Shock : molecular, cellular, and systemic pathobiological aspects and therapeutic approaches : the official journal the Shock Society, the European Shock Society, the Brazilian Shock Society, the International Federation of Shock Societies
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Clinical Trial Observational Study
Plasma Renin Concentration is Associated with Hemodynamic Deficiency and Adverse Renal Outcome in Septic Shock.
In septic shock, both systemic vasodilatation and glomerular arteriole dilatation are responsible for the drop in glomerular filtration observed in early acute kidney injury. Angiotensin II has been shown to act on both mechanisms. Our objective was to evaluate the impact of renin angiotensin system activation, on hemodynamic deficiency and renal outcome in patient with septic shock and to assess whether urinary sodium could be a reliable test for high plasma renin concentration screening. ⋯ Plasma renin concentration is associated with adverse renal outcome, probably through shock severity and insufficient glomerular efferent arterioles vasoconstriction. An association was observed between low natriuresis and high plasma renin concentration.
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Mechanical ventilation is known to activate oxidative stress and proteolytic pathways in the diaphragm. Trauma by inducing inflammation and activating proteolytic pathways may potentiate the effects of mechanical ventilation on the diaphragm. In a blunt chest trauma with concomitant injuries we tested the hypothesis that trauma via inflammation further activates the proteolytic pathways and worsens atrophy in the diaphragm. ⋯ Trauma and mechanical ventilation induced proteolysis and atrophy in the diaphragm, but only polytrauma induced an inflammatory response in the diaphragm. The additional traumatic inflammatory stimulus did not increase the levels of the prementioned variables. These data underline that inflammation is not a major contributor to ventilator-induced diaphragmatic dysfunction.
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Research into potential use of perfluorocarbons for liquid ventilation and as oxygen delivery agents in humans has been underway since the 1960s. While partial liquid ventilation with perfluorocarbons showed promise in animal models and early human investigation, randomized controlled human trials failed to show benefit and an elevated rate of adverse events. Initial approval of Fluosol-DA (Green Cross Corporation, Osaka, Japan) by the United States Food and Drug Administration as an oxygen delivery agent for use in high-risk coronary angioplasty represents the only approved application of these compounds to supplement tissue oxygenation, but the compound was rendered obsolete and removed from the market with the development of advanced angioplasty catheters in the 1990s. ⋯ Early clinical trials of perflubron emulsion in non-cardiac and cardiac surgery were promising, but dose restriction and the requirement for high inspired oxygen concentration to maximize oxygen delivery for prolonged periods of time limited the clinical utility as a replacement for the oxygen carrying capacity of red blood cells. Identification of excess serious adverse events in treated patients resulted in discontinuation of pivotal clinical trials. Continued research investigating different formulations of perfluorocarbons has shown promise in animal studies, but continued research is necessary to prove safety and efficacy in humans.
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Clinical Trial Observational Study
The Effect of Nutrition on Early Stress-Induced Hyperglycemia, Serum Insulin Levels, and Exogenous Insulin Administration in Critically Ill Patients with Septic Shock: A Prospective Observational Study.
Stress-induced hyperglycemia is common among septic shock patients. Nutritional support influences glucose homeostasis but this effect has never been studied in septic shock. We aimed to determine the course of hyperglycemia and serum insulin levels in critically ill septic shock patients and to address the effects of caloric intake on glycemia, insulin levels, and exogenous insulin requirements. ⋯ In patients with septic shock marked reduced serum insulin levels can be observed during the first 36 h after intensive care unit (ICU) admission that have to be compensated by exogenous insulin administration, a phenomenon gradually improving after 36 h. Feeding is positively associated with exogenous insulin requirements. These results suggest that strategies to manage stress-induced hyperglycemia in patients with septic shock should consider frequent glycemic monitoring, conservative insulin dosing to prevent hypoglycemia when insulin resistance disappears, and slow progressive nutrition support during the early ICU phase as caloric loading may worsen hyperglycemia. This approach may attenuate the risk of glucose variability, hypo- and hyperglycemia and associated poor outcomes.
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Antithrombin (AT) III physiological levels are decreased during septic shock and supplementation therapy could therefore be beneficial. ⋯ In our model of endotoxic shock, a single low dose of recombinant human AT did not prevent DIC occurrence, severity, inflammatory profile, or hemodynamic alterations.