1
|
Jozwiak M. Alternatives to norepinephrine in septic shock: Which agents and when? JOURNAL OF INTENSIVE MEDICINE 2022; 2:223-232. [PMID: 36788938 PMCID: PMC9924015 DOI: 10.1016/j.jointm.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/28/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022]
Abstract
Vasopressors are the cornerstone of hemodynamic management in patients with septic shock. Norepinephrine is currently recommended as the first-line vasopressor in these patients. In addition to norepinephrine, there are many other potent vasopressors with specific properties and/or advantages that act on vessels through different pathways after activation of specific receptors; these could be of interest in patients with septic shock. Dopamine is no longer recommended in patients with septic shock because its use is associated with a higher rate of cardiac arrhythmias without any benefit in terms of mortality or organ dysfunction. Epinephrine is currently considered as a second-line vasopressor therapy, because of the higher rate of associated metabolic and cardiac adverse effects compared with norepinephrine; however, it may be considered in settings where norepinephrine is unavailable or in patients with refractory septic shock and myocardial dysfunction. Owing to its potential effects on mortality and renal function and its norepinephrine-sparing effect, vasopressin is recommended as second-line vasopressor therapy instead of norepinephrine dose escalation in patients with septic shock and persistent arterial hypotension. However, two synthetic analogs of vasopressin, namely, terlipressin and selepressin, have not yet been employed in the management of patients with septic shock, as their use is associated with a higher rate of digital ischemia. Finally, angiotensin Ⅱ also appears to be a promising vasopressor in patients with septic shock, especially in the most severe cases and/or in patients with acute kidney injury requiring renal replacement therapy. Nevertheless, due to limited evidence and concerns regarding safety (which remains unclear because of potential adverse effects related to its marked vasopressor activity), angiotensin Ⅱ is currently not recommended in patients with septic shock. Further studies are needed to better define the role of these vasopressors in the management of these patients.
Collapse
Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire l'Archet 1, 151 route Saint Antoine de Ginestière, 06200 Nice, France,Equipe 2 CARRES UR2CA – Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur UCA, 06103 Nice, France
| |
Collapse
|
2
|
Laghlam D, Jozwiak M, Nguyen LS. Renin-Angiotensin-Aldosterone System and Immunomodulation: A State-of-the-Art Review. Cells 2021; 10:cells10071767. [PMID: 34359936 PMCID: PMC8303450 DOI: 10.3390/cells10071767] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 12/11/2022] Open
Abstract
The renin–angiotensin system (RAS) has long been described in the field of cardiovascular physiology as the main player in blood pressure homeostasis. However, other effects have since been described, and include proliferation, fibrosis, and inflammation. To illustrate the immunomodulatory properties of the RAS, we chose three distinct fields in which RAS may play a critical role and be the subject of specific treatments. In oncology, RAS hyperactivation has been associated with tumor migration, survival, cell proliferation, and angiogenesis; preliminary data showed promise of the benefit of RAS blockers in patients treated for certain types of cancer. In intensive care medicine, vasoplegic shock has been associated with severe macro- and microcirculatory imbalance. A relative insufficiency in angiotensin II (AngII) was associated to lethal outcomes and synthetic AngII has been suggested as a specific treatment in these cases. Finally, in solid organ transplantation, both AngI and AngII have been associated with increased rejection events, with a regional specificity in the RAS activity. These elements emphasize the complexity of the direct and indirect interactions of RAS with immunomodulatory pathways and warrant further research in the field.
Collapse
|
3
|
Franzén S, Frithiof R. Pre-treatment with the angiotensin receptor 1 blocker losartan protects renal blood flow and oxygen delivery after propofol-induced hypotension in pigs. Sci Rep 2020; 10:17924. [PMID: 33087778 PMCID: PMC7578078 DOI: 10.1038/s41598-020-74640-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/24/2020] [Indexed: 01/28/2023] Open
Abstract
Hypotensive events are strongly correlated to the occurrence of perioperative acute kidney injury, but the underlying mechanisms for this are not completely elucidated. We hypothesised that anaesthesia-induced hypotension causes renal vasoconstriction and decreased oxygen delivery via angiotensin II-mediated renal vasoconstriction. Pigs were anaesthetised, surgically prepared and randomised to vehicle/losartan treatment (0.15 mg*kg−1). A deliberate reduction in arterial blood pressure was caused by infusion of propofol (30 mg*kg−1) for 10 min. Renal function and haemodynamics were recorded 60 min before and after hypotension. Propofol induced hypotension in all animals (p < 0.001). Renal blood flow (RBF) and renal oxygen delivery (RDO2) decreased significantly regardless of treatment but more so in vehicle-treated compared to losartan-treated (p = 0.001, p = 0.02, respectively). During recovery RBF and RDO2 improved to a greater extent in the losartan-treated compared to vehicle-treated (+ 28 ml*min−1, 95%CI 8–50 ml*min−1, p = 0.01 and + 3.1 ml*min−1, 95%CI 0.3–5.8 ml*min−1, p = 0.03, respectively). Sixty minutes after hypotension RBF and RDO2 remained depressed in vehicle-treated, as renal vascular resistance was still increased (p < 0.001). In losartan-treated animals RBF and RDO2 had normalised. Pre-treatment with losartan improved recovery of renal blood flow and renal oxygen delivery after propofol-induced hypotension, suggesting pronounced angiotensin II-mediated renal vasoconstriction during blood pressure reductions caused by anaesthesia.
Collapse
Affiliation(s)
- Stephanie Franzén
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala University Hospital, Entrance 78, 1st floor, 75185, Uppsala, Sweden.
| | - Robert Frithiof
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala University Hospital, Entrance 78, 1st floor, 75185, Uppsala, Sweden
| |
Collapse
|
4
|
Ospina-Tascón GA, Hernandez G, Alvarez I, Calderón-Tapia LE, Manzano-Nunez R, Sánchez-Ortiz AI, Quiñones E, Ruiz-Yucuma JE, Aldana JL, Teboul JL, Cavalcanti AB, De Backer D, Bakker J. Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis. Crit Care 2020; 24:52. [PMID: 32059682 PMCID: PMC7023737 DOI: 10.1186/s13054-020-2756-3] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 01/29/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Optimal timing for the start of vasopressors (VP) in septic shock has not been widely studied since it is assumed that fluids must be administered in advance. We sought to evaluate whether a very early start of VP, even without completing the initial fluid loading, might impact clinical outcomes in septic shock. METHODS A total of 337 patients with sepsis requiring VP support for at least 6 h were initially selected from a prospectively collected database in a 90-bed mixed-ICU during a 24-month period. They were classified into very-early (VE-VPs) or delayed vasopressor start (D-VPs) categories according to whether norepinephrine was initiated or not within/before the next hour of the first resuscitative fluid load. Then, VE-VPs (n = 93) patients were 1:1 propensity matched to D-VPs (n = 93) based on age; source of admission (emergency room, general wards, intensive care unit); chronic and acute comorbidities; and lactate, heart rate, systolic, and diastolic pressure at vasopressor start. A risk-adjusted Cox proportional hazard model was fitted to assess the association between VE-VPs and day 28 mortality. Finally, a sensitivity analysis was performed also including those patients requiring VP support for less than 6 h. RESULTS Patients subjected to VE-VPs received significantly less resuscitation fluids at vasopressor starting (0[0-510] vs. 1500[650-2300] mL, p < 0.001) and during the first 8 h of resuscitation (1100[500-1900] vs. 2600[1600-3800] mL, p < 0.001), with no significant increase in acute renal failure and/or renal replacement therapy requirements. VE-VPs was related with significant lower net fluid balances 8 and 24 h after VPs. VE-VPs was also associated with a significant reduction in the risk of death compared to D-VPs (HR 0.31, CI95% 0.17-0.57, p < 0.001) at day 28. Such association was maintained after including patients receiving vasopressors for < 6 h. CONCLUSION A very early start of vasopressor support seems to be safe, might limit the amount of fluids to resuscitate septic shock, and could lead to better clinical outcomes.
Collapse
Affiliation(s)
- Gustavo A Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia.
- Translational Medicine Laboratory in Critical Care and Advanced Trauma Surgery, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia.
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ingrid Alvarez
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Luis E Calderón-Tapia
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Ramiro Manzano-Nunez
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Alvaro I Sánchez-Ortiz
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Egardo Quiñones
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Juan E Ruiz-Yucuma
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - José L Aldana
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
- Translational Medicine Laboratory in Critical Care and Advanced Trauma Surgery, Fundación Valle del Lili, Universidad Icesi, Cali, Colombia
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique Hôpitaux de Paris, Université Paris-Sud, Paris, France
| | | | - Daniel De Backer
- Intensive Care Department, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Jan Bakker
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pulmonary and Critical Care, New York University, New York, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA
| |
Collapse
|
5
|
Jensen TW, Olsen NV. Angiotensin II during Experimentally Simulated Central Hypovolemia. Front Cardiovasc Med 2016; 3:6. [PMID: 26973842 PMCID: PMC4776081 DOI: 10.3389/fcvm.2016.00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/18/2016] [Indexed: 11/13/2022] Open
Abstract
Central hypovolemia, defined as diminished blood volume in the heart and pulmonary vascular bed, is still an unresolved problem from a therapeutic point of view. The development of pharmaceutical agents targeted at specific angiotensin II receptors, such as the non-peptidergic AT2-receptor agonist compound 21, is yielding many opportunities to uncover more knowledge about angiotensin II receptor profiles and possible therapeutic use. Cardiovascular, anti-inflammatory, and neuroprotective therapeutic use of compound 21 have been suggested. However, there has not yet been a focus on the use of these agents in a hypovolemic setting. We argue that the latest debates on the effect of angiotensin II during hypovolemia might guide for future studies, investigating the effect of such agents during experimentally simulated central hypovolemia. The purpose of this review is to examine the role of angiotensin II during episodes of central hypovolemia. To examine this, we reviewed results from studies with three experimental models of simulated hypovolemia: head up tilt table test, lower body negative pressure, and hemorrhage of animals. A systemic literature search was made with the use of PubMed/MEDLINE for studies that measured variables of the renin–angiotensin system or its effect during simulated hypovolemia. Twelve articles, using one of the three models, were included and showed a possible organ-protective effect and an effect on the sympathetic system of angiotensin II during hypovolemia. The results support the possible organ-protective vasodilatory role for the AT2-receptor during hypovolemia on both the kidney and the splanchnic tissue.
Collapse
Affiliation(s)
- Theo Walther Jensen
- Department of Neuroscience and Pharmacology, The Health Faculty, University of Copenhagen , Copenhagen , Denmark
| | - Niels Vidiendal Olsen
- Department of Neuroscience and Pharmacology, The Health Faculty, University of Copenhagen, Copenhagen, Denmark; Department of Neuroanaesthesia, The Neuroscience Centre, University Hospital of Copenhagen (Rigshospitalet), Copenhagen, Denmark
| |
Collapse
|
6
|
Garg M, Angus PW, Burrell LM, Herath C, Gibson PR, Lubel JS. Review article: the pathophysiological roles of the renin-angiotensin system in the gastrointestinal tract. Aliment Pharmacol Ther 2012; 35:414-28. [PMID: 22221317 PMCID: PMC7159631 DOI: 10.1111/j.1365-2036.2011.04971.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 11/29/2011] [Accepted: 12/13/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND The renin-angiotensin system (RAS) is a homeostatic pathway widely known to regulate cardiovascular and renal physiology; however, little is known about its influence in gastrointestinal tissues. AIM To elicit the anatomical distribution and physiological significance of the components of the RAS in the gastrointestinal tract. METHODS An extensive online literature review including Pubmed and Medline. RESULTS There is evidence for RAS involvement in gastrointestinal physiology and pathophysiology, with all the components required for autonomous regulation identified throughout the gastrointestinal tract. The RAS is implicated in the regulation of glucose, amino acid, fluid and electrolyte absorption and secretion, motility, inflammation, blood flow and possibly malignant disease within the gastrointestinal tract. Animal studies investigating the effects of RAS blockade in a range of conditions including inflammatory bowel disease, functional gut disorders, gastrointestinal malignancy and even intestinal ischaemia have been encouraging to date. Given the ready availability of drugs that modify the RAS and their excellent safety profile, an opportunity exists for investigation of their possible therapeutic role in a variety of human gastrointestinal diseases. CONCLUSIONS The gastrointestinal renin-angiotensin system appears to be intricately involved in a number of physiological processes, and provides a possible target for novel investigative and therapeutic approaches.
Collapse
Affiliation(s)
- M. Garg
- Department of Gastroenterology & HepatologyEastern HealthVic., Australia,Eastern Health Clinical SchoolMonash UniversityVic., Australia
| | - P. W. Angus
- Department of MedicineMelbourne UniversityVic., Australia,Gastroenterology and Liver Transplant UnitAustin HospitalVic., Australia
| | - L. M. Burrell
- Department of MedicineMelbourne UniversityVic., Australia
| | - C. Herath
- Department of MedicineMelbourne UniversityVic., Australia
| | - P. R. Gibson
- Department of Gastroenterology & HepatologyEastern HealthVic., Australia,Eastern Health Clinical SchoolMonash UniversityVic., Australia
| | - J. S. Lubel
- Department of Gastroenterology & HepatologyEastern HealthVic., Australia,Gastroenterology and Liver Transplant UnitAustin HospitalVic., Australia,Eastern Health Clinical SchoolMonash UniversityVic., Australia
| |
Collapse
|
7
|
Salgado DR, Rocco JR, Silva E, Vincent JL. Modulation of the renin-angiotensin-aldosterone system in sepsis: a new therapeutic approach? Expert Opin Ther Targets 2010; 14:11-20. [PMID: 20001206 DOI: 10.1517/14728220903460332] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE OF THE FIELD Severe sepsis is characterized by relative hypotension associated with a high cardiac output, peripheral vasodilation, and organ dysfunction. The renin-angiotensin-aldosterone system (RAAS) is primarily activated to increase blood pressure, but recently potential pro-inflammatory effects of angiotensin II have attracted interest because of the reported association between angiotensin II levels and organ failure and mortality in sepsis. RAAS antagonists could represent a new therapeutic option in this setting. AREAS COVERED IN THIS REVIEW The role of RAAS activation in severe sepsis and septic shock, and the potential benefits (and risks) of using RAAS antagonists. WHAT THE READER WILL GAIN Insight into RAAS function in severe sepsis and the potential for RAAS inhibitors to be used as an adjunctive therapy in patients with severe sepsis, with discussion of promising results from animal models of sepsis. TAKE HOME MESSAGE Use of RAAS antagonists is an emerging therapeutic option in severe sepsis because these agents may reduce endothelial damage, organ failure, and mortality. However, timing of administration of RAAS antagonists is important because reduced RAAS function may contribute to refractive hypotension later on in septic shock and benefits of RAAS antagonists seem to be restricted to the early phases of sepsis.
Collapse
Affiliation(s)
- Diamantino Ribeiro Salgado
- Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Department of Internal Medicine, Cidade Universitària - Ilha do Fundão - Rio de Janeiro, Brazil.
| | | | | | | |
Collapse
|
8
|
The angiotensin II type 2 receptor and the gastrointestinal tract. J Renin Angiotensin Aldosterone Syst 2009; 11:43-8. [DOI: 10.1177/1470320309347788] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The renin-angiotensin system (RAS) is well known for its vital involvement in body fluid homeostasis and circulation. However, very little research has been devoted to the impact of this regulatory system on the gastrointestinal (GI) system. This is surprising because the GI tract is fundamental for the intake and excretion of fluid and electrolytes (and nutrients), and it accommodates a large proportion of bodily haemodynamics and host defence systems. The RAS is well expressed and active in the GI tract, although the exact roles for the key mediator angiotensin II (Ang II) and its receptors in general, and the type 2 (AT 2) receptor in particular, are not completely settled. There are several reports showing Ang II regulation of intestinal fluid and electrolyte transport. For example, mucosaprotective duodenal bicarbonate-rich secretion is inhibited by Ang II via type 1 (AT1) receptor-mediated facilitation of sympathoadrenergic activity, but this secretory process can also be stimulated by Ang II via AT2 receptors. Novel data from human oesophagus and jejunum suggest that the AT1 receptor mediates muscular contractions and that the AT2 receptor regulates epithelial functions. Data are accumulating suggesting involvement of AT1 and AT2 receptors in GI inflammation and carcinogenesis. The picture of the RAS and AT 2 receptor in the GI tract is, however, far from complete. Much more basic research is needed with regard to GI pathophysiology before concluding clinical significance and potential applicability of pharmacological interferences with the RAS.
Collapse
|
9
|
Laesser M, Oi Y, Ewert S, Fändriks L, Aneman A. The angiotensin II receptor blocker candesartan improves survival and mesenteric perfusion in an acute porcine endotoxin model. Acta Anaesthesiol Scand 2004; 48:198-204. [PMID: 14995942 DOI: 10.1111/j.0001-5172.2004.00283.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Blockade of the angiotensin II type 1 (AT1) receptor has been demonstrated to ameliorate splanchnic hypoperfusion in acute experimental circulatory failure. This study focused on hemodynamic changes and survival in pigs treated with AT1 blockade prior to or during acute endotoxinemia. METHODS Escherichia coli lipopolysaccharide endotoxin was infused in anesthetized and mechanically ventilated pigs. Systemic, renal, mesenteric and jejunal mucosal perfusion as well as systemic oxygen and acid-base balance were monitored. The selective AT1 receptor blocker candesartan was administered prior to as well as during endotoxinemia. Control animals received the saline vehicle. RESULTS Pre-treatment with candesartan resulted in higher survival rate (83%, 10 out of 12 animals) compared with 50% (6 of 12) in control animals and 27% (3 of 11) in animals treated during endotoxinemia. Pre-treatment with candesartan resulted in higher cardiac output, mixed venous oxygen saturation, arterial standard base-excess, portal venous blood flow during endotoxin infusion compared with controls and animals treated during endotoxinemia. No adverse effects were found on neither systemic nor renal circulation. CONCLUSION The favorable results of AT1 receptor blockade prior to endotoxinemia are lost when blockade is established during endotoxinemia demonstrating the importance of the renin-angiotensin system and its dynamic involvement in acute endotoxinemic shock.
Collapse
Affiliation(s)
- M Laesser
- Department of Physiology, Göteborg University, Göteborg, Sweden
| | | | | | | | | |
Collapse
|
10
|
McCloskey CA, Zuckerbraun BS, Gallo DJ, Vodovotz Y, Billiar TR. A Role for Angiotensin II in the Activation of Extracellular Signal-Regulated Kinases in the Liver During Hemorrhagic Shock. Shock 2003; 20:316-9. [PMID: 14501944 DOI: 10.1097/01.shk.0000084341.58020.c5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hemorrhagic shock (HS) is a complex process that initiates a global stress response. However, the earliest signaling pathways responsible for initiating this response remain unidentified. We have investigated the involvement of the extracellular signal-regulated kinases (ERK 1/2; also known as p42/44) and their activation in the liver by angiotensin II in the early signal transduction after HS. Hemorrhage of mice to 25 mmHg for 30 min was associated with the activation of ERK 1/2 in the liver, and this was accompanied by a 6.7-fold elevation of circulating angiotensin II levels. Similar results were obtained in rats. Both the angiotensin II levels and ERK 1/2 phosphorylation were suppressed by administration of an angiotensin-converting enzyme inhibitor peptide. Plasma from shocked rats, but not shocked rats treated with the angiotensin-converting enzyme inhibitor, increased ERK 1/2 phosphorylation in cultured hepatocytes. Together, these data suggest that angiotensin II is an important stimulus for ERK 1/2 activation in the liver during HS.
Collapse
Affiliation(s)
- Carol A McCloskey
- Department of Surgery, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pennsylvania 15213, USA.
| | | | | | | | | |
Collapse
|
11
|
Yokoyama Y, Schwacha MG, Bland KI, Chaudry IH. Effect of estradiol administration on splanchnic perfusion after trauma-hemorrhage and sepsis. Curr Opin Crit Care 2003; 9:137-42. [PMID: 12657977 DOI: 10.1097/00075198-200304000-00010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review focuses on the latest mechanistic understanding of the effects of estradiol on the splanchnic circulation and the possibility of estradiol treatment as an adjunct for the treatment of trauma-hemorrhage and sepsis. RECENT FINDINGS Systemic hypotension induced by shock accompanies marked alterations in blood flow to various organs. Decreased splanchnic perfusion is frequently observed after insults, such as severe hemorrhage or sepsis, which leads to the destruction of the intestinal mucosal barrier and hepatic dysfunction. Studies suggest that estradiol acts as a facilitator of the intestinal blood flow via the increased production of nitric oxide, decreased production of vasoconstrictors, attenuated neutrophil adhesion, and decreased formation of oxygen free radicals. SUMMARY Trauma-hemorrhage results in decreased circulating blood volume. In contrast, sepsis is an inflammatory state mainly mediated by bacterial products. However, these divergent insults show similar pathophysiologic alterations in terms of the splanchnic circulation. Because estradiol effectively protects the organs from circulatory failure after various adverse circulatory conditions, many studies are being performed to clarify the molecular mechanism of estradiol action with regard to tissue circulation. Estradiol improves the macro- and microcirculation of the splanchnic organs by multiple mechanisms. Nonetheless, it remains unclear which mechanism plays the most important role in the treatment of trauma-hemorrhage and sepsis. Additional studies are required to elucidate the precise mechanism of estradiol action and to determine the usefulness of estradiol treatment for severe hemorrhage and sepsis in patients.
Collapse
Affiliation(s)
- Yukihiro Yokoyama
- Center for Surgical Research and Department of Surgery, University of Alabama, Birmingham 35294-0019, USA
| | | | | | | |
Collapse
|
12
|
Burgener D, Laesser M, Treggiari-Venzi M, Oi Y, Jolliet P, Strasser S, Hadengue A, Aneman A. Endothelin-1 blockade corrects mesenteric hypoperfusion in a porcine low cardiac output model. Crit Care Med 2001; 29:1615-20. [PMID: 11505140 DOI: 10.1097/00003246-200108000-00019] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study the importance of endothelin-1-induced vasoconstriction in a model of acute and maintained low cardiac output, by investigating regional changes within the mesenteric and particularly the intestinal mucosal circulation. DESIGN Prospective, controlled animal study. SETTING University-affiliated research laboratory. SUBJECTS Thirteen fasted, anesthetized, mechanically ventilated landrace pigs. MEASUREMENTS AND MAIN RESULTS Cardiac output, portal venous blood flow, renal arterial flow, jejunal mucosal microcirculation by laser Doppler flowmetry, jejunal capnotonometry (Pco2 gap), and jejunal mucosal oxygenation (tPo2) were monitored. Cardiac tamponade was established to reduce portal venous blood flow to a preset end point at two thirds of baseline. Measurements were made at baseline, after 90 mins of cardiac tamponade, and 90 mins after the administration of the combined endothelinA/endothelinB antagonist tezosentan at 1 mg.kg-1.hr-1 during tamponade in seven animals. Six animals served as time controls and received only the vehicle. Cardiac tamponade decreased portal venous blood flow, renal arterial flow, and laser Doppler flowmetry, whereas the Pco2 gap increased. The change in tPo2 failed to gain statistical significance (p =.08). Administration of tezosentan during tamponade restored portal venous blood flow and laser Doppler flowmetry to baseline values, increased tPo2 above baseline, and decreased Pco2 gap. No effect on renal arterial flow was observed. Investigated variables remained unchanged in control animals after induction of cardiac tamponade. CONCLUSIONS Endothelin-1 blockade in acute cardiac failure improves mesenteric, but not renal, perfusion, illustrating the regional importance of endothelin-1-induced vasoconstriction. Importantly, endothelin-1 blockade restored mucosal blood flow and oxygenation, which might be particularly interesting considering the implications for maintenance of mucosal barrier integrity in low output states.
Collapse
Affiliation(s)
- D Burgener
- Division of Gastroenterology and Hepatology, Geneva University Hospital, 1211 Geneva 4, Switzerland.
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Ackland G, Grocott MPW, Mythen MG. Understanding gastrointestinal perfusion in critical care: so near, and yet so far. Crit Care 2000; 4:269-81. [PMID: 11094506 PMCID: PMC137256 DOI: 10.1186/cc709] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2000] [Accepted: 08/08/2000] [Indexed: 02/08/2023] Open
Abstract
An association between abnormal gastrointestinal perfusion and critical illness has been suggested for a number of years. Much of the data to support this idea comes from studies using gastric tonometry. Although an attractive technology, the interpretation of tonometry data is complex. Furthermore, current understanding of the physiology of gastrointestinal perfusion in health and disease is incomplete. This review considers critically the striking clinical data and basic physiological investigations that support a key role for gastrointestinal hypoperfusion in initiating and/or perpetuating critical disease.
Collapse
Affiliation(s)
- Gareth Ackland
- Centre for Anaesthesia, University College London, London, UK
| | | | | |
Collapse
|