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O’Hara KC, Ranches J, Roche LM, Schohr TK, Busch RC, Maier GU. Impacts from Wildfires on Livestock Health and Production: Producer Perspectives. Animals (Basel) 2021; 11:ani11113230. [PMID: 34827962 PMCID: PMC8614491 DOI: 10.3390/ani11113230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Wildfires are increasing in frequency and severity across the Western United States. Efforts to understand the health impacts on humans are widespread and expanding; however, very little is known about the impact of wildfires and smoke exposure on livestock. This work presents the results of a survey of cattle, sheep, and goat producers in California, Oregon, and Nevada, on their experiences during the 2020 wildfire season. While few direct impacts of fires were reported among the 70 responses, 26% of respondents reported they had to evacuate livestock and 19% reported pasture losses. Indirect losses from smoke exposure, including pneumonia and reproductive losses were reported more broadly. This preliminary work highlights the need to better understand impacts of wildfires on livestock and how policy changes can help support the livestock production industry through these crises. Abstract Wildfires are increasing in frequency and severity across the Western United States. However, there is limited information available on the impacts these fires are having on the livelihood of livestock producers and their animals. This work presents the results of a survey evaluating the direct and indirect impacts of the 2020 wildfire season on beef cattle, dairy cattle, sheep, and goat, producers in California, Oregon, and Nevada. Seventy completed surveys were collected between May and July 2021. While dairy producers reported no direct impacts from the fires, beef, sheep, and goat producers were impacted by evacuations and pasture lost to fires. Only beef producers reported losses due to burns and burn-associated deaths or euthanasia. Dairy, beef, sheep, and goat producers observed reduced conception, poor weight gain, and drops in milk production. All but dairy producers also observed pneumonia. Lower birthweights, increased abortion rates, and unexplained deaths were reported in beef cattle, sheep, and goats. This work documents the wide-ranging impacts of wildfires on livestock producers and highlights the need for additional work defining the health impacts of fire and smoke exposure in livestock, as well as the policy changes needed to support producers experiencing direct and indirect losses.
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Affiliation(s)
- Kathleen C. O’Hara
- Center for Animal Disease Modeling and Surveillance (CADMS), School of Veterinary Medicine, University of California, Davis, CA 95616, USA;
| | - Juliana Ranches
- Eastern Oregon Agricultural Research Center (EOARC), Oregon State University, Burns, OR 97720, USA;
| | - Leslie M. Roche
- Department of Plant Sciences, University of California Davis, Davis, CA 95616, USA;
| | - Tracy Kay Schohr
- University of California Cooperative Extension, Plumas-Sierra-Butte Counties, Quincy, CA 96130, USA;
| | - Roselle C. Busch
- Department of Population Health & Reproduction, School of Veterinary Medicine, University of California Davis, Davis, CA 95616, USA;
| | - Gabriele U. Maier
- Department of Population Health & Reproduction, School of Veterinary Medicine, University of California Davis, Davis, CA 95616, USA;
- Correspondence:
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Zhang S, Huang X, Xiu H, Zhang Z, Zhang K, Cai J, Cai Z, Chen Z, Zhang Z, Cui W, Zhang G, Xiang M. The attenuation of Th1 and Th17 responses via autophagy protects against methicillin-resistant Staphylococcus aureus-induced sepsis. Microbes Infect 2021; 23:104833. [PMID: 33930602 DOI: 10.1016/j.micinf.2021.104833] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 02/07/2023]
Abstract
Whether autophagy affects methicillin-resistant Staphylococcus aureus (MRSA)-induced sepsis and the associated mechanisms are largely unknown. This study investigated the role of autophagy in MRSA-induced sepsis. The levels of microtubule-associated protein light chain 3 (LC3)-II/I, Beclin-1 and p62 after USA300 infection were examined by Western blotting and immunohistochemical staining. Bacterial burden analysis, hematoxylin-eosin staining, and Kaplan-Meier analysis were performed to evaluate the effect of autophagy on MRSA-induced sepsis. IFN-γ and IL-17 were analyzed by ELISA, and CD4+ T cell differentiation was assessed by flow cytometry. Our results showed that LC3-II/I and Beclin-1 were increased, while p62 was decreased after infection. Survival rates were decreased in the LC3B-/- and Beclin-1+/- groups, accompanied by worsened organ injuries and increased IFN-γ and IL-17 levels, whereas rapamycin alleviated organ damage, decreased IFN-γ and IL-17 levels, and improved the survival rate. However, there was no significant difference in bacterial burden. Flow cytometric analysis showed that rapamycin treatment decreased the frequencies of Th1 and Th17 cells, whereas these cells were upregulated in the LC3B-/- and Beclin-1+/- groups. Therefore, autophagy plays a protective role in MRSA-induced sepsis, which may be partly associated with the alleviation of organ injuries via the downregulation of Th1 and Th17 responses. These results provide a nonantibiotic treatment strategy for sepsis.
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Affiliation(s)
- Shufang Zhang
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang 310009, China
| | - Xiaofang Huang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Huiqing Xiu
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Jiachang Cai
- Clinical Microbiology Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zhijian Cai
- Institute of Immunology, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Zhanghui Chen
- Clinical Research Center, Zhanjiang Central Hospital, Guangdong Medical University, Zhanjiang 510004, China
| | - Zhaocai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Wei Cui
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Gensheng Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
| | - Meixiang Xiang
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang 310009, China.
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Duburcq T, Durand A, Tournoys A, Gnemmi V, Bonner C, Gmyr V, Hubert T, Pattou F, Jourdain M. Single Low Dose of Human Recombinant Antithrombin (ATryn) has no Impact on Endotoxin-Induced Disseminated Intravascular Coagulation: An Experimental Randomized Open Label Controlled Study. Shock 2019; 52:e60-e67. [PMID: 30325871 DOI: 10.1097/shk.0000000000001274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Antithrombin (AT) III physiological levels are decreased during septic shock and supplementation therapy could therefore be beneficial. OBJECTIVE We hypothesized that the use of recombinant human AT could reduce disseminated intravascular coagulation (DIC) occurrence. METHODS We conducted a randomized open label controlled experimental study. Ten female "Large White" pigs were challenged with i.v. infusion of Escherichia coli endotoxin. Two groups of 5 pigs were randomly assigned to receive either recombinant human AT 100 U/kg over 30 min (ATryn group) or 0.9% saline (control group). AT III levels, coagulation, hemostasis, inflammation parameters, hemodynamics, and microcirculatory parameters were measured over a 5-h period. Immediately after euthanasia, kidneys were withdrawn for histology evaluation. Statistical analysis was performed with nonparametric tests and Dunn's test for multiple comparisons. RESULTS AT III activity was significantly higher in the ATryn group than in the control group from 60% (213% [203-223] vs. 104% [98-115], P = 0.008, respectively) to 300 min (115% [95-124] vs. 79% [67-93], P = 0.03). Recombinant human AT supplementation had no impact on hemodynamics, microcirculatory parameters, and sequential changes of coagulation parameters (platelet count, fibrinogen level, thrombin-AT complexes, and von Willebrand factor). Interleukin 6 and tumor necrosis factor α values were statistically the same for both groups throughout the study. Percentage of thrombosed glomeruli and percentage of thrombosed capillary in glomerulus were not significantly different between both groups. CONCLUSIONS In our model of endotoxic shock, a single low dose of recombinant human AT did not prevent DIC occurrence, severity, inflammatory profile, or hemodynamic alterations.
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Affiliation(s)
- Thibault Duburcq
- INSERM UMR 1190, Translational Research for Diabetes, European Genomic Institute for Diabetes, University of Lille, Lille, France
- CHU Lille, Centre de Réanimation, Lille, France
| | | | | | | | - Caroline Bonner
- INSERM UMR 1190, Translational Research for Diabetes, European Genomic Institute for Diabetes, University of Lille, Lille, France
| | - Valery Gmyr
- INSERM UMR 1190, Translational Research for Diabetes, European Genomic Institute for Diabetes, University of Lille, Lille, France
| | - Thomas Hubert
- INSERM UMR 1190, Translational Research for Diabetes, European Genomic Institute for Diabetes, University of Lille, Lille, France
| | - François Pattou
- INSERM UMR 1190, Translational Research for Diabetes, European Genomic Institute for Diabetes, University of Lille, Lille, France
- Institut Pasteur de Lille, Lille, France
| | - Mercedes Jourdain
- INSERM UMR 1190, Translational Research for Diabetes, European Genomic Institute for Diabetes, University of Lille, Lille, France
- CHU Lille, Centre de Réanimation, Lille, France
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Gupta K, Mehrotra M, Kumar P, Gogia AR, Prasad A, Fisher JA. Smoke Inhalation Injury: Etiopathogenesis, Diagnosis, and Management. Indian J Crit Care Med 2018; 22:180-188. [PMID: 29657376 PMCID: PMC5879861 DOI: 10.4103/ijccm.ijccm_460_17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Smoke inhalation injury is a major determinant of morbidity and mortality in fire victims. It is a complex multifaceted injury affecting initially the airway; however, in short time, it can become a complex life-threatening systemic disease affecting every organ in the body. In this review, we provide a summary of the underlying pathophysiology of organ dysfunction and provide an up-to-date survey of the various critical care modalities that have been found beneficial in caring for these patients. Major pathophysiological change is development of edema in the respiratory tract. The tracheobronchial tree is injured by steam and toxic chemicals, leading to bronchoconstriction. Lung parenchyma is damaged by the release of proteolytic elastases, leading to release of inflammatory mediators, increase in transvascular flux of fluids, and development of pulmonary edema and atelectasis. Decreased levels of surfactant and immunomodulators such as interleukins and tumor-necrosis-factor-α accentuate the injury. A primary survey is conducted at the site of fire, to ensure adequate airway, breathing, and circulation. A good intravenous access is obtained for the administration of resuscitation fluids. Early intubation, preferably with fiberoptic bronchoscope, is prudent before development of airway edema. Bronchial hygiene is maintained, which involves therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation. Pharmacological agents such as beta-2 agonists, racemic epinephrine, N-acetyl cysteine, and aerosolized heparin are used for improving oxygenation of lungs. Newer agents being tested are perfluorohexane, porcine pulmonary surfactant, and ClearMate. Early diagnosis and treatment of smoke inhalation injury are the keys for better outcome.
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Affiliation(s)
- Kapil Gupta
- Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mayank Mehrotra
- Department of Anesthesia, Integral Institute of Medical Sciences, Lucknow, India
| | - Parul Kumar
- Department of Emergency Medicine, Sinai Health Systems, Chicago, USA
| | - Anoop Raj Gogia
- Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Arun Prasad
- Department of Anaesthesia, University Health Network, and University of Toronto, Toronto, Canada
| | - Joseph Arnold Fisher
- Department of Anaesthesia, University Health Network, and University of Toronto, Toronto, Canada
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Helms J, Clere-Jehl R, Bianchini E, Le Borgne P, Burban M, Zobairi F, Diehl JL, Grunebaum L, Toti F, Meziani F, Borgel D. Thrombomodulin favors leukocyte microvesicle fibrinolytic activity, reduces NETosis and prevents septic shock-induced coagulopathy in rats. Ann Intensive Care 2017; 7:118. [PMID: 29222696 PMCID: PMC5722785 DOI: 10.1186/s13613-017-0340-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 11/27/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Septic shock-induced disseminated intravascular coagulation is responsible for increased occurrence of multiple organ dysfunction and mortality. Immunothrombosis-induced coagulopathy may contribute to hypercoagulability. We aimed at determining whether recombinant human thrombomodulin (rhTM) could control exaggerated immunothrombosis by studying procoagulant responses, fibrinolysis activity borne by microvesicles (MVs) and NETosis in septic shock. METHODS In a septic shock model after a cecal ligation and puncture-induced peritonitis (H0), rats were treated with rhTM or a placebo at H18, resuscitated and monitored during 4 h. At H22, blood was sampled to perform coagulation tests, to characterize MVs and to detect neutrophils extracellular traps (NETs). Lungs were stained with hematoxylin-eosin for inflammatory injury assessment. RESULTS Coagulopathy was attenuated in rhTM-treated septic rats compared to placebo-treated rats, as attested by a significant decrease in procoagulant annexin A5+-MVs and plasma procoagulant activity of phospholipids and by a significant increase in antithrombin levels (84 ± 8 vs. 64 ± 6%, p < 0.05), platelet count (582 ± 157 vs. 319 ± 91 × 109/L, p < 0.05) and fibrinolysis activity borne by MVs (2.9 ± 0.26 vs. 0.48 ± 0.29 U/mL urokinase, p < 0.05). Lung histological injury score showed significantly less leukocyte infiltration. Decreased procoagulant activity and lung injury were concomitant with decreased leukocyte activation as attested by plasma leukocyte-derived MVs and NETosis reduction after rhTM treatment (neutrophil elastase/DNA: 93 ± 33 vs. 227 ± 48 and citrullinated histones H3/DNA: 96 ± 16 vs. 242 ± 180, mOD for 109 neutrophils/L, p < 0.05). CONCLUSION Thrombomodulin limits procoagulant responses and NETosis and at least partly restores hemostasis control during immunothrombosis. Neutrophils might thus stand as a promising therapeutic target in septic shock-induced coagulopathy.
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Affiliation(s)
- Julie Helms
- UMR INSERM 1176-Universite Paris Sud, Hôpital Bicêtre, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
- Réanimation Médicale, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, 20 Rue Leblanc, 75015 Paris, France
| | - Raphaël Clere-Jehl
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Elsa Bianchini
- UMR INSERM 1176-Universite Paris Sud, Hôpital Bicêtre, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Pierrick Le Borgne
- Service d’Accueil des Urgences, Hôpital de Hautepierre, CHU de Strasbourg, 1 Avenue de Molière, 67200 Strasbourg, France
| | - Mélanie Burban
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Fatiha Zobairi
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Jean-Luc Diehl
- Réanimation Médicale, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, 20 Rue Leblanc, 75015 Paris, France
| | - Lelia Grunebaum
- Laboratoire d’hématologie et hémostase, Hôpital de Hautepierre, CHU de Strasbourg, 1 Avenue de Molière, 67200 Strasbourg, France
| | - Florence Toti
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Ferhat Meziani
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Delphine Borgel
- UMR INSERM 1176-Universite Paris Sud, Hôpital Bicêtre, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
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Sousse LE, Herndon DN, Andersen CR, Zovath A, Finnerty CC, Mlcak RP, Cox RA, Traber DL, Hawkins HK. Pulmonary histopathologic abnormalities and predictor variables in autopsies of burned pediatric patients. Burns 2015; 41:519-27. [PMID: 25445004 PMCID: PMC4380749 DOI: 10.1016/j.burns.2014.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 01/21/2023]
Abstract
UNLABELLED Pulmonary abnormalities occur in 30-80% of fatalities after burn. The objective of our study is to investigate lung pathology in autopsy tissues of pediatric burn patients. METHODS Three scientists with pathology training in pediatric burn care reviewed masked autopsy slides of burned children who died after admission to a burn center from 2002 to 2012 (n=43). Autopsy lung tissue was assigned scores for histologic abnormalities in 9 categories, including alveolar and interstitial fibrosis, hyaline membranes, and type II epithelial cell proliferation. Scores were then tested for correlation with age, TBSA burn, number of days between burn and death, time between burn and admission, and the presence of inhalation injury using analyses with linear models. RESULTS Type II epithelial cell proliferation was significantly more common in cases with a longer time between burn and admission (p<0.02). Interstitial fibrosis was significantly more severe in cases with longer survival after burn (p<0.01). The scores for protein were significantly higher in cases with longer survival after burn (p<0.03). Enlarged air spaces were significantly more prominent in cases with longer survival after burn (p<0.01), and in cases with the presence of inhalation injury (p<0.01). CONCLUSIONS Histological findings associated with diffuse alveolar damage (DAD), which is the pathological correlate of the acute respiratory distress syndrome (ARDS), were seen in approximately 42% of autopsies studied. Protein-rich alveolar edema, which is the abnormality that leads to ARDS, may occur from multiple causes, including inhalation injury.
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Affiliation(s)
- Linda E Sousse
- Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA; Shriners Hospitals for Children, Burn Unit, Galveston, TX 77555, USA
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA; Shriners Hospitals for Children, Burn Unit, Galveston, TX 77555, USA
| | - Clark R Andersen
- Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA; Shriners Hospitals for Children, Burn Unit, Galveston, TX 77555, USA
| | - Andrew Zovath
- Shriners Hospitals for Children, Burn Unit, Galveston, TX 77555, USA
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA; Shriners Hospitals for Children, Burn Unit, Galveston, TX 77555, USA
| | - Ronald P Mlcak
- Shriners Hospitals for Children, Burn Unit, Galveston, TX 77555, USA
| | - Robert A Cox
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA; Shriners Hospitals for Children, Burn Unit, Galveston, TX 77555, USA
| | - Daniel L Traber
- Anesthesiology, University of Texas Medical Branch, Galveston, TX 77555, USA; Shriners Hospitals for Children, Burn Unit, Galveston, TX 77555, USA
| | - Hal K Hawkins
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA; Shriners Hospitals for Children, Burn Unit, Galveston, TX 77555, USA.
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Kraft R, Herndon DN, Mlcak RP, Finnerty CC, Cox RA, Williams FN, Jeschke MG. Bacterial respiratory tract infections are promoted by systemic hyperglycemia after severe burn injury in pediatric patients. Burns 2013; 40:428-35. [PMID: 24074819 DOI: 10.1016/j.burns.2013.07.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 07/10/2013] [Accepted: 07/11/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Burns are associated with hyperglycemia leading to increased incidence of infections with pneumonia being one of the most prominent and adverse complications. Recently, various studies in critically ill patients indicated that increased pulmonary glucose levels with airway/blood glucose threshold over 150 mg/dl lead to an overwhelming growth of bacteria in the broncho-pulmonary system, subsequently resulting in an increased risk of pulmonary infections. The aim of the present study was to determine whether a similar cutoff value exists for severely burned pediatric patients. METHODS One-hundred six severely burned pediatric patients were enrolled in the study. Patients were divided in two groups: high (H) defined as daily average glucose levels >75% of LOS >150 mg/dl), and low (L) with daily average glucose levels >75% of the LOS <150 mg/dl). Incidences of pneumonia, atelectasis, and acute respiratory distress syndrome (ARDS) were assessed. Incidence of infections, sepsis, and respiratory parameters were recorded. Blood was analyzed for glucose and insulin levels. Statistical analysis was performed using Student's t-test and chi-square test. Significance was set at p<0.05. RESULTS Patient groups were similar in demographics and injury characteristics. Pneumonia in patients on the mechanical ventilation (L: 21%, H: 32%) and off mechanical ventilation (L: 5%, H: 15%), as well as ARDS were significantly higher in the high group (L: 3%, H: 19%), p<0.05, while atelectasis was not different. Patients in the high group required significantly longer ventilation compared to low patients (p<0.05). Furthermore, incidence of infection and sepsis were significantly higher in the high group, p<0.05. CONCLUSION Our results indicate that systemic glucose levels over 150 mg/dl are associated with a higher incidence of pneumonia confirming the previous studies in critically ill patients.
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Affiliation(s)
- Robert Kraft
- Department of Trauma, Klinikum Memmingen, Germany
| | - David N Herndon
- Shriners Hospitals for Children, Galveston, TX, United States; Department of Surgery, United States
| | - Ronald P Mlcak
- Shriners Hospitals for Children, Galveston, TX, United States
| | - Celeste C Finnerty
- Shriners Hospitals for Children, Galveston, TX, United States; Department of Surgery, United States; Sealy Center for Molecular Medicine, and the Institute for Translational Science, University Texas Medical Branch, Galveston, TX, United States
| | - Robert A Cox
- Shriners Hospitals for Children, Galveston, TX, United States
| | | | - Marc G Jeschke
- Department of Surgery, Division of Plastic Surgery, Department of Immunology, Ross Tilley Burn Centre - Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada.
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Geng WY, Liu ZB, Song NN, Geng WY, Zhang GH, Jin WZ, Li L, Cao YX, Zhu DN, Shen LL. Effects of electroacupuncture at Zusanli (ST36) on inflammatory cytokines in a rat model of smoke-induced chronic obstructive pulmonary disease. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2013; 11:213-9. [PMID: 23743164 DOI: 10.3736/jintegrmed2013024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Improvement in lung function was reported after acupuncture treatment of chronic obstructive pulmonary disease (COPD), but little is known about the underlying mechanisms. Because an immune response imbalance could be seen in COPD, we hypothesize that electroacupuncture (EA) may play a role in regulating inflammatory cytokines and contribute to lung protection in a rat model of smoke-induced COPD. METHODS A COPD model using male Sprague-Dawley rats exposed to cigarette smoke was established. The rats were randomly divided into four groups (control, sham, COPD, and COPD plus EA), and COPD model was evaluated by measuring pulmonary pathological changes and lung function. EA was applied to the acupuncture point Zusanli (ST36) for 30 min/d for 14 d in sham and COPD rats. Bronchoalveolar lavage fluid (BALF) was used to measure levels of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and malonaldehyde (MDA). RESULTS Compared with the control rats, COPD rats had significant changes in lung resistance (RL) and lung compliance (CL) (both P<0.01), bronchi and bronchiole airway obstruction (P<0.01), and levels of MDA, TNF-α, and IL-1β (P<0.01). There were no significant differences between the control and the sham groups. Compared with the COPD rats, the COPD plus EA rats had decreased RL and increased CL (both P<0.05), and reduced bronchi and bronchiole airway obstruction (P<0.05, P<0.01, respectively), while levels of TNF-α, IL-1β, and MDA in BALF were lowered (P<0.05 and P<0.01, respectively). However, TNF-α and IL-1β levels of the EA group rats remained higher than those of the control group (P<0.05). CONCLUSION EA at ST36 can reduce lung injury in a COPD rat model, and beneficial effects may be related to down-regulation of inflammatory cytokines. The anti-inflammatory and antioxidant effects may prolong the clinical benefit of EA.
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Affiliation(s)
- Wen-ye Geng
- Department of Physiology and Pathophysiology, Shanghai Medical College of Fudan University, Shanghai, China
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Lange M, Cox RA, Traber DL, Hamahata A, Nakano Y, Traber LD, Enkhbaatar P. Time course of early histopathological lung changes in an ovine model of acute lung injury and pulmonary infection. Exp Lung Res 2013; 39:201-6. [DOI: 10.3109/01902148.2013.794254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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10
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Antithrombin Reduces Inflammation and Microcirculatory Perfusion Failure in Closed Soft-Tissue Injury and Endotoxemia. Crit Care Med 2013; 41:867-73. [DOI: 10.1097/ccm.0b013e3182742d2c] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Yip LY, Lim YF, Chan HN. Safety and potential anticoagulant effects of nebulised heparin in burns patients with inhalational injury at Singapore General Hospital Burns Centre. Burns 2011; 37:1154-60. [DOI: 10.1016/j.burns.2011.07.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Revised: 06/28/2011] [Accepted: 07/04/2011] [Indexed: 12/01/2022]
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12
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Lange M, Cox RA, Enkhbaatar P, Whorton EB, Nakano Y, Hamahata A, Jonkam C, Esechie A, von Borzyskowski S, Traber LD, Traber DL. Predictive role of arterial carboxyhemoglobin concentrations in ovine burn and smoke inhalation-induced lung injury. Exp Lung Res 2011; 37:239-45. [PMID: 21309735 DOI: 10.3109/01902148.2010.538133] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Inhalation injury frequently occurs in burn patients and contributes to the morbidity and mortality of these injuries. Arterial carboxyhemoglobin has been proposed as an indicator of the severity of inhalation injury; however, the interrelation between arterial carboxyhemoglobin and histological alterations has not yet been investigated. Chronically instrumented sheep were subjected to a third degree burn of 40% of the total body surface area and inhalation of 48 breaths of cotton smoke. Carboxyhemoglobin was measured immediately after injury and correlated to clinical parameters of pulmonary function as well as histopathology scores from lung tissue harvested 24 hours after the injury. The injury was associated with a significant decline in pulmonary oxygenation and increases in pulmonary shunting, lung lymph flow, wet/dry weight ratio, congestion score, edema score, inflammation score, and airway obstruction scores. Carboxyhemoglobin was negatively correlated to pulmonary oxygenation and positively correlated to pulmonary shunting, lung lymph flow, and lung wet/dry weight ratio. No significant correlations could be detected between carboxyhemoglobin and histopathology scores and airway obstruction scores. Arterial carboxyhemoglobin in sheep with combined burn and inhalation injury are correlated with the degree of pulmonary failure and edema formation, but not with certain histological alterations including airway obstruction scores.
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Affiliation(s)
- Matthias Lange
- Department of Anesthesiology, Investigational Intensive Care Unit, University of Texas Medical Branch and Shriners Burns Hospital for Children, Galveston, Texas 77550, USA.
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13
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Abstract
Changes in coagulation may have a profound impact on outcomes following severe burns and the coagulation abnormalities after thermal injury are incompletely described. We postulated that thermal injury induces a systemic hypercoagulable state. With Institutional Review Board approval, five patients were consented for enrollment in this case series. After obtaining informed consent, blood was drawn on hospital days 1, 2, 3, 5, and 7 or until discharge if discharge was in less than 7 days. Standard coagulation testing was performed, as well as a battery of sophisticated specialized coagulation assays. Other data collected includes fluid resuscitation volumes, pharmacologic interventions, and general physiologic information. Results (n = 5) demonstrate that burns less than 6% total body surface area appear to have little effect on coagulation. Burns greater than 6% appear to induce a systemic hypercoagulable state with a phase and magnitude relationship proportional to total body surface area burned. Severe burns greater than 40% appear to induce a consumptive coagulopathy. Prothrombin fragment 1.2 may represent a useful screening test for a burn-induced hypercoagulable state.
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Morita N, Enkhbaatar P, Maybauer DM, Maybauer MO, Westphal M, Murakami K, Hawkins HK, Cox RA, Traber LD, Traber DL. Impact of bronchial circulation on bronchial exudates following combined burn and smoke inhalation injury in sheep. Burns 2010; 37:465-73. [PMID: 21195551 DOI: 10.1016/j.burns.2010.11.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 10/19/2010] [Accepted: 11/03/2010] [Indexed: 01/11/2023]
Abstract
UNLABELLED We previously reported bronchial circulation contributes to pulmonary edema and increases shunt fraction following smoke inhalation, and bronchial blood flow significantly increases in inhalation injury. We hypothesized reduction of bronchial blood flow reduces exudation to the airway and ameliorates lung injury from combined burn and smoke insults (B&S injury). METHOD Merino ewes (n=28) randomly divided into three groups: (1) bronchial artery ligated and injured (injury+ligation group); (2) bronchial artery left intact and injured (injury+no ligation group); (3) bronchial artery ligated but not injured (no injury+ligation group) were subjected to a flame burn and inhalation injury under halothane anesthesia. Parameters were analyzed using Scheffe's post hoc test (P<0.05). All Groups were resuscitated with Ringer lactate solution and placed on a ventilator for 48h. RESULTS Pulmonary gas exchange (PaO(2)/FiO(2)) improved in injury+ligation group. Further, obstruction score, an index of airway cast formation, significantly changed between injury+no ligation group compared to both ligation groups. CONCLUSION Bronchial circulation plays a significant role in lung injury after B&S injury, and reduction of bronchial blood flow by bronchial artery ligation reduces bronchial exudates, resulting in improved gas exchange.
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Affiliation(s)
- Naoki Morita
- Department of Anesthesiology, The University of Texas Medical Branch and Shriners Hospital for Children, Galveston, TX 77555, USA
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15
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Update on Antithrombin for the Treatment of Burn Trauma and Smoke Inhalation Injury. Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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16
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Rehberg S, Maybauer MO, Enkhbaatar P, Maybauer DM, Yamamoto Y, Traber DL. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009; 3:283-297. [PMID: 20161170 PMCID: PMC2722076 DOI: 10.1586/ers.09.21] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Smoke inhalation injury continues to increase morbidity and mortality in burn patients in both the third world and industrialized countries. The lack of uniform criteria for the diagnosis and definition of smoke inhalation injury contributes to the fact that, despite extensive research, mortality rates have changed little in recent decades. The formation of reactive oxygen and nitrogen species, as well as the procoagulant and antifibrinolytic imbalance of alveolar homeostasis, all play a central role in the pathogenesis of smoke inhalation injury. Further hallmarks include massive airway obstruction owing to cast formation, bronchospasm, the increase in bronchial circulation and transvascular fluid flux. Therefore, anticoagulants, antioxidants and bronchodilators, especially when administered as an aerosol, represent the most promising treatment strategies. The purpose of this review article is to provide an overview of the pathophysiological changes, management and treatment options of smoke inhalation injury based on the current literature.
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Affiliation(s)
- Sebastian Rehberg
- Department of Anesthesiology, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA, Tel.: +1 409 772 6405, ,
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Dickneite G. A comparison of the pharmacokinetics of antithrombin derived from human plasma and from transgenic goats and the prevention of sepsis in an animal model. Biopharm Drug Dispos 2008; 29:356-65. [DOI: 10.1002/bdd.623] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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20
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Krebs J, Ferguson SJ, Hoerstrup SP, Goss BG, Haeberli A, Aebli N. Influence of bone marrow fat embolism on coagulation activation in an ovine model of vertebroplasty. J Bone Joint Surg Am 2008; 90:349-56. [PMID: 18245595 DOI: 10.2106/jbjs.g.00058] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intraoperative cardiovascular deterioration as a result of pulmonary embolization of bone marrow fat is a potentially serious complication during vertebroplasty. The release of fatty material and thromboplastin from the bone marrow cavity during vertebroplasty may activate the coagulation cascade resulting in thrombogenesis, and pharmacological prophylaxis may therefore prevent cardiovascular complications. Thus, the effects of bone marrow fat embolism on coagulation activation during vertebroplasty were investigated with use of an animal model. METHODS Polymethylmethacrylate was injected into three lumbar vertebrae of six sheep in order to force bone marrow fat into the circulation. Invasive blood pressures and heart rate were recorded continuously until sixty minutes after the last injection. Cardiac output, arterial and mixed venous blood gas parameters, and coagulation parameters were measured at selected time-points. Postmortem lung biopsy specimens were assessed for the presence of intravascular fat. RESULTS Embolization of bone marrow fat resulted in a sudden and dramatic increase in mean pulmonary arterial pressure and a decrease in mean arterial blood pressure. There were no significant changes in any coagulation parameter from before the injection to after the injection. Intravascular fat and bone marrow cells were present in all lung lobes. CONCLUSIONS Injection of polymethylmethacrylate into vertebral bodies caused embolization of bone marrow fat with subsequent transient cardiovascular deterioration, but no changes in coagulation parameters were observed. Thromboembolism did not contribute to the observed cardiovascular changes.
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Affiliation(s)
- Jörg Krebs
- MEM Research Center, Institute for Surgical Technology and Biomechanics, Medical Faculty, University of Bern, Stauffacherstrasse 78, 3014 Bern, Switzerland.
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21
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Lavrentieva A, Kontakiotis T, Bitzani M, Papaioannou-Gaki G, Parlapani A, Thomareis O, Tsotsolis N, Giala MA. Early coagulation disorders after severe burn injury: impact on mortality. Intensive Care Med 2008; 34:700-6. [PMID: 18193192 DOI: 10.1007/s00134-007-0976-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Accepted: 11/30/2007] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the time course of coagulation markers in the early postburn period and clarify the role of coagulation alterations in organ failure and in mortality prognosis. DESIGN AND SETTING This prospective study was conducted in the burn ICU of a tertiary hospital. PATIENTS 45 patients with severe thermal burn injury. MEASUREMENTS AND RESULTS Clinical data and coagulation and fibrinolysis parameters were measured during the first postburn week. The ICU 28-day mortality rate was 33%. Significant differences in the time course of coagulation markers were observed between survivors and nonsurvivors. SOFA score distinguished between patients with overt and nonovert disseminated intravascular coagulation (DIC) during the overall investigation period. Presence of overt DIC was related to mortality (OR=0.1). Antithrombin, protein S, plasminogen activator inhibitor 1, and SOFA score on day 3, protein C on day 5, and thrombin/antithrombin complexes on day 7 revealed a good prognostic value for ICU mortality, according to the area under ROC curves. CONCLUSIONS Severe thermal injury is associated with the early activation of coagulation cascade, presence of DIC, organ failure, and increased mortality.
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Enkhbaatar P, Cox RA, Traber LD, Westphal M, Aimalohi E, Morita N, Prough DS, Herndon DN, Traber DL. Aerosolized anticoagulants ameliorate acute lung injury in sheep after exposure to burn and smoke inhalation. Crit Care Med 2007; 35:2805-10. [PMID: 18074480 DOI: 10.1097/01.ccm.0000291647.18329.83] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Acute lung injury is a detrimental complication for victims of burn accidents. Airway obstruction plays an important role in pulmonary dysfunction in these patients. In this study, we tested the hypothesis that aerosolized anticoagulants will reduce the degree of airway obstruction and improve pulmonary function in sheep with severe combined burn and smoke inhalation injury by preventing the formation of airway fibrin clots. DESIGN Prospective, randomized, controlled, experimental animal study. SETTING Investigational intensive care unit at a university hospital. SUBJECTS Adult female sheep. INTERVENTIONS After 7 days of surgical recovery, sheep were given a cutaneous burn (40% of total body surface, third degree) and insufflated with cotton smoke (48 breaths, <40 degrees C) under halothane anesthesia. After injury, sheep were placed on ventilators and resuscitated with lactated Ringer's solution. Sheep were randomly divided into five groups: sham, noninjured and nontreated (n = 6); control, injured and aerosolized with saline (n = 6); recombinant human antithrombin (rhAT) + heparin, injured and aerosolized with rhAT (290 units for each) and heparin (10,000 units for each) (n = 6); rhAT, injured and aerosolized with rhAT alone (290 units for each; n = 5); and heparin, injured and aerosolized with heparin alone (10,000 units for each; n = 5). rhAT and heparin were aerosolized every 4 hrs, starting at 2 hrs postinjury. MEASUREMENTS AND MAIN RESULTS Cardiopulmonary hemodynamics were monitored during a 48-hr experimental time period. Control sheep developed multiple signs of acute lung injury. This pathophysiology included decreased pulmonary gas exchange and lung compliance, increased pulmonary edema, and extensive airway obstruction. These variables were stable in sham animals. The aerosolization of rhAT or heparin alone did not significantly improve deteriorated pulmonary gas exchange. However, aerosolization of these anticoagulants in combination significantly attenuated all the observed pulmonary pathophysiology. CONCLUSIONS The results provide definitive evidence that aerosolized rhAT and heparin in combination may be a novel treatment strategy for pulmonary pathology in burn victims with smoke inhalation injury.
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Affiliation(s)
- Perenlei Enkhbaatar
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA.
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23
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Aerosolized anticoagulants ameliorate acute lung injury in sheep after exposure to burn and smoke inhalation. Crit Care Med 2007. [DOI: 10.1097/00003246-200712000-00020] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Enkhbaatar P, Traber LD, Traber DL. Antithrombin in Burn Trauma. Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
<zakljucak> U ovom radu prikazani su neki od patofizioloskih aspekata inhalacionih povreda pluca, nezavisno od toga da li su bile udruzene s opekotinama ili nisu. Mada tacan mehanizam akutne inhalacione povrede pluca nije razjasnjen u potpunosti, na osnovu mnogobrojnih istrazivanja moze se zakljuciti da ogromnu ulogu u tim procesima imaju NO, PARP i opstrukcija vazdusnih puteva.
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Affiliation(s)
- Tatjana Vulović
- Klinicki centar Kragujevac, Centar za anesteziju, Kragujevać, Srbija.
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26
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Affiliation(s)
- Daniel L Traber
- Investigational Intensive Care Unit, Department of Anesthesiology, University of Texas Medical Branch and Shriners Burns Hospital for Children, Galveston,TX 77555-0833, USA.
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Maybauer DM, Maybauer MO, Traber LD, Westphal M, Nakano YY, Enkhbaatar P, Morita N, Herndon DN, Traber DL. Effects of severe smoke inhalation injury and septic shock on global hemodynamics and microvascular blood flow in sheep. Shock 2006; 26:489-95. [PMID: 17047520 DOI: 10.1097/01.shk.0000230300.78515.ed] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This prospective, randomized, controlled experimental study looks at the effects on global and regional microvascular blood flow (RMBF) in an ovine model of septic shock after severe smoke inhalation injury. Sixteen sheep were randomized into two groups, a control group (no injury, n = 8) and a smoke/sepsis (SS) group (n = 8), which received an insufflation of 4 sets of 12 breaths of cotton smoke (<40 degrees C) followed by instillation of live Pseudomonas aeruginosa into both lung lobes, according to an established protocol. All sheep were mechanically ventilated with 100% oxygen, and fluid resuscitated with lactated Ringer's solution for the entire duration of the 24-h experimental period to maintain hematocrit at baseline (BL) levels. Healthy control animals were not subjected to the injury and received only 4 x 12 breaths of room air and instillation of the vehicle (normal saline). Blood flow was analyzed using colored microspheres. Control animals remained hemodynamically stable and had no statistical changes from BL in visceral or cerebral blood flow during the entire experimental period. All SS animals developed a hypotensive, hyperdynamic circulation, characterized by a significant increase in heart rate and cardiac output with a simultaneous significant fall in mean arterial pressure, which, in combination, led to a fall in systemic vascular resistance index versus BL (P < 0.001, each). In visceral organs, the trachea showed a significant increase in RMBF (P < 0.001). In addition, skeletal muscle significantly increased versus BL and versus controls over time (P < 0.01). Whereas the pancreas displayed a significant drop in RMBF versus BL and controls (P < 0.05), no statistical differences occurred in the renal cortex, spleen, and ileum. All investigated cerebral structures, such as the cortex cerebri, basal ganglia, thalamus, hippocampus, pons, medulla oblongata, and cerebellum showed a significant increase in RMBF versus BL and versus control animals (P < 0.05, each). These data differ in areas of normal, increased, and decreased RMBF during septic shock after smoke inhalation injury and show differences to former studies of our group investigating RMBF in ovine models of either smoke inhalation or P. aeruginosa infusion. The results of this study reflect the complex pathophysiological variances of the combined injury and may provide a basis for future investigations for the treatment of this kind of injury.
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Affiliation(s)
- Dirk M Maybauer
- Departments of Anesthesiology and Surgery, Investigational Intensive Care Unit, The University of Texas Medical Branch and Shriners Burns Hospital for Children, Galveston, Texas, U.S.A.
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28
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Maybauer MO, Maybauer DM, Fraser JF, Traber LD, Westphal M, Enkhbaatar P, Cox RA, Huda R, Hawkins HK, Morita N, Murakami K, Mizutani A, Herndon DN, Traber DL. Recombinant human activated protein C improves pulmonary function in ovine acute lung injury resulting from smoke inhalation and sepsis. Crit Care Med 2006; 34:2432-8. [PMID: 16810106 DOI: 10.1097/01.ccm.0000230384.61350.fa] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the effects of recombinant human activated protein C (rhAPC) on pulmonary function in acute lung injury (ALI) resulting from smoke inhalation in association with a bacterial challenge. DESIGN Prospective, randomized, controlled, experimental animal study with repeated measurements. SETTING Investigational intensive care unit at a university hospital. SUBJECTS Eighteen sheep (37.2 +/- 1.0 kg) were operatively prepared and randomly allocated to either the sham, control, or rhAPC group (n = 6 each). After a tracheotomy had been performed, ALI was produced in the control and rhAPC group by insufflation of 4 sets of 12 breaths of cotton smoke. Then, a 30 mL suspension of live Pseudomonas aeruginosa bacteria (containing 2-5 x 10(11) colony forming units) was instilled into the lungs according to an established protocol. The sham group received only the vehicle, i.e., 4 sets of 12 breaths of room air and instillation of 30 mL normal saline. The sheep were studied in the awake state for 24 hrs and were ventilated with 100% oxygen. RhAPC (24 mug/kg/hr) was intravenously administered. The infusion was initiated 1 hr post-injury and lasted until the end of the experiment. The animals were resuscitated with Ringer's lactate solution to maintain constant pulmonary artery occlusion pressure. MEASUREMENTS AND MAIN RESULTS In comparison with nontreatment in controls, the infusion of rhAPC significantly attenuated the fall in Pao2/Fio2 ratio (control group values were 521 +/- 22 at baseline [BL], 72 +/- 5 at 12 hrs, and 74 +/- 7 at 24 hrs, vs. rhAPC group values of 541 +/- 12 at BL, 151 +/- 29 at 12 hours [p < .05 vs. control], and 118 +/- 20 at 24 hrs), and significantly reduced the increase in pulmonary microvascular shunt fraction (Qs/Qt; control group at BL, 0.14 +/- 0.02, and at 24 hrs, 0.65 +/- 0.08; rhAPC group at BL, 0.24 +/- 0.04, and at 24 hrs, 0.45 +/- 0.02 [p < .05 vs. control]) and the increase in peak airway pressure (mbar; control group at BL, 20 +/- 1, and at 24 hrs, 36 +/- 4; rhAPC group at BL, 21 +/- 1, and at 24 hrs, 28 +/- 2 [p < .05 vs. control]). In addition, rhAPC limited the increase in lung 3-nitrotyrosine (after 24 hrs [%]: sham, 7 +/- 2; control, 17 +/- 1; rhAPC, 12 +/- 1 [p < .05 vs. control]), a reliable indicator of tissue injury. However, rhAPC failed to prevent lung edema formation. RhAPC-treated sheep showed no difference in activated clotting time or platelet count but exhibited less fibrin degradation products (1/6 animals) than did controls (4/6 animals). CONCLUSIONS Recombinant human activated protein C attenuated ALI after smoke inhalation and bacterial challenge in sheep, without bleeding complications.
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Affiliation(s)
- Marc O Maybauer
- Department of Anesthesiology, Investigational Intensive Care Unit, The University of Texas Medical Branch, and Shriners Burn Hospital for Children, Galveston, USA
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Wiedermann CJ, Hoffmann JN, Juers M, Ostermann H, Kienast J, Briegel J, Strauss R, Keinecke HO, Warren BL, Opal SM. High-dose antithrombin III in the treatment of severe sepsis in patients with a high risk of death: efficacy and safety. Crit Care Med 2006; 34:285-92. [PMID: 16424704 DOI: 10.1097/01.ccm.0000194731.08896.99] [Citation(s) in RCA: 138] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To explore if patients with severe sepsis and with a predicted high risk of death (according to the Simplified Acute Physiology Score II) might have a treatment benefit from high-dose antithrombin III. DESIGN Subgroup analysis of a randomized, placebo-controlled, double-blind, prospective phase III study. SETTING Unifactorial and multifactorial reanalysis of prospectively defined populations from the KyberSept trial. PATIENTS We studied 1,008 patients (43.6% of the overall intention-to-treat population, n = 2,314) with a predicted mortality rate of 30-60% at study entry as defined by the Simplified Acute Physiology Score II. INTERVENTIONS Patients were randomized in a 1:1 fashion to receive either high-dose antithrombin III (30,000 IU intravenously over the period of 4 days) or placebo. MEASUREMENTS AND MAIN RESULTS In a Kaplan-Meier analysis of patients with a predicted mortality of 30-60%, the survival time when followed up for 90 days after admission was increased in the high-dose antithrombin III group compared with placebo (p = .04). If heparin was avoided during the 4-day treatment phase with high-dose antithrombin III (n = 140) or placebo (n = 162), the treatment effect appeared to be even more pronounced: 28-day mortality rate, 35.7% vs. 44.4% (risk ratio, 0.804; 95% confidence interval, 0.607-1.064); 56-day mortality rate, 39.9% vs. 52.2% (risk ratio, 0.764; 95% confidence interval, 0.593-0.984); 90-day mortality rate, 42.8% vs. 55.1% (risk ratio, 0.776; 95% confidence interval, 0.614-0.986). Like in the overall population, the percentage with any bleeding was increased in patients receiving high-dose antithrombin III compared with placebo. Survival rates were in favor of high-dose antithrombin III in patients both with and without bleeding complications. CONCLUSIONS Treatment with high-dose antithrombin III may increase survival time up to 90 days in patients with severe sepsis and high risk of death. This benefit may even be stronger when concomitant heparin is avoided.
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Abstract
INTRODUCTION Smoke inhalation and respiratory complications are still the major causes of mortality in severely burned patients. STATE OF THE ART The diagnosis is suspected clinically on the basis of history and physical examination and can be confirmed bronchoscopically. Respiratory failure in burned patients occurs through a number of associated mechanisms. Pneumonitis and adult respiratory distress syndrome (ARDS) are common early complications. New pulmonary treatments and advances in ventilation have reduced the incidence of both barotrauma and infectious complications. Tracheal stenosis can occur as a late complication of prolonged mechanical ventilation. PERSPECTIVES Clinical and experimental studies have shown that damage to the mucosal barrier and the release of inflammatory mediators are the most important pathophysiological events following smoke inhalation. Manipulation of the inflammatory response following inhalation may be a treatment option in the distant future. CONCLUSION Inhalation injury occurring in burned patients can produce severe respiratory and systemic complications.
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Affiliation(s)
- L Bargues
- Centre de Traitement des Brûlés, Hôpital d'Instruction des Armées Percy, Clamart, France.
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31
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Enkhbaatar P, Traber DL. Pathophysiology of acute lung injury in combined burn and smoke inhalation injury. Clin Sci (Lond) 2004; 107:137-43. [PMID: 15151496 DOI: 10.1042/cs20040135] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2004] [Revised: 05/14/2004] [Accepted: 05/19/2004] [Indexed: 11/17/2022]
Abstract
In the U.S.A., more than 1 million burn injuries occur every year. Although the survival from burn injury has increased in recent years with the development of effective fluid resuscitation management and early surgical excision of burned tissue, the mortality of burn injury is still high. In these fire victims, progressive pulmonary failure and cardiovascular dysfunction are important determinants of morbidity and mortality. The morbidity and mortality increases when burn injury is associated with smoke inhalation. In the present review, we will describe the pathophysiological aspects of acute lung injury induced by combined burn and smoke inhalation and examine various therapeutic approaches.
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Affiliation(s)
- Perenlei Enkhbaatar
- Department of Anesthesiology, University of Texas Medical Branch, 610 Texas Ave, Galveston, TX 77555, USA
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Enkhbaatar P, Murakami K, Cox R, Westphal M, Morita N, Brantley K, Burke A, Hawkins H, Schmalstieg F, Traber L, Herndon D, Traber D. AEROSOLIZED TISSUE PLASMINOGEN INHIBITOR IMPROVES PULMONARY FUNCTION IN SHEEP WITH BURN AND SMOKE INHALATION. Shock 2004; 22:70-5. [PMID: 15201705 DOI: 10.1097/01.shk.0000129201.38588.85] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute respiratory distress syndrome is a major complication in patients with thermal injury. The obstruction of the airway by cast material, composed in part of fibrin, contributes to deterioration of pulmonary gas exchange. We tested the effect of aerosol administration of tissue plasminogen activator, which lyses fibrin clots, on acute lung injury in sheep that had undergone combined burn/smoke inhalation injury. Anesthetized sheep were given a 40% total body surface, third degree burn and were insufflated with cotton smoke. Tissue plasminogen activator (TPA) was nebulized every 4 h at 1 or 2 mg for each nebulization, beginning 4 h after injury. Injured but untreated control sheep developed multiple symptoms of acute respiratory distress syndrome: decreased pulmonary gas exchange, increased pulmonary edema, and extensive airway obstruction. These control animals also showed increased pulmonary transvascular fluid flux and increased airway pressures. These variables were all stable in sham animals. Nebulization of saline or 1 mg of TPA only slightly improved measures of pulmonary function. Treatment of injured sheep with 2 mg of TPA attenuated all the pulmonary abnormalities noted above. The results provide evidence that clearance of airway obstructive cast material is crucial in managing acute respiratory distress syndrome resulting from combined burn and smoke inhalation injury.
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Affiliation(s)
- Perenlei Enkhbaatar
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555, USA
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Sheridan RL, Tompkins RG. What's new in burns and metabolism. J Am Coll Surg 2004; 198:243-63. [PMID: 14759783 DOI: 10.1016/j.jamcollsurg.2003.11.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2003] [Accepted: 11/10/2003] [Indexed: 12/31/2022]
Affiliation(s)
- Robert L Sheridan
- Burn Surgery Service, Shriners Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA
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