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Rahman MM, Islam F, -Or-Rashid MH, Mamun AA, Rahaman MS, Islam MM, Meem AFK, Sutradhar PR, Mitra S, Mimi AA, Emran TB, Fatimawali, Idroes R, Tallei TE, Ahmed M, Cavalu S. The Gut Microbiota (Microbiome) in Cardiovascular Disease and Its Therapeutic Regulation. Front Cell Infect Microbiol 2022; 12:903570. [PMID: 35795187 PMCID: PMC9251340 DOI: 10.3389/fcimb.2022.903570] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/09/2022] [Indexed: 12/11/2022] Open
Abstract
In the last two decades, considerable interest has been shown in understanding the development of the gut microbiota and its internal and external effects on the intestine, as well as the risk factors for cardiovascular diseases (CVDs) such as metabolic syndrome. The intestinal microbiota plays a pivotal role in human health and disease. Recent studies revealed that the gut microbiota can affect the host body. CVDs are a leading cause of morbidity and mortality, and patients favor death over chronic kidney disease. For the function of gut microbiota in the host, molecules have to penetrate the intestinal epithelium or the surface cells of the host. Gut microbiota can utilize trimethylamine, N-oxide, short-chain fatty acids, and primary and secondary bile acid pathways. By affecting these living cells, the gut microbiota can cause heart failure, atherosclerosis, hypertension, myocardial fibrosis, myocardial infarction, and coronary artery disease. Previous studies of the gut microbiota and its relation to stroke pathogenesis and its consequences can provide new therapeutic prospects. This review highlights the interplay between the microbiota and its metabolites and addresses related interventions for the treatment of CVDs.
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Naqvi S, Asar TO, Kumar V, Al-Abbasi FA, Alhayyani S, Kamal MA, Anwar F. A cross-talk between gut microbiome, salt and hypertension. Biomed Pharmacother 2021; 134:111156. [PMID: 33401080 DOI: 10.1016/j.biopha.2020.111156] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/21/2022] Open
Abstract
Cardiac disorders contribute to one of the major causes of fatality across the world. Hypertensive patients, even well maintained on drugs, possess a high risk to cardiovascular diseases. It is, therefore, highly important to identify different factors and pathways that lead to risk and progression of cardiovascular disorders. Several animals and human studies suggest that taxonomical alterations in the gut are involved in the cardiovascular physiology. In this article, with the help of various experimental evidences, we suggest that the host gut-microbiota plays an important in this pathway. Short chain fatty acids (SCFAs) and Trimethyl Amine -n-Oxide (TMAO) are the two major products of gut microbiome. SCFAs present a crucial role in regulating the blood pressure, while TMAO is involved in pathogenesis of atherosclerosis and other coronary artery diseases, including hypertension. We prove that there exists a triangular bridge connecting the gap between dietary salt, hypertension and gut microbiome. We also present some of the dietary interventions which can regulate and control microbiota that can prevent cardiovascular complications.We strongly believe that this article would improve the understanding the role of gut microbiota in hypertension, and will be helpful in the development of novel therapeutic strategies for prevention of hypertension through restoring gut microbiome homeostasis in the near future.
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Affiliation(s)
- Salma Naqvi
- Department of Biomedical Sciences, College of Medicine, Gulf Medical University, Ajman, United Arab Emirates
| | - Turky Omar Asar
- Department of Biochemistry, Faculty of Sciences, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Biology, College of Science and Arts at Alkamil, University of Jeddah, Jeddah, Saudi Arabia
| | - Vikas Kumar
- Natural Product Discovery Laboratory, Department of Pharmaceutical Sciences, Shalom Institute of Health and Allied Sciences. Sam Higginbottom University of Agriculture, Technology and Sciences, Naini, Prayagraj, 211007, India.
| | - Fahad A Al-Abbasi
- Department of Biochemistry, Faculty of Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sultan Alhayyani
- Department of Chemistry. College of Sciences & Arts, Rabigh King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammad Amjad Kamal
- Novel Global Community Educational Foundation, Australia; King Fahd Medical Research Center, King Abdulaziz University, P. O. Box 80216, Jeddah, 21589, Saudi Arabia; Enzymoics, 7 Peterlee Place, Hebersham, NSW, 27707, Australia
| | - Firoz Anwar
- Department of Biochemistry, Faculty of Sciences, King Abdulaziz University, Jeddah, Saudi Arabia.
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Hemodynamic correlates of nutritional indexes in heart failure. J Cardiol 2018; 71:557-563. [DOI: 10.1016/j.jjcc.2017.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/24/2017] [Accepted: 11/02/2017] [Indexed: 11/20/2022]
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Zhang X, Xuan W, Yin P, Wang L, Wu X, Wu Q. Gastric tonometry guided therapy in critical care patients: a systematic review and meta-analysis. Crit Care 2015; 19:22. [PMID: 25622724 PMCID: PMC4350856 DOI: 10.1186/s13054-015-0739-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 01/13/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction The value of gastric intramucosal pH (pHi) can be calculated from the tonometrically measured partial pressure of carbon dioxide (\documentclass[12pt]{minimal}
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\begin{document}$$ {P}_{C{O}_2} $$\end{document}PCO2) in the stomach and the arterial bicarbonate content. Low pHi and increase of the difference between gastric mucosal and arterial \documentclass[12pt]{minimal}
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\begin{document}$$ {P}_{C{O}_2} $$\end{document}PCO2 (\documentclass[12pt]{minimal}
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\begin{document}$$ {P}_{C{O}_2} $$\end{document}PCO2 gap) reflect splanchnic hypoperfusion and are good indicators of poor prognosis. Some randomized controlled trials (RCTs) were performed based on the theory that normalizing the low pHi or \documentclass[12pt]{minimal}
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\begin{document}$$ {P}_{C{O}_2} $$\end{document}PCO2 gap could improve the outcomes of critical care patients. However, the conclusions of these RCTs were divergent. Therefore, we performed a systematic review and meta-analysis to assess the effects of this goal directed therapy on patient outcome in Intensive Care Units (ICUs). Methods We searched PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov for randomized controlled trials comparing gastric tonometry guided therapy with control groups. Baseline characteristics of each included RCT were extracted and displayed in a table. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous outcomes. Another measure of effect (risk difference, RD) was used to reassess the effects of gastric tonometry on total mortality. We performed sensitivity analysis for total mortality. Continuous outcomes were presented as standardised mean differences (SMDs) together with 95% CIs. Results The gastric tonometry guided therapy significantly reduced total mortality (OR, 0.732; 95% CI, 0.536 to 0.999, P = 0.049; I2 = 0%; RD, −0.056; 95% CI, −0.109 to −0.003, P = 0.038; I2 = 0%) when compared with control groups. However, after excluding the patients with normal pHi on admission, the beneficial effects of this therapy did not exist (OR, 0.736; 95% CI 0.506 to 1.071, P = 0.109; I2 = 0%). ICU length of stay, hospital length of stay and days intubated were not significantly improved by this therapy. Conclusions In critical care patients, gastric tonometry guided therapy can reduce total mortality. Patients with normal pHi on admission contributed to the ultimate result of this outcome; it may indicate that these patients may be more sensitive to this therapy.
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Affiliation(s)
- Xin Zhang
- Department of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Surgery Building, Union Hospital, No. 1277, Jiefang Road, Wuhan City, Hubei Province, 430022, China.
| | - Wei Xuan
- Department of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Surgery Building, Union Hospital, No. 1277, Jiefang Road, Wuhan City, Hubei Province, 430022, China.
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, No. 13, Hangkong Road, Wuhan City, Hubei Province, 430030, China.
| | - Linlin Wang
- Department of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Surgery Building, Union Hospital, No. 1277, Jiefang Road, Wuhan City, Hubei Province, 430022, China.
| | - Xiaodan Wu
- Department of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Surgery Building, Union Hospital, No. 1277, Jiefang Road, Wuhan City, Hubei Province, 430022, China.
| | - Qingping Wu
- Department of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Surgery Building, Union Hospital, No. 1277, Jiefang Road, Wuhan City, Hubei Province, 430022, China.
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Vollmer C, Schwartges I, Behmke R, Bauer I, Picker O. Hypercapnia counteracts captopril-induced depression of gastric mucosal oxygenation. J Endocrinol 2013; 218:245-53. [PMID: 23757508 DOI: 10.1530/joe-13-0132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hypercapnia (HC) increases systemic oxygen delivery (DO2) and gastric mucosal oxygenation. However, it activates the renin-angiotensin-aldosterone system (RAAS), which conversely reduces mesenteric perfusion. The aims of this study were to evaluate the effect of RAAS inhibition during normocapnia and HC on oral and gastric mucosal oxygenation (μHbO2) and to assess the effect of blood pressure under these circumstances. Five dogs were repeatedly anesthetized to study the effects of ACE inhibition (ACE-I; 5 mg/kg captopril, followed by 0.25 mg/kg per h) on μHbO2 (reflectance spectrophotometry) and hemodynamic variables during normocapnia (end-tidal CO2=35 mmHg) and HC (end-expiratory carbon dioxide (etCO2)=70 mmHg). In the control group, the dogs were subjected to HC alone. To exclude the effects of reduced blood pressure, in one group, blood pressure was maintained at baseline values via titrated phenylephrine (PHE) infusion during HC and additional captopril infusion. ACE-I strongly reduced gastric μHbO2 from 72±2 to 65±2% and mean arterial pressure (MAP) from 64±2 to 48±4 mmHg, while DO2 remained unchanged. This effect was counteracted in the presence of HC, which increased gastric μHbO2 from 73±3 to 79±6% and DO2 from 15±2 to 22±4 ml/kg per min during ACE-I without differences during HC alone. However, MAP decreased similar to that observed during ACE-I alone from 66±3 to 47±5 mmHg, while left ventricular contractility (dPmax) increased from 492±63 to 758±119 mmHg/s. Titrated infusion of PHE had no additional effects on μHbO2. In summary, our data suggest that RAAS inhibition reduces gastric mucosal oxygenation in healthy dogs. HC not only abolishes this effect, but also increases μHbO2, DO2, and dPmax. The increase in μHbO2 during ACE-I under HC is in accordance with our results independent of blood pressure.
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Affiliation(s)
- Christian Vollmer
- Department of Anesthesiology, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany.
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Girbes ARJ, Groeneveld ABJ. Circulatory optimization of the patient with or at risk for shock. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.11.2.77.88] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lu HL, Wang ZY, Huang X, Han YF, Wu YS, Guo X, Kim YC, Xu WX. Excitatory regulation of angiotensin II on gastric motility and its mechanism in guinea pig. ACTA ACUST UNITED AC 2011; 167:170-6. [PMID: 21256873 DOI: 10.1016/j.regpep.2011.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 01/11/2011] [Accepted: 01/14/2011] [Indexed: 11/24/2022]
Abstract
In the present study, we investigated the effect of Ang II on gastric smooth muscle motility and its mechanism using intracellular recording and whole-cell patch clamp techniques. Ang II dose-dependently increased the tonic contraction and the frequency of spontaneous contraction in the gastric antral circular smooth muscles of guinea pig. ZD7155, an Ang II type 1 receptor (AT(1)R) blocker, completely blocked the effect of Ang II on the spontaneous contraction of gastric smooth muscle. In contrast, TTX, a sodium channel blocker, failed to block the effect. Furthermore, nicardipine, a voltage-gated Ca(2+)-channel antagonist, did not block the effect of Ang II on the tonic contraction of gastric smooth muscle, but external free-calcium almost completely blocked this effect. Both ryanodine, an inhibitor of calcium-induced Ca(2+) release (CICR) from ryanodine-sensitive calcium stores, and thapsigargin, which depletes calcium in calcium stores, almost completely blocked the effect of Ang II on tonic contraction. However, 2-APB, an inositol trisphosphate (IP(3)) receptor blocker, significantly, but not completely, blocked the Ang II effect on tonic contraction. We also determined that Ang II depolarized membrane potential and increased slow wave frequency in a dose-dependent manner. It also inhibited delayed rectifying potassium currents in a dose-dependent manner, but did not affect L-type calcium currents or calcium-activated potassium currents. These results suggest that Ang II plays an excitatory regulation in gastric motility via AT(1)R-IP(3) and the CICR signaling pathway. The Ang II-induced inhibition of delayed rectifying potassium currents that depolarize membrane potential is also involved in the potentiation of tonic contraction and the frequency of spontaneous contraction in the gastric smooth muscle of guinea pig.
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Affiliation(s)
- Hong-Li Lu
- Department of Physiology, Shanghai Jiaotong University School of Medicine, 800 Dongchuan Road, 328# Wenxuan Medical Building, Shanghai, 200240, China
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The small intestine: a critical linkage in pathophysiology of cardiac cachexia. Int J Cardiol 2010; 146:277-8. [PMID: 21112652 DOI: 10.1016/j.ijcard.2010.10.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 10/23/2010] [Indexed: 12/14/2022]
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Doerschug KC, Delsing AS, Schmidt GA, Ashare A. Renin-angiotensin system activation correlates with microvascular dysfunction in a prospective cohort study of clinical sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R24. [PMID: 20175923 PMCID: PMC2875539 DOI: 10.1186/cc8887] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 12/30/2009] [Accepted: 02/22/2010] [Indexed: 12/28/2022]
Abstract
Introduction Microvascular dysregulation characterized by hyporesponsive vessels and heterogeneous bloodflow is implicated in the pathogenesis of organ failure in sepsis. The renin-angiotensin system (RAS) affects the microvasculature, yet the relationships between RAS and organ injury in clinical sepsis remain unclear. We tested our hypothesis that systemic RAS mediators are associated with dysregulation of the microvasculature and with organ failure in clinical severe sepsis. Methods We studied 30 subjects with severe sepsis, and 10 healthy control subjects. Plasma was analyzed for plasma renin activity (PRA) and angiotensin II concentration (Ang II). Using near-infrared spectroscopy, we measured the rate of increase in the oxygen saturation of thenar microvascular hemoglobin after five minutes of induced forearm ischemia. In so doing, we assessed bulk microvascular hemoglobin influx to the tissue during reactive hyperemia. We studied all subjects 24 hours after the development of organ failure. We studied a subset of 12 subjects at an additional timepoint, eight hours after recognition of organ failure (early sepsis). Results After 24 hours of resuscitation to clinically-defined endpoints of preload and arterial pressure, Ang II and PRA were elevated in septic subjects and the degree of elevation correlated negatively with the rate of microvascular reoxygenation during reactive hyperemia. Early RAS mediators correlated with microvascular dysfunction. Early Ang II also correlated with the extent of organ failure realized during the first day of sepsis. Conclusions RAS is activated in clinical severe sepsis. Systemic RAS mediators correlate with measures of microvascular dysregulation and with organ failure.
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Affiliation(s)
- Kevin C Doerschug
- Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, Iowa, 52242, USA.
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Sandek A, Rauchhaus M, Anker SD, von Haehling S. The emerging role of the gut in chronic heart failure. Curr Opin Clin Nutr Metab Care 2008; 11:632-9. [PMID: 18685461 DOI: 10.1097/mco.0b013e32830a4c6e] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Chronic heart failure is a multisystem disease with increased sympathetic tone, an anabolic/catabolic dysbalance, and chronic inflammation. Recent studies suggest an altered morphology, permeability, and absorption of the digestive tract in chronic heart failure. Due to nonocclusive mesenterial ischaemia and disturbed intestinal microcirculation, bacterial endotoxin is thought to enter the bloodstream through the hypoperfused, oedematous gut wall, thereby triggering an inflammatory response. Circulating cytokines act as cardiosuppressors. Their plasma levels predict increased mortality in chronic heart failure. RECENT FINDINGS The present article focuses on specific alterations of the gastric, small intestinal, and large intestinal region in chronic heart failure. It describes the leaky intestinal barrier with an augmented bacterial biofilm that may contribute to chronic inflammation and malnutrition. Furthermore, we review methods for bowel perfusion measurement and potential therapeutic approaches. SUMMARY It remains unclear whether increased adherent bacteria in patients with chronic heart failure are a primary or secondary event and whether they contribute to systemic inflammation. Both lack of mucosal integrity with consecutive local and systemic inflammation and dysfunction of transport proteins may worsen the clinical symptoms of chronic heart failure. Therefore, future studies need to address the pathophysiology of the intestinal barrier whose reactivity seems to be crucial for heart function.
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Affiliation(s)
- Anja Sandek
- Applied Cachexia Research, Department of Cardiology, Campus Virchow-Klinikum, Charité, Berlin, Germany
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Rahal L, Garrido AG, Cruz RJ, Rocha e Silva M, Poli-de-Figueiredo LF. Systemic and regional hemodynamic effects of enalaprilat infusion in experimental normotensive sepsis. Braz J Med Biol Res 2006; 39:1205-15. [PMID: 16981048 DOI: 10.1590/s0100-879x2006000900008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Accepted: 06/28/2006] [Indexed: 11/21/2022] Open
Abstract
Angiotensin-converting enzyme inhibitors have been shown to improve splanchnic perfusion in distinct shock states. We hypothesized that enalaprilat potentiates the benefits of early fluid resuscitation in severe experimental sepsis, particularly in the splanchnic region. Anesthetized and mechanically ventilated mongrel dogs received an intravenous infusion of live Escherichia coli over a period of 30 min. Thereafter, two interventions were performed: fluid infusion (normal saline, 32 mL/kg over 30 min) and enalaprilat infusion (0.02 mg kg(-1) min(-1) for 60 min) in randomized groups. The following groups were studied: controls (fluid infusion, N = 4), E1 (enalaprilat infusion followed by fluid infusion, N = 5) and E2 (fluid infusion followed by enalaprilat infusion, N = 5). All animals were observed for a 120 min after bacterial infusion. Mean arterial pressure, cardiac output (CO), portal vein blood flow (PVBF), systemic and regional oxygen-derived variables, and lactate levels were measured. Rapid and progressive reductions in CO and PVBF were induced by the infusion of live bacteria, while minor changes were observed in mean arterial pressure. Systemic and regional territories showed a significant increase in oxygen extraction and lactate levels. Widening venous-arterial and portal-arterial pCO2 gradients were also detected. Fluid replacement promoted transient benefits in CO and PVBF. Enalaprilat after fluid resuscitation did not affect systemic or regional hemodynamic variables. We conclude that in this model of normotensive sepsis inhibition of angiotensin-converting enzyme did not interfere with the course of systemic or regional hemodynamic and oxygen-derived variables.
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Affiliation(s)
- L Rahal
- Divisão de Experimentação, Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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N/A, 王 岚. N/A. Shijie Huaren Xiaohua Zazhi 2006; 14:1721-1725. [DOI: 10.11569/wcjd.v14.i17.1721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Krack A, Sharma R, Figulla HR, Anker SD. The importance of the gastrointestinal system in the pathogenesis of heart failure. Eur Heart J 2005; 26:2368-74. [PMID: 15980032 DOI: 10.1093/eurheartj/ehi389] [Citation(s) in RCA: 193] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Chronic heart failure (CHF) is a multi-organ disease with increasing evidence for the involvement of the gastrointestinal (GI) system in this syndrome. In recent research, the gut has received very little attention from cardiologists as its role in the pathogenesis of cardiovascular disease is poorly understood. Intestinal ischaemia may play an important role in bacterial translocation by increasing bowel permeability. Decreased cardiac function can reduce bowel perfusion and so clearly impairs the function of the intestinal barrier. There is an increasing evidence to suggest that a 'leaky' bowel wall may lead to translocation of bacteria and/or endotoxin, which may be an important stimulus for inflammatory cytokine activation in CHF. Impaired functioning of the GI system may also contribute to malnutrition and cachexia in CHF. It is hoped that by improving our understanding of the role of the gut in cardiac disease will lead to the development of novel therapeutic strategies in the future.
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Affiliation(s)
- Andreas Krack
- Clinical Cardiology, NHLI, Imperial College School of Medicine, London, UK.
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Tweddell JS, Hoffman GM. Postoperative management in patients with complex congenital heart disease. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 5:187-205. [PMID: 11994879 DOI: 10.1053/pcsu.2002.31499] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Life-threatening problems occur in the neonate and infant after cardiac surgery because of the interplay of diminished cardiac output (CO), increased metabolic demand, inflammatory responses to cardiopulmonary bypass, and maladaptive responses to stress. Therefore, the postoperative management of patients with complex congenital heart defects is directed at optimization of oxygen delivery to maintain end-organ function and promote wound healing. Traditionally, assessment of circulation in the postoperative congenital heart patient has depended on indirect assessment of CO using parameters such as blood pressure, pulses, capillary refill, and urine output. Because of the limitations of indirect and observer-dependent assessment of CO, we rely on objective measures of tissue oxygen levels for the complex postoperative patient. We have found that continuous monitoring of the mixed venous saturation (SvO2) allows for identification of acute changes in systemic oxygen delivery and frequently precedes other indicators of decreased CO. The postoperative patient can be expected to have a period of decreasing CO, and the need for intervention should be anticipated because critical low output syndrome will develop in a subset of patients. Strategies for postoperative care are developed based on the diagnosis and procedure, but optimizing SvO2 is a consistent goal. A uniform approach to airway maintenance, vascular access, and drug infusions, all universal concerns during the perioperative period, minimizes the potential for these predictable and necessary interventions to result in morbidity or mortality. Management of the postoperative single ventricle patient targets stabilization of the systemic vascular resistance through the use of vasodilators to improve systemic perfusion and simplify ventilator management. Management of any individual patient should be driven by objective analysis of available data and must include efforts to re-evaluate the treatment plan as well as to identify unanticipated problems.
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Affiliation(s)
- James S Tweddell
- Divisions of Cardiothoracic Surgery, Pediatric Anesthesia, and Critical Care, The Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
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Abstract
IMPLICATIONS Insufficient splanchnic blood flow in critically ill patients is the result of a multitude of different diseases, treatment modalities and their interplay, and is associated with increased morbidity and mortality. A combination of diminished and heterogeneous mesenteric blood flow, impaired or exhausted regulatory mechanisms and adverse drug effects may coexist with normal systemic hemodynamics.
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Affiliation(s)
- Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital, Bern, Switzerland
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Wall P, Buising C, Henderson L, Freeman B, Vincent R, Albright J, Paradise N. Enalaprilat improves systemic and mesenteric blood flow during resuscitation from hemorrhagic shock in dogs. Shock 2003; 19:289-96. [PMID: 12630531 DOI: 10.1097/00024382-200303000-00015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We investigated the systemic and mesenteric cardiovascular effects of administering enalaprilat during resuscitation from hemorrhage. Dogs were hemorrhaged (mean arterial pressure [MAP] 40-45 mmHg for 30 min, then 30-35 mmHg for 30 min) and were then resuscitated with intermittent lactated Ringer's solution (200 mL/kg/h during first 40 min, and 60 mL/kg/h during the following 130 min, MAP 75-80 mmHg). A constant-rate infusion of saline with or without enalaprilat (0.02 mg/kg/h) was initiated after 40 min of resuscitation. Blood flows declined with hemorrhage, increased with resuscitation, and then declined during the initial 40 min of resuscitation. Enalaprilat administration resulted in blood flow increases not seen in the controls (ending values for cardiac index: 2.8 +/- 0.4 L/min/m2 vs. 1.6 +/- 0.3 L/min/m2; celiac arterial flow 314 +/- 66 L/min/m2 vs. 139 +/- 13 mL/min/m2; and portal venous flow 596 +/- 172 L/min/m2 vs. 414 +/- 81 mL/min/m2 for enalaprilat versus controls, respectively). The greater flows with enalaprilat appeared to be due to prevention of the increases in afterload noted in the controls (ending arterial elastance values 3.73 +/- 0.97 mmHg/m2/mL vs. 7.74 +/- 1.80 mmHg/m2/mL for enalaprilat versus controls, respectively). We conclude that administration of a constant-rate infusion of enalaprilat during resuscitation can be used to improve systemic and mesenteric blood flow.
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Affiliation(s)
- Piper Wall
- Department of Surgery Education and Trauma Research, Iowa Methodist Medical Center, Des Moines, Iowa 50309, USA
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Flint RS, Windsor JA. The role of the intestine in the pathophysiology and management of severe acute pancreatitis. HPB (Oxford) 2003; 5:69-85. [PMID: 18332961 PMCID: PMC2020573 DOI: 10.1080/13651820310001108] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The outcome of severe acute pancreatitis has scarcely improved in 10 years. Further impact will require new paradigms in pathophysiology and treatment. There is accumulating evidence to support the concept that the intestine has a key role in the pathophysiology of severe acute pancreatitis which goes beyond the notion of secondary pancreatic infection. Intestinal ischaemia and reperfusion and barrier failure are implicated in the development of multiple organ failure. DISCUSSION Conventional management of severe acute pancreatitis has tended to ignore the intestine. More recent attempts to rectify this problem have included 1) resuscitation aimed at restoring intestinal blood flow through the use of appropriate fluids and splanchnic-sparing vasoconstrictors or inotropes; 2) enteral nutrition to help maintain the integrity of the intestinal barrier; 3) selective gut decontamination and prophylactic antibiotics to reduce bacterial translocation and secondary infection. Novel therapies are being developed to limit intestinal injury, and these include antioxidants and anti-cytokine agents. This paper focuses on the role of the intestine in the pathogenesis of severe acute pancreatitis and reviews the implications for management.
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Affiliation(s)
- RS Flint
- Pancreatitis Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of AucklandAucklandNew Zealand
| | - JA Windsor
- Pancreatitis Research Group, Department of Surgery, Faculty of Medical and Health Sciences, University of AucklandAucklandNew Zealand
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Wall P, Buising C, Henderson L, Rickers T, Cárdenas A, Owens L, Timberlake G, Paradise N. Enalaprilat improves systemic cardiovascular parameters and mesenteric blood flow during hypotensive resuscitation from hemorrhagic shock in dogs. Shock 2002; 17:228-33. [PMID: 11900343 DOI: 10.1097/00024382-200203000-00012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Resuscitative interventions that improve mesenteric perfusion without causing instability in systemic arterial pressures may be helpful for improving trauma patient outcomes. Blocking angiotensin II formation with enalaprilat may be such an intervention. Two questions were addressed in this two-part study investigating resuscitation from hemorrhagic shock in dogs: Can systemic arterial pressures be maintained while administering a constant rate infusion of enalaprilat during resuscitation, and can enalaprilat improve cardiovascular status during resuscitation? Animals were hemorrhaged to a mean arterial pressure (MAP) of 40 to 45 mmHg for 30 min and then 30 to 35 mmHg for 30 min. Group I (n = 5) was resuscitated to a MAP 60 to 65 mmHg with enalaprilat (0.02 mg/kg/h). Group II was resuscitated to a MAP 40 to 45 mmHg with (n = 5) or without (n = 5) enalaprilat. Resuscitation in both groups consisted of intermittent intravenous lactated Ringer's solution (60 mL/kg/h) to reach and maintain the target MAPs. Systemic arterial pressures were unaffected by enalaprilat during resuscitation in Group I, allowing us to proceed to the second study. During severely hypotensive resuscitation (Group II), systemic arterial pressures were also stable and enalaprilat administration was associated with increases (P < or = 0.02) in cardiac index (+1.2 L/min/m2), stroke volume index (SVI) (+14.5 mL/m2), superior mesenteric artery flow (+80 mL/min), stroke work (+561 mmHg/mL/m2), and left ventricular power output (+55.7 mmHg/L/min/m2). Corresponding increases were not observed in controls. We conclude that administration of a constant rate infusion of enalaprilat during resuscitation can be accomplished without causing a hypotensive crisis. Since enalaprilat significantly improved cardiovascular status including mesenteric perfusion even during intentional hypotension, it has potential value for improving the treatment of trauma patients.
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Affiliation(s)
- Piper Wall
- Iowa Methodist Medical Center, Surgery Education Department and Trauma Research, Des Moines 50309, USA
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Broomé M, Aneman A, Lehtipalo S, Arnerlöv C, Johansson G, Winsö O, Biber B. Splanchnic vasoconstriction by angiotensin II is arterial pressure dependent. Acta Anaesthesiol Scand 2002; 46:57-63. [PMID: 11903073 DOI: 10.1034/j.1399-6576.2002.460110.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Our hypothesis was that splanchnic vasoconstriction by exogenous angiotensin II (Ang II) is significantly potentiated by local mechanisms increasing vasomotor tone and that splanchnic tissue oxygenation during administration of Ang II is perfusion pressure dependent. The aim was to study local splanchnic circulatory effects and tissue oxygenation during intravenous infusion of Ang II at different levels of regional arterial driving pressure in a whole-body large animal model. METHODS Ang II was infused in incremental doses (0-200 microg x h-1) in anaesthetised instrumented pigs (n=8). Mean superior mesenteric arterial pressure (PSMA) was adjusted by a local variable perivascular occluder. Perivascular ultrasound and laser-Doppler flowmetry were used for measurements of mesenteric venous blood flow and superficial intestinal blood flow, respectively. Intestinal oxygenation was evaluated by oxygen tissue tension (PtiO2) and lactate fluxes. RESULTS Ang II produced prominent and dose-dependent increases in mesenteric vascular resistance (RSMA) when the intestine was exposed to systemic arterial pressure, but Ang II increased RSMA only minimally when PSMA was artificially kept constant at a lower level (50 mmHg) by the occluder. Although Ang II decreased PtiO2 at a PSMA of 50 mmHg, splanchnic lactate production was not observed. CONCLUSION We demonstrate that splanchnic vasoconstriction by exogenous Ang II is dependent on arterial driving pressure, suggesting significant potentiation through autoregulatory increases in vasomotor tone. Intestinal hypoxaemia does not seem to occur during short-term infusion of Ang II in doses that significantly increases systemic arterial pressure.
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Affiliation(s)
- M Broomé
- Dept. of Surgical and Perioperative Science, Anaesthesiology and Intensive Care, Umeå University Hospital, Umeå, Sweden.
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Andel H, Rab M, Andel D, Felfernig M, Hörauf K, Felfernig D, Schramm W, Zimpfer M. Impact of early high caloric duodenal feeding on the oxygen balance of the splanchnic region after severe burn injury. Burns 2001; 27:389-93. [PMID: 11348751 DOI: 10.1016/s0305-4179(00)00134-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Early enteral nutrition is recommended in burned patients. Depending on the amount administered, enteral feeding causes an increase of intestinal oxygen-demand. Although early moderate enteral nutrition has been shown to be beneficial, early high calorie enteral nutrition might lead to an imbalance of the O(2)-balance of the gut since intestinal perfusion is decreased after major burns. In 20 severely burned patients during the first 48 h of early high caloric duodenal feeding an assessment of the CO(2)-gap between the arterial and the gastric CO(2), as parameter for the intestinal O(2)-balance, was performed. Time points were prior to starting the enteral nutrition (BASE) subsequently every 30 min after increasing the amount of nutrition administered and from the 11th to the 48th h after beginning of nutrition in intervals of 6 h. In none of the patients was the CO(2)-gap increased during the rapid increase of enteral nutrition. On the contrary the CO(2)-gap decreased significantly. We conclude that high caloric duodenal feeding in the early hypodynamic postburn phase does not have adverse effects on the oxygen balance of the intestine.
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Affiliation(s)
- H Andel
- Department of Anesthesiology and Intensive Care, Vienna Medical School, University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Broome M, Aneman A, Haney M, Häggmark S, Johansson G, Biber B. Angiotensin II mesenteric and renal vasoregulation: dissimilar modulatory effects with nitroprusside. Acta Anaesthesiol Scand 2000; 44:1238-45. [PMID: 11065204 DOI: 10.1034/j.1399-6576.2000.441009.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The role of systemic arterial pressure for the vascular effects of angiotensin II (Ang II) and the interactions between Ang II and perfusion pressure-dependent local vascular control mechanisms are not well understood. This study addresses these aspects of exogenous Ang II in the mesenteric and renal regional circulations. METHODS Ang II was infused in incremental doses (0-200 microg/h) in anesthetized instrumented pigs (n=10). Renal and portal blood flows were measured by perivascular ultrasound. In the second part of the study, sodium nitroprusside (SNP) was infused at doses titrated to keep mean arterial pressure constant, in spite of concurrent Ang II administration. RESULTS Powerful dose-dependent vasoconstrictions by Ang II were found in renal and mesenteric vascular beds (at highest Ang II doses vascular resistances increased by 109% and 88% respectively). Ang II-induced vasoconstriction was fully inhibited in the mesenteric, but not in the renal circulation, during conditions of constant mean arterial pressures achieved by SNP infusion. CONCLUSIONS Mesenteric, but not renal, vasoconstriction by Ang II was inhibited by pharmacological maintenance of perfusion pressure. This could reflect differences between these vascular beds as regards the importance of co-acting myogenic pressure-dependent vasoconstriction. Alternatively, as the drug chosen for pressure control, sodium nitroprusside, serves as a nitric oxide donor, the relative balance between nitric oxide-mediated vasodilation and Ang II-induced vasoconstriction could have regional differences.
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Affiliation(s)
- M Broome
- Department of Surgical and Perioperative Science, Anesthesiology and Intensive Care, Umeå University Hospital, Sweden.
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Schweizer A, Hohn L, Morel DR, Spiliopoulos A, Licker M. Postoperative fatal intestinal necrosis after enalapril treatment in a patient with rheumatoid arthritis. J Clin Anesth 2000; 12:72-4. [PMID: 10773514 DOI: 10.1016/s0952-8180(99)00125-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The inappropriate use of antihypertensive medications may cause hypotensive responses associated with organ failure. We describe a patient who developed nonocclusive splanchnic ischemia leading to death following the administration of enalapril to treat postoperative hypertension. The mechanisms and consequences of refractory hypotension induced by angiotensin-converting enzyme inhibitors are discussed.
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Affiliation(s)
- A Schweizer
- Division of Anesthesiology, University Hospital, Geneva, Switzerland
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Abstract
The prehospital phase of head injury, also called the critical phase, consists of trauma-induced apnea and stress catecholamine release. This immediate period after head injury remains poorly summarized in the literature and essentially ignored with respect to treatment. A MEDLINE search of the literature on apneustic response and catecholamine surge after head injury and a review of literature from my acquired references revealed 116 references (from more than 600) that were pertinent. Apnea induced by head injury produces hypoxia, hypercarbia, and subsequent cardiac failure and hypotension, which, along with substantially elevated catecholamine values, promote secondary mechanisms of organ injury. Treatment for this immediate period after head injury requires a rapid response to the scene of trauma and development of treatment options that can be instituted at the scene of injury.
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Affiliation(s)
- J L Atkinson
- Department of Neurologic Surgery, Mayo Clinic Rochester, Minn 55905, USA
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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.
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Affiliation(s)
- Gareth Ackland
- Centre for Anaesthesia, University College London, London, UK
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Aneman A, Bengtsson J, Snygg J, Holm M, Pettersson A, Fändriks L. Differentiation of the peptidergic vasoregulatory response to standardized splanchnic hypoperfusion by acute hypovolaemia or sepsis in anaesthetized pigs. ACTA PHYSIOLOGICA SCANDINAVICA 1999; 166:293-300. [PMID: 10468666 DOI: 10.1046/j.1365-201x.1999.00574.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study was performed to integratively investigate the vasoregulatory response during standardized splanchnic hypoperfusion in pigs. Splanchnic perfusion was reduced to 50% of baseline by: haemorrhage by 20 and 40% of the estimated total blood volume; femoral venous infusion of live E. coli to establish sepsis of systemic origin; portal venous infusion of live E. coli to establish sepsis of splanchnic origin. Invasive haemodynamic monitoring and radioimmunoassay analyses of arterial plasma concentrations of angiotensin II, endothelin-1 and atrial natriuretic peptide were carried out. Acute hypovolaemia reduced systemic and splanchnic vascular resistances following transient increases and increased angiotensin II levels (+587%), whereas endothelin-1 and atrial natriuretic peptide levels did not change significantly. Systemic sepsis following femoral venous infusion of E. coli resulted in increased splanchnic vascular resistance and increased levels of angiotensin II (+274%), endothelin-1 (+134%) and atrial natriuretic peptide (+185%). Infusion of E. coli via the portal venous route induced an increase in splanchnic vascular resistance associated with particularly elevated levels of angiotensin II (+1770%) as well as increased endothelin-1 (+201%) and atrial natriuretic peptide (+229%) concentrations. Hypovolaemia and sepsis, although standardized with a predefined level of splanchnic hypoperfusion, elicited differentiated cardiovascular and vasopeptidergic responses. Sepsis, particularly of portal origin, notably increased splanchnic vascular resistance related to increased production of the vasoconstrictors angiotensin II and endothelin-1. The role of atrial natriuretic peptide as a vasodilator seems to be of subordinate importance in hypovolaemia and sepsis.
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Affiliation(s)
- A Aneman
- Department of Anaesthesiology and Intensive Care, Sahlgrens University Hospital, Göteborg, Sweden
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Gastrointestinal PCO2 tonometry in 1998. Curr Opin Crit Care 1999. [DOI: 10.1097/00075198-199906000-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hepatosplanchnic perfusion. Curr Opin Crit Care 1999. [DOI: 10.1097/00075198-199906000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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FitzGerald JF, Fox SH, Civetta JM, Kirton OC, Hudson-Civetta JA. Strategies to prevent organ failure. Curr Opin Anaesthesiol 1999; 12:115-9. [PMID: 17013301 DOI: 10.1097/00001503-199904000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The gastrointestinal tract and the generalized inflammatory response initiated by severe injury or infection have been implicated in the pathophysiology of multiple-organ system failure. Once multiple-organ system failure has occurred, treatment focuses on supporting end-organ function. Recent studies have shown, however, that it may be possible to reduce the incidence and prevalence of multiple-organ system failure by controlling the reperfusion injury cascade, normalizing gastrointestinal blood flow and preserving the integrity of the gastrointestinal immune barrier.
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Miller PR, Kincaid EH, Meredith JW, Chang MC. Threshold values of intramucosal pH and mucosal-arterial CO2 gap during shock resuscitation. THE JOURNAL OF TRAUMA 1998; 45:868-72. [PMID: 9820694 DOI: 10.1097/00005373-199811000-00004] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The gastric intramucosal pH (pHi) and gastric mucosal-arterial CO2 gap (GAP) estimate visceral perfusion and predict outcome. Threshold values of these variables for use during resuscitation, however, remain poorly defined. The purpose of this study was to develop clinically derived cutoffs for both pHi and GAP for predicting death and multiple organ failure (MOF) in trauma patients. METHODS This was a cohort study of 114 consecutive trauma patients who had pHi determined at 24 hours after intensive care unit admission. The corresponding GAP for each of these values of pHi was obtained through chart review. Receiver operating characteristic curves were constructed for both pHi and GAP with respect to death and MOF. These curves were used to determine the value of each variable that maximized the sum of sensitivity and specificity in predicting outcome. chi2 tests and odds ratios were used to determine if significant differences in outcome occurred above and below these cutoff values. RESULTS Of 114 patients who had pHi determined at 24 hours after admission, 108 had corresponding GAP values available. The values of pHi and GAP that maximized sensitivity and specificity were 7.25 and 18 mm Hg, respectively. The odds ratio for pHi versus death was 4.6 and for pHi versus MOF was 4.3. The odds ratios for GAP versus death and MOF were 2.9 and 3.3, respectively. CONCLUSION In trauma patients, the ability to predict death and MOF is maximized at values of pHi less than 7.25 and GAP greater than 18 mm Hg. These values represent clinically derived cutoffs that should be useful for evaluating the adequacy of intestinal perfusion during resuscitation.
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Affiliation(s)
- P R Miller
- Department of General Surgery, The Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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