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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Post-traumatic inflammation is connected to monocyte dysfunction characterized by reduced NF-kappaB translocation during the first post-traumatic days. Because the exact dynamic of monocytic NF-kappaB translocation in patients directly after trauma remains unclear, the aim of this pilot study was to measure the intranuclear presence of NF-kappaB in monocytes from patients with multiple injuries initially after the trauma and during the early post-traumatic period and to compare these results with downstream-placed mRNA expression alteration of TNF-alpha, as well as with clinical data. Eleven patients were enrolled with an Injury Severity Score of 16 to 66 points, and blood samples were drawn on admission within 90 min and at 6, 12, 24, 48, and 72 h after trauma. ⋯ In contrast, TNF-alpha mRNA was not increased on admission (1.7 +/- 0.9) and decreased even below baseline after 12 h. The substantial information of our study arises from the analysis of the dynamic of NF-kappaB translocation of monocytes. Enabled by closely matched sequential blood sampling strictly standardized to the traumatic event, an essential increase of monocytic signal transduction and transcription could be elucidated in the very early post-traumatic period, which precedes the down-regulation of the innate immune system.
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Although the expression of monocyte histocompatibility leukocyte antigen (HLA)-DR has been shown to be decreased during human sepsis, its level of expression in other nonseptic critical conditions is unclear. The aim of this study was to compare the level of HLA-DR expression on circulating monocytes among patients with septic, hemorrhagic, and cardiogenic shocks and severe sepsis without shock. ⋯ Catecholamine infusion, mechanical ventilation, positive blood culture, and number of units of blood or plasma transfused did not correlate with decreased HLA-DR expression. Thus, the decrease in HLA-DR expression is specific to septic shock and is associated, in septic shock patients, with increased mortality risk.
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Previous studies have shown that administering trans-sodium crocetinate (TSC) as a treatment of hemorrhagic shock leads to increased whole-body oxygen consumption and survival as well as protection of the liver and kidney. It has been suggested that TSC increases oxygen delivery by increasing the diffusivity of oxygen through plasma. However, as with any novel mechanism of action, there are always questions about whether the results could also be ascribed to other, previously described mechanisms of action. ⋯ The data show that treatment with TSC results in lower concentrations of TNF-alpha in the liver and spleen as well as lower concentrations of IL-10 in the spleen. Again, similar effects on other cytokines have been seen with 100% oxygen. These results support the hypothesis that the effects of TSC on hemorrhagic shock are mediated via an effect on oxygen.
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The aim of this study was to test the effects of using a high-viscosity fluid after small-volume hyperosmotic resuscitation from hemorrhagic shock and to compare this to hyperosmotic followed by hyperoncotic resuscitation. Studies were made in the awake hamster window chamber preparation with the animals subjected to hemorrhage of 50% of blood volume and resuscitated with a small volume of a 7.5% NaCl solution, which was followed within minutes by infusion of 25% of withdrawn volume of either 0.7% or 0.8% alginate solutions (A0.7%, 7.6 cp; and A0.8%, 10.2 cp) or 5% hydroxyethyl starch (HES 5%, 2.1 cp). All modalities of resuscitation returned blood pressure to near baseline values in 5 min, which remained elevated after 90 min with A0.7% and A0.8% but returned to near shock values in 15 min with HES 5%. ⋯ The high-viscosity fluids provide a novel small-volume method of resuscitation that maximizes microvascular perfusion for extended periods until surgical control of bleeding is possible. Results show that high-plasma-viscosity resuscitation provides a more consistent and prolonged resuscitation than hyperoncotic treatment. The increase in viscosity presents a gradual recovery in blood pressure and may be used as an alternative for small-volume hypotensive resuscitation, increasing tissue perfusion while potentially limiting hemorrhage in vascular injuries of the major blood vessels.
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Randomized Controlled Trial Clinical Trial
Severity of emergency department hypotension predicts adverse hospital outcome.
Arterial hypotension often signifies inadequate systemic perfusion. We hypothesize that in a heterogeneous emergency department (ED) population with clinically suspected circulatory shock, the severity of hypotension on presentation predicts in-hospital outcome. We performed a secondary analysis of patients with nontraumatic shock enrolled in a noninterventional, randomized, controlled trial. ⋯ Sustained hypotension was the strongest independent predictor of an adverse hospital outcome (odds ratio 3.1; 95% CI 1.5-7.1). Mortality among patients who present to the ED with undifferentiated shock is high. The depth and duration of systolic blood pressure appears to have a dose-response relationship to adverse hospital outcome.