Oxygen consumption during septic shock. Effects of inotropic drugs

Septic shock may be defined as a clinical entity wherein a patient has an inadequate peripheral metabolism in the presence of circulating bacteria. The demands for metabolic requirements of the tissues and hence for oxygen transport to these tissues are then markedly high. The average response to increased metabolism in such patients is a percentage increase in cardiac output that is comparable to the percentage increase in oxygen consumption while oxygen extraction rate does not change or even decreases in severe or/and advanced septic shock. This emphasizes the high priority placed by the body on the ability to increase blood flow from the heart in the presence of increased metabolic demands due to sepsis. Concerning the myocardium, oxygen consumption is low in hyper- and hypodynamic states of septic shock, probably and partially due to marked arterial vasodilatation. However, in hypodynamic states, the lower value of perfusion pressure may account for a decrease in myocardial oxygen supply, especially in subendocardial areas and may be responsible for myocardial ischaemia, more especially as myocardial oxygen extraction as well as systemic oxygen extraction is impaired. The goal of therapeutics is to improve oxygen availability through: (1) maintenance of haemoglobin levels and (2) increases in stroke volume using inotropic drugs since these drugs may produce a rise in myocardial oxygen supply higher than their drug-induced increase in oxygen requirements in hypodynamic states of septic shock.     

Changes in haemoglobin binding curve and oxygen transport in chronic hypoxic lung disease.

Direct measurements of the factors determining blood oxygen transport in 10 patients with chronic hypoxic respiratory failure led to the conclusion that wide differences in the position of their oxygen binding curves, due to spontaneous differences in red-cell 2, 3-diphosphoglycerate, had little effect on oxygen delivery to the tissues, as assessed by the mixed venous oxygen tension when they were breathing air. This result arises from the shape of the oxygen binding curve. A drug which could shift the curve to the right would help tissue oxygenation in cardiogenic and other forms of shock, when a low cardiac output can not be improved though arterial blood can be well oxygenated.     

Interaction of cultured mammalian cells with WR-2721 and its thiol, WR-1065: implications for mechanisms of radioprotection

An isothermal microcalorimeter was used to measure changes in heat flow when radioprotective drugs were added to cultured mammalian cells. The heat produced when WR-2721 was added continued for at least 90 min. WR-2721 was dephosphorylated by the cells to thiol (WR-1065) which oxidizes to disulphide. In the microcalorimeter, thiols give an immediate burst of heat due to this oxidation. A biological oxygen monitor revealed that WR-1065 and cysteamine rapidly consumed all the oxygen in culture medium. (10 mM WR-1065 deoxygenated medium in 2 min.) Rapid consumption of oxygen by radioprotective thiols indicates that they will not co-exist with oxygen for long in cells. This has two important implications with respect to mechanisms of radioprotection: (1) oxygen in tissues will be consumed rapidly and could result in local hypoxia; and, (2) at modest doses of protective agents the thiol will be consumed in oxic cells and hence very little will be available for reactions such as hydrogen donation. Our results indicate that anoxia is probably the principal mechanism of protection by aminothiols in mammals and aerated cells. This has major implications for clinical applications of radioprotectors and these are discussed.     

Evaluation of the antioxidant properties of the angiotensin-converting enzyme inhibitor,captopril and the nucleotide enhancing agent,acadesine

The angiotensin-converting enzyme inhibitor, captopril and the nucleotide enhancing agent, acadesine, protect myocardial tissue from ischaemia/reperfusion-induced injury. Although both drugs have well established, independent mechanisms of cardiac protection, they may also have antioxidant activity which could contribute to their beneficial action. In this study we have examined the antioxidant activity of captopril and acadesine by examining their ability to scavenge ABTS radicals, formed from the interaction of ferryl metmyoglobin with phenothiazine in the presence of hydrogen peroxide. For comparison, we compared these results to those obtained for a range of other drugs commonly used for the treatment of cardiovascular disorders. These included verapamil (arrhythmia), isosorbide dinitrate (angina), atenolol (hypertension) and enalapril (congestive heart failure). The antioxidant properties of these drugs were then compared to the well characterised antioxidants, Trolox (a water soluble vitamin E analogue), ascorbate and glutathione. Captopril and acadesine were both shown to be efficient scavengers of ABTS radicals, importantly at drug concentrations expected to be found in vivo. These data confirm that the antioxidant potential of captopril and acadesine may be an important component of their mechanism of action, with both drugs probably protecting the myocardium against oxygen derived free radicals during ischaemia/reperfusion.     

Effects of Hypoxic Exposure during Feeding on SDA and Postprandial Cardiovascular Physiology in the Atlantic Cod,Gadus morhua

Some Atlantic cod in the Bornholm Basin undertake vertical foraging migrations into severely hypoxic bottom water. Hypoxic conditions can reduce the postprandial increase in gastrointestinal blood flow (GBF). This could subsequently postpone or reduce the postprandial increase in oxygen consumption (MO₂), i.e. the SDA, leading to a disturbed digestion. Additionally, a restricted oxygen uptake could result in an oxygen debt that needs to be compensated for upon return to normoxic waters and this may also affect the ability to process the food. Long-term cardio-respiratory measurements were made on fed G. morhua in order to understand how the cardio-respiratory system of feeding fish respond to a period of hypoxia and a subsequent return to normoxia. These were exposed to 35% water oxygen saturation for 90 minutes, equivalent to the time and oxygen level cod voluntarily endure when searching for food in the Bornholm Basin. We found that i) gastric and intestinal blood flows, cardiac output and MO₂ increased after feeding, ii) gastric and intestinal blood flows were spared in hypoxia, and iii) there were no indications of an oxygen debt at the end of the hypoxic period. The magnitude and time course of the measured variables are similar to values obtained from fish not exposed to the hypoxic period. In conclusion, when cod in the field search for and ingest prey under moderate hypoxic conditions they appear to stay within safe limits of oxygen availability as we saw no indications of an oxygen debt, or negative influence on digestive capacity, when simulating field observations.     

An improved rebreathing method for measuring mixed venous carbon dioxide tension and its clinical application.

The mixed venous carbon dioxide tension (PVCO2) can be measured at the bedside by a rebreathing equilibrium technique that is quick, simple and noninvasive. Only one brief period of rebreathing is required. The technique is accurate even when the lungs are not normal, and gives a graphic record that allows verification of the accuracy of the estimate. The PVCO2 is affected mainly by changes in alveolar ventilation and cardiac output. It can be measured instead of the arterial carbon dioxide tension (PACO2) to follow changes in alveolar ventilation when the cardiac output is normal (PaCO2 = 0.8 PVCO2). When the cardiac output is abnormal, measurement of both PaCO2 and PvCO2 is useful in determining how much the cardiac output is reduced. Consideration of the relation between oxygen consumption and carbon dioxide production suggests that the equation PaCO2 = 0.8 PVCO2 - 12 indicates a reduction in cardiac output that may impair the oxygen supply to tissues. Simple corrections can be applied to allow for variations in arterial oxygen saturation and hemoglobin concentration that will affect this relationship.     

The Chemotherapy of Cardiac Arrest

Direct-air ventilation, external cardiac compression, and external defibrillation are established techniques for patients who unexpectedly develop cardiac arrest. The proper use of drugs can increase the incidence of successful resuscitation. Intracardiac adrenaline (epinephrine) acts as a powerful stimulant during cardiac standstill and, in addition, converts fine ventricular fibrillation to a coarser type, more responsive to electrical defibrillation. Routine use of intravenous sodium bicarbonate is recommended to combat the severe metabolic acidosis accompanying cardiac arrest. Lidocaine is particularly useful when ventricular fibrillation or ventricular tachycardia tends to recur. Analeptics are contraindicated, since they invariably increase oxygen requirements of already hypoxic cerebral tissues. The following acrostic is a useful mnemonic for recalling the details of the management of cardiac arrest in their proper order: A (Airway), B (Breathing), C (Circulation), D (Diagnosis of underlying cause), E (Epinephrine), F (Fibrillation), G (Glucose intravenously), pH (Sodium bicarbonate), I (Intensive care).     

急性缺氧性缺氧时心脏功能的改变

F_(IO_2)(吸入气氧浓度)为12.35、9.87及7.7l％,分别吸入10、8及5min时,心功能呈代偿性增强改变。F_(IO_2)为9.37％、吸入20min时心功能的变化趋势与9.87％8min时仍基本相同。继发性缺二氧化碳对缺氧引起的心功能代偿性增强,在一定程度上起抵消作用。F_(IO_2)为9.87％时的缺氧程度约相当于18km高空加压供氧总压值为15.3kPa(115mmHg)时的缺氧。单纯从缺氧因素考虑,将总压值由常用的17.3kPa(130mmHg)降低为15.3kPa是可允许的。     

Temperature and Food as Factors Influencing Oxygen Consumption of Intertidal Organisms, Particularly Limpets

SYNOPSIS: In intertidal animals rates of oxygen consumptionspan an order of magnitude (even when standardised for bodysize and temperature). This may reflect different adaptationsto this variable habitat. Temperatures range widely and potentiallyincrease metabolic expenditure during the heat of the day, whileperiods of feeding may be restricted. The balance between intakeand expenditure of energy may limit zonation, body size, andeven mode of reproduction. One pattern is that species sufferingshortage of food ("conservers") have low rates of oxygen consumptionwhile those with abundant food ("exploiters") have high rates.Conservers appear to have several means of reducing metaboliccosts, but exploiters maintain high (seemingly wasteful) ratesof oxygen consumption. Oxygen consumption cannot, however, be considered separately,since it reflects turnover,including growth rate and reproductiveoutput. There is also the question whether differences betweenspecies are genetically controlled, or simply phenotypic responsesto food availability. Comparisons of populations with differentamounts of food suggest that exploiters substantially reduceoxygen consumption when food is scarce, but conservers are relativelyfixed in their pattern of slow growth and low reproductive output,even if food is experimentally increased. Growth and reproduction are positively correlated, at leastwithin taxonomically related groups (as exemplified by patellaceanlimpets) but both are inversely related to longevity.Thus growthand reproduction are not necessarily "traded off," but are bothlow in "conservers" and both high in "exploiters."     

Chronic obstructive pulmonary disease.

Outpatient management of chronic obstructive pulmonary disease (COPD) is reviewed in this paper. Smoking cessation is probably important, although its benefit in established COPD is unproven. Bronchodilator therapy may be of more than symptomatic benefit and is indicated in virtually all patients. Specific beta 2-agonists are the most widely used agents and can be given in substantially larger doses than are usually recommended. Ipratropium bromide, an anticholinergic drug, is about as effective as a beta 2-agonist, but in large doses the two drugs do not seem to have additive effects, unlike theophylline and beta 2-agonists. Systemic corticosteroids decrease airway obstruction substantially in a small number of patients with COPD; these agents should be reserved for these patients and used sparingly. Inhaled steroids are of little benefit, as are respiratory stimulants and depressants. Broad-spectrum antibiotic therapy helps to relieve symptomatic exacerbations of COPD, particularly those characterized by increased dyspnea, sputum volume and sputum purulence. Cor pulmonale is best managed by diuretics and oxygen, with digoxin reserved for left ventricular failure and supraventricular arrhythmias. Continuous oxygen therapy at home is indicated for the patients who have chronic arterial hypoxemia.     

New Trends in the Treatment of Angina Pectoris

Traditionally when considering the pharmacologic basis of therapy in angina pectoris, attention is focussed on alterations of coronary blood flow. Yet the diseased coronary arteries in these patients often do not appear to be capable of responding to vasodilatory drugs. Since the pain of myocardial ischemia is relieved by a number of interventions without an increase in coronary blood flow, the concept herein considered is that angina pector is best viewed as an unfavorable relation between myocardial oxygen requirements and availability. Thus, the clinical value of the major antianginal agents is thought to be based importantly upon their actions to reduce myocardial oxygen consumption rather than to increase coronary blood flow.Sublingual nitroglycerin possesses a powerful dilator effect on veins which reduces venous return and thereby the size of the heart and intra-myocardial tension; thus myocardial oxygen requirements are diminished.The beta-adrenergic receptor blocking drug, propranolol (Inderal®), inhibits sympathetic stimulation of the heart at rest and during exercise. Thus, myocardial oxygen requirements are diminished by the reduction in heart rate and diminished contractility. As a result of this latter action, cardiac output is reduced and thereby arterial pressure and intramyocardial tension is lowered. In patients with advanced heart disease and borderline cardiac compensation, propranolol is hazardous because it removes the availability of one of the important reserve mechanisms for maintaining cardiac compensation—the sympathetic support of the failing heart.The introduction of electrical stimulation of the carotid sinus nerves as a means of therapy in patients with angina pectoris has provided a powerful tool for the treatment of patients with refractory ischemic pain.     

Cardiac mitochondrial energy metabolism in heart failure: Role of cardiolipin and sirtuins

Mitochondrial oxidation of fatty acids accounts for the majority of cardiac ATP production in the heart. Fatty acid utilization by cardiac mitochondria is controlled at the level of fatty acid uptake, lipid synthesis, mobilization and mitochondrial import and oxidation. Consequently defective mitochondrial function appears to be central to the development of heart failure. Cardiolipin is a key mitochondrial phospholipid required for the activity of the electron transport chain. In heart failure, loss of cardiolipin and tetralinoleoylcardiolipin helps to fuel the generation of excessive reactive oxygen species that are a by-product of inefficient mitochondrial electron transport chain complexes I and III. In this vicious cycle, reactive oxygen species generate lipid peroxides and may, in turn, cause oxidation of cardiolipin catalyzed by cytochrome c leading to cardiomyocyte apoptosis. Hence, preservation of cardiolipin and mitochondrial function may be keys to the prevention of heart failure development. In this review, we summarize cardiac energy metabolism and the important role that fatty acid uptake and metabolism play in this process and how defects in these result in heart failure. We highlight the key role that cardiolipin and sirtuins play in cardiac mitochondrial β-oxidation. In addition, we review the potential of pharmacological modulation of cardiolipin through the polyphenolic molecule resveratrol as a sirtuin-activator in attenuating mitochondrial dysfunction. Finally, we provide novel experimental evidence that resveratrol treatment increases cardiolipin in isolated H9c2 cardiac myocytes and tetralinoleoylcardiolipin in the heart of the spontaneously hypertensive rat and hypothesize that this leads to improvement in mitochondrial function. This article is part of a Special Issue entitled: Heart Lipid Metabolism edited by G.D. Lopaschuk.     

活性氧诱导心律失常的分子生物学机制研究

心律失常特别是室性心律失常可能导致心源性猝死,已经成为临床上常见和重点问题。多种原因可能诱发心律失常如:冠状动脉粥样硬化性心脏病,瓣膜病,肥厚性心肌病等心脏源性病变,很多代谢性物质改变也可能增加心律失常的发生概率。近年发现活性氧可能是诱发各种心律失常的一个重要因素,活性氧不仅参与重要离子通道和转运受体的调控,同时本身也作为一个重要的第二信来调节一些关键酶的活性如:蛋白激酶A(PKA),蛋白激酶C(PKC),钙离子依赖性蛋白激酶II(CaMKII)。最近有研究发现长期的活性氧代谢紊乱可能引起细胞遗传物质如miRNA的改变,引起长期的心律失常如房颤。本文主要对活性氧导致心律失常的可能机制做一总结,为心律失常的防治提供一些可能潜在方向。     

Effect of anthracyclines and mitoxantrone on oxygen uptake and ATP intracellular concentration in rat heart slices

The clinical use of anthracycline antibiotics is severely limited by dose-dependent cardiotoxicity. This accounts for our interest in differences on respiratory control of cardiac cells induced by two new anticancer agents epirubicin and mitoxantrone. Cellular oxygen uptake was measured for increasing drugs concentrations with a Warburg manometric apparatus and intracellular ATP by high-pressure liquid chromatography in rat heart slices incubated for 60′ with anthracyclines or mitoxantrone. Epirubicin inhibits endogenous respiration by 18% versus control while doxorubicin and mitoxantrone reduce oxygen uptake by 34 and 46%, respectively. ATP intracellular concentration was significantly reduced by all anticancer agents but particularly by mitoxantrone 86%.These results may be related to the biochemical side effects produced by these drugs on bioenergetics and cellular respiratory control.     

Cardiac glycosides as novel cancer therapeutic agents

The class of steroid-like compounds designated cardiac glycosides includes well-known drugs such as digoxin, digitoxin, and ouabain. Their continued efficacy in treatment of congestive heart failure and as anti-arrhythmic agents is well appreciated. Less well known, however, is the emerging role of this category of compounds in the prevention and/or treatment of proliferative diseases such as cancer. New findings within the past five years have revealed these compounds to be involved in complex cell-signal transduction mechanisms, resulting in selective control of human tumor but not normal cellular proliferation. As such, they represent a promising form of targeted cancer chemotherapy. New clinical studies of their anticancer potential as single or adjuvant treatments may provide insight into these potentially valuable therapeutic options. This review focuses on recent findings on cellular pharmacology of cardiac glycosides as they relate to treatment of human cancer and attempts to explain why these agents have been overlooked in the past.     

Cardiorespiratory performance in salmonids during exercise at high temperature: insights into cardiovascular design limitations in fishes

Studies in the laboratory with salmonids and now in the field with wild salmon clearly show that critical swimming performance has an optimum temperature. This temperature optimum is coincident with maximum aerobic scope and maximum cardiac scope. At a temperature that is higher than this optimum, however, whole animal performance declines abruptly. Evidence is presented here to suggest that this is directly associated with a decline in cardiac scope which limits oxygen supply to tissues. It is further suggested that the decline in maximum cardiac performance could reflect problems with the heart's own oxygen supply. The reasoning behind this suggestion is that, at temperatures at or below the optimum and probably because of a limitation on oxygen diffusion in skeletal muscle during exercise, venous oxygen does not fall below a threshold level during exercise, and so the heart receives just enough oxygen for its own muscular activity via the cardiac circulation (i.e. the venous return to the heart). However, because high temperature favours increased oxygen extraction by skeletal muscle, which consequently lowers venous oxygen, cardiac oxygen supply may become insufficient to meet cardiac oxygen demand. The hypoxic myocardium then cannot maintain cardiac scope and internal oxygen delivery to tissue declines.     

Pericellular oxygen depletion during ordinary tissue culturing, measured with oxygen microsensors

Recent research has found important differences in oxygen tension in proximity to certain mammalian cells when grown in culture. Oxygen has a low diffusion rate through cell culture media, thus, as a result of normal respiration, a decrease in oxygen tension develops close to the cells. Therefore, for the purpose of standardization and optimization, it is important to monitor pericellular oxygen tension and cell oxygen consumption. Here, we describe an integrated oxygen microsensor and recording system that allows measurement of oxygen concentration profiles in vertical transects through a 1.6-mm deep, stagnant, medium layer covering a cell culture. The measurement set-up reveals that, when confluent, a conventional culture of adherent cells, although exposed to the constant oxygen tension of ambient air, may experience pericellular oxygen tensions below the level required to sustain full oxidative metabolism. Depletions reported are even more prominent and potentially aggravating when the cell culture is incubated at reduced oxygen tensions (down to around 4% oxygen). Our results demonstrate that, if the pericellular oxygen tension is not measured, it is impossible to relate in vitro culture results (for example, gene expression to the oxygen tension experienced by the cell), as this concentration may deviate very substantially from the oxygen concentration recorded in the gas phase.     

Caloric excess or restriction mediated modulation of metabolic enzyme acetylation-proposed effects on cardiac growth and function

Caloric excess has been postulated to disrupt cardiac function via (i) the generation of toxic intermediates, (ii) via protein glycosylation and (iii) through the generation of reactive oxygen species. It is now increasingly being recognized that the nutrient intermediates themselves may modulate metabolic pathways through the post-translational modifications of metabolic enzymes. In light of the high energy demand of the heart, these nutrient mediated modulations in metabolic pathway functioning may play an important role in cardiac function and in the capacity of the heart to adapt to biomechanical stressors. In this review the role of protein acetylation and deacetylation in the control of metabolic programs is explored. Although not extensively investigated directly in the heart, the emerging data support that these nutrient mediated post-translational regulatory events (i) modulate cardiac metabolic pathways, (ii) integrate nutrient flux mediated post-translational effects with cardiac function and (iii) may be important in the development of cardiac pathology. Areas of investigation that need to be explored are highlighted. This article is part of a Special Issue entitled: Mitochondria and Cardioprotection.