1
|
Perez-Garzon M, Poveda-Henao C, Bastidas-Goyes A, Robayo-Amortegui H. Oxygen Debt as Predictor of Mortality and Multiple Organ Dysfunction Syndrome in Severe COVID-19 Patients: A Retrospective Study. J Intensive Care Med 2024; 39:358-367. [PMID: 37876236 DOI: 10.1177/08850666231208433] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Background: Oxygen debt (DEOx) represents the disparity between resting and shock oxygen consumption (VO2) and is associated with metabolic insufficiency, acidosis, severity, and mortality. This study aimed to assess the reliability of DEOx as an indirect quantitative measure for predicting multiple organ dysfunction syndrome (MODS) and 28-day mortality in patients admitted to the intensive care unit (ICU) with respiratory syndrome severe acute coronavirus type 2 (SARS-CoV-2) infection, in comparison to the Acute Physiology and Chronic Health Evaluation II (APACHE II), sepsis-related organ failure assessment (SOFA), and 4C scores. Methods: A retrospective cohort study was conducted, including ICU patients with SARS-CoV-2 infection between 2020 and 2021. Clinical data were extracted from the EPIMED Monitor Database®. APACHE II, SOFA, and 4C scores were calculated upon ICU admission, and their accuracy in predicting 28-day mortality and MODS was compared to DEOx. Multivariate logistic regression analysis was performed to analyze the outcome variables. Results: 708 patients were included, with a mortality rate of 44.4%. DEOx value was 11.16 ml O2/kg. The mean age was 58.7 years. Multivariate analysis showed that DEOx was independently associated with mortality, intubation, and renal injury. Each point increase in creatinine was associated with a higher risk of MODS. To determine the precision of the scores, area under the receiver operating characteristic curves (AUROC) analysis was performed with weak discrimination and similar behavior for the primary outcomes. The most accurate scale for mortality and MODS was 4C with an AUC of 0.683 and APACHE II with an AUC of 0.814, while that of the AUROC of DEOx was 0.612 and 0.646, respectively. Conclusions: DEOx showed similar predictive value to established scoring systems in critically ill patients with SARS-CoV-2 infection. The correlation of DEOx with these scores may facilitate early intervention in critically ill patients.
Collapse
Affiliation(s)
- Michel Perez-Garzon
- Department of Medicine, Universidad de La Sabana. Chia Cundinamarca. Bogotá DC, Colombia
- Critical Medicine and Intensive Care, Msc Mechanical Ventilation and Respiratory Support, Department of Investigation, Fundación Clínica Shaio. Bogota DC. Colombia
| | - Claudia Poveda-Henao
- Department of Medicine, Universidad de La Sabana. Chia Cundinamarca. Bogotá DC, Colombia
- Critical Medicine and Intensive Care, Msc Mechanical Ventilation and Respiratory Support, Department of Investigation, Fundación Clínica Shaio. Bogota DC. Colombia
- Clinical Cardiology, Intensive Care Department, Shaio Clinic Foundation. Bogota DC. Colombia
| | - Alirio Bastidas-Goyes
- Department of Medicine, Universidad de La Sabana. Chia Cundinamarca. Bogotá DC, Colombia
| | - Henry Robayo-Amortegui
- Critical Care Resident, Department of Medicine, Universidad de La Sabana. Chia Cundinamarca. Bogotá DC, Colombia
| |
Collapse
|
2
|
Michel PG, Claudia PH, Andrea RS, Maria DA, Henry RA. Oxygen debt as a predictor of high-flow nasal cannula therapy failure in SARS-CoV-2 patients with acute respiratory failure: A retrospective cohort study. Heart Lung 2024; 64:176-181. [PMID: 38278127 DOI: 10.1016/j.hrtlng.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/20/2023] [Accepted: 10/23/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) is known for its rapid progression to acute hypoxemic respiratory failure (AHRF). The increased use of oxygen therapy during the pandemic and the progression of AHRF have highlighted the need to promptly determine the need for orotracheal intubation (OTI). OBJETIVE To determine the validity of quantitative measurement of oxygen debt (DEOx) according to arterial gases compared to the use of iROX in patients with high-flow nasal cannula (HFNC) therapy requirement, presenting with acute respiratory failure as a consequence of SARS-CoV-2 infection. In addition, we aimed to identify the factors associated with the need for orotracheal intubation (OTI). METHODS A retrospective observational cohort study of a database collected from patients with SARS-CoV-2 infection admitted to intensive care units with AHRF and had received HFNC upon admission during the Covid-19 pandemic (March 23, 2020 through August 02, 2021). The variables of interest were factors determining the predictive ability of DEOx and iROX. We used a multiple logarithmic regression model to correct for confounding and mixed-effects variables, and validated for OTI in patients treated with HFNC. RESULTS From a total of 373 patients treated with HFNC, 317 patients (84.9%) required invasive mechanical ventilation. APACHE II (AOR 1.44; 95% CI: 1.14-1.83, p 0,032), vasopressor use (AOR 27.7; 95% CI: 1.83 - 420,63, p 0,017), and DEOx (AOR 1.26; 95% CI: 1.10 - 1.44, p 0,001) were associated with the need for intubation. The predictive model between iROX and DEOx evidenced an AUC of 0.535 vs. 0.606, respectively, with a DEOx cut off point of 7.14 (±10.16, p < 0.01). DEOx as an independent factor of OTI presents an OR 2,48 with cut point 4.5 mlO2/kg (AUC 0.780, CI 95%, 0.753 - 0.808, p < 0.01). CONCLUSIONS DEOx is a valuable measurment to identify the need for OTI in patients with SARS-CoV-2 who were under management with HFNC with a predictive value superior to iROX, being a reproducible and valid quantitative method for the need OTI that can be implemented in other critically illconditions. Further studies are required to characterize the usefulness of DEOx more precisely.
Collapse
Affiliation(s)
- Perez-Garzon Michel
- Critical Medicine and Intensive Care, Fundación Clínica Shaio, Bogota DC, Colombia; Msc Mechanical Ventilation and Respiratory Support, Department of Investigation, Fundación Clínica Shaio, Bogota DC, Colombia; Msc Clinical Epidemiology, Department of Intensive Care and Research, Fundación Clínica Shaio, Bogota DC, Colombia.
| | - Poveda-Henao Claudia
- Critical Medicine and Intensive Care, Fundación Clínica Shaio, Bogota DC, Colombia; Msc Mechanical Ventilation and Respiratory Support, Department of Investigation, Fundación Clínica Shaio, Bogota DC, Colombia; Clinical Cardiology, Intensive Care Department, Fundación Clínica Shaio, Bogota DC, Colombia
| | - Rozo-Salinas Andrea
- Critical Medicine and Intensive Care, Fundación Clínica Shaio, Bogota DC, Colombia
| | - Diaz-Ardila Maria
- Physiotherapist, Clinical Epidemiology, Physiotherapy Department, Fundación Clínica Shaio, Bogotá DC, Colombia
| | - Robayo-Amortegui Henry
- Critical Care Resident, Department of Medicine, Universidad de La Sabana, Chia Cundinamarca, Colombia
| |
Collapse
|
3
|
Ye H, He S, Du Y, Wang Y, Hu Y, Zhao C, Jin Y, Liu F, Guo Y. Involvement of CD44 and MAPK14-mediated ferroptosis in hemorrhagic shock. Apoptosis 2024; 29:154-168. [PMID: 37751106 DOI: 10.1007/s10495-023-01894-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2023] [Indexed: 09/27/2023]
Abstract
To elucidate the induction of ferroptotic pathways and the transcriptional modulation of pivotal genes in the context of hemorrhagic shock. The R software was used to analyze the GSE64711 dataset, isolating genes relevant to ferroptosis. Enrichment analyses and protein interaction networks were assembled. Using WGCNA hub genes were identified and intersected with ferroptosis-related genes, highlighting hub genes CD44 and MAPK14. In a rat hemorrhagic shock model, cardiac ROS, Fe2+, MDA, and GSH levels were assessed. Key ferroptotic proteins (SLC7A11/GPX4) in myocardial tissues were examined via western blot. Hub genes, CD44 and MAPK14, expressions were confirmed through immunohistochemistry. Analyzing the GSE64711 dataset revealed 337 differentially expressed genes, including 12 linked to ferroptosis. Enrichment analysis highlighted pathways closely related to ferroptosis. Using Genemania, we found these genes mainly affect ROS metabolism and oxidative stress response. WGCNA identified CD44 and MAPK14 as hub genes. Rat myocardial tissue validation showed significant cardiac damage and elevated ROS and MDA levels, and decreased GSH levels in the hemorrhagic shock model. The ferroptotic pathway SLC7A11/GPX4 was activated, and immunohistochemistry showed a significant increase in the expression levels of CD44 and MAPK14 in the hemorrhagic shock rat model. We demonstrated the presence of tissue ferroptosis in hemorrhagic shock by combining bioinformatics analysis with in vivo experimentation. Specifically, we observed the activation of the SLC7A11/GPX4 ferroptotic pathway. Further, CD44 and MAPK14 were identified as hub genes in hemorrhagic shock.
Collapse
Affiliation(s)
- Haoran Ye
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Shasha He
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yuan Du
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Yuchen Wang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Yahui Hu
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Chunxia Zhao
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yueting Jin
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Fangyu Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Yuhong Guo
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.
- Beijing Institute of Chinese Medicine, Beijing, China.
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China.
| |
Collapse
|
4
|
Zheng D, Yu GL, Zhou YP, Zhang QM, Wang CG, Zhang S. Association between lactic acidosis and multiple organ dysfunction syndrome after cardiopulmonary bypass. PeerJ 2024; 12:e16769. [PMID: 38313014 PMCID: PMC10838087 DOI: 10.7717/peerj.16769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/16/2023] [Indexed: 02/06/2024] Open
Abstract
Background The relationship between hyperlactatemia and prognosis after cardiopulmonary bypass (CPB) is controversial, and some studies ignore the presence of lactic acidosis in patients with severe hyperlactacemia. This study explored the association between lactic acidosis (LA) and the occurrence of multiple organ dysfunction syndrome (MODS) after cardiopulmonary bypass. Methods This study was a post hoc analysis of patients who underwent cardiac surgery between February 2017 and August 2018 and participated in a prospective study at Taizhou Hospital. The data were collected at: ICU admission (H0), and 4, 8, 12, 24, and 48 h after admission. Blood lactate levels gradually increased after CPB, peaking at H8 and then gradually decreasing. The patients were grouped as LA, hyperlactatemia (HL), and normal control (NC) based on blood test results 8 h after ICU admission. Basic preoperative, perioperative, and postoperative conditions were compared between the three groups, as well as postoperative perfusion and oxygen metabolism indexes. Results There were 22 (19%), 73 (64%), and 19 (17%) patients in the LA, HL, and NC groups, respectively. APACHE II (24h) and SOFA (24h) scores were the highest in the LA group (P < 0.05). ICU stay duration was the longest for the LA group (48.5 (42.5, 50) h), compared with the HL (27 (22, 48) h) and NC (27 (25, 46) h) groups (P = 0.012). The LA group had the highest incidence of MODS (36%), compared with the HL (14%) and NC (5%) groups (P = 0.015). In the LA group, the oxygen extraction ratio (O2ER) was lower (21.5 (17.05, 32.8)%) than in the HL (31.3 (24.8, 37.6)%) and the NC group (31.3 (29.0, 35.4) %) (P = 0.018). In the univariable analyses, patient age (OR = 1.054, 95% CI [1.003-1.109], P = 0.038), the LA group (vs. the NC group, (OR = 10.286, 95% CI [1.148-92.185], P = 0.037), and ΔPCO2 at H8 (OR = 1.197, 95% CI [1.022-1.401], P = 0.025) were risk factor of MODS after CPB. Conclusions We speculated that there was correlation between lactic acidosis and MODS after CPB. In addition, LA should be monitored intensively after CPB.
Collapse
Affiliation(s)
- Dan Zheng
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Guo-Liang Yu
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Yi-Ping Zhou
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Qiao-Min Zhang
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Chun-Guo Wang
- Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Sheng Zhang
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| |
Collapse
|
5
|
Ji JY, Seo YH, Jung HS, Chun HR, Park JS, Kim WJ, Ahn JM, Park YJ, Shin YE, Park CH. Coronary Artery Occlusion with Sharp Blood Pressure Drop during General Anesthesia Induction: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:232. [PMID: 38399520 PMCID: PMC10890261 DOI: 10.3390/medicina60020232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
Most anesthetics reduce cardiac functions and lower blood pressure (BP), potentially causing excessive BP reduction in dehydrated patients or those with heart conditions, such as coronary artery disease (CAD). Considering the increased prevalence of cardiovascular disease with age, anesthesiologists must be cautious about BP reduction during general anesthesia in older adults. In the present case, a 76-year-old male patient with undiagnosed CAD in a hypovolemic state experienced a significant drop in systolic BP to the fifties during propofol and sevoflurane anesthesia. Despite the use of vasopressors, excessive hypotension persisted, leading to anesthesia suspension. Subsequent cardiac examinations, including computed tomography heart angio and calcium score, and coronary angiogram, revealed a near total occlusion of the proximal left anterior descending coronary artery (pLAD) and the formation of collateral circulation. After 5 days of hydration and anticoagulation medications and confirmation of normovolemic state, general anesthesia was attempted again and successfully induced; a normal BP was maintained throughout the surgery. Thus, it is important to conduct a thorough cardiac evaluation and maintain normovolemia for general anesthesia in older adults.
Collapse
Affiliation(s)
- Jae Young Ji
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Yong Han Seo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Ho Soon Jung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Hea Rim Chun
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Jin Soo Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Woo Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Jae Min Ahn
- Department of Neurosurgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Yu Jun Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Ye Eun Shin
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Chan Ho Park
- Department of Radiology, Soonchunhyang University Hospital Cheonan, 31, Sooncheonhyang 6-gil, Donam-gu, Cheonan 31151, Republic of Korea;
| |
Collapse
|
6
|
Liebrecht LK, Khoraki J, Li R, Archambault C, Bane J, Deitch R, Broadway M, Eldering G, Mangino MJ. Metabolic Tissue Swelling and Local Microcirculation in Splanchnic Artery Occlusion Shock: Implications for Critical Illness. J Pharmacol Exp Ther 2024; 388:27-36. [PMID: 37739805 PMCID: PMC10765417 DOI: 10.1124/jpet.123.001831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/01/2023] [Accepted: 09/08/2023] [Indexed: 09/24/2023] Open
Abstract
Trauma is a leading cause of death in the United States. Advancements in shock resuscitation have been disappointing because the correct upstream mechanisms of injury are not being targeted. Recently, significant advancements have been shown using new cell-impermeant molecules that work by transferring metabolic water from swollen ischemic cells to the capillary, which restores tissue perfusion by microcirculatory decompression. The rapid normalization of oxygen transfer improves resuscitation outcomes. Since poor resuscitation and perfusion of trauma patients also causes critical illness and sepsis and can be mimicked by ischemia-reperfusion of splanchnic tissues, we hypothesized that inadequate oxygenation of the gut during trauma drives development of later shock and critical illness. We further hypothesized that this is caused by ischemia-induced water shifts causing compression no-reflow. To test this, the superior mesenteric artery of juvenile anesthetized swine was occluded for 30 minutes followed by 8 hours of reperfusion to induce mild splanchnic artery occlusion (SAO) shock. One group received the impermeant polyethylene glycol 20,000 Da (PEG-20k) that prevents metabolic cell swelling, and the other received a lactated Ringer's vehicle. Survival doubled in PEG-20k-treated swine along with improved macrohemodynamics and intestinal mucosal perfusion. Villus morphometry and plasma inflammatory cytokines normalized with impermeants. Plasma endotoxin rose over time after reperfusion, and impermeants abolished the rise. Inert osmotically active cell impermeants like PEG-20k improve intestinal reperfusion injury, SAO shock, and early signs of sepsis, which may be due to early restoration of mucosal perfusion and preservation of the septic barrier by reversal of ischemic compression no-reflow. SIGNIFICANCE STATEMENT: Significant advancements in treating shock and ischemia have been disappointing because the correct upstream causes have not been targeted. This study supports that poor tissue perfusion after intestinal ischemia from shock is caused by capillary compression no-reflow secondary to metabolic cell and tissue swelling since selectively targeting this issue with novel polyethylene glycol 20,000 Da-based cell-impermeant intravenous solutions reduces splanchnic artery occlusion shock, doubles survival time, restores tissue microperfusion, and preserves gut barrier function.
Collapse
Affiliation(s)
- Loren K Liebrecht
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Jad Khoraki
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Ru Li
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Caitlin Archambault
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - John Bane
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Rebecca Deitch
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Michael Broadway
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Gerard Eldering
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Martin J Mangino
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| |
Collapse
|
7
|
Jeleff A, Suh N, Schranc Á, Diaper J, Bendjelid K, Schiffer E. New Noninvasive Method for the Assessment of Central Venous Oxygen Saturations in Critically Ill Patients. J Cardiothorac Vasc Anesth 2024; 38:170-174. [PMID: 37827917 DOI: 10.1053/j.jvca.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/05/2023] [Accepted: 09/15/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES To compare noninvasive external jugular vein oxygen saturations (SjvO2) and central venous oxygen saturation (ScvO2) from a blood sample in patients admitted to the intensive care unit. DESIGN A prospective, comparative, monocentric clinical trial design was used. SETTING The study was performed in the Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva (Switzerland). PARTICIPANTS A total of 79 patients were enrolled; patients with confirmed COVID-19 infection requiring invasive mechanical ventilation (patients with COVID-19, n = 36) and patients after liver transplantation (posttransplant patients, n = 43). INTERVENTIONS Simultaneous measurement of SjvO2 by near-infrared spectroscopy and ScvO2 from central venous blood samples using a blood gas analyzer in stable hemodynamic conditions. MEASUREMENTS AND MAIN RESULTS A strong linear correlation was evidenced in both the COVID-19 and posttransplant patient groups between the 2 modalities. The Bland-Altman analysis showed low bias in accordance with low percentage error in both groups (0.57% and 8.09% for patients with COVID-19; 0.00% and 13.72% for posttransplant patients). CONCLUSIONS Central venous oxygen saturation can be estimated reasonably by the continuous noninvasive measurement of SjvO2 using near-infrared spectroscopy.
Collapse
Affiliation(s)
- Alexandre Jeleff
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Noémie Suh
- Division of Intensive Care, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Álmos Schranc
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland.
| | - John Diaper
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Karim Bendjelid
- Division of Intensive Care, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Eduardo Schiffer
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| |
Collapse
|
8
|
Kang HS, Khoraki J, Li R, Xu H, Archambault C, Liebrecht LK, Mangino MJ. Restoring microcirculatory perfusion in a preclinical model of severe hemorrhagic shock: The role of microcirculatory function. J Trauma Acute Care Surg 2023; 95:755-761. [PMID: 37335954 DOI: 10.1097/ta.0000000000004003] [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: 06/21/2023]
Abstract
BACKGROUND No reflow in capillaries (no reflow) is the lack of tissue perfusion that occurs once central hemodynamics are restored. This prevents oxygen transfer and debt repayment to vital tissues after shock resuscitation. Since metabolic swelling of cells and tissues can cause no reflow, it is a target for study in shock. We hypothesize no reflow secondary to metabolic cell swelling causes the problem not addressed by current strategies that increase central hemodynamics alone. METHODS Anesthetized swine were bled until plasma lactate reached 7.5 mM to 9 mM. Intravenous low volume resuscitation solutions were administered (6.8 mL/kg over 5 minutes) consisting of; (1) lactated Ringer (LR), (2) autologous whole blood, (3) high-dose vitamin C (200 mg/kg), or (4) 10% PEG-20k, a polymer-based cell impermeant that corrects metabolic cell swelling. Outcomes were macrohemodynamics (MAP), plasma lactate, capillary flow in the gut and tongue mucosa using orthogonal polarization spectral imaging (OPSI), and survival to 4 hours. RESULTS All PEG-20k resuscitated swine survived 240 minutes with MAP above 60 mm Hg compared with 50% and 0% of the whole blood and LR groups, respectively. The vitamin C group died at just over 2 hours with MAPs below 40 and high lactate. The LR swine only survived 30 minutes and died with low MAP and high lactate. Capillary flow positively correlated ( p < 0.05) with survival and MAP. Sublingual OPSI correlated with intestinal OPSI and OPSI was validated with a histological technique. DISCUSSION Targeting micro-hemodynamics in resuscitation may be more important than macrohemodynamics. Fixing both is optimal. Sublingual OPSI is clinically achievable to assess micro-hemodynamic status. Targeting tissue cell swelling that occurs during ATP depletion in shock using optimized osmotically active cell impermeants in crystalloid low volume resuscitation solutions improves perfusion in shocked tissues, which leverages a primary mechanism of injury.
Collapse
Affiliation(s)
- Hae Sung Kang
- From the Departments of Surgery, Virginia Commonwealth University, School of Medicine, Richmond, VA
| | | | | | | | | | | | | |
Collapse
|
9
|
Werner M, Bergis B, Leblanc PE, Wildenberg L, Duranteau J, Vigué B, Harrois A. Femoral blood gas analysis, another tool to assess hemorrhage severity following trauma: an exploratory prospective study. Scand J Trauma Resusc Emerg Med 2023; 31:31. [PMID: 37340485 PMCID: PMC10280927 DOI: 10.1186/s13049-023-01095-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Veno-arterial carbon dioxide tension difference (ΔPCO2) and mixed venous oxygen saturation (SvO2) have been shown to be markers of the adequacy between cardiac output and metabolic needs in critical care patients. However, they have hardly been assessed in trauma patients. We hypothesized that femoral ΔPCO2 (ΔPCO2 fem) and SvO2 (SvO2 fem) could predict the need for red blood cell (RBC) transfusion following severe trauma. METHODS We conducted a prospective and observational study in a French level I trauma center. Patients admitted to the trauma room following severe trauma with an Injury Severity Score (ISS) > 15, who had arterial and venous femoral catheters inserted were included. ΔPCO2 fem, SvO2 fem and arterial blood lactate were measured over the first 24 h of admission. Their abilities to predict the transfusion of at least one pack of RBC (pRBCH6) or hemostatic procedure during the first six hours of admission were assessed using receiver operating characteristics curve. RESULTS 59 trauma patients were included in the study. Median ISS was 26 (22-32). 28 patients (47%) received at least one pRBCH6 and 21 patients (35,6%) had a hemostatic procedure performed during the first six hours of admission. At admission, ΔPCO2 fem was 9.1 ± 6.0 mmHg, SvO2 fem 61.5 ± 21.6% and blood lactate was 2.7 ± 1.9 mmol/l. ΔPCO2 fem was significantly higher (11.6 ± 7.1 mmHg vs. 6.8 ± 3.7 mmHg, P = 0.003) and SvO2 fem was significantly lower (50 ± 23 mmHg vs. 71.8 ± 14.1 mmHg, P < 0.001) in patients who were transfused than in those who were not transfused. Best thresholds to predict pRBCH6 were 8.1 mmHg for ΔPCO2 fem and 63% for SvO2 fem. Best thresholds to predict the need for a hemostatic procedure were 5.9 mmHg for ΔPCO2 fem and 63% for SvO2 fem. Blood lactate was not predictive of pRBCH6 or the need for a hemostatic procedure. CONCLUSION In severe trauma patients, ΔPCO2 fem and SvO2 fem at admission were predictive for the need of RBC transfusion and hemostatic procedures during the first six hours of management while admission lactate was not. ΔPCO2 fem and SvO2 fem appear thus to be more sensitive to blood loss than blood lactate in trauma patients, which might be of importance to early assess the adequation of tissue blood flow with metabolic needs.
Collapse
Affiliation(s)
- Marie Werner
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Équipe DYNAMIC, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Benjamin Bergis
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Équipe DYNAMIC, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Pierre-Etienne Leblanc
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Lucille Wildenberg
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Jacques Duranteau
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Équipe DYNAMIC, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Bernard Vigué
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Anatole Harrois
- Service d’Anesthésie Réanimation Chirurgicale, DMU 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire et Douleur, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Équipe DYNAMIC, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| |
Collapse
|
10
|
Shock in Trauma. Emerg Med Clin North Am 2023; 41:1-17. [DOI: 10.1016/j.emc.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
11
|
Ganushchak YM, Kurniawati ER, van der Horst IC, van Kuijk SM, Weerwind PW, Lorusso R, Maessen JG. Patterns of oxygen debt repayment in cardiogenic shock patients sustained with extracorporeal life support: A retrospective study. J Crit Care 2022; 71:154044. [DOI: 10.1016/j.jcrc.2022.154044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 03/04/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
|
12
|
Characteristics and Risk Factors of Myocardial Injury after Traumatic Hemorrhagic Shock. J Clin Med 2022; 11:jcm11164799. [PMID: 36013038 PMCID: PMC9409653 DOI: 10.3390/jcm11164799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/05/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Myocardial injury increases major adverse cardiovascular events and mortality in patients with traumatic hemorrhagic shock, but its prevalence and risk factors remain unclear. This study aimed to assess the prevalence and risk factors of myocardial injury after traumatic hemorrhagic shock. This was an observational, retrospective cohort study of patients with traumatic hemorrhagic shock at a tertiary university hospital from November 2012 to July 2021. Patient characteristics and clinical variables were recorded in 314 patients. The outcome was the occurrence of myocardial injury after traumatic hemorrhagic shock. Risk factors for myocardial injury were identified using logistic regression. The incidence of myocardial injury after the traumatic hemorrhagic shock was 42.4%, and 95.5% of myocardial injuries occurred within the first three days after trauma. In the multivariate analysis, the independent risk factors for myocardial injury after traumatic hemorrhagic shock included heart rate of >100 beats/min (OR [odds ratio], 3.33; 95% confidence interval [CI], 1.56−7.09; p = 0.002), hemoglobin level of <70 g/L (OR, 3.50; 95% CI, 1.15−10.60; p = 0.027), prothrombin time of >15 s (OR, 2.39; 95% CI, 1.12−5.10; p = 0.024), acute kidney injury (OR, 2.75; 95% CI, 1.27−5.93; p = 0.01), and a higher APACHE II score (OR, 1.08; 95% CI, 1.01−1.15; p = 0.018). The area under the receiver operating characteristic curve for the prediction of myocardial injury after a traumatic hemorrhagic shock was 0.67 (95% CI, 0.68−0.79) for a heart rate of >100 beats/min, 0.67 (95% CI, 0.61−0.73) for hemoglobin level of <70 g/L, 0.66 (95% CI, 0.60−0.73) for prothrombin time of >15 s, 0.70 (95% CI, 0.64−0.76) for acute kidney injury, and 0.78 (95% CI, 0.73−0.83) for APACHE II scores. The incidence rate of myocardial injury in traumatic hemorrhagic shock is high, and heart rates of >100 beats/min, hemoglobin levels of <70 g/L, prothrombin times of >15 s, AKI and higher APACHE II scores are independent risk factors for myocardial injury after traumatic hemorrhagic shock. These findings may help clinicians to identify myocardial injury after traumatic hemorrhagic shock early and initiate appropriate treatment.
Collapse
|
13
|
Hof S, Marcus C, Kuebart A, Schulz J, Truse R, Raupach A, Bauer I, Flögel U, Picker O, Herminghaus A, Temme S. A Toolbox to Investigate the Impact of Impaired Oxygen Delivery in Experimental Disease Models. Front Med (Lausanne) 2022; 9:869372. [PMID: 35652064 PMCID: PMC9149176 DOI: 10.3389/fmed.2022.869372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/25/2022] [Indexed: 12/29/2022] Open
Abstract
Impaired oxygen utilization is the underlying pathophysiological process in different shock states. Clinically most important are septic and hemorrhagic shock, which comprise more than 75% of all clinical cases of shock. Both forms lead to severe dysfunction of the microcirculation and the mitochondria that can cause or further aggravate tissue damage and inflammation. However, the detailed mechanisms of acute and long-term effects of impaired oxygen utilization are still elusive. Importantly, a defective oxygen exploitation can impact multiple organs simultaneously and organ damage can be aggravated due to intense organ cross-talk or the presence of a systemic inflammatory response. Complexity is further increased through a large heterogeneity in the human population, differences in genetics, age and gender, comorbidities or disease history. To gain a deeper understanding of the principles, mechanisms, interconnections and consequences of impaired oxygen delivery and utilization, interdisciplinary preclinical as well as clinical research is required. In this review, we provide a "tool-box" that covers widely used animal disease models for septic and hemorrhagic shock and methods to determine the structure and function of the microcirculation as well as mitochondrial function. Furthermore, we suggest magnetic resonance imaging as a multimodal imaging platform to noninvasively assess the consequences of impaired oxygen delivery on organ function, cell metabolism, alterations in tissue textures or inflammation. Combining structural and functional analyses of oxygen delivery and utilization in animal models with additional data obtained by multiparametric MRI-based techniques can help to unravel mechanisms underlying immediate effects as well as long-term consequences of impaired oxygen delivery on multiple organs and may narrow the gap between experimental preclinical research and the human patient.
Collapse
Affiliation(s)
- Stefan Hof
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Carsten Marcus
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Anne Kuebart
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Jan Schulz
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Richard Truse
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Annika Raupach
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Inge Bauer
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Ulrich Flögel
- Experimental Cardiovascular Imaging, Department of Molecular Cardiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Olaf Picker
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Anna Herminghaus
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sebastian Temme
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
14
|
Kusumastuti NP, Ontoseno T, Endaryanto A. Renal Oxygen Saturation as an Early Indicator of Shock in Children. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:123-131. [PMID: 35388273 PMCID: PMC8977478 DOI: 10.2147/oaem.s357320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Shock is a life-threatening syndrome in which tissue perfusion and oxygen delivery are inadequate. Near-infrared spectroscopy (NIRS) has been suggested as a noninvasive tool for monitoring and detecting the state of inadequate tissue perfusion. Renal and mesenteric oximetry show decreased cardiac output earlier than systemic or global parameters of tissue oxygenation or cerebral oximetry. However, until now there has been no study on the validity of regional renal oxygen saturation (rRSO2) by NIRS for diagnosing shock in children. Purpose To analyze the validity of rRSO2 by NIRS to diagnose shock in children. Patients and Methods This cross-sectional study was conducted in critically ill children (aged 1 month–18 years) who were admitted to the pediatric intensive care unit (PICU), from September to November 2020, consecutively. Patients were classified into two groups: shock and non-shock. The diagnosis of shock is based on clinical criteria (tachycardia, sign of hypoperfusion and decrease systolic blood pressure <P5 according to age). Measurement of rRSO2 by NIRS was performed by the doctor in charge when the patient came to PICU. The baseline rRSO2 value (%) made a receiver operating characteristic (ROC) curve and was used to find the optimal cut-off value and calculated sensitivity and specificity. Results We enrolled 20 critically ill patients. The baseline rRSO2 in the shock (n=10) and non-shock (n=10) groups were, 44.00±4.95 vs 78.70±4.52 (p 0.003). The optimal cutoff value of the baseline rRSO2 to predict shock is less than 58.5% with area under the curve (AUC) value is 94.4% (95% CI of 84.4–100%), p 0.001, sensitivity 90% and specificity 90% in critically ill children. Conclusion The rRSO2 value by NIRS can differentiate between shock and non-shock in critically ill patients accurately.
Collapse
Affiliation(s)
- Neurinda Permata Kusumastuti
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
- Departement of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
- Correspondence: Neurinda Permata Kusumastuti, Department of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Jl. Mayjend Prof. Dr. Moestopo No. 6-8, Airlangga, Gubeng, Surabaya, East Java, 60286, Indonesia, Tel +62 811316712, Email
| | - Teddy Ontoseno
- Departement of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
| | - Anang Endaryanto
- Departement of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
| |
Collapse
|
15
|
Dyer WB, Tung JP, Li Bassi G, Wildi K, Jung JS, Colombo SM, Rozencwajg S, Simonova G, Chiaretti S, Temple FT, Ainola C, Shuker T, Palmieri C, Shander A, Suen JY, Irving DO, Fraser JF. An Ovine Model of Hemorrhagic Shock and Resuscitation, to Assess Recovery of Tissue Oxygen Delivery and Oxygen Debt, and Inform Patient Blood Management. Shock 2021; 56:1080-1091. [PMID: 34014886 DOI: 10.1097/shk.0000000000001805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Aggressive fluid or blood component transfusion for severe hemorrhagic shock may restore macrocirculatory parameters, but not always improve microcirculatory perfusion and tissue oxygen delivery. We established an ovine model of hemorrhagic shock to systematically assess tissue oxygen delivery and repayment of oxygen debt; appropriate outcomes to guide Patient Blood Management. METHODS Female Dorset-cross sheep were anesthetized, intubated, and subjected to comprehensive macrohemodynamic, regional tissue oxygen saturation (StO2), sublingual capillary imaging, and arterial lactate monitoring confirmed by invasive organ-specific microvascular perfusion, oxygen pressure, and lactate/pyruvate levels in brain, kidney, liver, and skeletal muscle. Shock was induced by stepwise withdrawal of venous blood until MAP was 30 mm Hg, mixed venous oxygen saturation (SvO2) < 60%, and arterial lactate >4 mM. Resuscitation with PlasmaLyte® was dosed to achieve MAP > 65 mm Hg. RESULTS Hemorrhage impacted primary outcomes between baseline and development of shock: MAP 89 ± 5 to 31 ± 5 mm Hg (P < 0.01), SvO2 70 ± 7 to 23 ± 8% (P < 0.05), cerebral regional tissue StO2 77 ± 11 to 65 ± 9% (P < 0.01), peripheral muscle StO2 66 ± 8 to 16 ± 9% (P < 0.01), arterial lactate 1.5 ± 1.0 to 5.1 ± 0.8 mM (P < 0.01), and base excess 1.1 ± 2.2 to -3.6 ± 1.7 mM (P < 0.05). Invasive organ-specific monitoring confirmed reduced tissue oxygen delivery; oxygen tension decreased and lactate increased in all tissues, but moderately in brain. Blood volume replacement with PlasmaLyte® improved primary outcome measures toward baseline, confirmed by organ-specific measures, despite hemoglobin reduced from baseline 10.8 ± 1.2 to 5.9 ± 1.1 g/dL post-resuscitation (P < 0.01). CONCLUSION Non-invasive measures of tissue oxygen delivery and oxygen debt repayment are suitable outcomes to inform Patient Blood Management of hemorrhagic shock, translatable for pre-clinical assessment of novel resuscitation strategies.
Collapse
Affiliation(s)
- Wayne B Dyer
- Australian Red Cross Lifeblood, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - John-Paul Tung
- Australian Red Cross Lifeblood, Brisbane, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Medical Engineering Research Facility, Queensland University of Technology, Brisbane, Australia
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Karin Wildi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Cardiovascular Research Institute, Basel, Switzerland
| | - Jae-Seung Jung
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Sebastiano Maria Colombo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Pathophysiology and Transplantation, Universita degli Studi di Milano, Milano, Italy
| | - Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Sorbonne Université, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Medical ICU, Pitié-Salpêtrière University Hospital, Paris, France
| | - Gabriela Simonova
- Australian Red Cross Lifeblood, Brisbane, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Fergal T Temple
- Australian Red Cross Lifeblood, Brisbane, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Tristan Shuker
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Chiara Palmieri
- School of Veterinary Science, The University of Queensland, Brisbane, Australia
| | - Aryeh Shander
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood
- TeamHealth, Englewood Health, Englewood
- UF College of Medicine, University of Florida, Gainesville
- Department of Anesthesiology, Medicine and Surgery, Icahn School of Medicine, Mount Sinai Hospital, New York
- Department of Anesthesiology and Critical Care, Rutgers University, Newark
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - David O Irving
- Australian Red Cross Lifeblood, Sydney, Australia
- Faculty of Health, University of Technology, Sydney, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| |
Collapse
|
16
|
Sardesai NR, Gaski GE, Gunderson ZJ, Cunningham CM, Slaven J, Meagher AD, McKinley TO, Natoli RM. Base Deficit ≥ 6 within 24 h of Injury is a risk factor for fracture nonunion in the polytraumatized patient. Injury 2021; 52:3271-3276. [PMID: 34053772 DOI: 10.1016/j.injury.2021.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/07/2021] [Accepted: 05/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Polytrauma patients are at risk for fracture nonunion, but the reasons are poorly understood. Increased base deficit (BD) is associated with hypovolemic shock. Although shock delays bone healing in animal models, there have been no clinical studies evaluating the impact of BD on nonunion risk. MATERIALS AND METHODS Patients age ≥ 16 with injury severity score > 16 that presented to an academic Level One trauma center with an operative femur or tibia fracture were reviewed. Clinical notes and radiographs were assessed to determine fracture healing status. Patient demographics, injury characteristics, BD, and number of packed red blood cell transfusions were recorded. Bivariate and multivariate analyses of multiple risk factors associated with nonunion were conducted to investigate the association of BD with nonunion. RESULTS The union group was comprised of 243 fractures; there were 36 fractures in the nonunion group. The following predictors were associated with nonunion: smoking (p = 0.009), alcohol use (p < 0.001), open fracture (p < 0.001), and treatment for deep infection at fracture site (p = 0.016). Additionally, worst BD over 24 h ≥ 6 (p = 0.031) was significant for nonunion development. A multivariate logistic regression analysis revealed worst BD ≥6 over 24 h remained significantly associated with the development of nonunion (odds ratio 3.02, p = 0.011) when adjusting for other risk factors. CONCLUSIONS A BD ≥ 6 within 24 h of admission was associated with a significantly increased risk of developing lower extremity fracture nonunion in polytrauma patients, even after adjusting for multiple other risk factors. Acute post-traumatic acidosis may have effects on long-term fracture healing.
Collapse
Affiliation(s)
- Neil R Sardesai
- Center for Orthopaedic Specialists, 18133 Ventura Blvd, Suite 302, Tarzana, CA 91356 United States
| | - Greg E Gaski
- Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA 22042 United States
| | - Zachary J Gunderson
- Indiana University School of Medicine, 1801 North Senate Blvd, MPC 1, Suite 535 Indianapolis, IN 46202 United States.
| | - Connor M Cunningham
- Indiana University School of Medicine, 1801 North Senate Blvd, MPC 1, Suite 535 Indianapolis, IN 46202 United States.
| | - James Slaven
- Indiana University School of Medicine, 1801 North Senate Blvd, MPC 1, Suite 535 Indianapolis, IN 46202 United States.
| | - Ashley D Meagher
- Indiana University School of Medicine, 1801 North Senate Blvd, MPC 1, Suite 535 Indianapolis, IN 46202 United States.
| | - Todd O McKinley
- Indiana University School of Medicine, 1801 North Senate Blvd, MPC 1, Suite 535 Indianapolis, IN 46202 United States.
| | - Roman M Natoli
- Indiana University School of Medicine, 1801 North Senate Blvd, MPC 1, Suite 535 Indianapolis, IN 46202 United States.
| |
Collapse
|
17
|
Kumar A, Sinha C, Sinha AK, Surabhi, Singh S, Singh K. Postoperative bradycardia following bladder exstrophy surgery: An anesthesiologist's nightmare. Saudi J Anaesth 2021; 15:457-458. [PMID: 34658740 PMCID: PMC8477768 DOI: 10.4103/sja.sja_257_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/10/2021] [Accepted: 04/11/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Amarjeet Kumar
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Chandni Sinha
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Amit Kumar Sinha
- Department of Paediatric Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Surabhi
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Saras Singh
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Kritika Singh
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
| |
Collapse
|
18
|
Merz T, McCook O, Denoix N, Radermacher P, Waller C, Kapapa T. Biological Connection of Psychological Stress and Polytrauma under Intensive Care: The Role of Oxytocin and Hydrogen Sulfide. Int J Mol Sci 2021; 22:9192. [PMID: 34502097 PMCID: PMC8430789 DOI: 10.3390/ijms22179192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/06/2021] [Accepted: 08/20/2021] [Indexed: 12/12/2022] Open
Abstract
This paper explored the potential mediating role of hydrogen sulfide (H2S) and the oxytocin (OT) systems in hemorrhagic shock (HS) and/or traumatic brain injury (TBI). Morbidity and mortality after trauma mainly depend on the presence of HS and/or TBI. Rapid "repayment of the O2 debt" and prevention of brain tissue hypoxia are cornerstones of the management of both HS and TBI. Restoring tissue perfusion, however, generates an ischemia/reperfusion (I/R) injury due to the formation of reactive oxygen (ROS) and nitrogen (RNS) species. Moreover, pre-existing-medical-conditions (PEMC's) can aggravate the occurrence and severity of complications after trauma. In addition to the "classic" chronic diseases (of cardiovascular or metabolic origin), there is growing awareness of psychological PEMC's, e.g., early life stress (ELS) increases the predisposition to develop post-traumatic-stress-disorder (PTSD) and trauma patients with TBI show a significantly higher incidence of PTSD than patients without TBI. In fact, ELS is known to contribute to the developmental origins of cardiovascular disease. The neurotransmitter H2S is not only essential for the neuroendocrine stress response, but is also a promising therapeutic target in the prevention of chronic diseases induced by ELS. The neuroendocrine hormone OT has fundamental importance for brain development and social behavior, and, thus, is implicated in resilience or vulnerability to traumatic events. OT and H2S have been shown to interact in physical and psychological trauma and could, thus, be therapeutic targets to mitigate the acute post-traumatic effects of chronic PEMC's. OT and H2S both share anti-inflammatory, anti-oxidant, and vasoactive properties; through the reperfusion injury salvage kinase (RISK) pathway, where their signaling mechanisms converge, they act via the regulation of nitric oxide (NO).
Collapse
Affiliation(s)
- Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Nicole Denoix
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
- Clinic for Psychosomatic Medicine and Psychotherapy, Medical Center, Ulm University, 89081 Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Christiane Waller
- Department of Psychosomatic Medicine and Psychotherapy, Nuremberg General Hospital, Paracelsus Medical University, 90471 Nuremberg, Germany;
| | - Thomas Kapapa
- Clinic for Neurosurgery, Medical Center, Ulm University, 89081 Ulm, Germany;
| |
Collapse
|
19
|
Edwards TH, Rizzo JA, Pusateri AE. Hemorrhagic shock and hemostatic resuscitation in canine trauma. Transfusion 2021; 61 Suppl 1:S264-S274. [PMID: 34269447 DOI: 10.1111/trf.16516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/27/2022]
Abstract
Hemorrhage is a significant cause of death among military working dogs and in civilian canine trauma. While research specifically aimed at canine trauma is limited, many principles from human trauma resuscitation apply. Trauma with significant hemorrhage results in shock and inadequate oxygen delivery to tissues. This leads to aberrations in cellular metabolism, including anaerobic metabolism, decreased energy production, acidosis, cell swelling, and eventual cell death. Considering blood and endothelium as a single organ system, blood failure is a syndrome of endotheliopathy, coagulopathy, and platelet dysfunction. In severe cases following injury, blood failure develops and is induced by inadequate oxygen delivery in the presence of hemorrhage, tissue injury, and acute stress from trauma. Severe hemorrhagic shock is best treated with hemostatic resuscitation, wherein blood products are used to restore effective circulating volume and increase oxygen delivery to tissues without exacerbating blood failure. The principles of hemostatic resuscitation have been demonstrated in severely injured people and the authors propose an algorithm for applying this to canine patients. The use of plasma and whole blood to resuscitate severely injured canines while minimizing the use of crystalloids and colloids could prove instrumental in improving both mortality and morbidity. More work is needed to understand the canine patient that would benefit from hemostatic resuscitation, as well as to determine the optimal resuscitation strategy for these patients.
Collapse
Affiliation(s)
- Thomas H Edwards
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA
| | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony E Pusateri
- Naval Medical Research Unit San Antonio, Joint Base San Antonio - Fort Sam Houston, Texas, USA
| |
Collapse
|
20
|
Sul YH, Lee JY, Kim SH, Ye JB, Lee JS, Yoon SY, Choi JH. Risk factors for acute kidney injury in critically ill patients with torso injury: A retrospective observational single-center study. Medicine (Baltimore) 2021; 100:e26723. [PMID: 34398045 PMCID: PMC8294861 DOI: 10.1097/md.0000000000026723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/06/2021] [Indexed: 01/04/2023] Open
Abstract
Acute kidney injury (AKI) is common in trauma patients and associated with poor outcomes. Identifying AKI risk factors in trauma patients is important for risk stratification and provision of optimal intensive care unit (ICU) treatment. This study identified AKI risk factors in patients admitted to critical care after sustaining torso injuries.We performed a retrospective chart review involving 380 patients who sustained torso injuries from January 2016 to December 2019. Patients were included if they were aged >15 years, admitted to an ICU, survived for >48 hours, and had thoracic and/or abdominal injuries and no end-stage renal disease. AKI was defined according to the Kidney Disease Improving Global Outcomes definition and staging system. Clinical and laboratory variables were compared between the AKI and non-AKI groups (n = 72 and 308, respectively). AKI risk factors were assessed using multivariate logistic regression analysis.AKI occurred in 72 (18.9%) patients and was associated with higher mortality than non-AKI patients (26% vs 4%, P < .001). Multivariate logistic regression analysis identified bowel injury, cumulative fluid balance >2.5 L for 24 hours, lactate levels, and vasopressor use (adjusted odds ratio: 2.953, 2.058, 1.170, and 2.910; 95% confidence interval: 1.410-6.181, 1.017-4.164, 1.019-1.343, and 1.414-5.987; P = .004, .045, .026, and .004, respectively) as independent risk factors for AKI.AKI in patients admitted to the ICU with torso injury had a substantial mortality. Recognizing risk factors at an early stage could aid risk stratification and provision of optimal ICU care.
Collapse
Affiliation(s)
- Young Hoon Sul
- Deparment of Trauma Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, Republic of Korea
- Department of Trauma Surgery, College of Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Jin Young Lee
- Deparment of Trauma Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Se Heon Kim
- Deparment of Trauma Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jin Bong Ye
- Deparment of Trauma Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jin Suk Lee
- Deparment of Trauma Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Su Young Yoon
- Department of Cardiovascular and Thoracic Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jung Hee Choi
- Department of Anesthesiology and Pain Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| |
Collapse
|
21
|
Lervik A, Forr Toverud S, Bohlin J, Haga HA. Macrocirculatory Parameters and Oxygen Debt Indices in Pigs During Propofol Or Alfaxalone Anesthesia When Subjected to Experimental Stepwise Hemorrhage. Front Vet Sci 2021; 8:664112. [PMID: 34095276 PMCID: PMC8173164 DOI: 10.3389/fvets.2021.664112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Pigs are anesthetized when used for emergency procedures live tissue training (LTT) of civilian and military medical personnel or for experimental purposes, but there is a paucity in the literature regarding anesthesia of pigs for this purpose. Objective(s): The main goals of the study were to compare oxygen debt, macrocirculatory parameters, and time to cardiac arrest between pigs in hemorrhagic shock and anesthetized with propofol-ketamine-dexmedetomidine or alfaxalone-ketamine-dexmedetomidine. Design: A prospective, non-blinded randomized study design was used. Sixteen pigs were randomized in blocks of four to be anesthetized with either propofol-ketamine-dexmedetomidine (n = 8) or alfaxalone-ketamine-dexmedetomidine (n = 8) as a continuous infusion. Interventions: Premedication with ketamine 15 mg kg-1 and midazolam 1 mg kg-1 was given i.m. Anesthesia was maintained with propofol 8 mg kg-1 h-1 or alfaxalone 5 mg kg-1 h-1 combined with ketamine 5 mg kg-1 h-1 and dexmedetomidine 4 μg kg-1 h-1 i.v. A stepwise, volume-controlled model for hemorrhage was created by exsanguination. Main Outcome Measures: Indices of oxygen debt (lactate, base excess, and oxygen extraction), macrocirculatory (PR, SAP, DAP, MAP, and CI, SVI, and TPR) variables, and time to death was compared between groups. Results: Pigs in the alfaxalone group had significantly higher SAP than pigs given propofol. No difference in other macrocirculatory variables or indices of oxygen debt could be found. A blood loss of 50% of the total blood volume or more was possible in most pigs with both anesthetic regimes. Conclusions: Pigs anesthetized with propofol or alfaxalone combined with ketamine and dexmedetomidine tolerated substantial blood loss.
Collapse
Affiliation(s)
- Andreas Lervik
- Department of Companion Animal Clinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
| | - Simen Forr Toverud
- Animal Health and Welfare Branch, Veterinary Inspectorate, Norwegian Armed Forces Joint Medical Services, Sessvollmoen, Norway
| | - Jon Bohlin
- Division of Infection Control and Environmental Health, Department for Method Development and Analysis, Norwegian Institute of Public Health, Oslo, Norway.,Center for Fertility and Health Analysis, Norwegian Institute of Public Health, Oslo, Norway
| | - Henning Andreas Haga
- Department of Companion Animal Clinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
| |
Collapse
|
22
|
Seichter F, Vogt J, Tütüncü E, Hagemann LT, Wachter U, Gröger M, Kress S, Radermacher P, Mizaikoff B. Metabolic monitoring via on-line analysis of 13C-enriched carbon dioxide in exhaled mouse breath using substrate-integrated hollow waveguide infrared spectroscopy and luminescence sensing combined with Bayesian sampling. J Breath Res 2021; 15:026013. [PMID: 33630755 DOI: 10.1088/1752-7163/ab8dcd] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In studies that target specific functions or organs, the response is often overlaid by indirect effects of the intervention on global metabolism. The metabolic side of these interactions can be assessed based on total energy expenditure (TEE) and the contributions of the principal energy sources, carbohydrates, proteins and fat to whole body CO2 production. These parameters can be identified from indirect calorimetry using respiratory oxygen intake and CO2 dioxide production data that are combined with the response of the 13CO2 release in the expired air and the glucose tracer enrichment in plasma following a 13C glucose stable isotope infusion. This concept is applied to a mouse protocol involving anesthesia, mechanical respiration, a disease model, like hemorrhage and therapeutic intervention. It faces challenges caused by a small sample size for both breath and plasma as well as changes in metabolic parameters caused by disease and intervention. Key parameters are derived from multiple measurements, all afflicted with errors that may accumulate leading to unrealistic values. To cope with these challenges, a sensitive on-line breath analysis system based on substrate-integrated hollow waveguide infrared spectroscopy and luminescence (iHWG-IR-LS) was used to monitor gas exchange values. A Bayesian statistical model is developed that uses established equations for indirect calorimetry to predict values for respiratory gas exchange and tracer data that are consistent with the corresponding measurements and also provides statistical error bands for these parameters. With this new methodology, it was possible to estimate important metabolic parameters (respiratory quotient (RQ), relative contribution of carbohydrate, protein and fat oxidation fcarb, ffat and fprot , total energy expenditure TEE) in a resolution never available before for a minimal invasive protocol of mice under anesthesia.
Collapse
Affiliation(s)
- Felicia Seichter
- Institute of Analytical and Bioanalytical Chemistry, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Shi J, Dai W, Carreno J, Zhao L, Kloner RA. Therapeutic Hypothermia Improves Long-Term Survival and Blunts Inflammation in Rats During Resuscitation of Hemorrhagic Shock. Ther Hypothermia Temp Manag 2020; 10:237-243. [DOI: 10.1089/ther.2020.0024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jianru Shi
- HMRI Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, California, USA
- Division of Cardiovascular Medicine of the Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Wangde Dai
- HMRI Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, California, USA
- Division of Cardiovascular Medicine of the Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Juan Carreno
- HMRI Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, California, USA
| | - Lifu Zhao
- HMRI Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, California, USA
| | - Robert A. Kloner
- HMRI Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, California, USA
- Division of Cardiovascular Medicine of the Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
24
|
Quantitative Assessment of Blood Lactate in Shock: Measure of Hypoxia or Beneficial Energy Source. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2608318. [PMID: 33150168 PMCID: PMC7603544 DOI: 10.1155/2020/2608318] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/18/2020] [Indexed: 12/16/2022]
Abstract
Blood lactate concentration predicts mortality in critically ill patients and is clinically used in the diagnosis, grading of severity, and monitoring response to therapy of septic shock. This paper summarizes available quantitative data to provide the first comprehensive description and critique of the accepted concepts of the physiology of lactate in health and shock, with particular emphasis on the controversy of whether lactate release is simply a manifestation of tissue hypoxia versus a purposeful transfer ("shuttle") of lactate between tissues. Basic issues discussed include (1) effect of nonproductive lactate-pyruvate exchange that artifactually enhances flux measurements obtained with labeled lactate, (2) heterogeneous tissue oxygen partial pressure (Krogh model) and potential for unrecognized hypoxia that exists in all tissues, and (3) pathophysiology that distinguishes septic from other forms of shock. Our analysis suggests that due to exchange artifacts, the turnover rate of lactate and the lactate clearance are only about 60% of the values of 1.05 mmol/min/70 kg and 1.5 L/min/70 kg, respectively, determined from the standard tracer kinetics. Lactate turnover reflects lactate release primarily from muscle, gut, adipose, and erythrocytes and uptake by the liver and kidney, primarily for the purpose of energy production (TCA cycle) while the remainder is used for gluconeogenesis (Cori cycle). The well-studied physiology of exercise-induced hyperlactatemia demonstrates massive release from the contracting muscle accompanied by an increased lactate clearance that may occur in recovering nonexercising muscle as well as the liver. The very limited data on lactate kinetics in shock patients suggests that hyperlactatemia reflects both decreased clearance and increased production, possibly primarily in the gut. Our analysis of available data in health and shock suggests that the conventional concept of tissue hypoxia can account for most blood lactate findings and there is no need to implicate a purposeful production of lactate for export to other organs.
Collapse
|
25
|
Abstract
Goal-directed therapy couples therapeutic interventions with physiologic and metabolic targets to mitigate a patient's modifiable risks for death and complications. Goal-directed therapy attempts to improve quality-of-care metrics, including length of stay, rate of readmission, and cost per case. Debate persists around specific parameters and goals, the risk profiles that may benefit, and associated therapeutic strategies. Goal-directed therapy has demonstrated reduced complication rates and lengths of stay in noncardiac surgery studies. Establishing goal-directed therapy's early promise and role in cardiac surgery-namely, producing fewer complications and deaths-will require larger studies, including those with greater focus on high-risk patients.
Collapse
Affiliation(s)
- Kevin W Lobdell
- Atrium Health Cardiothoracic Surgery, Atrium Health's Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232, USA.
| | - Subhasis Chatterjee
- Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS: BCM 390, Houston, TX 77030, USA; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA. https://twitter.com/SXC71
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, Giessen 35392, Germany; Charity Medical University, Berlin, Germany. https://twitter.com/Mich_San_d
| |
Collapse
|
26
|
Kheirabadi BS, Miranda N, Terrazas IB, Voelker AN, de Guzman R, Wienandt NA, Brown AW, Dubick MA. Should Albumin be Considered for Prehospital Resuscitation in Austere Environments? A Prospective Randomized Survival Study in Rabbits. Shock 2020; 54:358-367. [PMID: 31743300 DOI: 10.1097/shk.0000000000001480] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The new guidelines for prehospital care of combat casualties in shock recommend administration of whole blood or blood components to increase blood pressure to a permissible hypotensive level (i.e., hypotensive resuscitation [HR]). We investigated if 2 h of HR using limited volumes of whole blood, plasma, or albumin would lead to full recovery and long-term survival of rabbits subjected to severe hemorrhagic shock (HS). METHODS Following instrumentation, laparotomy was performed on IV-anesthetized spontaneously breathing New Zealand white rabbits (3.0 kg -3.5 kg). Next, ∼40% of rabbits' blood volume was removed producing HS (mean arterial pressure [MAP]∼20 mm Hg). Fifteen minutes later, rabbits were resuscitated with a limited volume (12.5 mL/kg) of rabbit whole blood (fresh whole blood [FWB]), rabbit fresh frozen plasma (FFP), or 5% human albumin (ALB) to a target pressure (MAP) of 60 mm Hg (n=8/grp) and monitored for 2 h. Liver bleeding time was measured at baseline and 10 min after HR. Subsequently, animals were fully resuscitated (blood + lactated Ringer [LR]), surgically repaired, and recovered for 8 days. An untreated group (n = 6) was also included. RESULTS Following HS, lactate and base deficit levels were increased to 8.2 ± 1.6 and 12.9 ± 3.1 mM respectively with no difference among groups. A lower volume of FWB volume was required to reach the target MAP (P < 0.05 vs. ALB) but MAP declined during the HR period (P < 0.01 vs. ALB). FWB provided higher hematocrit and platelets but it did not reduce lactate level faster than other fluids. Beside higher fibrinogen, no differences were found in hemostatic or resuscitative effects of FFP versus ALB. Bleeding time was prolonged with ALB and FFP fluids but unchanged with FWB. Untreated rabbits died during shock or shortly after. All treated rabbits except one recovered and lived for 8 days with normal blood tests and similar tissue histology. CONCLUSIONS Two hours of HR using a limited volume of FWB, FFP, or ALB led to full recovery and long-term survival of rabbits subjected to HS. Apart from bleeding time, no clinically significant differences were found among the three fluids. Five percent human albumin solutions are isotonic, iso-oncotic, ready-to-use, stable, and compatible with all blood types and should be considered for prehospital resuscitation where blood products are not available or not accepted.
Collapse
|
27
|
Raa A, Sunde GA, Bolann B, Kvåle R, Bjerkvig C, Eliassen HS, Wentzel-Larsen T, Heltne JK. Validation of a point-of-care capillary lactate measuring device (Lactate Pro 2). Scand J Trauma Resusc Emerg Med 2020; 28:83. [PMID: 32811544 PMCID: PMC7437027 DOI: 10.1186/s13049-020-00776-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/05/2020] [Indexed: 11/21/2022] Open
Abstract
Background The measurement of lactate in emergency medical services has the potential for earlier detection of shock and can be performed with a point-of-care handheld device. Validation of a point-of-care handheld device is required for prehospital implementation. Aim The primary aim was to validate the accuracy of Lactate Pro 2 in healthy volunteers and in haemodynamically compromised intensive care patients. The secondary aim was to evaluate which sample site, fingertip or earlobe, is most accurate compared to arterial lactate. Methods Arterial, venous and capillary blood samples from fingertips and earlobes were collected from intensive care patients and healthy volunteers. Arterial and venous blood lactate samples were analysed on a stationary hospital blood gas analyser (ABL800 Flex) as the reference device and compared to the Lactate Pro 2. We used the Bland-Altman method to calculate the limits of agreement and used mixed effect models to compare instruments and sample sites. A total of 49 intensive care patients with elevated lactate and 11 healthy volunteers with elevated lactate were included. Results There was no significant difference in measured lactate between Lactate Pro 2 and the reference method using arterial blood in either the healthy volunteers or the intensive care patients. Capillary lactate measurement in the fingertip and earlobe of intensive care patients was 47% (95% CI (29 to 68%), p < 0.001) and 27% (95% CI (11 to 45%), p < 0.001) higher, respectively, than the corresponding arterial blood lactate. In the healthy volunteers, we found that capillary blood lactate in the fingertip was 14% higher than arterial blood lactate (95% CI (4 to 24%), p = 0.003) and no significant difference between capillary blood lactate in the earlobe and arterial blood lactate. Conclusion Our results showed that the handheld Lactate Pro 2 had good agreement with the reference method using arterial blood in both intensive care patients and healthy volunteers. However, we found that the agreement was poorer using venous blood in both groups. Furthermore, the earlobe may be a better sample site than the fingertip in intensive care patients.
Collapse
Affiliation(s)
- Anette Raa
- University of Bergen, Vognstølen 18 C, 5096, Bergen, Norway.
| | - Geir Arne Sunde
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Helicopter Emergency Medical Services, Bergen, Norway
| | - Bjørn Bolann
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Reidar Kvåle
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christopher Bjerkvig
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Helicopter Emergency Medical Services, Bergen, Norway.,Norwegian Navy Special Operations Commando, Norwegian Armed Forces, Bergen, Norway
| | - Håkon S Eliassen
- Norwegian Navy Special Operations Commando, Norwegian Armed Forces, Bergen, Norway.,Haraldsplass Diaconal Hospital, Bergen, Norway
| | - Tore Wentzel-Larsen
- Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway.,Norwegian Centre of Violence and Traumatic Stress Studies, Oslo, Norway.,Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Jon-Kenneth Heltne
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Helicopter Emergency Medical Services, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
28
|
Hong W, Mo F, Zhang Z, Huang M, Wei X. Nicotinamide Mononucleotide: A Promising Molecule for Therapy of Diverse Diseases by Targeting NAD+ Metabolism. Front Cell Dev Biol 2020; 8:246. [PMID: 32411700 PMCID: PMC7198709 DOI: 10.3389/fcell.2020.00246] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 03/24/2020] [Indexed: 02/05/2023] Open
Abstract
NAD+, a co-enzyme involved in a great deal of biochemical reactions, has been found to be a network node of diverse biological processes. In mammalian cells, NAD+ is synthetized, predominantly through NMN, to replenish the consumption by NADase participating in physiologic processes including DNA repair, metabolism, and cell death. Correspondingly, aberrant NAD+ metabolism is observed in many diseases. In this review, we discuss how the homeostasis of NAD+ is maintained in healthy condition and provide several age-related pathological examples related with NAD+ unbalance. The sirtuins family, whose functions are NAD-dependent, is also reviewed. Administration of NMN surprisingly demonstrated amelioration of the pathological conditions in some age-related disease mouse models. Further clinical trials have been launched to investigate the safety and benefits of NMN. The NAD+ production and consumption pathways including NMN are essential for more precise understanding and therapy of age-related pathological processes such as diabetes, ischemia–reperfusion injury, heart failure, Alzheimer’s disease, and retinal degeneration.
Collapse
Affiliation(s)
- Weiqi Hong
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Mo
- West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Department of Biotherapy, Chengdu, China
| | - Ziqi Zhang
- West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Department of Biotherapy, Chengdu, China
| | - Mengyuan Huang
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
29
|
Shock volume: Patient-specific cumulative hypoperfusion predicts organ dysfunction in a prospective cohort of multiply injured patients. J Trauma Acute Care Surg 2019. [PMID: 29521799 DOI: 10.1097/ta.0000000000001871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Multiply injured patients are at risk of developing hemorrhagic shock and organ dysfunction. We determined how cumulative hypoperfusion predicted organ dysfunction by integrating serial Shock Index measurements. METHODS In this study, we calculated shock volume (SHVL) which is a patient-specific index that quantifies cumulative hypoperfusion by integrating abnormally elevated Shock Index (heart rate/systolic blood pressure ≥ 0.9) values acutely after injury. Shock volume was calculated at three hours (3 hr), six hours (6 hr), and twenty-four hours (24 hr) after injury. Organ dysfunction was quantified using Marshall Organ Dysfunction Scores averaged from days 2 through 5 after injury (aMODSD2-D5). Logistic regression was used to determine correspondence of 3hrSHVL, 6hrSHVL, and 24hrSHVL to organ dysfunction. We compared correspondence of SHVL to organ dysfunction with traditional indices of shock including the initial base deficit (BD) and the lowest pH measurement made in the first 24 hr after injury (minimum pH). RESULTS SHVL at all three time intervals demonstrated higher correspondence to organ dysfunction (R = 0.48 to 0.52) compared to initial BD (R = 0.32) and minimum pH (R = 0.32). Additionally, we compared predictive capabilities of SHVL, initial BD and minimum pH to identify patients at risk of developing high-magnitude organ dysfunction by constructing receiver operator characteristic curves. SHVL at six hours and 24 hours had higher area under the curve compared to initial BD and minimum pH. CONCLUSION SHVL is a non-invasive metric that can predict anticipated organ dysfunction and identify patients at risk for high-magnitude organ dysfunction after injury. LEVEL OF EVIDENCE Prognostic study, level III.
Collapse
|
30
|
A systematic review of large animal models of combined traumatic brain injury and hemorrhagic shock. Neurosci Biobehav Rev 2019; 104:160-177. [PMID: 31255665 DOI: 10.1016/j.neubiorev.2019.06.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 01/08/2023]
Abstract
Traumatic brain injury (TBI) and severe blood loss (SBL) frequently co-occur in human trauma, resulting in high levels of mortality and morbidity. Importantly, each of the individual post-injury cascades is characterized by complex and potentially opposing pathophysiological responses, complicating optimal resuscitation and therapeutic approaches. Large animal models of poly-neurotrauma closely mimic human physiology, but a systematic literature review of published models has been lacking. The current review suggests a relative paucity of large animal poly-neurotrauma studies (N = 52), with meta-statistics revealing trends for animal species (exclusively swine), characteristics (use of single biological sex, use of juveniles) and TBI models. Although most studies have targeted blood loss volumes of 35-45%, the associated mortality rates are much lower relative to Class III/IV human trauma. This discrepancy may result from potentially mitigating experimental factors (e.g., mechanical ventilation prior to or during injury, pausing/resuming blood loss based on physiological parameters, administration of small volume fluid resuscitation) that are rarely associated with human trauma, highlighting the need for additional work in this area.
Collapse
|
31
|
Convertino VA, Lye KR, Koons NJ, Joyner MJ. Physiological comparison of hemorrhagic shock and V˙ O 2max: A conceptual framework for defining the limitation of oxygen delivery. Exp Biol Med (Maywood) 2019; 244:690-701. [PMID: 31042073 PMCID: PMC6552402 DOI: 10.1177/1535370219846425] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPACT STATEMENT Disturbance of normal homeostasis occurs when oxygen delivery and energy stores to the body's tissues fail to meet the energy requirement of cells. The work submitted in this review is important because it advances the understanding of inadequate oxygen delivery as it relates to early diagnosis and treatment of circulatory shock and its relationship to disturbance of normal functioning of cellular metabolism in life-threatening conditions of hemorrhage. We explored data from the clinical and exercise literature to construct for the first time a conceptual framework for defining the limitation of inadequate delivery of oxygen by comparing the physiology of hemorrhagic shock caused by severe blood loss to maximal oxygen uptake induced by intense physical exercise. We also provide a translational framework in which understanding the fundamental relationship between the body's reserve to compensate for conditions of inadequate oxygen delivery as a limiting factor to V ˙ O2max helps to re-evaluate paradigms of triage for improved monitoring of accurate resuscitation in patients suffering from hemorrhagic shock.
Collapse
Affiliation(s)
- Victor A Convertino
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Kristen R Lye
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Natalie J Koons
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Michael J Joyner
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
| |
Collapse
|
32
|
Jouffroy R, Philippe P, Saade A, Carli P, Vivien B. Prognostic Value of Blood Lactate and Base Deficit in Refractory Cardiac Arrest Cases Undergoing Extracorporeal Life Support. Turk J Anaesthesiol Reanim 2019; 47:407-413. [PMID: 31572993 DOI: 10.5152/tjar.2019.65391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 09/26/2018] [Indexed: 12/23/2022] Open
Abstract
Objective Cardiac arrest (CA) resuscitation is associated with an 'ischaemia-reperfusion' syndrome characterised by lactic acidosis as assessed by lactate and base deficit (BD). Both biomarkers are usually measured in patients suffering from refractory CA (RCA) subjected to extracorporeal life support (ECLS) to evaluate tissue reperfusion. However, their prognostic value has never been compared. The aim of the present study was to compare the prognostic value of both biomarkers measured at 0 and 3 h after the initiation of ECLS in patients with RCA on mortality. Methods Patients who were admitted to the intensive care unit with RCA were consecutively included in the study. Results Sixty-six patients were included. Lactate correlated with BD (R2=0.44, p<0.001). An area under the curve of 0.72 (95% confidence interval (CI) 0.59-0.84) was found for lactate and of 0.60 (95% CI 0.46-0.73) for BD. Using multivariable logistic regression, lactate (odds ratio (OR) 1.22, 95% CI 1.03-1.48) remained associated with mortality on day 28, but not BD (OR 0.99, 95% CI 0.86-1.14). Conclusion We report a difference in the prognostic value of lactate and BD on mortality. Three hours from the initiation of ECLS in patients with RCA, lactate should be preferred to BD to predict the efficiency of ECLS.
Collapse
Affiliation(s)
- Romain Jouffroy
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Pascal Philippe
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Anastasia Saade
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Pierre Carli
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Benoit Vivien
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| |
Collapse
|
33
|
Oller L, Dyer WB, Santamaría L, Largo C, Javidroozi M, Shander A. The effect of a novel intravenous fluid (Oxsealife®) on recovery from haemorrhagic shock in pigs. Anaesthesia 2019; 74:765-777. [DOI: 10.1111/anae.14627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - W. B. Dyer
- Australian Red Cross Blood Service and Faculty of Medicine and Health University of Sydney Sydney NSW Australia
| | - L. Santamaría
- Department of Anatomy, Histology, and Neuroscience School of Medicine Autonomous University of Madrid Madrid Spain
| | - C. Largo
- Department of Experimental Surgery IdiPAZ Hospital La Paz Madrid Spain
| | - M. Javidroozi
- TeamHealth Research Institute TeamHealth Englewood NJ USA
| | - A. Shander
- Departments of Anesthesiology Critical Care and Hyperbaric Medicine Englewood Hospital and Medical Center Englewood NJ USA
| |
Collapse
|
34
|
Jouffroy R, Saade A, Philippe P, Carli P, Vivien B. Prognostic Value of Blood Lactate and Lactate Clearance in Refractory Cardiac Arrest Treated by Extracorporeal Life Support. Turk J Anaesthesiol Reanim 2019; 47:48-54. [PMID: 31276111 PMCID: PMC6598657 DOI: 10.5152/tjar.2018.96992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/08/2018] [Indexed: 06/09/2023] Open
Abstract
OBJECTIVE During cardiac arrest (CA) resuscitation, an 'ischaemia-reperfusion' syndrome occurs leading to multiorgan failure reflected by an increase in blood lactate. Blood lactate is a diagnosis and prognosis biomarker in extracorporeal life support (ECLS), but its kinetic appears more informative to assess a patient's outcome. The aim of the present study was to describe the prognostic value of blood lactate and lactate clearance (LC) 3 (H3) and 6 h (H6) after the initiation of ECLS in the treatment of refractory CA. METHODS Patients admitted to the intensive care unit for refractory CA were included. Lactate measurements were performed at the initiation of ECLS (H0) and at H3 and H6 upon the initiation of ECLS. LC was measured from 0 to 3 h (LC03), 0 to 6 h (LC06) and 3 to 6 h (LC36). The primary endpoint was in-hospital mortality within 28 days. RESULTS Sixty-six patients were enrolled in the study. Lactate levels were higher in deceased patients. Increased mortality was observed with increasing levels of lactate at H3 and H6 and with decreasing LC03. Using logistic regression, an association was observed between mortality and lactate at H3 with an odds ratio (OR) of 1.21 (95% confidence interval (CI) 1.05-1.42); LC03, OR of 0.93 (95% CI 0.87-0.99) and LC06, OR of 0.96 (95% CI 0.92-0.99). CONCLUSION Blood lactate and LC within the first 3 h of ECLS in refractory CA are associated with mortality. LC is a more relevant parameter than blood lactate, taking into account both the production and elimination of lactate. We suggest to preferentially use LC to assess the patient's outcome.
Collapse
Affiliation(s)
- Romain Jouffroy
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Anastasia Saade
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Pascal Philippe
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Pierre Carli
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Benoit Vivien
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| |
Collapse
|
35
|
Compensatory Reserve Index: Performance of A Novel Monitoring Technology to Identify the Bleeding Trauma Patient. Shock 2019; 49:295-300. [PMID: 28767544 DOI: 10.1097/shk.0000000000000959] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Hemorrhage is one of the most substantial causes of death after traumatic injury. Standard measures, including systolic blood pressure (SBP), are poor surrogate indicators of physiologic compromise until compensatory mechanisms have been overwhelmed. Compensatory Reserve Index (CRI) is a novel monitoring technology with the ability to assess physiologic reserve. We hypothesized CRI would be a better predictor of physiologic compromise secondary to hemorrhage than traditional vital signs. METHODS A prospective observational study of 89 subjects meeting trauma center activation criteria at a single level I trauma center was conducted from October 2015 to February 2016. Data collected included demographics, SBP, heart rate, and requirement for hemorrhage-associated, life-saving intervention (LSI) (i.e., operation or angiography for hemorrhage, local or tourniquet control of external bleeding, and transfusion >2 units PRBC). Receiver-operator characteristic (ROC) curves were formulated and appropriate thresholds were calculated to compare relative value of the metrics for predictive modeling. RESULTS For predicting hemorrhage-related LSI, CRI demonstrated a sensitivity of 83% and a negative predictive value (NPV) of 91% as compared with SBP with a sensitivity to detect hemorrhage of 26% (P < 0.05) and an NPV of 78%. ROC curves generated from admission CRI and SBP measures demonstrated values of 0.83 and 0.62, respectively. CRI identified significant hemorrhage requiring potentially life-saving therapy more reliably than SBP (P < 0.05). CONCLUSION The CRI device demonstrated superior capacity over systolic blood pressure in predicting the need for posttraumatic hemorrhage intervention in the acute resuscitation phase after injury.
Collapse
|
36
|
Hemorrhagic blood failure: Oxygen debt, coagulopathy, and endothelial damage. J Trauma Acute Care Surg 2019; 82:S41-S49. [PMID: 28328671 DOI: 10.1097/ta.0000000000001436] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
37
|
Harrois A, Soyer B, Gauss T, Hamada S, Raux M, Duranteau J. Prevalence and risk factors for acute kidney injury among trauma patients: a multicenter cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:344. [PMID: 30563549 PMCID: PMC6299611 DOI: 10.1186/s13054-018-2265-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 11/16/2018] [Indexed: 12/23/2022]
Abstract
Background Organ failure, including acute kidney injury (AKI), is the third leading cause of death after bleeding and brain injury in trauma patients. We sought to assess the prevalence, the risk factors and the impact of AKI on outcome after trauma. Methods We performed a retrospective analysis of prospectively collected data from a multicenter trauma registry. AKI was defined according to the risk, injury, failure, loss of kidney function and end-stage kidney disease (RIFLE) classification from serum creatinine only. Prehospital and early hospital risk factors for AKI were identified using logistic regression analysis. The predictive models were internally validated using bootstrapping resampling technique. Results We included 3111 patients in the analysis. The incidence of AKI was 13% including 7% stage R, 3.7% stage I and 2.3% stage F. AKI incidence rose to 42.5% in patients presenting with hemorrhagic shock; 96% of AKI occurred within the 5 first days after trauma. In multivariate analysis, prehospital variables including minimum prehospital mean arterial pressure, maximum prehospital heart rate, secondary transfer to the trauma center and data early collected after hospital admission including injury severity score, renal trauma, blood lactate and hemorrhagic shock were independent risk factors in the models predicting AKI. The model had good discrimination with area under the receiver operating characteristic curve of 0.85 (0.82–0.88) to predict AKI stage I or F and 0.80 (0.77–0.83) to predict AKI of all stages. Rhabdomyolysis severity, assessed by the creatine kinase peak, was an additional independent risk factor for AKI when it was forced into the model (OR 1.041 (1.015–1.069) per step of 1000 U/mL, p < 0.001). AKI was independently associated with a twofold increase in ICU mortality. Conclusions AKI has an early onset and is independently associated with mortality in trauma patients. Its prevalence varies by a factor 3 according to the severity of injuries and hemorrhage. Prehospital and early hospital risk factors can provide good performance for early prediction of AKI after trauma. Hence, studies aiming to prevent AKI should target patients at high risk of AKI and investigate therapies early in the course of trauma care. Electronic supplementary material The online version of this article (10.1186/s13054-018-2265-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Anatole Harrois
- Université paris Sud, Université Paris Saclay, Department of Anesthesiology and Critical Care, Assistance Publique-Hopitaux de Paris (AP-HP), Bicêtre Hopitaux Universitaires Paris Sud, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, F-94275, Le Kremlin Bicêtre, France.
| | - Benjamin Soyer
- Université paris Sud, Université Paris Saclay, Department of Anesthesiology and Critical Care, Assistance Publique-Hopitaux de Paris (AP-HP), Bicêtre Hopitaux Universitaires Paris Sud, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, F-94275, Le Kremlin Bicêtre, France
| | - Tobias Gauss
- Hôpitaux Universitaires Paris Nord Val de Seine, Department of Anesthesiology and Critical Care, AP-HP, Beaujon, 100 avenue du Général Leclerc, 92110, Clichy, France.,Hôpital de Beaujon, Anesthésie-Réanimation, 100, boulevard du Général Leclerc, 92110, Clichy, France
| | - Sophie Hamada
- Université paris Sud, Université Paris Saclay, Department of Anesthesiology and Critical Care, Assistance Publique-Hopitaux de Paris (AP-HP), Bicêtre Hopitaux Universitaires Paris Sud, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, F-94275, Le Kremlin Bicêtre, France
| | - Mathieu Raux
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département d'Anesthésie Réanimation, Paris, France.,Hôpital Pitié-Salpétrière, Anesthésie-Réanimation, 47-83 Boulevard de l'Hopital, 75013, Paris, France
| | - Jacques Duranteau
- Université paris Sud, Université Paris Saclay, Department of Anesthesiology and Critical Care, Assistance Publique-Hopitaux de Paris (AP-HP), Bicêtre Hopitaux Universitaires Paris Sud, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, F-94275, Le Kremlin Bicêtre, France
| | | |
Collapse
|
38
|
Buck RK, Stegmann GF, Poore LA, Shaik T, Gray T, Zeiler GE. Xenotransfusion with packed bovine red blood cells to a wildebeest calf (Connochaetes taurinus). J S Afr Vet Assoc 2018; 89:e1-e6. [PMID: 30326712 PMCID: PMC6244219 DOI: 10.4102/jsava.v89i0.1669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 12/16/2022] Open
Abstract
A 4-month-old female blue wildebeest (Connochaetes taurinus) was presented for bilateral pelvic limb fracture repair. Clinical examination under anaesthesia revealed a water-hammer pulse and a haematocrit of 0.13. A xenotransfusion was performed using bovine (Bos taurus) erythrocytes because of inability to acquire a wildebeest donor. Clinical parameters improved following transfusion and the post-operative haematocrit value was 0.31. The wildebeest remained physiologically stable with a gradually declining haematocrit for the next three days. On the third post-operative day, the wildebeest refractured its femur and was humanely euthanised because of the poor prognosis for further fracture repair. Xenotransfusion using blood from domestic ruminants represents a life-saving short-term emergency treatment of anaemic hypoxia in wild ungulates. Domestic goats could be used as blood donors for rare ungulates where allodonors are not available.
Collapse
Affiliation(s)
- Roxanne K Buck
- Department of Companion Animal Clinical Studies, University of Pretoria.
| | | | | | | | | | | |
Collapse
|
39
|
Sims CA, Guan Y, Mukherjee S, Singh K, Botolin P, Davila A, Baur JA. Nicotinamide mononucleotide preserves mitochondrial function and increases survival in hemorrhagic shock. JCI Insight 2018; 3:120182. [PMID: 30185676 DOI: 10.1172/jci.insight.120182] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 07/10/2018] [Indexed: 12/26/2022] Open
Abstract
Hemorrhagic shock depletes nicotinamide adenine dinucleotide (NAD) and causes metabolic derangements that, in severe cases, cannot be overcome, even after restoration of blood volume and pressure. However, current strategies to treat acute blood loss do not target cellular metabolism. We hypothesized that supplemental nicotinamide mononucleotide (NMN), the immediate biosynthetic precursor to NAD, would support cellular energetics and enhance physiologic resilience to hemorrhagic shock. In a rodent model of decompensated hemorrhagic shock, rats receiving NMN displayed significantly reduced lactic acidosis and serum IL-6 levels, two strong predictors of mortality in human patients. In both livers and kidneys, NMN increased NAD levels and prevented mitochondrial dysfunction. Moreover, NMN preserved mitochondrial function in isolated hepatocytes cocultured with proinflammatory cytokines, indicating a cell-autonomous protective effect that is independent from the reduction in circulating IL-6. In kidneys, but not in livers, NMN was sufficient to prevent ATP loss following shock and resuscitation. Overall, NMN increased the time animals could sustain severe shock before requiring resuscitation by nearly 25% and significantly improved survival after resuscitation (P = 0.018), whether NMN was given as a pretreatment or only as an adjunct during resuscitation. Thus, we demonstrate that NMN substantially mitigates inflammation, improves cellular metabolism, and promotes survival following hemorrhagic shock.
Collapse
Affiliation(s)
- Carrie A Sims
- Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Trauma Center at Penn, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Penn Acute Research Collaboration (PARC) and
| | - Yuxia Guan
- The Trauma Center at Penn, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarmistha Mukherjee
- Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Khushboo Singh
- The Trauma Center at Penn, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul Botolin
- The Trauma Center at Penn, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Joseph A Baur
- Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
40
|
Suresh MR, Chung KK, Schiller AM, Holley AB, Howard JT, Convertino VA. Unmasking the Hypovolemic Shock Continuum: The Compensatory Reserve. J Intensive Care Med 2018; 34:696-706. [PMID: 30068251 DOI: 10.1177/0885066618790537] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hypovolemic shock exists as a spectrum, with its early stages characterized by subtle pathophysiologic tissue insults and its late stages defined by multi-system organ dysfunction. The importance of timely detection of shock is well known, as early interventions improve mortality, while delays render these same interventions ineffective. However, detection is limited by the monitors, parameters, and vital signs that are traditionally used in the intensive care unit (ICU). Many parameters change minimally during the early stages, and when they finally become abnormal, hypovolemic shock has already occurred. The compensatory reserve (CR) is a parameter that represents a new paradigm for assessing physiologic status, as it comprises the sum total of compensatory mechanisms that maintain adequate perfusion to vital organs during hypovolemia. When these mechanisms are overwhelmed, hemodynamic instability and circulatory collapse will follow. Previous studies involving CR measurements demonstrated their utility in detecting central blood volume loss before hemodynamic parameters and vital signs changed. Measurements of the CR have also been used in clinical studies involving patients with traumatic injuries or bleeding, and the results from these studies have been promising. Moreover, these measurements can be made at the bedside, and they provide a real-time assessment of hemodynamic stability. Given the need for rapid diagnostics when treating critically ill patients, CR measurements would complement parameters that are currently being used. Consequently, the purpose of this article is to introduce a conceptual framework where the CR represents a new approach to monitoring critically ill patients. Within this framework, we present evidence to support the notion that the use of the CR could potentially improve the outcomes of ICU patients by alerting intensivists to impending hypovolemic shock before its onset.
Collapse
Affiliation(s)
- Mithun R Suresh
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Kevin K Chung
- 2 Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,3 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alicia M Schiller
- 4 Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aaron B Holley
- 2 Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,3 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeffrey T Howard
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Victor A Convertino
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| |
Collapse
|
41
|
Carrara M, Babini G, Baselli G, Ristagno G, Pastorelli R, Brunelli L, Ferrario M. Blood pressure variability, heart functionality, and left ventricular tissue alterations in a protocol of severe hemorrhagic shock and resuscitation. J Appl Physiol (1985) 2018; 125:1011-1020. [PMID: 30001154 PMCID: PMC6230573 DOI: 10.1152/japplphysiol.00348.2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Autonomic control of blood pressure (BP) and heart rate (HR) is crucial during bleeding and hemorrhagic shock (HS) to compensate for hypotension and hypoxia. Previous works have observed that at the point of hemodynamic decompensation a marked suppression of BP and HR variability occurs, leading to irreversible shock. We hypothesized that recovery of the autonomic control may be decisive for effective resuscitation, along with restoration of mean BP. We computed cardiovascular indexes of baroreflex sensitivity and BP and HR variability by analyzing hemodynamic recordings collected from five pigs during a protocol of severe hemorrhage and resuscitation; three pigs were sham-treated controls. Moreover, we assessed the effects of severe hemorrhage on heart functionality by integrating the hemodynamic findings with measures of plasma high-sensitivity cardiac troponin T and metabolite concentrations in left ventricular (LV) tissue. Resuscitation was performed with fluids and norepinephrine and then by reinfusion of shed blood. After first resuscitation, mean BP reached the target value, but cardiovascular indexes were not fully restored, hinting at a partial recovery of the autonomic mechanisms. Moreover, cardiac troponins were still elevated, suggesting a persistent myocardial sufferance. After blood reinfusion all the indexes returned to baseline. In the harvested heart, LV metabolic profile confirmed the acute stress condition sensed by the cardiomyocytes. Variability indexes and baroreflex trends can be valuable tools to evaluate the severity of HS, and they may represent a more useful end point for resuscitation in combination with standard measures such as mean values and biological measures. NEW & NOTEWORTHY Autonomic control of blood pressure was highly impaired during hemorrhagic shock, and it was not completely recovered after resuscitation despite global restoration of mean pressures. Moreover, a persistent myocardial sufferance emerged from measured cardiac troponin T and metabolite concentrations of left ventricular tissue. We highlight the importance of combining global mean values and biological markers with measures of variability and autonomic control for a better characterization of the effectiveness of the resuscitation strategy.
Collapse
Affiliation(s)
- Marta Carrara
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan , Italy
| | - Giovanni Babini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan , Milan , Italy
| | - Giuseppe Baselli
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan , Italy
| | | | | | - Laura Brunelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Manuela Ferrario
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan , Italy
| |
Collapse
|
42
|
Hyperoxia or Therapeutic Hypothermia During Resuscitation from Non-Lethal Hemorrhagic Shock in Swine. Shock 2018; 48:564-570. [PMID: 28472012 DOI: 10.1097/shk.0000000000000884] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We previously demonstrated beneficial effects of 22 h of hyperoxia following near-lethal porcine hemorrhagic shock, whereas therapeutic hypothermia was detrimental. Therefore, we investigated whether shorter exposure to hyperoxia (12 h) would still improve organ function, and whether 12 h of hypothermia with subsequent rewarming could avoid deleterious effects after less severe hemorrhagic shock.Twenty-seven anesthetized and surgically instrumented pigs underwent 3 h of hemorrhagic shock by removal of 30% of the blood volume and titration of the mean arterial blood pressure (MAP) to 40 mm Hg. Post-shock, pigs were randomly assigned to control, hyperoxia (FIO2 100% for 12 h) or hypothermia group (34°C core temperature for 12 h with subsequent rewarming). Before, at the end of shock, after 12 and 23 h of resuscitation, data sets comprising hemodynamics, blood gases, and parameters of inflammation and organ function were acquired. Postmortem, kidney samples were collected for immunohistochemistry and western blotting.Hyperoxia exerted neither beneficial nor detrimental effects. In contrast, mortality in the hypothermia group was significantly higher compared with controls (67% vs. 11%). Hypothermia impaired circulation (MAP 64 (57;89) mm Hg vs. 104 (98; 114) mm Hg) resulting in metabolic acidosis (lactate 11.0 (6.6;13.6) mmol L vs. 1.0 (0.8;1.5) mmol L) and reduced creatinine clearance (26 (9;61) mL min vs. 77 (52;80) mL min) compared to the control group after 12 h of resuscitation. Impaired kidney function coincided with increased renal 3-nitrotyrosine formation and extravascular albumin accumulation.In conclusion, hyperoxia proved to be safe during resuscitation from hemorrhagic shock. The lacking organ-protective effects of hyperoxia compared to resuscitation from near-lethal hemorrhage suggest a dependence of the effectiveness of hyperoxia from shock severity. In line with our previous report, therapeutic hypothermia (and rewarming) was confirmed to be detrimental most likely due to vascular barrier dysfunction.
Collapse
|
43
|
Seichter F, Tütüncü E, Hagemann LT, Vogt J, Wachter U, Gröger M, Kress S, Radermacher P, Mizaikoff B. Online monitoring of carbon dioxide and oxygen in exhaled mouse breath via substrate-integrated hollow waveguide Fourier-transform infrared-luminescence spectroscopy. J Breath Res 2018; 12:036018. [DOI: 10.1088/1752-7163/aabf98] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
44
|
Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
Collapse
|
45
|
Noel-Morgan J, Muir WW. Anesthesia-Associated Relative Hypovolemia: Mechanisms, Monitoring, and Treatment Considerations. Front Vet Sci 2018; 5:53. [PMID: 29616230 PMCID: PMC5864866 DOI: 10.3389/fvets.2018.00053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/02/2018] [Indexed: 12/14/2022] Open
Abstract
Although the utility and benefits of anesthesia and analgesia are irrefutable, their practice is not void of risks. Almost all drugs that produce anesthesia endanger cardiovascular stability by producing dose-dependent impairment of cardiac function, vascular reactivity, and compensatory autoregulatory responses. Whereas anesthesia-related depression of cardiac performance and arterial vasodilation are well recognized adverse effects contributing to anesthetic risk, far less emphasis has been placed on effects impacting venous physiology and venous return. The venous circulation, containing about 65–70% of the total blood volume, is a pivotal contributor to stroke volume and cardiac output. Vasodilation, particularly venodilation, is the primary cause of relative hypovolemia produced by anesthetic drugs and is often associated with increased venous compliance, decreased venous return, and reduced response to vasoactive substances. Depending on factors such as patient status and monitoring, a state of relative hypovolemia may remain clinically undetected, with impending consequences owing to impaired oxygen delivery and tissue perfusion. Concurrent processes related to comorbidities, hypothermia, inflammation, trauma, sepsis, or other causes of hemodynamic or metabolic compromise, may further exacerbate the condition. Despite scientific and technological advances, clinical monitoring and treatment of relative hypovolemia still pose relevant challenges to the anesthesiologist. This short perspective seeks to define relative hypovolemia, describe the venous system’s role in supporting normal cardiovascular function, characterize effects of anesthetic drugs on venous physiology, and address current considerations and challenges for monitoring and treatment of relative hypovolemia, with focus on insights for future therapies.
Collapse
Affiliation(s)
- Jessica Noel-Morgan
- Center for Cardiovascular & Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - William W Muir
- QTest Labs, Columbus, OH, United States.,College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| |
Collapse
|
46
|
Wepler M, Demiselle J, Radermacher P, Asfar P, Calzia E. Before the ICU: does emergency room hyperoxia affect outcome? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018. [PMID: 29519235 PMCID: PMC5844124 DOI: 10.1186/s13054-018-1980-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Martin Wepler
- Klinik für Anästhesiologie, Universitätsklinikum Ulm, 89081, Ulm, Germany.,Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Julien Demiselle
- Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire Angers, 49933, Angers, France
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Pierre Asfar
- Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire Angers, 49933, Angers, France
| | - Enrico Calzia
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8/1, 89081, Ulm, Germany.
| |
Collapse
|
47
|
Bini R, Chiara O, Cimbanassi S, Olivero G, Trombetta A, Cotogni P. Evaluation of capillary leakage after vasopressin resuscitation in a hemorrhagic shock model. World J Emerg Surg 2018. [PMID: 29515645 PMCID: PMC5836391 DOI: 10.1186/s13017-018-0172-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Hemorrhagic shock (HS) is a major threat to patients with trauma and spontaneous bleeding. The aim of the study was to investigate early effects of vasopressin on metabolic and hemodynamic parameters and endothelium permeability by measuring capillary leakage compared to those of other resuscitation strategies in a HS model. Methods Forty-five Sprague-Dawley rats were randomized into five groups: S group (n = 5), sham-operated rats without shock or resuscitation; HS group (n = 10), HS and no resuscitation; RL group (n = 10), HS and resuscitation with Ringer’s lactate (RL); RLB group (n = 10), HS and resuscitation with two-third shed blood plus RL; and vasopressin group (n = 10), HS and resuscitation with RL, followed by continuous infusion of 0.04 U/kg/min vasopressin. The effects of resuscitation on hemodynamic parameters [mean arterial pressure (MAP), superior mesenteric artery blood flow (MBF), and mesenteric vascular resistances (MVR)], arterial blood gases, bicarbonate, base deficit, and lactate levels as well as on capillary leakage in the lung, ileum, and kidney were investigated. Capillary leakage was evaluated with Evans blue dye extravasation. Results In the vasopressin group, the MAP was higher than in the RL and RLB groups (p < 0.001), while MBF was decreased (p < 0.001). MVR were increased only in the vasopressin group (p < 0.001). Capillary leakage was increased in the lungs of the animals in the vasopressin group compared to that in the lungs of animals in the RLB group (p < 0.05); this increase was associated with the lowest partial pressure of oxygen (p < 0.05). Conversely, decreased capillary leakage was observed with vasopressin in the ileum (p < 0.05). Increased capillary leakage was observed in the kidney in the RLB and vasopressin groups (p < 0.05). Lastly, vasopressin use was associated with higher base deficit and lactate levels when compared to the RL and RLB groups (p < 0.001). Conclusion Although vasopressin was proposed as a vasoactive drug for provisional hemodynamic optimization in the early phase of HS resuscitation, the overall findings of this experimental study focus on the possible critical side effects of vasopressin on metabolic parameters and endothelium permeability.
Collapse
Affiliation(s)
- Roberto Bini
- 1Department of Surgery, S. Giovanni Bosco Hospital, Turin, Italy
| | - Osvaldo Chiara
- 2Trauma Center and Metropolitan Trauma Network Department, Niguarda Hospital, Milan, Italy
| | - Stefania Cimbanassi
- 2Trauma Center and Metropolitan Trauma Network Department, Niguarda Hospital, Milan, Italy
| | - Giorgio Olivero
- 3Department of Surgical Sciences, S. Giovanni Battista Hospital, University of Turin, Turin, Italy
| | | | - Paolo Cotogni
- 5Department of Anesthesia and Intensive Care, S. Giovanni Battista Hospital, University of Turin, Via Giovanni Giolitti 9, 10123 Turin, Italy
| |
Collapse
|
48
|
Wagner N, Dieteren S, Franz N, Köhler K, Mörs K, Nicin L, Schmidt J, Perl M, Marzi I, Relja B. Ethyl pyruvate ameliorates hepatic injury following blunt chest trauma and hemorrhagic shock by reducing local inflammation, NF-kappaB activation and HMGB1 release. PLoS One 2018; 13:e0192171. [PMID: 29420582 PMCID: PMC5805235 DOI: 10.1371/journal.pone.0192171] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 01/17/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The treatment of patients with multiple trauma including blunt chest/thoracic trauma (TxT) and hemorrhagic shock (H) is still challenging. Numerous studies show detrimental consequences of TxT and HS resulting in strong inflammatory changes, organ injury and mortality. Additionally, the reperfusion (R) phase plays a key role in triggering inflammation and worsening outcome. Ethyl pyruvate (EP), a stable lipophilic ester, has anti-inflammatory properties. Here, the influence of EP on the inflammatory reaction and liver injury in a double hit model of TxT and H/R in rats was explored. METHODS Female Lewis rats were subjected to TxT followed by hemorrhage/H (60 min, 35±3 mm Hg) and resuscitation/R (TxT+H/R). Reperfusion was performed by either Ringer`s lactated solution (RL) alone or RL supplemented with EP (50 mg/kg). Sham animals underwent all surgical procedures without TxT+H/R. After 2h, blood and liver tissue were collected for analyses, and survival was assessed after 24h. RESULTS Resuscitation with EP significantly improved haemoglobin levels and base excess recovery compared with controls after TxT+H/R, respectively (p<0.05). TxT+H/R-induced significant increase in alanine aminotransferase levels and liver injury were attenuated by EP compared with controls (p<0.05). Local inflammation as shown by increased gene expression of IL-6 and ICAM-1, enhanced ICAM-1 and HMGB1 protein expression and infiltration of the liver with neutrophils were also significantly attenuated by EP compared with controls after TxT+H/R (p<0.05). EP significantly reduced TxT+H/R-induced p65 activation in liver tissue. Survival rates improved by EP from 50% to 70% after TxT+H/R. CONCLUSIONS These data support the concept that the pronounced local pro-inflammatory response in the liver after blunt chest trauma and hemorrhagic shock is associated with NF-κB. In particular, the beneficial anti-inflammatory effects of ethyl pyruvate seem to be regulated by the HMGB1/NF-κB axis in the liver, thereby, restraining inflammatory responses and liver injury after double hit trauma in the rat.
Collapse
Affiliation(s)
- Nils Wagner
- Department of Trauma Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Scott Dieteren
- Department of Trauma Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Niklas Franz
- Department of Trauma Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Kernt Köhler
- Institute of Veterinary Pathology, Justus Liebig University Giessen, Giessen, Germany
| | - Katharina Mörs
- Department of Trauma Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Luka Nicin
- Department of Trauma Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Julia Schmidt
- Department of Trauma Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Mario Perl
- BG-Trauma Center Murnau, Murnau, Germany
| | - Ingo Marzi
- Department of Trauma Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Borna Relja
- Department of Trauma Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
- * E-mail:
| |
Collapse
|
49
|
Effects of Hyperoxia During Resuscitation From Hemorrhagic Shock in Swine With Preexisting Coronary Artery Disease. Crit Care Med 2017; 45:e1270-e1279. [PMID: 29028763 DOI: 10.1097/ccm.0000000000002767] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Investigation of the effects of hyperoxia during resuscitation from hemorrhagic shock in swine with preexisting coronary artery disease. DESIGN Prospective, controlled, randomized trial. SETTING University animal research laboratory. SUBJECTS Nineteen hypercholesterolemic pigs with preexisting coronary artery disease. INTERVENTIONS Anesthetized, mechanically ventilated, and surgically instrumented pigs underwent 3 hours of hemorrhagic shock (removal of 30% of the calculated blood volume and subsequent titration of mean arterial blood pressure ≈40 mm Hg). Postshock resuscitation (48 hr) comprised retransfusion of shed blood, crystalloids (balanced electrolyte solution), and norepinephrine support. Pigs were randomly assigned to "control" (FIO2 0.3, adjusted for arterial oxygen saturation ≥ 90%) and "hyperoxia" (FIO2 1.0 for 24 hr) groups. MEASUREMENTS AND MAIN RESULTS Before, at the end of shock and every 12 hours of resuscitation, datasets comprising hemodynamics, calorimetry, blood gases, cytokines, and cardiac and renal function were recorded. Postmortem, organs were sampled for immunohistochemistry, western blotting, and mitochondrial high-resolution respirometry. Survival rates were 50% and 89% in the control and hyperoxia groups, respectively (p = 0.077). Apart from higher relaxation constant τ at 24 hours, hyperoxia did not affect cardiac function. However, troponin values were lower (2.2 [0.9-6.2] vs 6.9 [4.8-9.8] ng/mL; p < 0.05) at the end of the experiment. Furthermore, hyperoxia decreased cardiac 3-nitrotyrosine formation and increased inducible nitric oxide synthase expression. Plasma creatinine values were lower in the hyperoxia group during resuscitation coinciding with significantly improved renal mitochondrial respiratory capacity and lower 3-nitrotyrosine formation. CONCLUSIONS Hyperoxia during resuscitation from hemorrhagic shock in swine with preexisting coronary artery disease reduced renal dysfunction and cardiac injury, potentially resulting in improved survival, most likely due to increased mitochondrial respiratory capacity and decreased oxidative and nitrosative stress. Compared with our previous study, the present results suggest a higher benefit of hyperoxia in comorbid swine due to an increased susceptibility to hemorrhagic shock.
Collapse
|
50
|
Abstract
The microvasculature plays a central role in the pathophysiology of hemorrhagic shock and is also involved in arguably all therapeutic attempts to reverse or minimize the adverse consequences of shock. Microvascular studies specific to hemorrhagic shock were reviewed and broadly grouped depending on whether data were obtained on animal or human subjects. Dedicated sections were assigned to microcirculatory changes in specific organs, and major categories of pathophysiological alterations and mechanisms such as oxygen distribution, ischemia, inflammation, glycocalyx changes, vasomotion, endothelial dysfunction, and coagulopathy as well as biomarkers and some therapeutic strategies. Innovative experimental methods were also reviewed for quantitative microcirculatory assessment as it pertains to changes during hemorrhagic shock. The text and figures include representative quantitative microvascular data obtained in various organs and tissues such as skin, muscle, lung, liver, brain, heart, kidney, pancreas, intestines, and mesentery from various species including mice, rats, hamsters, sheep, swine, bats, and humans. Based on reviewed findings, a new integrative conceptual model is presented that includes about 100 systemic and local factors linked to microvessels in hemorrhagic shock. The combination of systemic measures with the understanding of these processes at the microvascular level is fundamental to further develop targeted and personalized interventions that will reduce tissue injury, organ dysfunction, and ultimately mortality due to hemorrhagic shock. Published 2018. Compr Physiol 8:61-101, 2018.
Collapse
Affiliation(s)
- Ivo Torres Filho
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| |
Collapse
|