Acute and Critical Care

Original Article

Nutrition
Associations between systemic inflammation and intestinal permeability with Onodera's prognostic nutritional index in critically ill patients: Seyed Hossein Ardehali, Ghazaleh Eslamian, Shirin Malek; Acute Crit Care. 2021;36(4):361-368. Published online November 26, 2021; DOI: https://doi.org/10.4266/acc.2021.00178

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Background
Malnutrition is a potentially costly problem in critically ill patients admitted to the intensive care unit (ICU). The aim of this study is to evaluate the relationships between the Onodera’s prognostic nutritional index (OPNI) and intestinal permeability and between OPNI and systemic inflammation in critically ill patients.
Methods
This was a cross-sectional study conducted in the general ICU of a university-affiliated hospital. A total of 162 ICU-hospitalized adult patients admitted between May 2018 and December 2019, was included in the study sample. The OPNI was calculated at admission and categorized as ≤40 or >40. We assessed plasma endotoxin and zonulin concentrations as markers of intestinal permeability as well as serum interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP) as markers of systemic inflammation upon admission under stringent conditions. The relationships between these markers and OPNI were assessed after adjusting for potential confounders through estimation of a binary logistic regression model.
Results
Median (interquartile range) hs-CRP, IL-6 zonulin, and endotoxin were significantly greater in the low OPNI subgroup than in the high OPNI subgroup (all P<0.05). Multivariate analyses showed significant association between serum IL-6 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.64–0.96), serum hs-CRP (OR, 0.77; 95% CI, 0.53–0.92), plasma endotoxin (OR, 0.81; 95% CI, 0.72–0.93), and plasma zonulin (OR, 0.83; 95% CI, 0.75–0.98) levels with OPNI in the overall population.
Conclusions
Our results provide evidence that higher plasma endotoxin, zonulin, IL-6, and hs-CRP levels are associated with progressively lower OPNI in mixed ICU populations, particularly in surgical ICU patients.

Citations

Citations to this article as recorded by

Association of malnutrition status with 30-day mortality in patients with sepsis using objective nutritional indices: a multicenter retrospective study
Moon Seong Baek, Young Suk Kwon, Sang Soo Kang, Daechul Shim, Youngsang Yoon, Jong Ho Kim
Acute and Critical Care.2024; 39(1): 127. CrossRef
Practical parameters that can be used for nutritional assessment in patients hospitalized in the intensive care unit with the diagnosis of chronic obstructive pulmonary disease
Ramazan Baldemir, Mustafa Özgür Cirik
Medicine.2022; 101(24): e29433. CrossRef
Nutritional Status, Body Composition, and Inflammation Profile in Older Patients with Advanced Chronic Kidney Disease Stage 4–5: A Case-Control Study
Mar Ruperto, Guillermina Barril
Nutrients.2022; 14(17): 3650. CrossRef

Review Article

Infection
Up-to-date information on polymyxin B-immobilized fiber column direct hemoperfusion for septic shock: Chieko Mitaka, Makio Kusaoi, Izumi Kawagoe, Daizoh Satoh; Acute Crit Care. 2021;36(2):85-91. Published online April 4, 2021; DOI: https://doi.org/10.4266/acc.2021.00150

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Abstract PDF

Endotoxin adsorption therapy by polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) has been used for the treatment of septic shock patients. Endotoxin, an outer membrane component of Gram-negative bacteria, plays an important role in the pathogenesis of septic shock. Endotoxin triggers a signaling cascade for leukocytes, macrophage, and endothelial cells to secrete various mediators including cytokines and nitric oxide, leading to septic shock and multiple organ dysfunction syndrome. PMX-DHP directly adsorbed not only endotoxin but also monocytes and anandamide. It reduced blood levels of inflammatory cytokines such as interleukin (IL)-1, IL-6, tumor necrosis factor-alpha and IL-17A, adhesion molecules, plasminogen activator inhibitor 1, and high mobility group box-1. As a result, PMX-DHP increased blood pressure and reduced the dose of vasoactive-inotropic agents. PMX-DHP improved monocyte human leukocyte antigen-DR expression in patients with severe sepsis and septic shock. A post hoc analysis of EUPHRATES (Evaluating the Use of Polymyxin B Hemoperfusion in Randomized Controlled Trial of Adults Treated for Endotoxemia and Septic Shock) trial has shown that PMX-DHP significantly reduced 28-day mortality compared with the control group in septic shock patients with endotoxin activity assay level between 0.60 and 0.89. Longer duration of PMX-DHP may be another strategy to bring out the beneficial effects of PMX-DHP. Further studies are needed to confirm the efficacy of PMX-DHP treatment for septic shock.

Citations

Citations to this article as recorded by

Methods of Extracorporeal Hemocorrection in Sepsis (Review)
V. A. Kovzel, L. A. Davydova, A. V. Karzin, S. V. Tsarenko, V. Yu. Baturova, A. A. Polupan, A. I. Gutnikov
General Reanimatology.2023; 19(2): 68. CrossRef
Modifications of peripheral perfusion in patients with vasopressor-dependent septic shock treated with polymyxin B-direct hemoperfusion
Motohiro Sekino, Yu Murakami, Shuntaro Sato, Ryosuke Shintani, Shohei Kaneko, Naoya Iwasaki, Hiroshi Araki, Taiga Ichinomiya, Ushio Higashijima, Tetsuya Hara
Scientific Reports.2023;[Epub] CrossRef
Rhabdomyolysis secondary to hypervirulent Klebsiella pneumoniae infection: A case report
Naoko Niimi, Keiko Taga, Taiju Miyagami, Toshio Naito, Chieko Mitaka
Clinical Case Reports.2022;[Epub] CrossRef
Endotoxin Activity in Patients With Extracorporeal Membrane Oxygenation Life Support: An Observational Pilot Study
Chen-Tse Lee, Chih-Hsien Wang, Wing-Sum Chan, Yun-Yi Tsai, Tzu-Jung Wei, Chien-Heng Lai, Ming-Jiuh Wang, Yih-Sharng Chen, Yu-Chang Yeh
Frontiers in Medicine.2021;[Epub] CrossRef

Case Reports

Infection/Surgery
Refractory Septic Shock Treated with Nephrectomy under the Support of Extracorporeal Membrane Oxygenation: Young Kun Lee, Jeong Am Ryu, Jeong Hoon Yang, Chi-Min Park, Gee Young Suh, Kyeongman Jeon, Chi Ryang Chung; Korean J Crit Care Med. 2015;30(3):176-179. Published online August 31, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.3.176

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Abstract PDF: Conventional medical therapies have not been very successful in treating adults with refractory septic shock. The effects of direct hemoperfusion using polymyxin B and veno-arterial extracorporeal membrane oxygenation (ECMO) for refractory septic shock remain uncertain. A 66-year-old man was admitted to the emergency department and suffered from sepsis-induced hemodynamic collapse. For hemodynamic improvement, we performed direct hemoperfusion using polymyxin B. Computed tomography scan of this patient revealed emphysematous pyelonephritis (EPN), for which he underwent emergent nephrectomy with veno-arterial ECMO support. To the best of our knowledge, this is the first report of successful treatment of EPN with refractory septic shock using polymyxin B hemoperfusion and nephrectomy under the support of ECMO.

Infection
Polymyxin B Hemoperfusion in Pneumonic Septic Shock Caused by Gram-Negative Bacteria: Jung-Wan Yoo, Su Yeon Park, Jin Jeon, Jin Won Huh, Chae-Man Lim, Younsuck Koh, Sang-Bum Hong; Korean J Crit Care Med. 2015;30(3):171-175. Published online August 31, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.3.171

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Abstract PDF: Severe sepsis and septic shock are the main causes of death in critically ill patients. Early detection and appropriate treatment according to guidelines are crucial for achieving favorable outcomes. Endotoxin is considered to be a main element in the pathogenic induction of gram-negative bacterial sepsis. Polymyxin B hemoperfusion can remove endotoxin and is reported to improve clinical outcomes in patients with intra-abdominal septic shock, but its clinical efficacy for pneumonic septic shock remains unclear. Here, we report a case of a 51-year-old man with pneumonic septic shock caused by Pseudomonas aeruginosa, who recovered through polymyxin B hemoperfusion.

Original Articles

Effect of Endotoxin on Cerebrospinal Fluid Formation in the Rat: Dong Chan Kim, Yu Jeong Kim, Gi Chul Min; Korean J Crit Care Med. 2001;16(1):48-54.

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Abstract PDF: BACKGROUND
Bacterial lipopolysaccharide (LPS), an endotoxin, can increase nitric oxide (NO) production by expression of an inducible isoforms of nitric oxide synthase (iNOS). Bacterial infections of the central nervous system dilate cerebral vessels and increase cerebral blood flow. We hypothesized that systemic and intraventricular application of bacterial lipopolysaccharide would increase cerebrospinal fluid (CSF) production due to increase in blood flow to choroid plexus caused by NO-induced vasodilation.
METHODS
Ventriculocisternal perfusion was used to measure the production of CSF in pentobarbital-anesthetized rats. The lateral ventricle and cisterna magna were cannulated stereotactically and perfused continuously with artificial CSF with blue dextran 2000 as the indicator. Baseline collections of CSF began after steady state outflow was established; then, endotoxin was administered intravenously or intraventricularly. The baseline rate of CSF production was compared with that measured during 3 hours after endotoxin administration.
RESULTS
The baseline rate of CSF production was 2.6 0.3 (2.2~3.5)microliter/minute in the rat. There were no significant changes in CSF production rate after intravenous or intraventriculr administration of endotoxin.
CONCLUSIONS
We could not observe significant changes in CSF production rate with the ventriculocisternal perfusion method of measuring CSF production after intravenous or intraventriculr administration of endotoxin in the rats.

The Effects of Lipopolysaccharide on the Reactivity of Isolated Rat Trachea with or without Epithelium: Hyo Chul Shin, Yoon Hee Kim, Dong Sik Hur, Seok Hwa Yoon, Yong Sup Shin, Sae Jin Choi; Korean J Crit Care Med. 1998;13(1):25-32.

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Abstract PDF: BACKGOUND: Gram negative bacterial lipopolysaccharide (LPS) induces increase in the production of nitric oxide (NO), or a related substance derived from L-arginine in the animal tissue. Recent evidence indicates that airway epithelium may secrete NO or a related compound. It has multiple regulatory roles in the airways. In vitro, the effects of lipopolysaccharide (LPS) on the reactivity of rat' tracheal wall with or without epithelium were examined.
METHODS
Tracheas were removed from Sprague Dawley rats. Preparations were mounted for isometric recording in 20ml organ baths at 37degrees C containing Tis-buffered Tyrode solution continuously gassed with 100% O2. Tensions were measured with force displacement transducers and responses were recorded on a polygraph. Cummulative concentration-response curves were constructed for acetylcholine (Ach) in the tracheal strips with or without preincubation of Escherichia coli LPS (100 mcg/ml, 5hrs). And then effects of NO synthase inhibitors and removal of epithelium were examined.
RESULTS
In isolated perfused tracheas preincubated by LPS, both removed epithelium and intact epithelium of rat tracheal rings showed decreased Ach-induced contraction. In intact epithelium group, 10 (-5)M L-NAME (N-nitro-L-arginine methyl ester), 10 (-5)M L-arginine or dexamethasone pretreatment was restored in Ach-induced contraction response. But in the removed epithelium group, Ach-induced contraction was potentiated by L-arginine pretreatment and was not restored by the pretreatment of L-NAME and dexamethasone.
CONCLUSIONS
The results suggest that nitric oxide synthase is induced by endotoxin in the tracheal epithelium, resulting in inhibition of the contractile response.

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