate when compared with control and sepsis groups. Additional studies would be needed to determine whether assessment of cortisol kinetic parameters such as maximal cortisol secretion rate and free cortisol half-life is useful in the diagnosis or management of critical illness-related corticosteroid insufficiency.
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Drechsler S, Weixelbaumer KM, Weidinger A, Raeven P, Khadem A, Redl H, van Griensven M, Bahrami S, Remick D, Kozlov A, Osuchowski MF. Why do they die? Comparison of selected aspects of organ injury and dysfunction in mice surviving and dying in acute abdominal sepsis. Intensive Care Med Exp 2015. [PMID: 26215812 PMCID: PMC4513036 DOI: 10.1186/s40635-015-0048-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background The mechanisms of sepsis mortality remain undefined. While there is some evidence of organ damage, it is not clear whether this damage alone is sufficient to cause death. Therefore, we aimed to examine contribution of organ injury/dysfunction to early deaths in the mouse abdominal sepsis. Methods Female OF-1 mice underwent either medium-severity cecal ligation and puncture (CLP-Only) or non-lethal CLP-ODam (CLP with cisplatin/carbontetrachloride to induce survivable hepatotoxicity and nephrotoxicity). In the first experiment, blood was collected daily from survivors (SUR; CLP-Only and CLP-ODam groups) or until early death (DIED; CLP-Only). In the second experiment (CLP-Only), early outcome was prospectively predicted based on body temperature (BT) and pairs of mice predicted to survive (P-SUR) and die (P-DIE) were sacrificed post-CLP. The overall magnitude of organ injury/dysfunction was compared in retrospectively and prospectively stratified mice. Results At day 7 post-CLP, survival in CLP-Only was 48%, while CLP-ODam was non-lethal. In CLP-Only mice within 24 h of death, urea increased to 78 (versus 40 mg/dl in SUR), ALT to 166 (vs. 108 U/l), LDH to 739 (vs. 438 U/l) and glucose declined to 43 (vs. 62 mg/dl). In CLP-ODam, hypoglycemia was exacerbated (by 1.5-fold) and ALT and LDH were 20- and 8-fold higher versus DIED (CLP-Only) mice. In CLP-Only, predicted deaths (P-DIE) were preceded by a significant rise only in cystatin C (268 vs. 170 ng/ml in P-SUR) but not in creatinine and troponin I. Respiratory function of mitochondria in the liver and kidney of P-SUR and P-DIE CLP-Only mice was not impaired (vs. controls) and ATP level in organs remained similar among all groups. Histologic injury scores in the liver, kidney, heart and lung showed no major disparities among dying, surviving and control mice. Conclusions In CLP-Only mice, although the deregulation of parameters indicative of organ injury/dysfunction was greater in dying versus surviving mice, it never exceeded the changes in surviving CLP-ODam animals, and it was not followed by histopathological damage and/or mitochondrial dysfunction. This shows that interpretation of the contribution of the organ injury/dysfunction to early deaths in the CLP model is not straightforward and depends on the pathophysiological origin of the profiled disturbances. Electronic supplementary material The online version of this article (doi:10.1186/s40635-015-0048-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Susanne Drechsler
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Trauma Research Center of AUVA, Donaueschingenstrasse 13, Vienna, 1200, Austria,
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Prognostic significance of hypothalamic-pituitary-adrenal axis hormones in early sepsis: a study performed in the emergency department. Intensive Care Med 2014; 40:1499-508. [PMID: 25223852 DOI: 10.1007/s00134-014-3468-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 08/22/2014] [Indexed: 01/22/2023]
Abstract
PURPOSE The response of the hypothalamic-pituitary-adrenal (HPA) axis to the sustained stress of sepsis has been the focus of study in recent years because the early phase of sepsis is known to be dominated by major alterations in the HPA axis. This prospective observational study aimed at assessing the predictive values of copeptin and HPA hormones in determining sepsis progression and mortality in the emergency department (ED). METHODS Serum arginine vasopressin (AVP) and copeptin concentrations were measured upon ED admission. Baseline levels of total and free cortisol and adrenocorticotrophic hormone (ACTH) were measured within 24 h of ED admission. Mortality in Emergency Department Sepsis (MEDS) score was calculated at enrollment. RESULTS Our findings demonstrated that serum copeptin, baseline total cortisol, baseline free cortisol and baseline ACTH concentrations gradually increased, based upon the increasing severity of the disease (p < 0.001). Multivariate logistic regression analysis showed that copeptin and total cortisol baseline concentrations were independent predictors of septic shock (odds ratio = 1.034 and 1.355, respectively) and 28-day mortality (odds ratio = 1.039 and 1.499, respectively). The areas under the receiver operating characteristic curve (AUC) for copeptin level in prediction of septic shock was 0.856 and 28-day mortality was 0.826. Importantly, AUC analysis of the combination of copeptin, total cortisol baseline, MEDS score, and procalcitonin level resulted in a more significant prognostic ability than analysis of each parameter alone (p < 0.001). CONCLUSIONS Increased copeptin and HPA hormones baseline levels may provide crucial information for risk stratification in a variety of septic states in the ED. Furthermore, measurements of copeptin level and serum baseline cortisol concentration are promising independent prognostic markers for mortality in patients with severe sepsis or septic shock.
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Early administration of hydrocortisone replacement after the advent of septic shock: impact on survival and immune response*. Crit Care Med 2014; 42:1651-7. [PMID: 24674923 DOI: 10.1097/ccm.0000000000000318] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To investigate the impact of early initiation of hydrocortisone therapy on the clinical course of septic shock and on cytokine release. DESIGN Prospective study in patients with septic shock treated with low doses of hydrocortisone. SETTING ICUs and general wards. PATIENTS Over a 2-year period, 170 patients with septic shock treated with low doses of hydrocortisone were enrolled. Blood was sampled from 34 patients for isolation of peripheral blood mononuclear cells and cytokine stimulation before and 24 hours after the start of hydrocortisone. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After quartile analysis, patients were divided into those with early initiation of hydrocortisone (< 9 hr after vasopressors, n = 46) and those with late initiation of hydrocortisone (> 9 hr after vasopressors, n = 124). After adjusting for disease severity and type of infection, a protective effect of early hydrocortisone administration against unfavorable outcome was found (hazard ratio, 0.20; p = 0.012). Time of discontinuation of vasopressors was earlier among patients with initiation of hydrocortisone within 9 hours. Production of tumor necrosis factor-α was lower among patients who had had hydrocortisone early. CONCLUSIONS In patients receiving hydrocortisone for septic shock, early initiation of treatment was associated with improved survival. This treatment was also associated with attenuated stimulation of tumor necrosis factor-α.
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Brorsson C, Dahlqvist P, Nilsson L, Thunberg J, Sylvan A, Naredi S. Adrenal response after trauma is affected by time after trauma and sedative/analgesic drugs. Injury 2014; 45:1149-55. [PMID: 24975481 DOI: 10.1016/j.injury.2014.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 01/21/2014] [Accepted: 02/06/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The adrenal response in critically ill patients, including trauma victims, has been debated over the last decade. The aim of this study was to assess the early adrenal response after trauma. METHODS Prospective, observational study of 50 trauma patients admitted to a level-1-trauma centre. Serum and saliva cortisol were followed from the accident site up to five days after trauma. Corticosteroid binding globulin (CBG), dehydroepiandrosterone (DHEA) and sulphated dehydroepiandrosterone (DHEAS) were obtained twice during the first five days after trauma. The effect of time and associations between cortisol levels and; severity of trauma, infusion of sedative/analgesic drugs, cardiovascular dysfunction and other adrenocorticotropic hormone (ACTH) dependent hormones (DHEA/DHEAS) were studied. RESULTS There was a significant decrease over time in serum cortisol both during the initial 24 h, and from the 2nd to the 5th morning after trauma. A significant decrease over time was also observed in calculated free cortisol, DHEA, and DHEAS. No significant association was found between an injury severity score ≥ 16 (severe injury) and a low (< 200 nmol/L) serum cortisol at any time during the study period. The odds for a serum cortisol < 200 nmol/L was eight times higher in patients with continuous infusion of sedative/analgesic drugs compared to patients with no continuous infusion of sedative/analgesic drugs. CONCLUSION Total serum cortisol, calculated free cortisol, DHEA and DHEAS decreased significantly over time after trauma. Continuous infusion of sedative/analgesic drugs was independently associated with serum cortisol < 200 nmol/L.
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Affiliation(s)
- Camilla Brorsson
- Department of Anaesthesia and Intensive Care, Institution of Surgery and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden.
| | - Per Dahlqvist
- Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Leif Nilsson
- Department of Mathematics and Mathematical Statistics, Umeå University, 901 87 Umeå, Sweden
| | - Johan Thunberg
- Department of Anaesthesia and Intensive Care, Institution of Surgery and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Anders Sylvan
- Department of Surgery, Institution of Surgery and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Silvana Naredi
- Department of Anaesthesia and Intensive Care, Institution of Surgery and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden
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Steroids and vasopressin in septic shock-brother and sister or just distant cousins? Crit Care Med 2014; 42:1531-2. [PMID: 24836782 DOI: 10.1097/ccm.0000000000000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The interaction of vasopressin and corticosteroids in septic shock: a pilot randomized controlled trial. Crit Care Med 2014; 42:1325-33. [PMID: 24557425 DOI: 10.1097/ccm.0000000000000212] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Vasopressin and corticosteroids are both commonly used adjunctive therapies in septic shock. Retrospective analyses have suggested that there may be an interaction between these drugs, with higher circulating vasopressin levels and improved outcomes in patients treated with both vasopressin and corticosteroids. We aimed to test for an interaction between vasopressin and corticosteroids in septic shock. DESIGN Prospective open-label randomized controlled pilot trial. SETTING Four adult ICUs in London teaching hospitals. PATIENTS Sixty-one adult patients who had septic shock. INTERVENTIONS Initial vasopressin IV infusion titrated up to 0.06 U/min and then IV hydrocortisone (50 mg 6 hourly) or placebo. Plasma vasopressin levels were measured at 6-12 and 24-36 hours after hydrocortisone/placebo administration. MEASUREMENTS AND MAIN RESULTS Thirty-one patients were allocated to vasopressin + hydrocortisone and 30 patients to vasopressin + placebo. The hydrocortisone group required a shorter duration of vasopressin therapy (3.1 d; 95% CI, 1.1-5.1; shorter in hydrocortisone group) and required a lower total dose of vasopressin (ratio, 0.47; 95% CI, 0.32-0.71) compared with the placebo group. Plasma vasopressin levels were not higher in the hydrocortisone group compared with the placebo group (64 pmol/L difference at 6- to 12-hour time point; 95% CI, -32 to 160 pmol/L). Early vasopressin use was well tolerated with only one serious adverse event possibly related to study drug administration reported. There were no differences in mortality rates (23% 28-day mortality in both groups) or organ failure assessments between the two treatment groups. CONCLUSIONS Hydrocortisone spared vasopressin requirements, reduced duration, and reduced dose, when used together in the treatment of septic shock, but it did not alter plasma vasopressin levels. Further trials are needed to assess the clinical effectiveness of vasopressin as the initial vasopressor therapy with or without corticosteroids.
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Bernsmeier C, Antoniades CG, Wendon J. What's new in acute liver failure? Intensive Care Med 2014; 40:1545-8. [PMID: 24981954 DOI: 10.1007/s00134-014-3350-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/20/2014] [Indexed: 01/31/2023]
Affiliation(s)
- Christine Bernsmeier
- Liver Intensive Therapy Unit, Institute of Liver Studies, King's College London, Denmark Hill Campus, London, UK
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Orme RML, Perkins GD, McAuley DF, Liu KD, Mason AJ, Morelli A, Singer M, Ashby D, Gordon AC. An efficacy and mechanism evaluation study of Levosimendan for the Prevention of Acute oRgan Dysfunction in Sepsis (LeoPARDS): protocol for a randomized controlled trial. Trials 2014; 15:199. [PMID: 24894386 PMCID: PMC4061524 DOI: 10.1186/1745-6215-15-199] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 05/16/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Organ dysfunction consequent to infection ('severe sepsis') is the leading cause of admission to an intensive care unit (ICU). In both animal models and early clinical studies the calcium channel sensitizer levosimendan has been demonstrated to have potentially beneficial effects on organ function. The aims of the Levosimendan for the Prevention of Acute oRgan Dysfunction in Sepsis (LeoPARDS) trial are to identify whether a 24-hour infusion of levosimendan will improve organ dysfunction in adults who have septic shock and to establish the safety profile of levosimendan in this group of patients. METHODS/DESIGN This is a multicenter, randomized, double-blind, parallel group, placebo-controlled trial. Adults fulfilling the criteria for systemic inflammatory response syndrome due to infection, and requiring vasopressor therapy, will be eligible for inclusion in the trial. Within 24 hours of meeting these inclusion criteria, patients will be randomized in a 1:1 ratio stratified by the ICU to receive either levosimendan (0.05 to 0.2 μg.kg⁻¹.min⁻¹ or placebo for 24 hours in addition to standard care. The primary outcome measure is the mean Sequential Organ Failure Assessment (SOFA) score while in the ICU. Secondary outcomes include: central venous oxygen saturations and cardiac output; incidence and severity of renal failure using the Acute Kidney Injury Network criteria; duration of renal replacement therapy; serum bilirubin; time to liberation from mechanical ventilation; 28-day, hospital, 3 and 6 month survival; ICU and hospital length-of-stay; and days free from catecholamine therapy. Blood and urine samples will be collected on the day of inclusion, at 24 hours, and on days 4 and 6 post-inclusion for investigation of the mechanisms by which levosimendan might improve organ function. Eighty patients will have additional blood samples taken to measure levels of levosimendan and its active metabolites OR-1896 and OR-1855. A total of 516 patients will be recruited from approximately 25 ICUs in the United Kingdom. DISCUSSION This trial will test the efficacy of levosimendan to reduce acute organ dysfunction in adult patients who have septic shock and evaluate its biological mechanisms of action. TRIAL REGISTRATION Current controlled trials ISRCTN12776039 (19 September 2013).
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Affiliation(s)
- Robert M L’E Orme
- Department of Critical Care, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit and Heart of England NHS Foundation Trust, Warwick Medical School, University of Warwick, Gibbet Hill, Coventry CV4 7AL, UK
| | - Daniel F McAuley
- Centre for Infection and Immunity, Queens University of Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California, 521 Parnassus Avenue, Box 0532, San Francisco, CA 94143, USA
| | - Alexina J Mason
- School of Public Health, Imperial College London, Norfolk Place, London W2 1PG, UK
| | - Andrea Morelli
- Department of Anaesthesiology and Intensive Care, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care, University College London, Gower Street, London WC1E 6BT, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, Norfolk Place, London W2 1PG, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
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Symons JM. Moving beyond supportive care--current status of specific therapies in pediatric acute kidney injury. Pediatr Nephrol 2014; 29:173-81. [PMID: 23407998 DOI: 10.1007/s00467-013-2425-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 01/19/2013] [Accepted: 01/22/2013] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) remains a significant challenge, leading to increased morbidity, mortality, and medical costs. Therapy for AKI to this point has largely been supportive; specific interventions to treat established AKI have had minimal effect. Review of the pathogenesis of AKI reveals complex, interacting mechanisms, including changes in microcirculation, the immune system, and inflammation, and cell death from both necrosis and apoptosis. Past definitions of AKI have been imprecise; newer methods for AKI identification and classification, including novel biomarkers and improved criteria for defining AKI, may permit earlier intervention with greater potential for success. With improved understanding of pathophysiology and the opportunity for intervention before AKI is fully established, clinicians may be able to move beyond supportive care and improve outcomes.
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Affiliation(s)
- Jordan M Symons
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA,
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Hall TC, Bilku DK, Al-Leswas D, Neal CP, Horst C, Cooke J, Metcalfe MS, Dennison AR. A randomized controlled trial investigating the effects of parenteral fish oil on survival outcomes in critically ill patients with sepsis: a pilot study. JPEN J Parenter Enteral Nutr 2014; 39:301-12. [PMID: 24408035 DOI: 10.1177/0148607113518945] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Death from sepsis in the intensive care unit (ITU) is frequently preceded by the development of multiple organ failure as a result of uncontrolled inflammation. Treatment with ω-3 has been demonstrated to attenuate the effects of uncontrolled inflammation and may be clinically beneficial. METHOD A randomized control trial investigating the effects of parenteral ω-3 was carried out. Consecutive patients diagnosed with sepsis were entered into the study and randomized to receive either parenteral ω-3 or standard medical care only. The primary outcome measure was a reduction in organ dysfunction using the Sequential Organ Failure Assessment (SOFA) score as a surrogate marker. The secondary outcome measures were mortality, length of stay, mean C-reactive protein (CRP), and days free of organ dysfunction/failure. RESULTS Sixty patients were included in the study. The baseline demographics were matched for the two cohorts. Patients treated with parenteral ω-3 were associated with a significant reduction in new organ dysfunction (Δ-SOFA 2.2 ± 2.2 vs. 1.0 ± 1.5, P = .005 and maximum-SOFA 10.1 ± 4.2 vs. 8.1 ± 3.2, P = .041) and maximum CRP (186.7 ± 78 vs. 141.5 ± 62.6, P = .019). There was no significant reduction in the length of stay between cohorts. Patients treated with ω-3 in the strata of less severe sepsis had a significant reduction in mortality (P = .042). CONCLUSION The treatment of critically ill septic patients with parenteral ω-3 is safe. It is associated with a significant reduction in organ dysfunction. It may be associated with a reduction in mortality in patients with less severe sepsis.
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Affiliation(s)
| | | | | | | | - Cindy Horst
- University Hospitals of Leicester, Leicester, UK
| | - Jill Cooke
- University Hospitals of Leicester, Leicester, UK
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Abstract
OBJECTIVES Macrophages are important cells in immunity and the main producers of pro-inflammatory cytokines. The main objective was to evaluate if specific delivery of glucocorticoid to the macrophage receptor CD163 is superior to systemic glucocorticoid therapy in dampening the cytokine response to lipopolysaccharide infusion in pigs. DESIGN Two randomized, placebo-controlled trials. SETTING University hospital laboratory. SUBJECTS Female farm-bred pigs (26-31 kg). DESIGN A humanized antibody that binds to pig and human CD163 was produced, characterized, and conjugated with dexamethasone. In the first study (total n = 12), pigs were randomly assigned to four groups: 1) saline; 2) dexamethasone (1.0 mg/kg); 3) dexamethasone (0.02 mg/kg); and 4) anti-CD163-conjugated dexamethasone (0.02 mg/kg). In the second study (total n = 36), two additional groups were included in addition to the four original groups: 5) anti-CD163-conjugated dexamethasone (0.005 mg/kg); 6) unconjugated anti-CD163. Treatments were given 20 hours prior to infusion of lipopolysaccharide (1 µg × kg × h) for 5 hours. Blood samples were analyzed for cytokines, cortisol, and adrenocorticotropic hormone. RESULTS In the saline group, lipopolysaccharide increased cytokine and plasma cortisol levels. In both studies, dexamethasone (1 mg/kg) and anti-CD163 dexamethasone (0.02 mg/kg) uniformly attenuated tumor necrosis factor-α peak levels (both p < 0.05) compared with low-dose dexamethasone (0.02 mg/kg). However, dexamethasone 1 mg/kg significantly suppressed plasma cortisol and adrenocorticotropic hormone levels compared with anti-CD163 dexamethasone (0.02 mg/kg; p < 0.05). No significant hemodynamic difference existed between groups. The anti-CD163 dexamethasone drug conjugate exhibited a fast plasma clearance, with a half-life of approximately 5-8 minutes. CONCLUSION Targeted delivery of dexamethasone to macrophages using a humanized CD163 antibody as carrier exhibits anti-inflammatory effects comparable with 50 times higher concentrations of free dexamethasone and does not inhibit endogenous cortisol production. This antibody-drug complex showing similar affinity and specificity for human CD163 is, therefore, a promising drug candidate in this novel type of anti-inflammatory therapy.
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Gu X, Yao Y, Wu G, Lv T, Luo L, Song Y. The plasma mitochondrial DNA is an independent predictor for post-traumatic systemic inflammatory response syndrome. PLoS One 2013; 8:e72834. [PMID: 23977360 PMCID: PMC3748121 DOI: 10.1371/journal.pone.0072834] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 07/13/2013] [Indexed: 12/14/2022] Open
Abstract
Background and Purpose Mitochondrial DNA (mtDNA), a newly identified damage-associated molecular pattern, has been observed in trauma patients, however, little is known concerning the relationship between plasma mtDNA levels and concrete post-traumatic complications, particularly systemic inflammatory response syndrome (SIRS). The aim of this study is to determine whether plasma mtDNA levels are associated with injury severity and cloud predict post-traumatic SIRS in patients with acute traumatic injury. Patients and Methods Eighty-six consecutive patients with acute traumatic injury were prospectively enrolled in this study. The plasma mtDNA concentration was measured by a real-time, quantitative PCR assay for the human ND2 gene. The study population’s clinical and laboratory data were analyzed. Results The median plasma mtDNA was higher in trauma patients than in healthy controls (865.196 (251.042-2565.40)pg/ml vs 64.2147 (43.9049-80.6371)pg/ml, P<0.001) and was independently correlated with the ISS score (r=0.287, P<0.001). The plasma mtDNA concentration was also significantly higher in patients who developed post-traumatic SIRS than in patients who did not (1774.03 (564.870-10901.3)pg/ml vs 500.496 (145.415-1285.60)pg/ml, P<0.001). Multiple logistic regression analysis revealed that the plasma mtDNA was an independent predictors for post-traumatic SIRS (OR, 1.183 (95%CI, 1.015-1.379), P=0.032). Further ROC analysis demonstrated that a high plasma mtDNA level predicted post-traumatic SIRS with a sensitivity of 67% and a specificity of 76%, with a cut-off value of 1.3185 µg/ml being established, and the area under the ROC curves (AUC) was 0.725 (95% CI 0.613-0.837). Conclusions Plasma mtDNA was an independent indictor with moderate discriminative power to predict the risk of post-traumatic SIRS.
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Affiliation(s)
- Xiaoling Gu
- Department of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Yanwen Yao
- Department of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Guannan Wu
- Department of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Tangfeng Lv
- Department of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Liang Luo
- Department of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
- Intensive Care Unit, Wu xi Second Affiliated Hospital, Nanjing Medical University, Wu xi, China
| | - Yong Song
- Department of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
- * E-mail:
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Abstract
During sepsis, the liver plays a key role. It is implicated in the host response, participating in the clearance of the infectious agents/products. Sepsis also induces liver damage through hemodynamic alterations or through direct or indirect assault on the hepatocytes or through both. Accordingly, liver dysfunction induced by sepsis is recognized as one of the components that contribute to the severity of the disease. Nevertheless, the incidence of liver dysfunction remains imprecise, probably because current diagnostic tools are lacking, notably those that can detect the early liver insult. In this review, we discuss the epidemiology, diagnostic tools, and impact on outcome as well as the pathophysiological aspects, including the cellular events and clinical picture leading to liver dysfunction. Finally, therapeutic considerations with regard to the weakness of the pertinent specific approach are examined.
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Affiliation(s)
- Nicolas Nesseler
- Service d'Anesthésie-Réanimation 1, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033 Rennes, France
- INSERM UMR-S 991, Hôpital Pontchaillou, 2, rue Henri Le Guilloux, 35033 Rennes, France
- Université de Rennes 1, Faculté de Médecine, 2 avenue du Professeur Léon Bernard, 35033 Rennes, France
| | - Yoann Launey
- Service d'Anesthésie-Réanimation 1, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033 Rennes, France
- INSERM UMR-S 991, Hôpital Pontchaillou, 2, rue Henri Le Guilloux, 35033 Rennes, France
- Université de Rennes 1, Faculté de Médecine, 2 avenue du Professeur Léon Bernard, 35033 Rennes, France
| | - Caroline Aninat
- INSERM UMR-S 991, Hôpital Pontchaillou, 2, rue Henri Le Guilloux, 35033 Rennes, France
- Université de Rennes 1, Faculté de Médecine, 2 avenue du Professeur Léon Bernard, 35033 Rennes, France
| | - Fabrice Morel
- INSERM UMR-S 991, Hôpital Pontchaillou, 2, rue Henri Le Guilloux, 35033 Rennes, France
- Université de Rennes 1, Faculté de Médecine, 2 avenue du Professeur Léon Bernard, 35033 Rennes, France
| | - Yannick Mallédant
- Service d'Anesthésie-Réanimation 1, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033 Rennes, France
- INSERM UMR-S 991, Hôpital Pontchaillou, 2, rue Henri Le Guilloux, 35033 Rennes, France
- Université de Rennes 1, Faculté de Médecine, 2 avenue du Professeur Léon Bernard, 35033 Rennes, France
| | - Philippe Seguin
- Service d'Anesthésie-Réanimation 1, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033 Rennes, France
- INSERM UMR-S 991, Hôpital Pontchaillou, 2, rue Henri Le Guilloux, 35033 Rennes, France
- Université de Rennes 1, Faculté de Médecine, 2 avenue du Professeur Léon Bernard, 35033 Rennes, France
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Salvadori A, Pasquier P, Jarrassier A, Renner J, Merat S. Adverse cardiac events during catecholamine therapy: a role for hydrocortisone? Intensive Care Med 2012; 38:1725; author reply 1726. [DOI: 10.1007/s00134-012-2663-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2012] [Indexed: 11/27/2022]
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Supplemental corticosteroids after intubation using etomidate in severe sepsis and septic shock. Crit Care Med 2012; 40:2003-4; author reply 2004. [PMID: 22610230 DOI: 10.1097/ccm.0b013e31824e1d0a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Perman SM, Goyal M, Gaieski DF. Initial emergency department diagnosis and management of adult patients with severe sepsis and septic shock. Scand J Trauma Resusc Emerg Med 2012; 20:41. [PMID: 22737991 PMCID: PMC3507802 DOI: 10.1186/1757-7241-20-41] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 06/27/2012] [Indexed: 12/21/2022] Open
Abstract
Severe sepsis is a medical emergency affecting up to 18 million individuals world wide, with an annual incidence of 750,000 in North America alone. Mortality ranges between 28-50% of those individuals stricken by severe sepsis. Sepsis is a time critical illness, requiring early identification and prompt intervention in order to improve outcomes. This observation has led to increased awareness and education in the field of Emergency Medicine; it has also led to the implementation of critical interventions early in the course of patient management, specifically Early-Goal Directed Therapy, and rapid administration of appropriate antimicrobials. This review begins with a brief summary of the pathophysiology of sepsis, and then addresses the fundamental clinical aspects of ED identification and resuscitation of the septic patient.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
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Year in review in Intensive Care Medicine 2011. II. Cardiovascular, infections, pneumonia and sepsis, critical care organization and outcome, education, ultrasonography, metabolism and coagulation. Intensive Care Med 2012; 38:345-58. [PMID: 22270471 PMCID: PMC3291826 DOI: 10.1007/s00134-012-2467-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 01/02/2012] [Indexed: 12/14/2022]
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