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Greenwood JC, Morgan RW, Abella BS, Shofer FS, Baker WB, Lewis A, Ko TS, Forti RM, Yodh AG, Kao SH, Shin SS, Kilbaugh TJ, Jang DH. Carbon monoxide as a cellular protective agent in a swine model of cardiac arrest protocol. PLoS One 2024; 19:e0302653. [PMID: 38748750 PMCID: PMC11095756 DOI: 10.1371/journal.pone.0302653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 04/08/2024] [Indexed: 05/19/2024] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) affects over 360,000 adults in the United States each year with a 50-80% mortality prior to reaching medical care. Despite aggressive supportive care and targeted temperature management (TTM), half of adults do not live to hospital discharge and nearly one-third of survivors have significant neurologic injury. The current treatment approach following cardiac arrest resuscitation consists primarily of supportive care and possible TTM. While these current treatments are commonly used, mortality remains high, and survivors often develop lasting neurologic and cardiac sequela well after resuscitation. Hence, there is a critical need for further therapeutic development of adjunctive therapies. While select therapeutics have been experimentally investigated, one promising agent that has shown benefit is CO. While CO has traditionally been thought of as a cellular poison, there is both experimental and clinical evidence that demonstrate benefit and safety in ischemia with lower doses related to improved cardiac/neurologic outcomes. While CO is well known for its poisonous effects, CO is a generated physiologically in cells through the breakdown of heme oxygenase (HO) enzymes and has potent antioxidant and anti-inflammatory activities. While CO has been studied in myocardial infarction itself, the role of CO in cardiac arrest and post-arrest care as a therapeutic is less defined. Currently, the standard of care for post-arrest patients consists primarily of supportive care and TTM. Despite current standard of care, the neurological prognosis following cardiac arrest and return of spontaneous circulation (ROSC) remains poor with patients often left with severe disability due to brain injury primarily affecting the cortex and hippocampus. Thus, investigations of novel therapies to mitigate post-arrest injury are clearly warranted. The primary objective of this proposed study is to combine our expertise in swine models of CO and cardiac arrest for future investigations on the cellular protective effects of low dose CO. We will combine our innovative multi-modal diagnostic platform to assess cerebral metabolism and changes in mitochondrial function in swine that undergo cardiac arrest with therapeutic application of CO.
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Affiliation(s)
- John C. Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Ryan W. Morgan
- Resuscitation Science Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Benjamin S. Abella
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Frances S. Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Wesley B. Baker
- Resuscitation Science Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Alistair Lewis
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
- Department of Chemistry, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Tiffany S. Ko
- Resuscitation Science Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Rodrigo M. Forti
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Arjun G. Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Shih-Han Kao
- Resuscitation Science Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Samuel S. Shin
- Department of Pharmacology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Todd J. Kilbaugh
- Resuscitation Science Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - David H. Jang
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Resuscitation Science Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
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Greenwood JC, Talebi FM, Jang DH, Spelde AE, Gordon EK, Horak J, Acker MA, Kilbaugh TJ, Shofer FS, Augoustides JGT, Brenner JS, Muzykantov VR, Bakker J, Abella BS. Anaerobic Lactate Production Is Associated With Decreased Microcirculatory Blood Flow and Decreased Mitochondrial Respiration Following Cardiovascular Surgery With Cardiopulmonary Bypass. Crit Care Med 2024:00003246-990000000-00322. [PMID: 38578158 DOI: 10.1097/ccm.0000000000006289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
OBJECTIVES Quantify the relationship between perioperative anaerobic lactate production, microcirculatory blood flow, and mitochondrial respiration in patients after cardiovascular surgery with cardiopulmonary bypass. DESIGN Serial measurements of lactate-pyruvate ratio (LPR), microcirculatory blood flow, plasma tricarboxylic acid cycle cycle intermediates, and mitochondrial respiration were compared between patients with a normal peak lactate (≤ 2 mmol/L) and a high peak lactate (≥ 4 mmol/L) in the first 6 hours after surgery. Regression analysis was performed to quantify the relationship between clinically relevant hemodynamic variables, lactate, LPR, and microcirculatory blood flow. SETTING This was a single-center, prospective observational study conducted in an academic cardiovascular ICU. PATIENTS One hundred thirty-two patients undergoing elective cardiovascular surgery with cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients with a high postoperative lactate were found to have a higher LPR compared with patients with a normal postoperative lactate (14.4 ± 2.5 vs. 11.7 ± 3.4; p = 0.005). Linear regression analysis found a significant, negative relationship between LPR and microcirculatory flow index (r = -0.225; β = -0.037; p = 0.001 and proportion of perfused vessels: r = -0.17; β = -0.468; p = 0.009). There was not a significant relationship between absolute plasma lactate and microcirculation variables. Last, mitochondrial complex I and complex II oxidative phosphorylation were reduced in patients with high postoperative lactate levels compared with patients with normal lactate (22.6 ± 6.2 vs. 14.5 ± 7.4 pmol O2/s/106 cells; p = 0.002). CONCLUSIONS Increased anaerobic lactate production, estimated by LPR, has a negative relationship with microcirculatory blood flow after cardiovascular surgery. This relationship does not persist when measuring lactate alone. In addition, decreased mitochondrial respiration is associated with increased lactate after cardiovascular surgery. These findings suggest that high lactate levels after cardiovascular surgery, even in the setting of normal hemodynamics, are not simply a type B phenomenon as previously suggested.
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Affiliation(s)
- John C Greenwood
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Fatima M Talebi
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - David H Jang
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Audrey E Spelde
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Center for Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Frances S Shofer
- Department of Epidemiology & Biostatistics, Department of Emergency Medicine Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jacob S Brenner
- Division of Pulmonary, Allergy, & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vladimir R Muzykantov
- Department of Pharmacology and Center for Translational Targeted Therapeutics and Nanomedicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Benjamin S Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Mavroudis CD, Lewis A, Greenwood JC, Kelly M, Ko TS, Forti RM, Shin SS, Shofer FS, Ehinger JK, Baker WB, Kilbaugh TJ, Jang DH. Investigation of Cerebral Mitochondrial Injury in a Porcine Survivor Model of Carbon Monoxide Poisoning. J Med Toxicol 2024; 20:39-48. [PMID: 37847352 PMCID: PMC10774472 DOI: 10.1007/s13181-023-00971-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/30/2023] [Accepted: 09/08/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Carbon monoxide (CO) is a colorless and odorless gas that is a leading cause of environmental poisoning in the USA with substantial mortality and morbidity. The mechanism of CO poisoning is complex and includes hypoxia, inflammation, and leukocyte sequestration in brain microvessel segments leading to increased reactive oxygen species. Another important pathway is the effects of CO on the mitochondria, specifically at cytochrome c oxidase, also known as Complex IV (CIV). One of the glaring gaps is the lack of rigorous experimental models that may recapitulate survivors of acute CO poisoning in the early phase. The primary objective of this preliminary study is to use our advanced swine platform of acute CO poisoning to develop a clinically relevant survivor model to perform behavioral assessment and MRI imaging that will allow future development of biomarkers and therapeutics. METHODS Four swine (10 kg) were divided into two groups: control (n = 2) and CO (n = 2). The CO group received CO at 2000 ppm for over 120 min followed by 30 min of re-oxygenation at room air for one swine and 150 min followed by 30 min of re-oxygenation for another swine. The two swine in the sham group received room air for 150 min. Cerebral microdialysis was performed to obtain semi real-time measurements of cerebral metabolic status. Following exposures, all surviving animals were observed for a 24-h period with neurobehavioral assessment and imaging. At the end of the 24-h period, fresh brain tissue (cortical and hippocampal) was immediately harvested to measure mitochondrial respiration. RESULTS While a preliminary ongoing study, animals in the CO group showed alterations in cerebral metabolism and cellular function in the acute exposure phase with possible sustained mitochondrial changes 24 h after the CO exposure ended. CONCLUSIONS This preliminary research further establishes a large animal swine model investigating survivors of CO poisoning to measure translational metrics relevant to clinical medicine that includes a basic neurobehavioral assessment and post exposure cellular measures.
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Affiliation(s)
- Constantine D Mavroudis
- Divisions of Cardiothoracic Surgery, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
| | - Alistair Lewis
- Divisions of Cardiothoracic Surgery, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Matthew Kelly
- Divisions of Cardiothoracic Surgery, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Emergency Medicine, University of Alabama, Birmingham, AL, USA
| | - Tiffany S Ko
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Rodrigo M Forti
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Samuel S Shin
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Johannes K Ehinger
- Otorhinolaryngology, Head and Neck Surgery, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Otorhinolaryngology, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
| | - Wesley B Baker
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Todd J Kilbaugh
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - David H Jang
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Tang Z, Shao Y. Postoperative thrombocytopenia and subsequent consequences in acute type A aortic dissection. Ann Med 2023; 55:2281653. [PMID: 38071662 PMCID: PMC10880570 DOI: 10.1080/07853890.2023.2281653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES To ascertain if postoperative thrombocytopenia following open aortic surgery with a median sternotomy can predict early- and intermediate-term morbidity and mortality. METHODS From January 2018 to December 2022, a comparison was made between patients who had and didn't have postoperative thrombocytopenia (defined as a nadir < 75 × 103/μL after 72 h of open aortic surgery with median sternotomy). Intermediate-term mortality during follow-up was the main result, with cerebrovascular accident and acute renal injury requiring dialysis as secondary events. Inverse probability treatment weighting (IPTW) was used to account for selection bias between groups. The Kaplan-Meier method with the log-rank test was used to assess intermediate-term survivals following IPTW modification. To identify the nonlinear link between platelet nadir and mortality probability, a generalized additive mix model was applied. To help increase power in testing for the overall effect of platelet nadir on outcomes in the generalized additive mix model, the hazard ratios and 95% CIs for each subgroup and their interactions were examined. RESULTS The study included 457 patients, 347 male (75.9%), with mean age of 54 ± 12 years. The last follow-up was done on April 14th, 2023 and the median follow-up time was 16 (6-31) months. Following IPTW, patient characteristics were balanced among cohorts. Platelet nadir was found to be significantly inversely related to early-term mortality (IPTW-adjusted hazard ratio = 0.968 (0.960, 0.977), p < 0.001), and AKI requiring dialysis (IPTW-adjusted hazard ratio = 0.979 (0.971, 0.986), p < 0.001). A nonlinear relationship between platelet nadir and mortality risk probability during follow-up visually showed that the likelihood of mortality decreased with platelet nadir increased. In confounder-adjusted survival ('postoperative thrombocytopenia not acquired' vs 'postoperative thrombocytopenia'; HR: 0.086 [95% CI: 0.045-0.163]; p < 0.01) analysis, non-acquired postoperative thrombocytopenia was associated with a lower risk of mortality, and the treatment benefit was validated in IPTW-adjusted analysis, which showed an HR of 0.067. CONCLUSIONS Early postoperative thrombocytopenia following type A aortic dissection surgery is a risk factor for morbidity and mortality. Because postoperative thrombocytopenia can indicate a poor prognosis, monitoring early postoperative platelets helps identify individuals who may develop late postoperative problems, which is performed by this affordable biomarker.
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Affiliation(s)
- Zhiwei Tang
- Department of Cardiovascular Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yongfeng Shao
- Department of Cardiovascular Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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Greenwood JC, Talebi FM, Jang DH, Spelde AE, Gordon EK, Horak J, Acker MA, Kilbaugh TJ, Shofer FS, Augoustides JGT, Bakker J, Brenner JS, Muzykantov VR, Abella BS. Low postoperative perfused vessel density is associated with increased soluble endothelial cell adhesion molecules during circulatory shock after cardiac surgery. Microvasc Res 2023; 150:104595. [PMID: 37619889 PMCID: PMC10530427 DOI: 10.1016/j.mvr.2023.104595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/11/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Microcirculatory dysfunction after cardiovascular surgery is associated with significant morbidity and worse clinical outcomes. Abnormal capillary blood flow can occur from multiple causes, including cytokine-mediated vascular endothelial injury, microthrombosis, and an inadequate balance between vasoconstriction and vasodilation. In response to proinflammatory cytokines, endothelial cells produce cellular adhesion molecules (CAMs) which regulate leukocyte adhesion, vascular permeability, and thus can mediate tissue injury. The relationship between changes in microcirculatory flow during circulatory shock and circulating adhesion molecules is unclear. The objective of this study was to compare changes in plasma soluble endothelial cell adhesion molecules (VCAM-1, ICAM-1, and E-Selectin) in patients with functional derangements in microcirculatory blood flow after cardiovascular surgery. METHODS Adult patients undergoing elective cardiac surgery requiring cardiopulmonary bypass who exhibited postoperative shock were enrolled in the study. Sublingual microcirculation imaging was performed prior to surgery and within 2 h of ICU admission. Blood samples were taken at the time of microcirculation imaging for biomarker analysis. Plasma soluble VCAM-1, ICAM-1, and E-selectin in addition to plasma cytokines (IL-6, IL-8, and IL-10) were measured by commercially available enzyme-linked immunoassay. RESULTS Of 83 patients with postoperative shock who were evaluated, 40 patients with clinical shock had a postoperative perfused vessel density (PVD) >1 SD above (High PVD group = 28.5 ± 2.3 mm/mm2, n = 20) or below (Low PVD = 15.5 ± 2.0 mm/mm2, n = 20) the mean postoperative PVD and were included in the final analysis. Patient groups were well matched for comorbidities, surgical, and postoperative details. Overall, there was an increase in postoperative plasma VCAM-1 and E-Selectin compared to preoperative levels, but there was no difference between circulating ICAM-1. When grouped by postoperative microcirculation, patients with poor microcirculation were found to have increased circulating VCAM-1 (2413 ± 1144 vs. 844 ± 786 ng/mL; p < 0.0001) and E-Selectin (242 ± 119 vs. 87 ± 86 ng/mL; p < 0.0001) compared to patients with increased microcirculatory blood flow. Microcirculatory flow was not associated with a difference in plasma soluble ICAM-1 (394 ± 190 vs. 441 ± 256; p = 0.52). CONCLUSIONS Poor postoperative microcirculatory blood flow in patients with circulatory shock after cardiac surgery is associated with increased plasma soluble VCAM-1 and E-Selectin, indicating increased endothelial injury and activation compared to patients with a high postoperative microcirculatory blood flow. Circulating endothelial cell adhesion molecules may be a useful plasma biomarker to identify abnormal microcirculatory blood flow in patients with shock.
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Affiliation(s)
- John C Greenwood
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Fatima M Talebi
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David H Jang
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Audrey E Spelde
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Center for Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Frances S Shofer
- Department of Epidemiology & Biostatistics, Department of Emergency Medicine Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jan Bakker
- Division of Pulmonary, Allergy, and Critical Care Medicine, New York University, New York, NY, USA; Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jacob S Brenner
- Division of Pulmonary, Allergy, & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vladimir R Muzykantov
- Department of Pharmacology and Center for Translational Targeted Therapeutics and Nanomedicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin S Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Arteaga GM, Crow S. End organ perfusion and pediatric microcirculation assessment. Front Pediatr 2023; 11:1123405. [PMID: 37842022 PMCID: PMC10576530 DOI: 10.3389/fped.2023.1123405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 09/05/2023] [Indexed: 10/17/2023] Open
Abstract
Cardiovascular instability and reduced oxygenation are regular perioperative critical events associated with anesthesia requiring intervention in neonates and young infants. This review article addresses the current modalities of assessing this population's adequate end-organ perfusion in the perioperative period. Assuring adequate tissue oxygenation in critically ill infants is based on parameters that measure acceptable macrocirculatory hemodynamic parameters such as vital signs (mean arterial blood pressure, heart rate, urinary output) and chemical parameters (lactic acidosis, mixed venous oxygen saturation, base deficit). Microcirculation assessment represents a promising candidate for assessing and improving hemodynamic management strategies in perioperative and critically ill populations. Evaluation of the functional state of the microcirculation can parallel improvement in tissue perfusion, a term coined as "hemodynamic coherence". Less information is available to assess microcirculatory disturbances related to higher mortality risk in critically ill adults and pediatric patients with septic shock. Techniques for measuring microcirculation have substantially improved in the past decade and have evolved from methods that are limited in scope, such as velocity-based laser Doppler and near-infrared spectroscopy, to handheld vital microscopy (HVM), also referred to as videomicroscopy. Available technologies to assess microcirculation include sublingual incident dark field (IDF) and sublingual sidestream dark field (SDF) devices. This chapter addresses (1) the physiological basis of microcirculation and its relevance to the neonatal and pediatric populations, (2) the pathophysiology associated with altered microcirculation and endothelium, and (3) the current literature reviewing modalities to detect and quantify the presence of microcirculatory alterations.
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Affiliation(s)
- Grace M. Arteaga
- Department of Pediatric and Adolescent Medicine, Pediatric Critical Care, Mayo Clinic, Rochester MN, United States
| | - Sheri Crow
- Department of Pediatric and Adolescent Medicine, Pediatric Critical Care, Mayo Clinic, Rochester MN, United States
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