1
|
Porsche R, Steinhardt F, Knoerlein J, Schick MA. Phenylephrine versus cafedrine/theodrenaline (Akrinor) for the treatment of spinal anaesthesia-induced maternal hypotension during caesarean section: a retrospective single-centre cohort study. BMJ Open 2022; 12:e062512. [PMID: 36385024 PMCID: PMC9670961 DOI: 10.1136/bmjopen-2022-062512] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The main objective of this study was to assess the impact of phenylephrine and cafedrine/theodrenaline on the mother and newborn after spinal anaesthesia for caesarean section. SETTING University teaching hospital. DESIGN A single-centre retrospective data cohort study. PATIENTS All obstetric patients who were scheduled for caesarean section in a 2-year period. INTERVENTIONS Administration of either intravenous phenylephrine prophylactically or cafedrine/theodrenaline (Akrinor) reactively to maintain blood pressure after spinal anaesthesia. MAIN OUTCOME MEASURE Maternal hypotension, heart rate during caesarean section and after admission to IMC, fetal arterial cord pH and base excess levels, maternal volume resuscitation and the use of rescue medication. RESULTS 852 data sets could be included: n=440 Akrinor, n=412 in the phenylephrine cohort. During caesarean section blood pressure was slightly higher in the phenylephrine group compared with the Akrinor group, while hypotension <100 mm Hg systolic blood pressure (SBP) occurred significantly more often during arrival at the IMC after surgery when phenylephrine was used. Heart rate was lower and rescue medication was significantly more frequently given in the phenylephrine cohort. Irrespective of the medication used, women with baseline levels of <120 mm Hg SBP had a high risk to develop hypotension <100 mm Hg after spinal anaesthesia for caesarean section. While there was no statistical difference in mean umbilical arterial pH levels, the incidence of acidosis, defined as pH <7.2, was significantly higher with phenylephrine. CONCLUSION Phenylephrine was not superior to Akrinor to treat spinal anaesthesia-induced maternal hypotension during caesarean section. TRIAL REGISTRATION NUMBER DRKS00025795.
Collapse
Affiliation(s)
- Raphael Porsche
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Frederic Steinhardt
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julian Knoerlein
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Alexander Schick
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
2
|
Burkard N, Baar W, Flemming S, Schlegel N, Wollborn J, Schneider R, Brock RW, Wunder C, Schick MA. Standardized Colon Ascendens Stent Peritonitis in Rats - a Simple, Feasible Animal Model to Induce Septic Acute Kidney Injury. J Vis Exp 2022. [DOI: 10.3791/54448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
3
|
Abstract
The pleiotropic function of 3′,5′-cyclic adenosine monophosphate (cAMP)-dependent pathways in health and disease led to the development of pharmacological phosphodiesterase inhibitors (PDE-I) to attenuate cAMP degradation. While there are many isotypes of PDE, a predominant role of PDE4 is to regulate fundamental functions, including endothelial and epithelial barrier stability, modulation of inflammatory responses and cognitive and/or mood functions. This makes the use of PDE4-I an interesting tool for various therapeutic approaches. However, due to the presence of PDE4 in many tissues, there is a significant danger for serious side effects. Based on this, the aim of this review is to provide a comprehensive overview of the approaches and effects of PDE4-I for different therapeutic applications. In summary, despite many obstacles to use of PDE4-I for different therapeutic approaches, the current data warrant future research to utilize the therapeutic potential of phosphodiesterase 4 inhibition.
Collapse
Affiliation(s)
- Martin Alexander Schick
- Department of Anesthesiology and Critical Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany
- Correspondence:
| | - Nicolas Schlegel
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, 97080 Würzburg, Germany;
| |
Collapse
|
4
|
Rombach S, Benner A, Schick MA. [Sectio Caesarea under Gitelman Syndrome]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:289-295. [PMID: 33890260 DOI: 10.1055/a-1299-0579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Gitelman syndrome is a rare inherited renal tubulopathy characterized by hypokalemia, hypomagnesemia and metabolic alcalosis. It is caused by a mutation in the SLC12A3 gene leading to a dysfunction of the thiazide-sensitive sodium chloride cotransporter and the magnesium transporters in the distal convoluted tubules. Only few reports of pregnant woman with Gitelman syndrome exist. Due to many unsolved questions about the impact on pregnancy and the maternal and fetal outcome, the obstetric and anesthesiological management remains a challenge. We discuss the case of a primary cesarean delivery in a 22-year-old woman with a new diagnosed Gitelman syndrome focusing on the anesthesiological approach.
Collapse
Affiliation(s)
- Stephan Rombach
- Department of Anesthesiology and Critical Care Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Benner
- Department of Anesthesiology and Critical Care Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Alexander Schick
- Department of Anesthesiology and Critical Care Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
5
|
Wollborn J, Schlegel N, Schick MA. [Phosphodiesterase 4 inhibition for treatment of endothelial barrier and microcirculation disorders in sepsis]. Anaesthesist 2018; 66:347-352. [PMID: 28429038 DOI: 10.1007/s00101-017-0305-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Sepsis is commonly associated with loss of microvascular endothelial barrier function (capillary leak) and dysfunctional microcirculation, which both promote organ failure. The development of a distinct therapy of impaired endothelial barrier function and disturbed microcirculation is highly relevant because both of these phenomena constitute crucial processes which critically influence the prognosis of patients. Numerous in vivo and in vitro trials over the past years have fostered a better understanding of the pathophysiology of capillary leak. Furthermore, promising data in animal models show that therapeutic modulation of endothelial barrier function and microcirculation can be achieved by stabilizing endothelial cAMP (cyclic adenosine monophosphate) levels followed by activation of Rho-GTPase Rac1, e. g. by phosphodiesterase 4 inhibitors. This review summarizes and discusses recent findings of cellular mechanisms and in vivo trials.
Collapse
Affiliation(s)
- J Wollborn
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland
| | - N Schlegel
- Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - M A Schick
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
| |
Collapse
|
6
|
Rosenbaum C, Schick MA, Wollborn J, Heider A, Scholz CJ, Cecil A, Niesler B, Hirrlinger J, Walles H, Metzger M. Activation of Myenteric Glia during Acute Inflammation In Vitro and In Vivo. PLoS One 2016; 11:e0151335. [PMID: 26964064 PMCID: PMC4786261 DOI: 10.1371/journal.pone.0151335] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/26/2016] [Indexed: 12/29/2022] Open
Abstract
Background Enteric glial cells (EGCs) are the main constituent of the enteric nervous system and share similarities with astrocytes from the central nervous system including their reactivity to an inflammatory microenvironment. Previous studies on EGC pathophysiology have specifically focused on mucosal glia activation and its contribution to mucosal inflammatory processes observed in the gut of inflammatory bowel disease (IBD) patients. In contrast knowledge is scarce on intestinal inflammation not locally restricted to the mucosa but systemically affecting the intestine and its effect on the overall EGC network. Methods and Results In this study, we analyzed the biological effects of a systemic LPS-induced hyperinflammatory insult on overall EGCs in a rat model in vivo, mimicking the clinical situation of systemic inflammation response syndrome (SIRS). Tissues from small and large intestine were removed 4 hours after systemic LPS-injection and analyzed on transcript and protein level. Laser capture microdissection was performed to study plexus-specific gene expression alterations. Upon systemic LPS-injection in vivo we observed a rapid and dramatic activation of Glial Fibrillary Acidic Protein (GFAP)-expressing glia on mRNA level, locally restricted to the myenteric plexus. To study the specific role of the GFAP subpopulation, we established flow cytometry-purified primary glial cell cultures from GFAP promotor-driven EGFP reporter mice. After LPS stimulation, we analyzed cytokine secretion and global gene expression profiles, which were finally implemented in a bioinformatic comparative transcriptome analysis. Enriched GFAP+ glial cells cultured as gliospheres secreted increased levels of prominent inflammatory cytokines upon LPS stimulation. Additionally, a shift in myenteric glial gene expression profile was induced that predominantly affected genes associated with immune response. Conclusion and Significance Our findings identify the myenteric GFAP-expressing glial subpopulation as particularly susceptible and responsive to acute systemic inflammation of the gut wall and complement knowledge on glial involvement in mucosal inflammation of the intestine.
Collapse
Affiliation(s)
- Corinna Rosenbaum
- Department of Tissue Engineering and Regenerative Medicine (TERM), University Hospital Wuerzburg, Wuerzburg, Germany
| | | | - Jakob Wollborn
- Department of Anaesthesia and Critical Care, University of Wuerzburg, Wuerzburg Germany
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Andreas Heider
- Translational Centre for Regenerative Medicine, University of Leipzig, Leipzig, Germany
| | - Claus-Jürgen Scholz
- Interdisciplinary Centre for Clinical Research (IZKF), University Hospital Wuerzburg, Wuerzburg, Germany
| | - Alexander Cecil
- Department of Bioinformatics, University of Wuerzburg, Wuerzburg, Germany
| | - Beate Niesler
- Department of Human Molecular Genetics and nCounter Core Facility, Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Johannes Hirrlinger
- Carl-Ludwig-Institute for Physiology, University of Leipzig, Leipzig, Germany
- Department of Neurogenetics, Max-Planck-Institute for Experimental Medicine, Goettingen, Germany
| | - Heike Walles
- Department of Tissue Engineering and Regenerative Medicine (TERM), University Hospital Wuerzburg, Wuerzburg, Germany
- Translational Center ‘Regenerative Therapies for Oncology and Musculoskeletal Diseases’ (TZKME), Branch of the Fraunhofer Institute Interfacial Engineering and Biotechnology (IGB), Wuerzburg, Germany
| | - Marco Metzger
- Department of Tissue Engineering and Regenerative Medicine (TERM), University Hospital Wuerzburg, Wuerzburg, Germany
- Translational Center ‘Regenerative Therapies for Oncology and Musculoskeletal Diseases’ (TZKME), Branch of the Fraunhofer Institute Interfacial Engineering and Biotechnology (IGB), Wuerzburg, Germany
- * E-mail:
| |
Collapse
|
7
|
Schick MA, Baar W, Bruno RR, Wollborn J, Held C, Schneider R, Flemming S, Schlegel N, Roewer N, Neuhaus W, Wunder C. Balanced Hydroxyethylstarch (HES 130/0.4) Impairs Kidney Function In-Vivo without Inflammation. PLoS One 2015; 10:e0137247. [PMID: 26340751 PMCID: PMC4560431 DOI: 10.1371/journal.pone.0137247] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/14/2015] [Indexed: 01/04/2023] Open
Abstract
Volume therapy is a standard procedure in daily perioperative care, and there is an ongoing discussion about the benefits of colloid resuscitation with hydroxyethylstarch (HES). In sepsis HES should be avoided due to a higher risk for acute kidney injury (AKI). Results of the usage of HES in patients without sepsis are controversial. Therefore we conducted an animal study to evaluate the impact of 6% HES 130/0.4 on kidney integrity with sepsis or under healthy conditions Sepsis was induced by standardized Colon Ascendens Stent Peritonitis (sCASP). sCASP-group as well as control group (C) remained untreated for 24 h. After 18 h sCASP+HES group (sCASP+VOL) and control+HES (C+VOL) received 50 ml/KG balanced 6% HES (VOL) 130/0.4 over 6 h. After 24 h kidney function was measured via Inulin- and PAH-Clearance in re-anesthetized rats, and serum urea, creatinine (crea), cystatin C and Neutrophil gelatinase-associated lipocalin (NGAL) as well as histopathology were analysed. In vitro human proximal tubule cells (PTC) were cultured +/- lipopolysaccharid (LPS) and with 0.1-4.0% VOL. Cell viability was measured with XTT-, cell toxicity with LDH-test. sCASP induced severe septic AKI demonstrated divergent results regarding renal function by clearance or creatinine measure focusing on VOL. Soleley HES (C+VOL) deteriorated renal function without sCASP. Histopathology revealed significantly derangements in all HES groups compared to control. In vitro LPS did not worsen the HES induced reduction of cell viability in PTC cells. For the first time, we demonstrated, that application of 50 ml/KG 6% HES 130/0.4 over 6 hours induced AKI without inflammation in vivo. Severity of sCASP induced septic AKI might be no longer susceptible to the way of volume expansion.
Collapse
Affiliation(s)
- Martin Alexander Schick
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
- * E-mail:
| | - Wolfgang Baar
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Raphael Romano Bruno
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
| | - Jakob Wollborn
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Christopher Held
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Reinhard Schneider
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Sven Flemming
- Department of general, visceral, vascular and paediatric surgery (Department of Surgery I), University of Würzburg, Würzburg, Germany
| | - Nicolas Schlegel
- Department of general, visceral, vascular and paediatric surgery (Department of Surgery I), University of Würzburg, Würzburg, Germany
| | - Norbert Roewer
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
| | - Winfried Neuhaus
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
- Department of Medicinal Chemistry, University of Vienna, Vienna, Austria
- Institute of Medical Genetics, Medical University of Vienna, Vienna, Austria
| | - Christian Wunder
- Institute of Anaesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
| |
Collapse
|
8
|
Konrad F, Bury A, Schick MA, Ngamsri KC, Vollmer I, Reutershan J. 0997. The unrecognized effects of phosphodiesterase 4 on epithelial cells in pulmonary inflammation. Intensive Care Med Exp 2014. [PMCID: PMC4798108 DOI: 10.1186/2197-425x-2-s1-p82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
9
|
Schick MA, Isbary JT, Stueber T, Brugger J, Stumpner J, Schlegel N, Roewer N, Eichelbroenner O, Wunder C. Effects of crystalloids and colloids on liver and intestine microcirculation and function in cecal ligation and puncture induced septic rodents. BMC Gastroenterol 2012; 12:179. [PMID: 23245375 PMCID: PMC3547783 DOI: 10.1186/1471-230x-12-179] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 12/11/2012] [Indexed: 01/10/2023] Open
Abstract
Background Septic acute liver and intestinal failure is associated with a high mortality. We therefore investigated the influence of volume resuscitation with different crystalloid or colloid solutions on liver and intestine injury and microcirculation in septic rodents. Methods Sepsis was induced by cecal ligation and puncture (CLP) in 77 male rats. Animals were treated with different crystalloids (NaCl 0.9% (NaCl), Ringer’s acetate (RA)) or colloids (Gelafundin 4% (Gel), 6% HES 130/0.4 (HES)). After 24 h animals were re-anesthetized and intestinal (n = 6/group) and liver microcirculation (n = 6/group) were obtained using intravital microscopy, as well as macrohemodynamic parameters were measured. Blood assays and organs were harvested to determine organ function and injury. Results HES improved liver microcirculation, cardiac index and DO2-I, but significantly increased IL-1β, IL-6 and TNF-α levels and resulted in a mortality rate of 33%. Gel infused animals revealed significant reduction of liver and intestine microcirculation with severe side effects on coagulation (significantly increased PTT and INR, decreased haemoglobin and platelet count). Furthermore Gel showed severe hypoglycemia, acidosis and significantly increased ALT and IL-6 with a lethality of 29%. RA exhibited no derangements in liver microcirculation when compared to sham and HES. RA showed no intestinal microcirculation disturbance compared to sham, but significantly improved the number of intestinal capillaries with flow compared to HES. All RA treated animals survided and showed no severe side effects on coagulation, liver, macrohemodynamic or metabolic state. Conclusions Gelatine 4% revealed devastated hepatic and intestinal microcirculation and severe side effects in CLP induced septic rats, whereas the balanced crystalloid solution showed stabilization of macro- and microhemodynamics with improved survival. HES improved liver microcirculation, but exhibited significantly increased pro-inflammatory cytokine levels. Crystalloid infusion revealed best results in mortality and microcirculation, when compared with colloid infusion.
Collapse
|
10
|
Schick MA, Wunder C, Wollborn J, Roewer N, Waschke J, Germer CT, Schlegel N. Phosphodiesterase-4 inhibition as a therapeutic approach to treat capillary leakage in systemic inflammation. J Physiol 2012; 590:2693-708. [PMID: 22495586 DOI: 10.1113/jphysiol.2012.232116] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
In sepsis and systemic inflammation, increased microvascular permeability and consecutive breakdown of microcirculatory flow significantly contribute to organ failure and death. Evidence points to a critical role of cAMP levels in endothelial cells to maintain capillary endothelial barrier properties in acute inflammation. However, approaches to verify this observation in systemic models are rare. Therefore we tested here whether systemic application of the phosphodiesterase-4-inhibitors (PD-4-Is) rolipram or roflumilast to increase endothelial cAMP was effective to attenuate capillary leakage and breakdown of microcirculatory flow in severe lipopolysaccharide (LPS)-induced systemic inflammation in rats. Measurements of cAMP in mesenteric microvessels demonstrated significant LPS-induced loss of cAMP levels which was blocked by application of rolipram. Increased endothelial cAMP by application of either PD-4-I rolipram or roflumilast led to stabilization of endothelial barrier properties as revealed by measurements of extravasated FITC-albumin in postcapillary mesenteric venules. Accordingly, microcirculatory flow in mesenteric venules was significantly increased following PD-4-I treatment and blood gas analyses indicated improved metabolism. Furthermore application of PD-4-I after manifestation of LPS-induced systemic inflammation and capillary leakage therapeutically stabilized endothelial barrier properties as revealed by significantly reduced volume resuscitation for haemodynamic stabilization. Accordingly microcirculation was significantly improved following treatment with PD-4-Is. Our results demonstrate that inflammation-derived loss of endothelial cAMP contributes to capillary leakage which was blocked by systemic PD-4-I treatment. Therefore these data suggest a highly clinically relevant and applicable approach to stabilize capillary leakage in sepsis and systemic inflammation.
Collapse
Affiliation(s)
- Martin Alexander Schick
- University of Würzburg, Department of General, Visceral, Vascular and Paediatric Surgery (Department of Surgery I), Oberdürrbacherstraße 6, D-97080 Würzburg, Germany
| | | | | | | | | | | | | |
Collapse
|
11
|
Schick MA, Isbary TJ, Schlegel N, Brugger J, Waschke J, Muellenbach R, Roewer N, Wunder C. The impact of crystalloid and colloid infusion on the kidney in rodent sepsis. Intensive Care Med 2009; 36:541-8. [DOI: 10.1007/s00134-009-1704-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Accepted: 09/12/2009] [Indexed: 10/20/2022]
|