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Saravi B, Goebel U, Hassenzahl LO, Jung C, David S, Feldheiser A, Stopfkuchen-Evans M, Wollborn J. Capillary leak and endothelial permeability in critically ill patients: a current overview. Intensive Care Med Exp 2023; 11:96. [PMID: 38117435 PMCID: PMC10733291 DOI: 10.1186/s40635-023-00582-8] [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] [Received: 09/18/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023] Open
Abstract
Capillary leak syndrome (CLS) represents a phenotype of increased fluid extravasation, resulting in intravascular hypovolemia, extravascular edema formation and ultimately hypoperfusion. While endothelial permeability is an evolutionary preserved physiological process needed to sustain life, excessive fluid leak-often caused by systemic inflammation-can have detrimental effects on patients' outcomes. This article delves into the current understanding of CLS pathophysiology, diagnosis and potential treatments. Systemic inflammation leading to a compromise of endothelial cell interactions through various signaling cues (e.g., the angiopoietin-Tie2 pathway), and shedding of the glycocalyx collectively contribute to the manifestation of CLS. Capillary permeability subsequently leads to the seepage of protein-rich fluid into the interstitial space. Recent insights into the importance of the sub-glycocalyx space and preserving lymphatic flow are highlighted for an in-depth understanding. While no established diagnostic criteria exist and CLS is frequently diagnosed by clinical characteristics only, we highlight more objective serological and (non)-invasive measurements that hint towards a CLS phenotype. While currently available treatment options are limited, we further review understanding of fluid resuscitation and experimental approaches to target endothelial permeability. Despite the improved understanding of CLS pathophysiology, efforts are needed to develop uniform diagnostic criteria, associate clinical consequences to these criteria, and delineate treatment options.
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Affiliation(s)
- Babak Saravi
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center, University of Freiburg, University of Freiburg, Freiburg, Germany.
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, St. Franziskus-Hospital, Muenster, Germany
| | - Lars O Hassenzahl
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Duesseldorf, Germany
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Aarne Feldheiser
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Evang. Kliniken Essen-Mitte, Huyssens-Stiftung/Knappschaft, University of Essen, Essen, Germany
| | - Matthias Stopfkuchen-Evans
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Lobo DN. The 2023 Sir David Cuthbertson Lecture. A fluid journey: Experiments that influenced clinical practice. Clin Nutr 2023; 42:2270-2281. [PMID: 37820519 DOI: 10.1016/j.clnu.2023.09.029] [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: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Abstract
This review summarises some of my work on fluid and electrolyte balance over the past 25 years and shows how the studies have influenced clinical practice. Missing pieces in the jigsaw are filled in by summarising the work of others. The main theme is the biochemical, physiological and clinical problems caused by inappropriate use of saline solutions including the hyperchloraemic acidosis caused by 0.9% saline. The importance of accurate and near-zero fluid balance in clinical practice is also emphasised. Perioperative fluid and electrolyte therapy has important effects on clinical outcome in a U-shaped dose response fashion, in which excess or deficit progressively increases complications and worsens outcome. Salt and water overload, with weight gain in excess of 2.5 kg worsens surgical outcome, impairs gastrointestinal function and increases the risk of anastomotic dehiscence. Hyperchloraemic acidosis caused by overenthusiastic infusion of 0.9% saline leads to adverse outcomes and dysfunction of many organ systems, especially the kidney. Salt and water deficit causes similar adverse effects as fluid overload at the cellular level and also leads to worse outcomes. Serum albumin is shown to be affected mainly by dilution and inflammation and is not a good nutritional marker. These findings have been incorporated in the British consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) and National Institute for Health and Care Excellence (NICE) guidelines on intravenous fluid therapy in adults in hospital and are helping change clinical practice and improve outcomes.
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Affiliation(s)
- Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Radomsky L, Koch A, Olbertz C, Liu Y, Beushausen K, Keil J, Rauen U, Falk CS, Kühne JF, Kamler M. Composition of ex vivo perfusion solutions and kinetics define differential cytokine/chemokine secretion in a porcine cardiac arrest model of lung preservation. Front Cardiovasc Med 2023; 10:1245618. [PMID: 37808880 PMCID: PMC10556242 DOI: 10.3389/fcvm.2023.1245618] [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: 06/23/2023] [Accepted: 08/31/2023] [Indexed: 10/10/2023] Open
Abstract
Background Ex vivo lung perfusion (EVLP) uses continuous normothermic perfusion to reduce ischemic damage and to improve post-transplant outcomes, specifically for marginal donor lungs after the donation after circulatory death. Despite major efforts, the optimal perfusion protocol and the composition of the perfusate in clinical lung transplantation have not been identified. Our study aims to compare the concentration levels of cytokine/chemokine in different perfusion solutions during EVLP, after 1 and 9 h of cold static preservation (CSP) in a porcine cardiac arrest model, and to correlate inflammatory parameters to oxygenation capacities. Methods Following cardiac arrest, the lungs were harvested and were categorized into two groups: immediate (I-EVLP) and delayed EVLP (D-EVLP), after 1 and 9 h of CSP, respectively. The D-EVLP lungs were perfused with either Steen or modified Custodiol-N solution containing only dextran (CD) or dextran and albumin (CDA). The cytokine/chemokine levels were analyzed at baseline (0 h) and after 1 and 4 h of EVLP using Luminex-based multiplex assays. Results Within 4 h of EVLP, the concentration levels of TNF-α, IL-6, CXCL8, IFN-γ, IL-1α, and IL-1β increased significantly (P < 0.05) in all experimental groups. The CD solution contained lower concentration levels of TNF-α, IL-6, CXCL8, IFN-γ, IL-2, IL-12, IL-10, IL-4, IL-1RA, and IL-18 (P < 0.05) compared with those of the Steen solution. The concentration levels of all experimental groups have correlated negatively with the oxygenation capacity values (P < 0.05). Protein concentration levels did not reach statistical significance for I-EVLP vs. D-EVLP and CD vs. CDA solutions. Conclusion In a porcine cardiac arrest model, a longer period of CSP prior to EVLP did not result in an enhanced protein secretion into perfusates. The CD solution reduced the cytokine/chemokine secretion most probably by iron chelators and/or by the protecting effects of dextran. Supplementing with albumin did not further reduce the cytokine/chemokine secretion into perfusates. These findings may help in optimizing the preservation procedure of the lungs, thereby increasing the donor pool of organs.
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Affiliation(s)
- Lena Radomsky
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Achim Koch
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
| | - Carolin Olbertz
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
| | - Yongjie Liu
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
| | - Kerstin Beushausen
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Jana Keil
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Ursula Rauen
- Institute of Biochemistry, University of Duisburg-Essen, Essen, Germany
| | - Christine S. Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
- DZIF, German Center for Infectious Diseases, Germany, TTU-IICH, Hannover—Braunschweig site, Braunschweig,Germany
- DZL, German Center for Lung Diseases, BREATH site, Hannover, Germany
| | - Jenny F. Kühne
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
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Knežević D, Ćurko-Cofek B, Batinac T, Laškarin G, Rakić M, Šoštarič M, Zdravković M, Šustić A, Sotošek V, Batičić L. Endothelial Dysfunction in Patients Undergoing Cardiac Surgery: A Narrative Review and Clinical Implications. J Cardiovasc Dev Dis 2023; 10:jcdd10050213. [PMID: 37233179 DOI: 10.3390/jcdd10050213] [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] [Received: 04/10/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Abstract
Cardiac surgery is one of the highest-risk procedures, usually involving cardiopulmonary bypass and commonly inducing endothelial injury that contributes to the development of perioperative and postoperative organ dysfunction. Substantial scientific efforts are being made to unravel the complex interaction of biomolecules involved in endothelial dysfunction to find new therapeutic targets and biomarkers and to develop therapeutic strategies to protect and restore the endothelium. This review highlights the current state-of-the-art knowledge on the structure and function of the endothelial glycocalyx and mechanisms of endothelial glycocalyx shedding in cardiac surgery. Particular emphasis is placed on potential strategies to protect and restore the endothelial glycocalyx in cardiac surgery. In addition, we have summarized and elaborated the latest evidence on conventional and potential biomarkers of endothelial dysfunction to provide a comprehensive synthesis of crucial mechanisms of endothelial dysfunction in patients undergoing cardiac surgery, and to highlight their clinical implications.
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Affiliation(s)
- Danijel Knežević
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Božena Ćurko-Cofek
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Tanja Batinac
- Department of Clinical Medical Sciences I, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 2, 51000 Rijeka, Croatia
| | - Gordana Laškarin
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
- Hospital for Medical Rehabilitation of Hearth and Lung Diseases and Rheumatism "Thalassotherapia-Opatija", M. Tita 188, 51410 Opatija, Croatia
| | - Marijana Rakić
- Hospital for Medical Rehabilitation of Hearth and Lung Diseases and Rheumatism "Thalassotherapia-Opatija", M. Tita 188, 51410 Opatija, Croatia
| | - Maja Šoštarič
- Clinical Department of Anesthesiology and Perioperative Intensive Therapy, Division of Cardiac Anesthesiology and Intensive Therapy, University Clinical Center Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia
- Department of Anesthesiology and Reanimatology, Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia
| | - Marko Zdravković
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia
| | - Alan Šustić
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Vlatka Sotošek
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Lara Batičić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
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Sawashita Y, Kazuma S, Tokinaga Y, Kikuchi K, Hirata N, Masuda Y, Yamakage M. Albumin protects the ultrastructure of the endothelial glycocalyx of coronary arteries in myocardial ischemia-reperfusion injury in vivo. Biochem Biophys Res Commun 2023; 666:29-35. [PMID: 37172449 DOI: 10.1016/j.bbrc.2023.04.110] [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: 03/30/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023]
Abstract
Myocardial ischemia-reperfusion (I/R) injury induces endothelial glycocalyx (GCX) degradation. Several candidate GCX-protective factors including albumin have been identified, few have been demonstrated in in vivo studies and most albumins used to date have been heterologous. Albumin is a carrier protein for sphingosine 1-phosphate (S1P), which has protective effects on the cardiovascular system. However, changes inhibited by albumin in the endothelial GCX structure in I/R in vivo via the S1P receptor has not been reported. In this study, we aimed to determine whether albumin prevents the shedding of endothelial GCX in response to I/R in vivo. Rats were divided into four groups: control (CON), I/R, I/R with albumin preload (I/R + ALB), and I/R + ALB with S1P receptor agonist fingolimod (I/R + ALB + FIN). FIN acts as an initial agonist of S1P receptor 1 and downregulates the receptor in an inhibitory manner. The CON and I/R groups received saline and I/R + ALB and I/R + ALB + FIN groups received albumin solution before left anterior descending coronary artery ligation. Our study used rat albumin. Shedding of endothelial GCX was evaluated in the myocardium by electron microscopy, and the concentration of serum syndecan-1 was measured. Thus, albumin administration maintained the structure of endothelial GCX and prevented shedding of endothelial GCX via the S1P receptor in myocardial I/R, and FIN annihilated the protective effect of albumin against I/R injury.
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Affiliation(s)
- Yasuaki Sawashita
- Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, Japan
| | - Satoshi Kazuma
- Department of Intensive Care Medicine, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, Japan.
| | - Yasuyuki Tokinaga
- Department of Anesthesiology, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Kenichiro Kikuchi
- Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, Japan
| | - Naoyuki Hirata
- Department of Anesthesiology, Kumamoto University, School of Medicine, Kumamoto, Kumamoto, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, Japan
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Binder MS, Wu Y, Baker JW, Rowe JF, Wyatt DA, Choate C, Poelzing S, Joseph M. A retrospective comparison of albumin versus mannitol priming fluid with relation to postoperative atrial fibrillation. J Card Surg 2022; 37:3485-3491. [PMID: 36116062 PMCID: PMC9826347 DOI: 10.1111/jocs.16960] [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: 05/09/2022] [Revised: 08/10/2022] [Accepted: 08/27/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery which can result in increased mortality and increased healthcare costs. During Hurricane Maria (2017), a nationwide shortage of mannitol occurred, and our institution switched to the utilization of albumin as a priming fluid solution. We observed decreased rates of POAF during that time and began alternating albumin and mannitol priming fluid solutions. We hypothesized this observation may be from altered perinexal conduction from albumin utilization. METHODS A retrospective chart review of all patients from January 2020 through December 2020 who underwent cardiac surgery was performed, to determine if albumin was associated with reduced POAF rates. Two hundred and thirteen patients were identified and 4 were excluded. Two hundred and nine patients (110 albumin priming fluid and 99 mannitol priming fluid) were included in our final analysis. RESULTS Analysis was performed for all patients with POAF and in patients with new-onset AF (without a history of prior AF) after surgery. POAF rates showed no statistically significant difference between cohorts. For all patients, POAF occurred in 43% of the albumin subgroup and 47% of the mannitol subgroup (p = .53) and for patients with new-onset AF, POAF occurred in 35% of the albumin subgroup versus 42% of the mannitol subgroup (p = .36). Logistic regression revealed that age, ejection fraction and cardiopulmonary bypass time was associated with POAF, in our cohort. CONCLUSIONS The use of albumin compared to mannitol as priming fluid solutions was not associated with statistically significant reductions in POAF rate, in our population.
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Affiliation(s)
- M. Scott Binder
- Departments of Cardiology, Cardiothoracic SurgeryVirginia Tech CarilionRoanokeVirginiaUSA
| | - YingXing Wu
- Department of Health AnalyticsVirginia Tech CarilionRoanokeVirginiaUSA
| | - Joseph W. Baker
- Departments of Cardiology, Cardiothoracic SurgeryVirginia Tech CarilionRoanokeVirginiaUSA
| | - Joseph F. Rowe
- Departments of Cardiology, Cardiothoracic SurgeryVirginia Tech CarilionRoanokeVirginiaUSA
| | - David A. Wyatt
- Departments of Cardiology, Cardiothoracic SurgeryVirginia Tech CarilionRoanokeVirginiaUSA
| | - Cynthia Choate
- Departments of Cardiology, Cardiothoracic SurgeryVirginia Tech CarilionRoanokeVirginiaUSA
| | - Steven Poelzing
- Department of Biomedical Engineering and MechanicsVirginia Tech Fralin Biomedical Research InstituteRoanokeVirginiaUSA
| | - Mark Joseph
- Departments of Cardiology, Cardiothoracic SurgeryVirginia Tech CarilionRoanokeVirginiaUSA
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Lawrence-Mills SJ, Hughes D, Hezzell MJ, Butler M, Neal C, Foster RR, Welsh GI, Finch N. The microvascular endothelial glycocalyx: An additional piece of the puzzle in veterinary medicine. Vet J 2022; 285:105843. [PMID: 35654338 PMCID: PMC9587354 DOI: 10.1016/j.tvjl.2022.105843] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 04/29/2022] [Accepted: 05/25/2022] [Indexed: 01/01/2023]
Abstract
The endothelial glycocalyx (eGlx) is a critically important structure lining the luminal surface of endothelial cells. There is increasing evidence, in human patients and animal models, for its crucial role in the maintenance of health. Moreover, its damage is associated with the pathogenesis of multiple disease states. This review provides readers with an overview of the eGlx; summarising its structure, essential functions, and evidence for its role in disease. We highlight the lack of studies regarding the eGlx in cats and dogs, particularly in naturally occurring diseases. Importantly, we discuss techniques to aid its study, which can be applied to veterinary species. Finally, we present targeted therapies aimed at preserving, and in some cases, restoring damaged eGlx.
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Affiliation(s)
- Sara J Lawrence-Mills
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK; current affiliation The Royal Veterinary College, University of London, North Mimms, UK.
| | - David Hughes
- Bristol Veterinary School, University of Bristol, Langford, UK
| | | | - Matthew Butler
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Neal
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rebecca R Foster
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gavin I Welsh
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Natalie Finch
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Veterinary School, University of Bristol, Langford, UK; Langford Vets, Langford House, Langford, UK
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Foss NB. AHA STEROID trial, dexamethasone in acute high-risk abdominal surgery, the protocol for a randomized controlled trial. Acta Anaesthesiol Scand 2022; 66:640-650. [PMID: 35124808 DOI: 10.1111/aas.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/10/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Existing multimodal pathways for patients undergoing acute high-risk abdominal surgery for intestinal obstruction (IO) and perforated viscus (PV) have focused on rescue in the immediate perioperative period. However, there is little focus on the peri-operative pathophysiology of recovery in this patient group, as done to develop enhanced recovery pathways in elective care. Acute inflammation is the main driver of the perioperative pathophysiology leading to adverse outcomes. Pre-operative high-dose of glucocorticoids provides a reduction in the inflammatory response after surgery, effective pain relief in several major surgical procedures, as well as reduce fatigue and improving endothelial dysfunction. AIM To evaluate the effect of high-dose glucocorticoid on the inflammatory response, fluid distribution and recovery after acute high-risk abdominal surgery in patients with IO and PV. METHODS AHA STEROID trial is a sponsor-initiated single-center, randomized, double-blind placebo-controlled trial, assessing preoperative high-dose dexamethasone (1 mg/kg) versus placebo (normal saline) in patients undergoing emergency high-risk abdominal surgery. We plan to enroll 120 patients. Primary outcome is the reduction in C-reactive protein on postoperative day 1 as a marker of successful attenuation of the acute stress response. Secondary outcomes include perioperative changes in endothelial and other inflammatory markers, fluid distribution, pulmonary function, pain, fatigue, and mobilization. The statistical plan is outlined in the protocol. DISCUSSION The AHA STEROID trial will provide important evidence to guide the potential use of high-dose glucocorticoids in emergency high-risk abdominal surgery, with respect to different pathophysiologies.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology Rigshospitalet Denmark
| | | | - Jakob Højlund
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
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Qiu Y, Buffonge S, Ramnath R, Jenner S, Fawaz S, Arkill KP, Neal C, Verkade P, White SJ, Hezzell M, Salmon AHJ, Suleiman MS, Welsh GI, Foster RR, Madeddu P, Satchell SC. Endothelial glycocalyx is damaged in diabetic cardiomyopathy: angiopoietin 1 restores glycocalyx and improves diastolic function in mice. Diabetologia 2022; 65:879-894. [PMID: 35211778 PMCID: PMC8960650 DOI: 10.1007/s00125-022-05650-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 10/28/2021] [Indexed: 12/28/2022]
Abstract
AIMS/HYPOTHESIS Diabetic cardiomyopathy (DCM) is a serious and under-recognised complication of diabetes. The first sign is diastolic dysfunction, which progresses to heart failure. The pathophysiology of DCM is incompletely understood but microcirculatory changes are important. Endothelial glycocalyx (eGlx) plays multiple vital roles in the microcirculation, including in the regulation of vascular permeability, and is compromised in diabetes but has not previously been studied in the coronary microcirculation in diabetes. We hypothesised that eGlx damage in the coronary microcirculation contributes to increased microvascular permeability and hence to cardiac dysfunction. METHODS We investigated eGlx damage and cardiomyopathy in mouse models of type 1 (streptozotocin-induced) and type 2 (db/db) diabetes. Cardiac dysfunction was determined by echocardiography. We obtained eGlx depth and coverage by transmission electron microscopy (TEM) on mouse hearts perfusion-fixed with glutaraldehyde and Alcian Blue. Perivascular oedema was assessed from TEM images by measuring the perivascular space area. Lectin-based fluorescence was developed to study eGlx in paraformaldehyde-fixed mouse and human tissues. The eGlx of human conditionally immortalised coronary microvascular endothelial cells (CMVECs) in culture was removed with eGlx-degrading enzymes before measurement of protein passage across the cell monolayer. The mechanism of eGlx damage in the diabetic heart was investigated by quantitative reverse transcription-PCR array and matrix metalloproteinase (MMP) activity assay. To directly demonstrate that eGlx damage disturbs cardiac function, isolated rat hearts were treated with enzymes in a Langendorff preparation. Angiopoietin 1 (Ang1) is known to restore eGlx and so was used to investigate whether eGlx restoration reverses diastolic dysfunction in mice with type 1 diabetes. RESULTS In a mouse model of type 1 diabetes, diastolic dysfunction (confirmed by echocardiography) was associated with loss of eGlx from CMVECs and the development of perivascular oedema, suggesting increased microvascular permeability. We confirmed in vitro that eGlx removal increases CMVEC monolayer permeability. We identified increased MMP activity as a potential mechanism of eGlx damage and we observed loss of syndecan 4 consistent with MMP activity. In a mouse model of type 2 diabetes we found a similar loss of eGlx preceding the development of diastolic dysfunction. We used isolated rat hearts to demonstrate that eGlx damage (induced by enzymes) is sufficient to disturb cardiac function. Ang1 restored eGlx and this was associated with reduced perivascular oedema and amelioration of the diastolic dysfunction seen in mice with type 1 diabetes. CONCLUSIONS/INTERPRETATION The association of CMVEC glycocalyx damage with diastolic dysfunction in two diabetes models suggests that it may play a pathophysiological role and the enzyme studies confirm that eGlx damage is sufficient to impair cardiac function. Ang1 rapidly restores the CMVEC glycocalyx and improves diastolic function. Our work identifies CMVEC glycocalyx damage as a potential contributor to the development of DCM and therefore as a therapeutic target.
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Affiliation(s)
- Yan Qiu
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK.
| | - Stanley Buffonge
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Raina Ramnath
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Sophie Jenner
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Sarah Fawaz
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Kenton P Arkill
- Biodiscovery Institute, Medicine, University of Nottingham, Nottingham, UK
| | - Chris Neal
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Paul Verkade
- School of Biochemistry, University of Bristol, Bristol, UK
| | - Stephen J White
- Department of Life Sciences, Manchester Metropolitan University, Manchester, UK
| | - Melanie Hezzell
- Bristol Veterinary School, University of Bristol, Langford, UK
| | - Andrew H J Salmon
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
- Renal Service, Specialist Medicine and Health of Older People, North Shore Hospital, Waitemata District Health Board, Takapuna, Auckland, New Zealand
| | - M-Saadeh Suleiman
- Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Gavin I Welsh
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Rebecca R Foster
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Paolo Madeddu
- Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Simon C Satchell
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol, UK
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10
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Lawrence-Mills SJ, Neal CR, Satchell SC, Welsh GI, Foster RR, Finch N. Visualising the endothelial glycocalyx in dogs. Vet J 2022; 285:105844. [PMID: 35640795 PMCID: PMC9587350 DOI: 10.1016/j.tvjl.2022.105844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 04/21/2022] [Accepted: 05/25/2022] [Indexed: 12/28/2022]
Abstract
The endothelial glycocalyx (eGlx) lines the luminal surface of endothelial cells. It is critical in maintaining vascular health and when damaged contributes to many diseases. Its fragility makes studying the eGlx technically challenging. The current reference standard for eGlx visualisation, by electron microscopy using glutaraldehyde/Alcian blue perfusion fixation, has not been previously reported in dogs. Established techniques were applied to achieve visualisation of the eGlx in the microvasculature of reproductive tissue in five healthy dogs undergoing elective neutering. Uterine and testicular artery samples underwent perfusion fixation, in the presence of Alcian blue, prior to transmission electron microscopy imaging. Image processing software was used to determine eGlx depth. EGlx was visualised in the arteries of two dogs, one testicular and one uterine, with median (range) eGlx depths of 68.2 nm (32.1–122.9 nm) and 47.6 nm (26.1–129.4 nm) respectively. Study of the eGlx is technically challenging, particularly its direct visualisation in clinical samples. Further research is needed to develop more clinically applicable techniques to measure eGlx health. Canine glycocalyx has not previously been visualised using the reference technique. The endothelial glycocalyx was visualised in dog uterine and testicular arteries. Direct visualisation of the endothelial glycocalyx was technically challenging.
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11
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Leśnik P, Woźnica-Niesobska E, Janc J, Mierzchała-Pasierb M, Łysenko L. Effect of a 3% gelatin solution on urinary KIM-1 levels in patients after thyroidectomy: a preliminary randomized controlled trial. Sci Rep 2021; 11:23617. [PMID: 34880372 PMCID: PMC8655000 DOI: 10.1038/s41598-021-03108-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 11/29/2021] [Indexed: 12/03/2022] Open
Abstract
Optimal fluid therapy significantly affects the maintenance of proper tissue perfusion and, consequently, kidney function. An adverse effect of colloids on kidney function is related to the incidence of postoperative kidney failure. The study aimed to assess the effect of a 3% gelatin solution on kidney function based on the urinary kidney injury molecule-1 (uKIM-1) level. This study used a parallel design and enrolled 64 adult patients with a mean age of 52.5 ± 13.1 years, all of whom underwent a thyroidectomy procedure under general anesthesia. Patients were randomly assigned to three comparison groups, each receiving a different dose of 3% gelatin solution during the thyroidectomy procedure. The patients from study groups A (n = 21) and B (n = 21) received a 3% gelatin solution at a dose of 30 ml/kg and 15 ml/kg body weight, respectively, during the first hour of the procedure. The patients from the control group C (n = 22) received an isotonic multi-electrolyte solution. Serum creatinine levels were determined, and urine samples were collected to determine levels of uKIM-1 before, 2 h, and 24 h after surgery. The patients' demographic data, type and volume of fluid and hemodynamic status during the surgery were collected from relevant anesthesia protocols and were included in the study data. There were no statistically significant changes between groups in hemodynamic parameters such as systolic and diastolic blood pressure, heart rate, and oxygen saturation values. A statistically significant increase in uKIM-1 level was noted in patients receiving the 3% gelatin solution regardless of the dose. A statistically significant difference in uKIM-1 level was observed between groups A, B, and C measured 24 h after surgery, with the highest uKIM-1 level in group A. Measurement of uKIM-1 level could be an early and sensitive biomarker of kidney injury. Kidney toxicity of a 3% gelatin solution, evaluated based on the level of uKIM-1 in urine, correlates with transfused fluid volume. This study was retrospectively registered in the ISRCTN clinical trials registry (ISRCTN73266049, 08/04/2021: https://www.isrctn.com/ISRCTN73266049 ).
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Affiliation(s)
- Patrycja Leśnik
- Department of Anaesthesiology and Intensive Therapy, 4th Military Clinical Hospital, 50-560, Wrocław, Poland.
| | - Ewa Woźnica-Niesobska
- Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, 50-981, Wrocław, Poland
| | - Jarosław Janc
- Department of Anaesthesiology and Intensive Therapy, 4th Military Clinical Hospital, 50-560, Wrocław, Poland
| | | | - Lidia Łysenko
- Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, 50-981, Wrocław, Poland
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12
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Hanley C, Callum J, Karkouti K, Bartoszko J. Albumin in adult cardiac surgery: a narrative review. Can J Anaesth 2021; 68:1197-1213. [PMID: 33884561 DOI: 10.1007/s12630-021-01991-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population. SOURCE We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, and cardiopulmonary bypass. PRINCIPAL FINDINGS Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety. CONCLUSIONS In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.
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Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada.
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13
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Adamik KN, Yozova ID. Colloids Yes or No? - a "Gretchen Question" Answered. Front Vet Sci 2021; 8:624049. [PMID: 34277747 PMCID: PMC8282815 DOI: 10.3389/fvets.2021.624049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/05/2021] [Indexed: 12/13/2022] Open
Abstract
Colloid solutions, both natural and synthetic, had been widely accepted as having superior volume expanding effects than crystalloids. Synthetic colloid solutions were previously considered at least as effective as natural colloids, as well as being cheaper and easily available. As a result, synthetic colloids (and HES in particular) were the preferred resuscitation fluid in many countries. In the past decade, several cascading events have called into question their efficacy and revealed their harmful effects. In 2013, the medicines authorities placed substantial restrictions on HES administration in people which has resulted in an overall decrease in their use. Whether natural colloids (such as albumin-containing solutions) should replace synthetic colloids remains inconclusive based on the current evidence. Albumin seems to be safer than synthetic colloids in people, but clear evidence of a positive effect on survival is still lacking. Furthermore, species-specific albumin is not widely available, while xenotransfusions with human serum albumin have known side effects. Veterinary data on the safety and efficacy of synthetic and natural colloids is limited to mostly retrospective evaluations or experimental studies with small numbers of patients (mainly dogs). Large, prospective, randomized, long-term outcome-oriented studies are lacking. This review focuses on advantages and disadvantages of synthetic and natural colloids in veterinary medicine. Adopting human guidelines is weighed against the particularities of our specific patient populations, including the risk-benefit ratio and lack of alternatives available in human medicine.
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Affiliation(s)
- Katja-Nicole Adamik
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Science, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Ivayla D. Yozova
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
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14
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Smart L, Hughes D. The Effects of Resuscitative Fluid Therapy on the Endothelial Surface Layer. Front Vet Sci 2021; 8:661660. [PMID: 34026896 PMCID: PMC8137965 DOI: 10.3389/fvets.2021.661660] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/16/2021] [Indexed: 01/20/2023] Open
Abstract
The goal of resuscitative fluid therapy is to rapidly expand circulating blood volume in order to restore tissue perfusion. Although this therapy often serves to improve macrohemodynamic parameters, it can be associated with adverse effects on the microcirculation and endothelium. The endothelial surface layer (ESL) provides a protective barrier over the endothelium and is important for regulating transvascular fluid movement, vasomotor tone, coagulation, and inflammation. Shedding or thinning of the ESL can promote interstitial edema and inflammation and may cause microcirculatory dysfunction. The pathophysiologic perturbations of critical illness and rapid, large-volume fluid therapy both cause shedding or thinning of the ESL. Research suggests that restricting the volume of crystalloid, or “clear” fluid, may preserve some ESL integrity and improve outcome based on animal experimental models and preliminary clinical trials in people. This narrative review critically evaluates the evidence for the detrimental effects of resuscitative fluid therapy on the ESL and provides suggestions for future research directions in this field.
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Affiliation(s)
- Lisa Smart
- School of Veterinary Medicine, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, WA, Australia
| | - Dez Hughes
- Department of Veterinary Clinical Sciences, Faculty of Veterinary and Agricultural Sciences, Melbourne Veterinary School, Werribee, VIC, Australia
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15
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Haymet AB, Bartnikowski N, Wood ES, Vallely MP, McBride A, Yacoub S, Biering SB, Harris E, Suen JY, Fraser JF. Studying the Endothelial Glycocalyx in vitro: What Is Missing? Front Cardiovasc Med 2021; 8:647086. [PMID: 33937360 PMCID: PMC8079726 DOI: 10.3389/fcvm.2021.647086] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/19/2021] [Indexed: 12/16/2022] Open
Abstract
All human cells are coated by a surface layer of proteoglycans, glycosaminoglycans (GAGs) and plasma proteins, called the glycocalyx. The glycocalyx transmits shear stress to the cytoskeleton of endothelial cells, maintains a selective permeability barrier, and modulates adhesion of blood leukocytes and platelets. Major components of the glycocalyx, including syndecans, heparan sulfate, and hyaluronan, are shed from the endothelial surface layer during conditions including ischaemia and hypoxia, sepsis, atherosclerosis, diabetes, renal disease, and some viral infections. Studying mechanisms of glycocalyx damage in vivo can be challenging due to the complexity of immuno-inflammatory responses which are inextricably involved. Previously, both static as well as perfused in vitro models have studied the glycocalyx, and have reported either imaging data, assessment of barrier function, or interactions of blood components with the endothelial monolayer. To date, no model has simultaneously incorporated all these features at once, however such a model would arguably enhance the study of vasculopathic processes. This review compiles a series of current in vitro models described in the literature that have targeted the glycocalyx layer, their limitations, and potential opportunities for further developments in this field.
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Affiliation(s)
- Andrew B Haymet
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia.,Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - Nicole Bartnikowski
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia.,Science and Engineering Faculty, Queensland University of Technology, Brisbane, QLD, Australia
| | - Emily S Wood
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia.,Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - Michael P Vallely
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Angela McBride
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom.,Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Ho Chi Minh City, Vietnam
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Wellcome Trust Africa Asia Programme, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Scott B Biering
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Eva Harris
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia.,Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia.,Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia
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16
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Oshima K, King SI, McMurtry SA, Schmidt EP. Endothelial Heparan Sulfate Proteoglycans in Sepsis: The Role of the Glycocalyx. Semin Thromb Hemost 2021; 47:274-282. [PMID: 33794552 DOI: 10.1055/s-0041-1725064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
There is increasing recognition of the importance of the endothelial glycocalyx and its in vivo manifestation, the endothelial surface layer, in vascular homeostasis. Heparan sulfate proteoglycans (HSPGs) are a major structural constituent of the endothelial glycocalyx and serve to regulate vascular permeability, microcirculatory tone, leukocyte and platelet adhesion, and hemostasis. During sepsis, endothelial HSPGs are shed through the induction of "sheddases" such as heparanase and matrix metalloproteinases, leading to loss of glycocalyx integrity and consequent vascular dysfunction. Less well recognized is that glycocalyx degradation releases HSPG fragments into the circulation, which can shape the systemic consequences of sepsis. In this review, we will discuss (1) the normal, homeostatic functions of HSPGs within the endothelial glycocalyx, (2) the pathological changes in HSPGs during sepsis and their consequences on the local vascular bed, and (3) the systemic consequences of HSPG degradation. In doing so, we will identify potential therapeutic targets to improve vascular function during sepsis as well as highlight key areas of uncertainty that require further mechanistic investigation.
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Affiliation(s)
- Kaori Oshima
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Samantha I King
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sarah A McMurtry
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Eric P Schmidt
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Department of Medicine, Denver Health Medical Center, Denver, Colorado
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17
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Mahrous RSS, Ismail TI. Evaluation of two different fluids regimens on central venous-to-arterial Carbon Dioxide difference (pCO 2 gap) - a randomized controlled trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1896428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Rabab S. S. Mahrous
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Tarek I. Ismail
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Helwan University, Helwan, Egypt
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18
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Bihari S, Bannard-Smith J, Bellomo R. Albumin as a drug: its biological effects beyond volume expansion. CRIT CARE RESUSC 2020; 22:257-265. [PMID: 32900333 PMCID: PMC10692529 DOI: 10.1016/s1441-2772(23)00394-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Albumin is the most abundant and perhaps most important protein in human blood. Research has identified many of albumin's possible roles in modulating acid-base balance, modifying inflammation, maintaining vascular endothelial integrity, and binding endogenous and exogenous compounds. Albumin plays a key role in the homeostasis of vascular endothelium, offering protection from inflammation and damage to the glycocalyx. Albumin binds a diverse range of compounds. It transports, delivers and clears drugs, plus it helps with uptake, storage and disposal of potentially harmful biological products. The biological effects of albumin in critical illness are incompletely understood, but may enhance its clinical role beyond use as an intravenous fluid. In this article, we summarise the evidence surrounding albumin's biological and physiological effects beyond its use for plasma volume expansion, and explore potential mechanistic effects of albumin as a disease modifier in patients with critical illness.
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Affiliation(s)
- Shailesh Bihari
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, SA, Australia. ,
| | - Jonathan Bannard-Smith
- Department of Critical Care, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, VIC, Australia
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19
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Dunkel B. Science-in-brief: The role of the glycocalyx in critically ill patients with reference to the horse. Equine Vet J 2020; 52:790-793. [PMID: 32786127 DOI: 10.1111/evj.13328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Bettina Dunkel
- Department of Veterinary Clinical Sciences, The Royal Veterinary College, North Mymms, Hatfield, Hertfordshire, UK
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20
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Abstract
OBJECTIVES Sepsis is a significant cause of morbidity and mortality. Children with sepsis often have alterations in microcirculation and vascular permeability. Our objective is current evidence regarding the role of the endothelial glycocalyx as a determinant of capillary leakage in these patients. DATA SOURCES We reviewed PubMed, EMBASE, and Google scholar using MeSH terms "glycocalyx", "fluids", "syndecan", "endothelium", "vascular permeability", "edema", "sepsis", "septic shock", "children". STUDY SELECTION Articles in all languages were included. We include all studies in animals and humans related to glycocalyx and vascular permeability. DATA EXTRACTION Studies in children and adults, as well as animal studies, were included. DATA SYNTHESIS One of the fundamental components of the endothelial barrier structure is the glycocalyx. It is a variable thickness layer distributed throughout the whole body, which fulfills a very important function for life: the regulation of blood vessel permeability to water and solutes, favoring vascular protection, modulation, and hemostasis. In the last few years, there has been a special interest in glycocalyx disorders and their relationship to increased vascular permeability, especially in patients with sepsis in whom the alterations that occur in the glycocalyx are unknown when they are subjected to different water resuscitation strategies, vasopressors, etc. This review describes the structural and functional characteristics of the glycocalyx, alterations in patients with sepsis, with regard to its importance in vascular permeability conservation and the possible impact of strategies to prevent and/or treat the injury of this fundamental structure. CONCLUSIONS The endothelial glycocalyx is a fundamental component of the endothelium and an important determinant of the mechanotransduction and vascular permeability in patients with sepsis. Studies are needed to evaluate the role of the different types of solutions used in fluid bolus, vasoactive support, and other interventions described in pediatric sepsis on microcirculation, particularly on endothelial integrity and the glycocalyx.
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21
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Desideri S, Onions KL, Baker SL, Gamez M, El Hegni E Hussien H, Russell A, Satchell SC, Foster RR. Endothelial glycocalyx restoration by growth factors in diabetic nephropathy. Biorheology 2020; 56:163-179. [PMID: 31156139 DOI: 10.3233/bir-180199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The endothelial glycocalyx (eGlx) constitutes the first barrier to protein in all blood vessels. This is particularly noteworthy in the renal glomerulus, an ultrafiltration barrier. Leakage of protein, such as albumin, across glomerular capillaries results in albumin in the urine (albuminuria). This is a hall mark of kidney disease and can reflect loss of blood vessel integrity in microvascular beds elsewhere. We discuss evidence demonstrating that targeted damage to the glomerular eGlx results in increased glomerular albumin permeability. EGlx is lost in diabetes and experimental models demonstrate loss from glomerular endothelial cells. Vascular endothelial growth factor (VEGF)A is upregulated in early diabetes, which is associated with albuminuria. Treatment with paracrine growth factors such as VEGFC, VEGF165b and angiopoietin-1 can modify VEGFA signalling, rescue albumin permeability and restore glomerular eGlx in models of diabetes. Manipulation of VEGF receptor 2 signalling, or a common eGlx biosynthesis pathway by these growth factors, may protect and restore the eGlx layer. This would help to direct future therapeutics in diabetic nephropathy.
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Key Words
- Endothelial glycocalyx, diabetes, diabetic nephropathy, VEGF, VEGFC, VEGFA, VEGF165b, angiopoietin-1, vascular permeability, glomerulus, glomerular permeability
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Affiliation(s)
- Sara Desideri
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Karen L Onions
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Siân L Baker
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Monica Gamez
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Hesham El Hegni E Hussien
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Amy Russell
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Simon C Satchell
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Rebecca R Foster
- Bristol Renal, Bristol Heart Institute, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
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22
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Ruiz S, Vardon-Bounes F, Buléon M, Guilbeau-Frugier C, Séguelas MH, Conil JM, Girolami JP, Tack I, Minville V. Kinin B1 receptor: a potential therapeutic target in sepsis-induced vascular hyperpermeability. J Transl Med 2020; 18:174. [PMID: 32306971 PMCID: PMC7168845 DOI: 10.1186/s12967-020-02342-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/10/2020] [Indexed: 12/14/2022] Open
Abstract
Background In sepsis, the endothelial barrier becomes incompetent, with the leaking of plasma into interstitial tissues. VE-cadherin, an adherens junction protein, is the gatekeeper of endothelial cohesion. Kinins, released during sepsis, induce vascular leakage and vasodilation. They act via two G-protein coupled receptors: B1 (B1R) and B2 (B2R). B1R is inducible in the presence of pro-inflammatory cytokines, endotoxins or after tissue injury. It acts at a later stage of sepsis and elicits a sustained inflammatory response. The aim of our study was to investigate the relationships between B1R and VE-cadherin destabilization in vivo in a later phase of sepsis. Methods Experimental, prospective study in a university research laboratory. We used a polymicrobial model of septic shock by cecal ligation and puncture in C57BL6 male mice or C57BL6 male mice that received a specific B1R antagonist (R-954). We studied the influence of B1R on sepsis-induced vascular permeability 30 h after surgery for several organs, and VE-cadherin expression in the lung and kidneys by injecting R-954 just before surgery. The 96-h survival was determined in mice without treatment or in animals receiving R-954 as a “prophylactic” regimen (a subcutaneous injection of 200 µg/kg, prior to CLP and 24 h after CLP), or as a “curative” regimen (injection of 100 µg/kg at H6, H24 and H48 post-surgery). Results B1R inactivation helps to maintain MAP above 65 mmHg but induces different permeability profiles depending on whether or not organ perfusion is autoregulated. In our model, VE-cadherin was destabilized in vivo during septic shock. At a late stage of sepsis, the B1R blockade reduced the VE-cadherin disruption by limiting eNOS activation. The survival rate for mice that received R-954 after sepsis induction was higher than in animals that received an antagonist as a prophylactic treatment. Conclusions B1R antagonizing reduced mortality in our model of murine septic shock by limiting the vascular permeability induced by VE-cadherin destabilization through maintenance of the macrohemodynamics, consequently limiting organ dysfunctions.
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Affiliation(s)
- Stéphanie Ruiz
- Department of Anesthesiology and Intensive Care, Rangueil Hospital-University Hospital of Toulouse, 1 Avenue du Professeur Jean Poulhès TSA 50032, 31059, Toulouse Cedex 9, France. .,Institute of Metabolic and Cardiovascular Diseases, INSERM/UPS UMR, 1048-I2MC, Equipe 3, Paul Sabatier University, Toulouse, France.
| | - Fanny Vardon-Bounes
- Department of Anesthesiology and Intensive Care, Rangueil Hospital-University Hospital of Toulouse, 1 Avenue du Professeur Jean Poulhès TSA 50032, 31059, Toulouse Cedex 9, France.,Institute of Metabolic and Cardiovascular Diseases, INSERM/UPS UMR, 1048-I2MC, Equipe 3, Paul Sabatier University, Toulouse, France
| | - Marie Buléon
- Institute of Metabolic and Cardiovascular Diseases, INSERM/UPS UMR, 1048-I2MC, Equipe 3, Paul Sabatier University, Toulouse, France
| | - Céline Guilbeau-Frugier
- Institute of Metabolic and Cardiovascular Diseases, INSERM/UPS UMR, 1048-I2MC, Equipe 3, Paul Sabatier University, Toulouse, France.,Department of Forensic Medicine, Rangueil Hospital-University Hospital of Toulouse, 1 Avenue du Professeur Jean Poulhès TSA 50032, 31059, Toulouse Cedex 9, France.,Biological Electron Microscopy Center, Rangueil Faculty of Medicine, Toulouse University, Toulouse, France
| | - Marie-Hélène Séguelas
- Institute of Metabolic and Cardiovascular Diseases, INSERM/UPS UMR, 1048-I2MC, Equipe 3, Paul Sabatier University, Toulouse, France
| | - Jean-Marie Conil
- Department of Anesthesiology and Intensive Care, Rangueil Hospital-University Hospital of Toulouse, 1 Avenue du Professeur Jean Poulhès TSA 50032, 31059, Toulouse Cedex 9, France
| | - Jean-Pierre Girolami
- Institute of Metabolic and Cardiovascular Diseases, INSERM/UPS UMR, 1048-I2MC, Equipe 3, Paul Sabatier University, Toulouse, France
| | - Ivan Tack
- Institute of Metabolic and Cardiovascular Diseases, INSERM/UPS UMR, 1048-I2MC, Equipe 3, Paul Sabatier University, Toulouse, France.,Department of Physiology, Rangueil Hospital-University Hospital of Toulouse, 1 Avenue du Professeur Jean Poulhès TSA 50032, 31059, Toulouse Cedex 9, France
| | - Vincent Minville
- Department of Anesthesiology and Intensive Care, Rangueil Hospital-University Hospital of Toulouse, 1 Avenue du Professeur Jean Poulhès TSA 50032, 31059, Toulouse Cedex 9, France.,Institute of Metabolic and Cardiovascular Diseases, INSERM/UPS UMR, 1048-I2MC, Equipe 3, Paul Sabatier University, Toulouse, France
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Araibi H, van der Merwe E, Gwanyanya A, Kelly-Laubscher R. The effect of sphingosine-1-phosphate on the endothelial glycocalyx during ischemia-reperfusion injury in the isolated rat heart. Microcirculation 2020; 27:e12612. [PMID: 32017300 DOI: 10.1111/micc.12612] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/24/2020] [Accepted: 01/30/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Sphingosine-1-phosphate is a natural metabolite that is cardioprotective, but its effects on endothelial glycocalyx damage during ischemia-reperfusion are unknown. Therefore, we investigated the effect of sphingosine-1-phosphate on the endothelial glycocalyx during ischemia-reperfusion. METHODS Isolated hearts from Wistar rats were perfused on a Langendorff system with Krebs-Henseleit buffer and pretreated with sphingosine-1-phosphate (10 nmol/L) before ischemia-reperfusion. Infarct size was measured by triphenyl tetrazolium chloride staining (n ≥ 6 per group). Cardiac edema was assessed by calculating total water content (n = 7 per group) and histologically quantifying the interstitial compartment (n ≥ 3 per group). The post-ischemic coronary release of syndecan-1 was quantified using ELISA. Syndecan-1 immunostaining intensity was assessed in perfusion-fixed hearts (n ≥ 3 per group). RESULTS Pretreatment with sphingosine-1-phosphate decreased infarct size in isolated hearts subjected to ischemia-reperfusion (P = .01 vs ischemia-reperfusion). However, sphingosine-1-phosphate had no effect on syndecan-1 levels in the coronary effluent or on the intensity of the syndecan-1 immunostaining signal in cardiac tissue. Heart total water content was not significantly different between control and ischemic groups but was significantly decreased in hearts treated with sphingosine-1-phosphate alone. CONCLUSION These results suggest that sphingosine-1-phosphate-induced cardioprotection against ischemia-reperfusion injury is not mediated by the maintenance of syndecan-1 in the endothelial glycocalyx.
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Affiliation(s)
- Hala Araibi
- Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Elizabeth van der Merwe
- Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Asfree Gwanyanya
- Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Roisin Kelly-Laubscher
- Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Department of Biological Sciences, Faculty of Science, University of Cape Town, Cape Town, South Africa.,Department of Pharmacology & Therapeutics, The College of Medicine and Health, University College Cork, Cork, Ireland
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24
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Gaudette S, Hughes D, Boller M. The endothelial glycocalyx: Structure and function in health and critical illness. J Vet Emerg Crit Care (San Antonio) 2020; 30:117-134. [PMID: 32067360 DOI: 10.1111/vec.12925] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 04/23/2018] [Accepted: 05/24/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To conduct a narrative review of the current literature in reference to the structure and function of the endothelial glycocalyx (EG) and its contribution to the pathophysiology of conditions relevant to the veterinary emergency and critical care clinician. Novel therapies for restoring or preserving the EG will also be discussed. DATA SOURCES Online databases (PubMed, CAB abstracts, Scopus) were searched between January 1st 2017 and May 1st 2017 for English language articles without publication date restriction. Keywords included EG, endothelial surface layer, degradation, syndecan-1, heparan sulfate, critical illness, sepsis, trauma, and therapeutics. DATA SYNTHESIS The EG is a complex and important structure located on the luminal surface of all blood vessels throughout the body. It plays an important role in normal vascular homeostasis including control of fluid exchange across the vascular barrier. Loss or degradation of the EG has an impact on inflammation, coagulation, and vascular permeability and tone. These changes are essential components in the pathophysiology of many conditions including sepsis and trauma. A substantial body of experimental animal and human clinical research over the last decade has demonstrated increased circulating concentrations of EG degradation products in these conditions. However, veterinary-specific research into the EG and critical illness is currently lacking. The utility of EG degradation products as diagnostic and prognostic tools continues to be investigated and new therapies to preserve or improve EG structure and function are under development. CONCLUSIONS The recognition of the presence of the EG has changed our understanding of transvascular fluid flux and the pathophysiology of many conditions of critical illness. The EG is an exciting target for novel therapeutics to improve morbidity and mortality in conditions such as sepsis and trauma.
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Affiliation(s)
- Sarah Gaudette
- U-Vet Animal Hospital, Melbourne Veterinary School, University of Melbourne, Werribee, Victoria, 3030, Australia
| | - Dez Hughes
- U-Vet Animal Hospital, Melbourne Veterinary School, University of Melbourne, Werribee, Victoria, 3030, Australia.,Translational Research and Clinical Trials (TRACTS) Group, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, 3030, Australia
| | - Manuel Boller
- U-Vet Animal Hospital, Melbourne Veterinary School, University of Melbourne, Werribee, Victoria, 3030, Australia.,Translational Research and Clinical Trials (TRACTS) Group, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Werribee, Victoria, 3030, Australia
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25
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Abstract
The endothelial glycocalyx (EG) is the most luminal layer of the blood vessel, growing on and within the vascular wall. Shedding of the EG plays a central role in many critical illnesses. Degradation of the EG is associated with increased morbidity and mortality. Certain illnesses and iatrogenic interventions can cause degradation of the EG. It is not known whether restitution of the EG promotes the survival of the patient. First trials that focus on the reorganization and/or restitution of the EG seem promising. Nevertheless, the step "from bench to bedside" is still a big one.
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Affiliation(s)
- Jan Jedlicka
- Department of Anaesthesiology, University Hospital of Munich (LMU), Nussbaumstr. 20, Munich 80336, Germany
| | - Bernhard F Becker
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University, Marchioninistr. 27, Munich 81377, Germany
| | - Daniel Chappell
- Department of Anaesthesiology, University Hospital of Munich (LMU), Marchioninistr. 15, Munich 81377, Germany.
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26
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Andreeva AM, Vasiliev AS, Toropygin IY, Garina DV, Lamash N, Filippova A. Involvement of apolipoprotein A in maintaining tissue fluid balance in goldfish Carassius auratus. FISH PHYSIOLOGY AND BIOCHEMISTRY 2019; 45:1717-1730. [PMID: 31227941 DOI: 10.1007/s10695-019-00662-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/23/2019] [Indexed: 06/09/2023]
Abstract
Mammalian plasma proteins play a key role in maintaining tissue fluid balance because they are retained within capillaries and thus create colloid osmotic pressure. Likewise, fish plasma contain a considerable concentration oligomeric proteins which likely serve a similar role. To elucidate the functions of these oligomeric proteins, we analyzed blood serum (BS) and interstitial fluid (IF) complexes in goldfish from the wild and under experimental conditions using 2D electrophoresis and matrix-assisted laser desorption/ionization (MALDI). We detected protein compounds with MWs ranging from 50 to 155 kDa, organized as oligomeric complexes. The protein compounds consisted of apolipoproteins АроА-I and Аро-14 which are homological to mammalian АроА-I and АроА-II, respectively. The 155-kDa and 50-125-kDa oligomer complexes were located very low-density lipoproteins (LDL) and high-density lipoproteins (HDL) areas on the BS/IF proteomic maps, respectively. The latter resembled mammalian HDL plasma particles by size and contained lipids, so we considered them as HDL particle populations. Investigation of the uniform dissociation/association mechanism for HDL and LDL oligomers in goldfish, from the wild and under critical salinity conditions, showed the "125/110 → 85/60 kDa" reorganization. This was associated with overcoming physiological stress during spawning and under critical salinity conditions. Opposite reorganization "85/60 → 125/110 kDa" was associated with restoration of metabolic processes after stress. The association/dissociation reorganizations promoted equilibration of BS and IF osmolarities in all fish groups. We discuss the connection of these reorganizations with total protein distribution across the capillary wall and salinity, as well as the role of oligomeric apolipoproteins as universal metabolic regulators.
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Affiliation(s)
- Alla M Andreeva
- Ecological Biochemistry Laboratory, Papanin Institute for Biology of Inland Waters, Russian Academy of Sciences, House 109, Borok, Nekouzskii Raion, Yaroslavl, Oblast, Russia, 152742.
| | - Alexey S Vasiliev
- Ecological Biochemistry Laboratory, Papanin Institute for Biology of Inland Waters, Russian Academy of Sciences, House 109, Borok, Nekouzskii Raion, Yaroslavl, Oblast, Russia, 152742
| | - Ilya Yu Toropygin
- Institute of Biomedical Chemistry, Russian Academy of Sciences, Pogodinskaya Street, House 10, Building 8, Moscow, Russia, 119121
| | - Darina V Garina
- Ecological Biochemistry Laboratory, Papanin Institute for Biology of Inland Waters, Russian Academy of Sciences, House 109, Borok, Nekouzskii Raion, Yaroslavl, Oblast, Russia, 152742
| | - Nina Lamash
- Ecological Biochemistry Laboratory, Papanin Institute for Biology of Inland Waters, Russian Academy of Sciences, House 109, Borok, Nekouzskii Raion, Yaroslavl, Oblast, Russia, 152742
- National Scientific Center of Marine Biology, Far Eastern Branch of the Russian Academy of Sciences, Vladivostok, Russia, 690041
| | - Alexandra Filippova
- Ecological Biochemistry Laboratory, Papanin Institute for Biology of Inland Waters, Russian Academy of Sciences, House 109, Borok, Nekouzskii Raion, Yaroslavl, Oblast, Russia, 152742
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27
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Krüger-Genge A, Blocki A, Franke RP, Jung F. Vascular Endothelial Cell Biology: An Update. Int J Mol Sci 2019; 20:ijms20184411. [PMID: 31500313 PMCID: PMC6769656 DOI: 10.3390/ijms20184411] [Citation(s) in RCA: 505] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 06/28/2019] [Accepted: 07/01/2019] [Indexed: 12/20/2022] Open
Abstract
The vascular endothelium, a monolayer of endothelial cells (EC), constitutes the inner cellular lining of arteries, veins and capillaries and therefore is in direct contact with the components and cells of blood. The endothelium is not only a mere barrier between blood and tissues but also an endocrine organ. It actively controls the degree of vascular relaxation and constriction, and the extravasation of solutes, fluid, macromolecules and hormones, as well as that of platelets and blood cells. Through control of vascular tone, EC regulate the regional blood flow. They also direct inflammatory cells to foreign materials, areas in need of repair or defense against infections. In addition, EC are important in controlling blood fluidity, platelet adhesion and aggregation, leukocyte activation, adhesion, and transmigration. They also tightly keep the balance between coagulation and fibrinolysis and play a major role in the regulation of immune responses, inflammation and angiogenesis. To fulfill these different tasks, EC are heterogeneous and perform distinctly in the various organs and along the vascular tree. Important morphological, physiological and phenotypic differences between EC in the different parts of the arterial tree as well as between arteries and veins optimally support their specified functions in these vascular areas. This review updates the current knowledge about the morphology and function of endothelial cells, particularly their differences in different localizations around the body paying attention specifically to their different responses to physical, biochemical and environmental stimuli considering the different origins of the EC.
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Affiliation(s)
- Anne Krüger-Genge
- Department of Biomaterials and Healthcare, Division of Life Science and Bioprocesses, Fraunhofer Institute for Applied Polymer Research (IAP), Potsdam-Golm 14476, Germany.
- Department of Anesthesia, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS B3H 2Y9, Canada.
| | - Anna Blocki
- Institute for Tissue Engineering and Regenerative Medicine (ITERM), School of Biomedical Sciences (SBS), Chinese University of Hong Kong (CUHK), New Territories, Hong Kong, China
| | - Ralf-Peter Franke
- Central Institute for Biomedical Technology, Dep. Biomaterials, University of Ulm, Albert-Einstein-Allee 47, 89081 Ulm, Germany
| | - Friedrich Jung
- Institute of Biotechnology, Molecular Cell Biology, Brandenburg University of Technology, 01968 Senftenberg, Germany
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28
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László I, Janovszky Á, Lovas A, Vargán V, Öveges N, Tánczos T, Mikor A, Trásy D, Lóderer Z, Piffkó J, Szabó A, Molnár Z. Effects of goal-directed crystalloid vs. colloid fluid therapy on microcirculation during free flap surgery. Eur J Anaesthesiol 2019; 36:592-604. [DOI: 10.1097/eja.0000000000001024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Affiliation(s)
- Mohammed Ezzat Moemen
- Department of Anaesthesia and Intensive Care
Faculty of Medicine
Zagazig University
Zagazig Egypt
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30
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Milford EM, Reade MC. Resuscitation Fluid Choices to Preserve the Endothelial Glycocalyx. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:77. [PMID: 30850020 PMCID: PMC6408751 DOI: 10.1186/s13054-019-2369-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Elissa M Milford
- Intensive Care Medicine, 2nd General Health Battalion, Australian Army, Brisbane, QLD, Australia. .,Faculty of Medicine, The University of Queensland, Herston, QLD, Australia.
| | - Michael C Reade
- Faculty of Medicine, The University of Queensland and Australian Defence Force Joint Health Command, Brisbane, QLD, Australia.,Clinical Services, 2nd General Health Battalion, Australian Army, Brisbane, QLD, Australia
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31
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George SA, Hoeker G, Calhoun PJ, Entz M, Raisch TB, King DR, Khan M, Baker C, Gourdie RG, Smyth JW, Nielsen MS, Poelzing S. Modulating cardiac conduction during metabolic ischemia with perfusate sodium and calcium in guinea pig hearts. Am J Physiol Heart Circ Physiol 2019; 316:H849-H861. [PMID: 30707595 DOI: 10.1152/ajpheart.00083.2018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We previously demonstrated that altering extracellular sodium (Nao) and calcium (Cao) can modulate a form of electrical communication between cardiomyocytes termed "ephaptic coupling" (EpC), especially during loss of gap junction coupling. We hypothesized that altering Nao and Cao modulates conduction velocity (CV) and arrhythmic burden during ischemia. Electrophysiology was quantified by optically mapping Langendorff-perfused guinea pig ventricles with modified Nao (147 or 155 mM) and Cao (1.25 or 2.0 mM) during 30 min of simulated metabolic ischemia (pH 6.5, anoxia, aglycemia). Gap junction-adjacent perinexal width ( WP), a candidate cardiac ephapse, and connexin (Cx)43 protein expression and Cx43 phosphorylation at S368 were quantified by transmission electron microscopy and Western immunoblot analysis, respectively. Metabolic ischemia slowed CV in hearts perfused with 147 mM Nao and 2.0 mM Cao; however, theoretically increasing EpC with 155 mM Nao was arrhythmogenic, and CV could not be measured. Reducing Cao to 1.25 mM expanded WP, as expected during ischemia, consistent with reduced EpC, but attenuated CV slowing while delaying arrhythmia onset. These results were further supported by osmotically reducing WP with albumin, which exacerbated CV slowing and increased early arrhythmias during ischemia, whereas mannitol expanded WP, permitted conduction, and delayed the onset of arrhythmias. Cx43 expression patterns during the various interventions insufficiently correlated with observed CV changes and arrhythmic burden. In conclusion, decreasing perfusate calcium during metabolic ischemia enhances perinexal expansion, attenuates conduction slowing, and delays arrhythmias. Thus, perinexal expansion may be cardioprotective during metabolic ischemia. NEW & NOTEWORTHY This study demonstrates, for the first time, that modulating perfusate ion composition can alter cardiac electrophysiology during simulated metabolic ischemia.
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Affiliation(s)
- Sharon A George
- Department of Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University , Blacksburg, Virginia.,Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia
| | - Gregory Hoeker
- Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia
| | - Patrick J Calhoun
- Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia.,Department of Biological Sciences, Virginia Polytechnic Institute and State University , Blacksburg, Virginia
| | - Michael Entz
- Department of Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University , Blacksburg, Virginia.,Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia
| | - Tristan B Raisch
- Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia.,Translational Biology, Medicine, and Health Graduate Program, Virginia Polytechnic Institute and State University , Blacksburg, Virginia
| | - D Ryan King
- Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia.,Translational Biology, Medicine, and Health Graduate Program, Virginia Polytechnic Institute and State University , Blacksburg, Virginia
| | - Momina Khan
- Department of Human Food Nutrition and Exercise, Virginia Polytechnic Institute and State University , Blacksburg, Virginia
| | - Chandra Baker
- Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia
| | - Robert G Gourdie
- Department of Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University , Blacksburg, Virginia.,Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia
| | - James W Smyth
- Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia.,Department of Biological Sciences, Virginia Polytechnic Institute and State University , Blacksburg, Virginia
| | - Morten S Nielsen
- Department of Biomedical Sciences, University of Copenhagen , Copenhagen , Denmark
| | - Steven Poelzing
- Department of Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University , Blacksburg, Virginia.,Center for Heart and Reparative Medicine Research, Virginia Tech Carilion Research Institute , Roanoke, Virginia.,Translational Biology, Medicine, and Health Graduate Program, Virginia Polytechnic Institute and State University , Blacksburg, Virginia
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32
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Erstad BL. Albumin disposition in critically Ill patients. J Clin Pharm Ther 2018; 43:746-751. [DOI: 10.1111/jcpt.12742] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/10/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Brian L. Erstad
- Department of Pharmacy Practice & ScienceCollege of PharmacyUniversity of Arizona Tucson Arizona
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33
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Constantinescu A, Spaan J, Arkenbout EK, Vink H, VanTeeffelen J. Degradation of the endothelial glycocalyx is associated with chylomicron leakage in mouse cremaster muscle microcirculation. Thromb Haemost 2017; 105:790-801. [DOI: 10.1160/th10-08-0560] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 11/09/2010] [Indexed: 11/05/2022]
Abstract
SummaryA thick endothelial glycocalyx contributes to the barrier function of vascular endothelium in macro- and microcirculation. We hypothesised in the current study that diet-induced hyperlipidaemia perturbs the glycocalyx, resulting in decreased dimensions of this layer and increased transendothelial lipoprotein leakage in capillaries. Glycocalyx thickness was measured in mouse cremaster muscle capillaries by intravital microscopy from the distance between flowing red blood cells and the endothelial surface. In control C57BL/6 mice on standard chow, glycocalyx thickness measured 0.58 ± 0.01 (mean ± SEM) μm, and no lipo-proteins were observed in the tissue. After three months administration of an either mild or severe high-fat / high-cholesterol diet (HFC) to C57BL/6 and ApoE3-Leiden mice, circulating large lipoproteins appeared into the subendothelial space in an increasing proportion of cre-master capillaries, and these capillaries displayed reduced glycocalyx dimensions of 0.40 ± 0.02 and 0.30 ± 0.01 μm (C57BL/6 mice), and 0.37 ± 0.01 and 0.28 ± 0.01 μm (ApoE3-Leiden mice), after the mild and severe HFC diet, respectively. The chylomicron nature of the accumulated lipoproteins was confirmed by observations of subendothelial deposition of DiI-labeled chylomicrons in capillaries after inducing acute glycocalyx degradation by heparitinase in normolipidaemic C57BL/6 mice. It is concluded that while under control conditions the endothelial glycocalyx contributes to the vascular barrier against transvascular lipoprotein leakage in the microcirculation, diet-induced hyperlipidaemia reduces the thickness of the glycocalyx, thereby facilitating leakage of chylomicrons across the capillary wall.
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34
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Pillinger NL, Kam P. Endothelial glycocalyx: basic science and clinical implications. Anaesth Intensive Care 2017; 45:295-307. [PMID: 28486888 DOI: 10.1177/0310057x1704500305] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The classic Starling principle proposed that microvascular fluid exchange was determined by a balance of hydrostatic and oncotic pressures relative to the vascular wall and this movement of water was regulated by gaps in the intercellular spaces. However, current literature on the endothelial glycocalyx (a jelly-like protective layer covering the luminal surface of the endothelium) has revised Starling's traditional concepts. This article aims to summarise the literature on the glycocalyx related to its basic science, clinical settings inciting injury, protective strategies and clinical perspectives. Perioperative damage to the glycocalyx structure can increase vascular permeability leading to interstitial fluid shifts, oedema, and increased surgical morbidity. Pathological shedding of the glycocalyx occurs in response to mechanical cellular stress, endotoxins, inflammatory mediators, atrial natriuretic peptide, ischaemia-reperfusion injury, free oxygen radicals and hyperglycaemia. Increased understanding of the endothelial glycocalyx may change perioperative fluid management, and therapeutic strategies aimed at its preservation may improve patient outcomes.
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Affiliation(s)
- N L Pillinger
- Staff Specialist Anaesthetist, Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - Pca Kam
- Nuffield Professor of Anaesthetics, University of Sydney, Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales
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35
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Structural Behavior of the Endothelial Glycocalyx Is Associated With Pathophysiologic Status in Septic Mice: An Integrated Approach to Analyzing the Behavior and Function of the Glycocalyx Using Both Electron and Fluorescence Intravital Microscopy. Anesth Analg 2017; 125:874-883. [PMID: 28504989 DOI: 10.1213/ane.0000000000002057] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The endothelial surface layer (ESL) regulates vascular permeability to maintain fluid homeostasis. The glycocalyx (GCX), which has a complex and fragile ultrastructure, is an important component of the ESL. Abnormalities of the GCX have been hypothesized to trigger pathological hyperpermeability. Here, we report an integrated in vivo analysis of the morphological and functional properties of the GCX in a vital organ. METHODS We examined the behavior of the ESL and GCX, using both electron microscopy (EM) and intravital microscopy (IVM). We also compared morphological changes in the ESL of mouse skin in a glycosidase-treated and control group. Combined approaches were also used to examine both morphology and function in a lipopolysaccharide-induced septic model and the pathophysiological features of leukocyte-endothelial interactions and in vivo vascular permeability. RESULTS Using IVM, we identified an illuminated part of the ESL as the GCX and confirmed our observation using morphological and biochemical means. In septic mice, we found that the GCX was thinner than in nonseptic controls in both an EM image analysis (0.98 ± 2.08 nm vs 70.68 ± 36.36 nm, P< .001) and an IVM image analysis (0.36 ± 0.15 μm vs 1.07 ± 0.39 μm, P< .001). Under septic conditions, syndecan-1, a representative core protein of the GCX, was released into the blood serum at a higher rate in septic animals (7.33 ± 3.46 ng/mL) when compared with controls (below the limit of detection, P< .001). Significant increases in leukocyte-endothelial interactions, defined as the numbers of rolling or firm-sticking leukocytes, and molecular hyperpermeability to the interstitium were also observed after GCX shedding in vivo. CONCLUSIONS Using IVM, we visualized an illuminated part of the ESL layer that was subsequently confirmed as the GCX using EM. Severe sepsis induced morphological degradation of the GCX, accompanied by shedding of the syndecan-1 core protein and an increase in leukocyte-endothelial interactions affecting the vascular permeability. Our in vivo model describes a new approach to deciphering the relationship between structural and functional behaviors of the GCX.
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36
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Lindberg-Larsen V, Ostrowski SR, Lindberg-Larsen M, Rovsing ML, Johansson PI, Kehlet H. The effect of pre-operative methylprednisolone on early endothelial damage after total knee arthroplasty: a randomised, double-blind, placebo-controlled trial. Anaesthesia 2017; 72:1217-1224. [DOI: 10.1111/anae.13983] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2017] [Indexed: 12/24/2022]
Affiliation(s)
- V. Lindberg-Larsen
- Section for Surgical Pathophysiology; The Lundbeck Foundation Centre for Fast-Track Hip and Knee Arthroplasty; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - S. R. Ostrowski
- Section for Transfusion Medicine; Capital Region Blood Bank; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - M. Lindberg-Larsen
- Department of Orthopaedic Surgery; Copenhagen University Hospital, Bispebjerg and Frederiksberg; Denmark
| | - M. L. Rovsing
- Department of Anaesthesiology and Intensive Care Medicine; Copenhagen University Hospital, Bispebjerg and Frederiksberg; Denmark
| | - P. I. Johansson
- Section for Transfusion Medicine; Capital Region Blood Bank; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
- Department of Surgery; University of Texas Health Sciences; Houston Texas USA
| | - H. Kehlet
- Section for Surgical Pathophysiology; The Lundbeck Foundation Centre for Fast-Track Hip and Knee Arthroplasty; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
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37
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Ripollés-Melchor J, Chappell D, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Perioperative fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part I: Physiological background. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:328-338. [PMID: 28364973 DOI: 10.1016/j.redar.2017.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 06/07/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute of Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial de Salamanca, Universidad de Salamanca, Salamanca, España
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Rehm M, Hulde N, Kammerer T, Meidert AS, Hofmann-Kiefer K. State of the art in fluid and volume therapy. Anaesthesist 2017; 68:1-14. [DOI: 10.1007/s00101-017-0290-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Rehm M, Hulde N, Kammerer T, Meidert AS, Hofmann-Kiefer K. [State of the art in fluid and volume therapy : A user-friendly staged concept]. Anaesthesist 2017; 66:153-167. [PMID: 28213648 DOI: 10.1007/s00101-017-0272-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adequate fluid therapy is highly important for the perioperative outcome of our patients. Both, hypovolemia and hypervolemia can lead to an increase in perioperative complications and can impair the outcome. Therefore, perioperative infusion therapy should be target-oriented. The main target is to maintain the patient's preoperative normovolemia by using a sophisticated, rational infusion strategy.Perioperative fluid losses should be discriminated from volume losses (surgical blood loss or interstitial volume losses containing protein). Fluid losses as urine or perspiratio insensibilis (0.5-1.0 ml/kg/h) should be replaced by balanced crystalloids in a ratio of 1:1. Volume therapy step 1: Blood loss up to a maximum value of 20% of the patient's blood volume should be replaced by balanced crystalloids in a ratio of 4(-5):1. Volume therapy step 2: Higher blood losses should be treated by using iso-oncotic, preferential balanced colloids in a ratio of 1:1. For this purpose hydroxyethyl starch can also be used perioperatively if there is no respective contraindication, such as sepsis, burn injuries, critically ill patients, renal impairment or renal replacement therapy, and severe coagulopathy. Volume therapy step 3: If there is an indication for red cell concentrates or coagulation factors, a differentiated application of blood and blood products should be performed.
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Affiliation(s)
- M Rehm
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | - N Hulde
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - T Kammerer
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - A S Meidert
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - K Hofmann-Kiefer
- Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
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Distribution of Crystalloids and Colloids During Fluid Resuscitation: All Fluids Can be Good and Bad? ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2017. [DOI: 10.1007/978-3-319-51908-1_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Regulation of blood flow and volume exchange across the microcirculation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:319. [PMID: 27765054 PMCID: PMC5073467 DOI: 10.1186/s13054-016-1485-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Oxygen delivery to cells is the basic prerequisite of life. Within the human body, an ingenious oxygen delivery system, comprising steps of convection and diffusion from the upper airways via the lungs and the cardiovascular system to the microvascular area, bridges the gap between oxygen in the outside airspace and the interstitial space around the cells. However, the complexity of this evolutionary development makes us prone to pathophysiological problems. While those problems related to respiration and macrohemodynamics have already been successfully addressed by modern medicine, the pathophysiology of the microcirculation is still often a closed book in daily practice. Nevertheless, here as well, profound physiological understanding is the only key to rational therapeutic decisions. The prime guarantor of tissue oxygenation is tissue blood flow. Therefore, on the premise of intact macrohemodynamics, the microcirculation has three major responsibilities: 1) providing access for oxygenated blood to the tissues and appropriate return of volume; 2) maintaining global tissue flood flow, even in the face of changes in central blood pressure; and 3) linking local blood flow to local metabolic needs. It is an intriguing concept of nature to do this mainly by local regulatory mechanisms, impacting primarily on flow resistance, be this via endothelial or direct smooth muscle actions. The final goal of microvascular blood flow per unit of time is to ensure the needed exchange of substances between tissue and blood compartments. The two principle means of accomplishing this are diffusion and filtration. While simple diffusion is the quantitatively most important form of capillary exchange activity for the respiratory gases, water flux across the blood-brain barrier is facilitated via preformed specialized channels, the aquaporines. Beyond that, the vascular barrier is practically nowhere completely tight for water, with paracellular filtration giving rise to generally low but permanent fluid flux outwards into the interstitial space at the microvascular high pressure segment. At the more leaky venular aspect, both filtration and diffusion allow for bidirectional passage of water, nutrients, and waste products. We are just beginning to appreciate that a major factor for maintaining tissue fluid homeostasis appears to be the integrity of the endothelial glycocalyx.
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Ramalho GL, Vane MF, Lima LC, Vane LF, Amorim RB, Domingues MA, Moraes JMSD, Carvalho LRD, Tanaka PP, Vane LA. Noradrenaline and dobutamine effects on the volume expansion with normal saline in rabbits subjected to hemorrhage. Acta Cir Bras 2016; 31:621-628. [PMID: 27737348 DOI: 10.1590/s0102-865020160090000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/21/2016] [Indexed: 11/21/2022] Open
Abstract
PURPOSE: To evaluate the effects of dobutamine (DB), noradrenaline (NA), and their combination (NADB), on volume retention in rabbits submitted to hemorrhage. METHODS: Thirty six rabbits were randomly divided into 6 groups: SHAM, Control, Saline, DB, NA, DB+NA. All the animals, except for SHAM, were subjected to hemorrhage of 25% of the calculated blood volume. Control animals were replaced with their own blood. The other groups received NSS 3 times the volume withdrawn. The intravascular retention, hematocrit, diuresis, central venous pressure, mean arterial pressure, NGAL, dry-to-wet lung weight ratio (DTWR) and the lung and kidney histology were analyzed. RESULTS: Replacement with NSS and NA, DB or NA+DB did not produce differences in the intravascular retention. After hemorrhage, the animals presented a significant decrease in the MAP and CVP, which were maintained until volume replacement. Regarding NGAL, dry-to-wet-lung-weight ratio, lung and kidney histology, there were no statistical differences between the groups. CONCLUSION: The use of noradrenaline, dobutamine or their combination did not increase the intravascular retention of volume after normal saline infusion.
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Affiliation(s)
- Gualter Lisboa Ramalho
- Fellow PhD degree, Postgraduate Program in Anesthesiology, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu-SP, Brazil. Conception, design, intellectual and scientific content of the study
| | - Matheus Fachini Vane
- MD, Division of Anesthesiology, Medical School, University de São Paulo (USP), Brazil. Conception of the study, manuscript writing
| | | | - Lucas Fachini Vane
- Master, Guaratingueta School of Engineering, UNESP, Brazil. Acquisition of data
| | - Rosa Beatriz Amorim
- PhD, Department of Anesthesiology, Botucatu Medical School, UNESP, Brazil. Technical procedures
| | | | - José Mariano Soares de Moraes
- PhD, Division of Anesthesiology, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Brazil. Manuscript writing, critical revision
| | | | - Pedro Paulo Tanaka
- PhD, Department of Anesthesiology, Stanford University, Medical School, California, USA. Critical revision
| | - Luiz Antonio Vane
- Full Professor, Department of Anesthesiology, Botucatu Medical School, UNESP, Brazil. Manuscript writing, critical revision, supervised all phases of the study
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Nishimura A, Tabuchi Y, Kikuchi M, Masuda R, Goto K, Iijima T. The Amount of Fluid Given During Surgery That Leaks Into the Interstitium Correlates With Infused Fluid Volume and Varies Widely Between Patients. Anesth Analg 2016; 123:925-32. [DOI: 10.1213/ane.0000000000001505] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Ushiyama A, Kataoka H, Iijima T. Glycocalyx and its involvement in clinical pathophysiologies. J Intensive Care 2016; 4:59. [PMID: 27617097 PMCID: PMC5017018 DOI: 10.1186/s40560-016-0182-z] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/22/2016] [Indexed: 01/06/2023] Open
Abstract
Vascular hyperpermeability is a frequent intractable feature involved in a wide range of diseases in the intensive care unit. The glycocalyx (GCX) seemingly plays a key role to control vascular permeability. The GCX has attracted the attention of clinicians working on vascular permeability involving angiopathies, and several clinical approaches to examine the involvement of the GCX have been attempted. The GCX is a major constituent of the endothelial surface layer (ESL), which covers most of the surface of the endothelial cells and reduces the access of cellular and macromolecular components of the blood to the surface of the endothelium. It has become evident that this structure is not just a barrier for vascular permeability but contributes to various functions including signal sensing and transmission to the endothelium. Because GCX is a highly fragile and unstable layer, the image had been only obtained by conventional transmission electron microscopy. Recently, advanced microscopy techniques have enabled direct visualization of the GCX in vivo, most of which use fluorescent-labeled lectins that bind to specific disaccharide moieties of glycosaminoglycan (GAG) chains. Fluorescent-labeled solutes also enabled to demonstrate vascular leakage under the in vivo microscope. Thus, functional analysis of GCX is advancing. A biomarker of GCX degradation has been clinically applied as a marker of vascular damage caused by surgery. Fragments of the GCX, such as syndecan-1 and/or hyaluronan (HA), have been examined, and their validity is now being examined. It is expected that GCX fragments can be a reliable diagnostic or prognostic indicator in various pathological conditions. Since GCX degradation is strongly correlated with disease progression, pharmacological intervention to prevent GCX degradation has been widely considered. HA and other GAGs are candidates to repair GCX; further studies are needed to establish pharmacological intervention. Recent advancement of GCX research has demonstrated that vascular permeability is not regulated by simple Starling’s law. Biological regulation of vascular permeability by GCX opens the way to develop medical intervention to control vascular permeability in critical care patients.
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Affiliation(s)
- Akira Ushiyama
- Department of Environmental Health, National Institute of Public Health, Saitama, Japan
| | - Hanae Kataoka
- Department of Perioperative Medicine, Division of Anesthesiology, Showa University, School of Dentistry, Tokyo, Japan
| | - Takehiko Iijima
- Department of Perioperative Medicine, Division of Anesthesiology, Showa University, School of Dentistry, Tokyo, Japan
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Composition and Function of the Interstitial Fluid. Protein Sci 2016. [DOI: 10.1201/9781315374307-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Torres Filho IP, Torres LN, Salgado C, Dubick MA. Plasma syndecan-1 and heparan sulfate correlate with microvascular glycocalyx degradation in hemorrhaged rats after different resuscitation fluids. Am J Physiol Heart Circ Physiol 2016; 310:H1468-78. [DOI: 10.1152/ajpheart.00006.2016] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/31/2016] [Indexed: 01/24/2023]
Abstract
The endothelial glycocalyx plays an essential role in many physiological functions and is damaged after hemorrhage. Fluid resuscitation may further change the glycocalyx after an initial hemorrhage-induced degradation. Plasma levels of syndecan-1 and heparan sulfate have been used as indirect markers for glycocalyx degradation, but the extent to which these measures are representative of the events in the microcirculation is unknown. Using hemorrhage and a wide range of resuscitation fluids, we studied quantitatively the relationship between plasma biomarkers and changes in microvascular parameters, including glycocalyx thickness. Rats were bled 40% of total blood volume and resuscitated with seven different fluids (fresh whole blood, blood products, and crystalloids). Intravital microscopy was used to estimate glycocalyx thickness in >270 postcapillary venules from 58 cremaster preparations in 9 animal groups; other microvascular parameters were measured using noninvasive techniques. Systemic physiological parameters and blood chemistry were simultaneously collected. Changes in glycocalyx thickness were negatively correlated with changes in plasma levels of syndecan-1 ( r = −0.937) and heparan sulfate ( r = −0.864). Changes in microvascular permeability were positively correlated with changes in both plasma biomarkers ( r = 0.8, P < 0.05). Syndecan-1 and heparan sulfate were also positively correlated ( r = 0.7, P < 0.05). Except for diameter and permeability, changes in local microcirculatory parameters (red blood cell velocity, blood flow, and wall shear rate) did not correlate with plasma biomarkers or glycocalyx thickness changes. This work provides a quantitative framework supporting plasma syndecan-1 and heparan sulfate as valuable clinical biomarkers of glycocalyx shedding that may be useful in guiding resuscitation strategies following hemorrhage.
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Affiliation(s)
- Ivo P. Torres Filho
- Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Luciana N. Torres
- Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Christi Salgado
- Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Michael A. Dubick
- Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, Texas
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Adamik KN, Yozova ID, Regenscheit N. Controversies in the use of hydroxyethyl starch solutions in small animal emergency and critical care. J Vet Emerg Crit Care (San Antonio) 2016; 25:20-47. [PMID: 25655725 DOI: 10.1111/vec.12283] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 08/14/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To (1) review the development and medical applications of hydroxyethyl starch (HES) solutions with particular emphasis on its physiochemical properties; (2) critically appraise the available evidence in human and veterinary medicine, and (3) evaluate the potential risks and benefits associated with their use in critically ill small animals. DATA SOURCES Human and veterinary original research articles, scientific reviews, and textbook sources from 1950 to the present. HUMAN DATA SYNTHESIS HES solutions have been used extensively in people for over 30 years and ever since its introduction there has been a great deal of debate over its safety and efficacy. Recently, results of seminal trials and meta-analyses showing increased risks related to kidney dysfunction and mortality in septic and critically ill patients, have led to the restriction of HES use in these patient populations by European regulatory authorities. Although the initial ban on the use of HES in Europe has been eased, proof regarding the benefits and safety profile of HES in trauma and surgical patient populations has been requested by these same European regulatory authorities. VETERINARY DATA SYNTHESIS The veterinary literature is limited mostly to experimental studies and clinical investigations with small populations of patients with short-term end points and there is insufficient evidence to generate recommendations. CONCLUSIONS Currently, there are no consensus recommendations regarding the use of HES in veterinary medicine. Veterinarians and institutions affected by the HES restrictions have had to critically reassess the risks and benefits related to HES usage based on the available information and sometimes adapt their procedures and policies based on their reassessment. Meanwhile, large, prospective, randomized veterinary studies evaluating HES use are needed to achieve relevant levels of evidence to enable formulation of specific veterinary guidelines.
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Affiliation(s)
- Katja N Adamik
- Department of Veterinary Clinical Medicine, Division of Small Animal Emergency and Critical Care, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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Chen C, Chappell D, Annecke T, Conzen P, Jacob M, Welsch U, Zwissler B, Becker BF. Sevoflurane mitigates shedding of hyaluronan from the coronary endothelium, also during ischemia/reperfusion: an ex vivo animal study. HYPOXIA 2016; 4:81-90. [PMID: 27800510 PMCID: PMC5085283 DOI: 10.2147/hp.s98660] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Glycosaminoglycan hyaluronan (HA), a major constituent of the endothelial glycocalyx, helps to maintain vascular integrity. Preconditioning the heart with volatile anesthetic agents protects against ischemia/reperfusion injury. We investigated a possible protective effect of sevoflurane on the glycocalyx, especially on HA. The effect of pre-ischemic treatment with sevoflurane (15 minutes at 2% vol/vol gas) on shedding of HA was evaluated in 28 isolated, beating guinea pig hearts, subjected to warm ischemia (20 minutes at 37°C) followed by reperfusion (40 minutes), half with and half without preconditioning by sevoflurane. HA concentration was measured in the coronary effluent. Over the last 20 minutes of reperfusion hydroxyethyl starch (1 g%) was continuously infused and the epicardial transudate collected over the last 5 minutes for measuring the colloid extravasation. Additional hearts were fixed by perfusion after the end of reperfusion for immunohistology and electron microscopy. Sevoflurane did not significantly affect post-ischemic oxidative stress, but strongly inhibited shedding of HA during the whole period, surprisingly even prior to ischemia. Immunohistology demonstrated that heparan sulfates and SDC1 of the glycocalyx were also preserved by sevoflurane. Electron microscopy revealed shedding of glycocalyx caused by ischemia and a mostly intact glycocalyx in hearts exposed to sevoflurane. Coronary vascular permeability of the colloid hydroxyethyl starch was significantly decreased by sevoflurane vs the control. We conclude that application of sevoflurane preserves the coronary endothelial glycocalyx, especially HA, sustaining the vascular barrier against ischemic damage. This may explain beneficial effects associated with clinical use of volatile anesthetics against ischemia/reperfusion injury.
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Affiliation(s)
- Congcong Chen
- Department of Anesthesiology, Second Affiliated Hospital of Zhejiang University, Hangzhou, People's Republic of China; Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University, Munich, Germany
| | - Daniel Chappell
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany; Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University, Munich, Germany
| | - Thorsten Annecke
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany; Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University, Munich, Germany
| | - Peter Conzen
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany
| | - Matthias Jacob
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany; Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University, Munich, Germany
| | - Ulrich Welsch
- Institute of Anatomy, Ludwig-Maximilians-University, Munich, Germany
| | - Bernhard Zwissler
- Clinic of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany
| | - Bernhard F Becker
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University, Munich, Germany
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To use or not to use hydroxyethyl starch in intraoperative care: are we ready to answer the 'Gretchen question'? Curr Opin Anaesthesiol 2016; 28:370-7. [PMID: 25887196 DOI: 10.1097/aco.0000000000000194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The decision of the European Medicines Agency (EMA) against the use of hydroxyethyl starch (HES)-based volume replacement solutions in critically ill patients has led to a general uncertainty when dealing with HES-based solutions, even though HES-containing solutions can still be used for the treatment of hypovolaemia caused by acute (sudden) blood loss. This review discusses current evidence of the intraoperative use of HES-based solutions. RECENT FINDINGS HES solutions are often criticized for possible side-effects on the kidney, the coagulation system or tissue storage. Relevant differences exist between modern 6% HES 130/0.4 and older generation of starches. Because of pathophysiological differences between elective surgery and critical illness, the evidence on renal injury and coagulation impairment with HES administration cannot be generalized. Current data suggest that there is no clinically relevant impact of 6% HES 130/0.4 administration on perioperative renal function and coagulation. Over-resuscitation is a frequent problem associated with adverse outcomes. Due to the higher volume effect, fluid overload with HES is probably more harmful than with crystalloids, whereas goal-directed use of HES may be able to reduce intraoperative fluid accumulation and overload. SUMMARY The use of 6% HES 130/0.4 in elective surgery patients is associated with reduced fluid accumulation and no clinically relevant difference in bleeding or the rate of acute kidney injury as compared with crystalloid use alone. Current data do not allow a conclusion on mortality. As they provide no benefit, older starch preparations should not be used.
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