Activated protein C attenuates microvascular injury during systemic hypoxia.

In response to hypoxia, an inflammatory cascade is initiated and microvascular injury ensues. Specifically, within 10 min, leukocyte adherence to the endothelium begins, and leukocyte emigration and vascular leak soon follow. Activated protein C (APC) has been reported to have both anticoagulant and anti-inflammatory properties. Activated protein C is best described in its role as a treatment for sepsis. However, it has been used, with some success, in experimental models of hypoxic injury. We hypothesized that APC would be protective against microvascular injury during systemic hypoxia. Randomized prospective animal study. Adult male Sprague-Dawley rats. To characterize the microvascular response to APC exposure during hypoxia, four rat groups were used: saline control, APC infusion alone (100 mg/kg bolus), hypoxia alone (10% O2), and simultaneous hypoxia + APC infusion. Measurements of leukocyte adherence (no. per 100-microm venule), leukocyte emigration (no. per 4,000 microm(2)), and venular leak by fluorescein isothiacyanate-labeled albumin (Fo/Fi) were performed during intravital microscopy of the intact venular bed. Leukocyte adherence decreased from 14.5 (+/-1.2) cells/100-microm venule in hypoxic rats to 4.4 (+/-1.5) cells/100-microm venule in those treated with both hypoxic gas and APC infusion (P < 0.001). Similarly, leukocyte emigration in hypoxic rats reached 12.3 (+/- 2.2) cells/4,000-microm(2) venule, but was reduced to 3.5 (+/-0.3) cells/4,000-microm(2) venule (P <.001). Venular permeability to protein was also significantly decreased in the APC-treated group from 0.82 (+/-0.14) to 0.25 (+/-0.14) (P < 0.001). The infusion of APC attenuates the inflammatory response during systemic hypoxia at the microvascular level, as evidenced by measurements of leukocyte adherence, emigration, and venular permeability. Further investigation is needed to examine the potential role of APC in the treatment of hypoxic injury.

Deferoxamine mimics the pattern of hypoxia-related injury at the microvasculature.

Oxygen is essential for the maintenance of life, and when oxygen levels decline to critical levels, a program of complex mechanisms exists to i) sense hypoxia, ii) respond to minimize acute tissue injury, and iii) result in adaptations that offer protection against further hypoxia challenges. Alternative adaptation-related protection may also be inducible through the increased activity of hypoxia-inducible factors activated by hypoxia mimics such as iron chelation with deferoxamine (DFA). We have characterized a set of hypoxia-related responses at the microvasculature and postulated that microvascular injury in response to hypoxia could be reproduced by the reduction of bioavailable iron through chelation by DFA. We were able to induce a similar degree of leukocyte adherence and emigration and vascular leak with DFA infusion as compared with hypoxia exposure in an intact physiological rodent model. However, in contrast to hypoxia-exposed groups, we were unable to detect reactive oxygen species or alter the injury pattern with reactive oxygen species scavenger in the groups treated with DFA. Thus, we demonstrate that DFA mimics the pattern and intensity of hypoxia-related injury on the microvasculature; however, differences in the time course and mechanism of injury were identified. In addition, DFA saturated with iron did not completely reverse the effects of DFA, suggesting a mechanism(s) beyond a reduction in the bioavailability of iron. These findings may have importance in the targeting of iron for the development of hypoxia mimics that may offer protection against subsequent hypoxia exposure in clinical setting such as myocardial infarction and stroke.

Development and implementation of an ICU quality improvement checklist.

Hospitals, especially their intensive care units, are not particularly safe for patients. Life-threatening mistakes and omissions in care can and do occur. To deter omissions and mistakes wherever possible, our medical intensive care team developed a checklist of care issues that must be addressed daily for every patient in our intensive care unit. The checklist augments our daily, multidisciplinary quality rounds and informs all personnel when important items have been missed. It is too soon to tell whether the checklist has had an impact on our survival rate or length of stay, but we have documented clear improvement in our attention to these core intensive care issues. In addition, our team's collegiality and team bonding are enhanced by using an evidence-based tool to achieve our care goals. We share our checklist, so that others can use and/or adapt it in their pursuit of optimal care for their critically ill patients.

Effects of hypoxia and nitric oxide on ferritin content of alveolar cells.

Concentrations of ferritin in alveolar cells and on the alveolar surface are increased in patients with a variety of respiratory disorders. Ferritin synthesis by cells is modulated by iron content but is also influenced by stimuli other than iron. In this study we sought to determine whether in vitro exposure to hypoxia- or nitric oxide (NO)-induced ferritin accumulation or release by human alveolar macrophages (AMs) or a lung cancer-derived epithelial cell line (A549). Changes in cell content of iron and ferritin (L- and H-types), as well as ferritin content of cell supernatants, were determined after in vitro exposure to hypoxia (1% or 10% O(2), 18 hours) or the NO donor S-nitroso-N-acetylpenicillamine (SNAP, 0.01-1.0 mmol/L, 18 hours). Exposure to 1% O(2) increased ferritin content in both cell types (>fourfold increase; P <.005) without changing iron content. Treatment with SNAP increased ferritin content of A549 cells in a dose-dependent manner, whereas treatment of AMs decreased cellular iron and ferritin content and increased supernate ferritin content. Pretreatment of cells with N-acetylcysteine (500 micromol/L) reduced hypoxia-induced ferritin accumulation in alveolar cells and completely inhibited NO-induced ferritin accumulation in A549 cells. These findings indicate that exposure to 1% O(2)can increase ferritin content in alveolar cells, whereas NO can increase ferritin content (A549 cells) or decrease ferritin content (AMs).