A clinical classification system for grading platinum hypersensitivity reactions.

OBJECTIVES: Current grading systems for platinum hypersensitivities (pHSR) rely on subjective features rather than objective clinical signs leading to inconsistencies in grading. To standardize classification of pHSR, a clinical grading system was developed at our institution. We report the clinical outcomes our classification system and evaluate its correlation with the classification systems currently published and used in practice. METHODS: This was a retrospective review of patients with pHSR from 2011 to 2017. Demographics, chemotherapeutic histories (CT), and details of their initial HSR were collected. Mild reactions were defined as local skin manifestations only. Moderate-low reactions included widespread skin, respiratory or GI findings. Moderate-standard reactions were defined as transient cardiovascular compromise (CVC), hypoxia or neurologic changes whereas sustained changes (>10 min) were used to define severe reaction. Fischer Exact Tests (p < .05) and binary logistic regression analyses were performed. Spearman correlation were used to assess relationships between our grading system and the NCCN and CTCAEv4.0 criteria. RESULTS: 87 patients were identified with most having ovarian cancer (n = 55, 63.2%), receiving carboplatin (n = 62, 71.3%), and on second-line CT (n = 34, 42.5%). Chest pain was associated with transient CVC (OR 10.0, 95% CI 1.148-87.133) while nausea/vomiting (OR 8.420, 95% CI 1.263-55.275) was associated with transient hypoxia albeit less closely than transient hypotension (OR 17.010, 95% CI 2.026-142.825). Only presyncope/syncope remained associated with sustained CVC (OR 38.0, 95% CI 2.815-512.912) on logistic regression. The classification system was most strongly correlated with the NCCN grading system (ρ 0.761, p < .001). CONCLUSIONS: This classification system offers an objective means of grading pHSR severity and correlates with currently-used grading systems.

The Incidence of and Risk Factors for Postintubation Hypotension in the Immunocompromised Critically Ill Adult.

OBJECTIVES: Our primary aim was to ascertain the frequency of postintubation hypotension in immunocompromised critically ill adults with secondary aims of arriving at potential risk factors for the development of postintubation hypotension and its impact on patient-related outcomes. METHODS: Critically ill adult patients (≥18 years) were included from January 1, 2010, to December 31, 2014. We defined immunocompromised as patients with any solid organ or nonsolid organ malignancy or transplant, whether solid organ or not, requiring current chemotherapy. Postintubation hypotension was defined as a decrease in systolic blood pressure to less than 90 mm Hg or a decrease in mean arterial pressure to less than 65 mm Hg or the initiation of any vasopressor medication. Patients were then stratified based on development of postintubation hypotension. Potential risk factors and intensive care unit (ICU) outcome metrics were electronically captured by a validated data mart system. RESULTS: The final cohort included 269 patients. Postintubation hypotension occurred in 141 (52%; 95% confidence interval: 46-58) patients. Several risk factors predicted postintubation hypotension on univariate analysis; however, only Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability remained significant on all 4 multivariate analyses. Patients developing postintubation hypotension had higher ICU and hospital mortality (54 [38%] vs 31 [24%], P = .01; 69 [49%] vs 47 [37%], P = .04). CONCLUSION: Based on previous literature, we found a higher frequency of postintubation hypotension in the immunocompromised than in the nonimmunocompromised critically ill adult patients. Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability were significant predictors on multivariate analyses. Postintubation hypotension led to higher ICU and hospital mortality in those experiencing this complication.

Cardiotoxicity of Immunotherapy: Incidence, Diagnosis, and Management.

PURPOSE OF REVIEW: This review describes cardiotoxicity associated with adoptive T cell therapy and immune checkpoint blockade. RECENT FINDINGS: Cardiotoxicity is a rare but potentially fatal complication associated with novel immunotherapies. Both affinity-enhanced and chimeric antigen receptor T cells have been reported to cause hypotension, arrhythmia, and left ventricular dysfunction, typically in the setting of cytokine release syndrome. Immune checkpoint inhibitors are generally well-tolerated but have the potential to cause myocarditis, with clinical presentations ranging from asymptomatic cardiac biomarker elevation to heart failure, arrhythmia, and cardiogenic shock. Electrocardiography, cardiac biomarker measurement, and cardiac imaging are key components of the diagnostic evaluation. For suspected myocarditis, endomyocardial biopsy is recommended if the diagnosis remains unclear after initial testing. The incidence of immunotherapy-associated cardiotoxicity is likely underestimated and may increase as adoptive T cell therapy and immune checkpoint inhibitors are used in larger populations and for longer durations of therapy. Baseline and serial cardiac evaluation is recommended to facilitate early identification and treatment of cardiotoxicity.

Release of cytokines and hemodynamic instability during the reperfusion of a liver graft.

The objectives of this prospective, observational study were (1) to determine whether a transplanted liver graft releases proinflammatory cytokines into the systemic circulation upon reperfusion and (2) to determine whether they contribute to any subsequent hemodynamic instability observed after graft reperfusion (if this release occurs). Blood samples from 17 consecutive patients undergoing liver transplantation were analyzed for cytokines, including tumor necrosis factor α (TNF-α), interleukin-1ß (IL-1ß), IL-2, IL-6, and IL-8. Blood samples were obtained from the radial artery, portal vein, and flush blood (a sample taken from a catheter placed above the infrahepatic inferior vena cava clamp). The amount of catecholamines necessary to maintain a mean arterial pressure between 65 and 75 mm Hg during graft reperfusion was compared with the level of cytokines. A statistical analysis was performed with the least squares method, Kendall's tau-b test, and regression analysis. We demonstrated that flush blood from the liver grafts contained a significant amount and variety of cytokines. Most of these were removed by graft irrigation. The concentration of TNF-α in samples obtained from flush blood at the end of liver irrigation was significantly higher than the concentration in samples obtained from the radial artery (P = 0.0067) or portal vein (P = 0.0003) before reperfusion. This correlated directly with the amount of catecholamines used to treat hemodynamic instability. Although there were increased levels of IL-1ß, IL-2, and IL-8 in the flush blood, there was no statistically significant correlation between the levels of these cytokines and the amount of catecholamines used.

Preoperative heparin therapy causes immune-mediated hypotension upon heparin administration for cardiac surgery.

OBJECTIVE: To evaluate whether patients with positive or negative heparin antibodies who received heparin preoperatively by continuous infusion developed cardiovascular changes upon heparin administration prior to cardiopulmonary bypass. DESIGN: Clinical trial. SETTING: Single institution, academic hospital. PARTICIPANTS: Eighty (80) patients with good ventricular function on low-dose heparin infusion prior to surgery. INTERVENTIONS: Patients were divided into 2 equal groups: group A had negative heparin antibodies (% ratio < 0.26), group B had positive heparin antibodies (% ratio > 1.2). All patients received heparin, 400 units/kg, prior to institution of cardiopulmonary bypass. Cardiovascular changes, activated coagulation time (ACT), and histamine levels were measured before and 5 minutes after administration of heparin. Platelets also were counted before and 6 hours after surgery. MEASUREMENTS AND MAIN RESULTS: Significant hypotension and decreased cardiac index occurred in patients with positive heparin antibodies who received heparin prior to cardiac surgery. Histamine levels increased significantly 5 minutes after heparin administration. Significant thrombocytopenia occurred 6 hours after surgery in group B patients. There was a good correlation between heparin antibodies, histamine levels, thrombocytopenia and cardiovascular changes. Group B patients also had heparin resistance as manifested by a lower ACT after the loading doses of heparin. CONCLUSION: Patients with positive heparin antibodies pretreated with heparin prior to surgery developed a type of immune-mediated cardiovascular changes and postoperative thrombocytopenia.

Suspected recurrent anaphylaxis in different forms during general anesthesia.

We report on a patient who presented with recurrent severe shock during general anesthesia. The patient was a man scheduled for lung surgery whose first attack was a coronary spasm, which was followed by a second shock with severe bronchospasm and hypotension 4 weeks later. An elevated serum tryptase concentration was observed, and subsequent skin testing revealed negative reactions to some drugs administered in this case. This case serves to alert anesthetists to the possibility of some different forms of allergy and highlights the importance of rigorous investigation of all the reagents and phenomena.

Protamine-associated hypotension in patients on hemodialysis: retrospective study and prevalence of antiprotamine antibodies.

AIMS: Protamine, when administered to neutralize heparin in cardiovascular surgery, is associated with occasionally severe antigen-antibody reactions associated with substantial morbidity and mortality. The objective of this study is to investigate whether patients on hemodialysis are more susceptible to the protamine adverse effects. METHOD: First, a retrospective analysis of a protamine-associated hypotension episode (PAHE) in 239 patients undergoing coronary artery bypass grafting surgery was performed for the incidence study in the period of 1999 to 2005. Second, an ELISA determination of serum anti-protamine IgG antibody in 255 serum samples from individuals without previous surgical histories was conducted for prevalence survey. In both studies, patients on HD were matched for age with non HD patients. RESULTS: The highest incidence (57%) of PAHE occurred in patients on hemodialysis using of M-insulin (a mixed type of insulin aspart 30%, insulin aspart protamine 70%) formulation, and this group also exhibited a high anti-protamine IgG antibody titer in serum (odds ratio: 18.31). CONCLUSIONS: A substantial proportion of patients on hemodialysis are at high risk of acquiring protamine adverse effects, but definite conclusion about the association between uremia and PAHE, however, still needs to be made with caution.

Direct hemoperfusion with polymyxin-B-immobilized fiber columns improves septic hypotension and reduces inflammatory mediators in septic patients with colorectal perforation.

PURPOSE: Although some studies have reported favorable effects of direct hemoperfusion with polymyxin-B-immobilized fiber columns (PMX) for the treatment of septic shock, few studies have demonstrated the efficacy of PMX in studies with a uniform case definition and without any other blood purification techniques. MATERIALS AND METHODS: Fifty-two patients with severe sepsis or septic shock secondary to colorectal perforation were treated with PMX. Hemodynamic alterations and plasma concentrations of endotoxin, interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-8, and IL-10 were evaluated following PMX treatment. RESULTS: We observed a significant reduction in plasma endotoxin in the nonsurvivors immediately after PMX treatment compared to before treatment. Systolic blood pressure was markedly increased and circulating levels of IL-1beta, IL-1Ra, and IL-8 were significantly reduced during a 2-h interval of PMX. CONCLUSIONS: Our findings suggested that PMX treatment appears to adsorb endotoxin and also modulates circulating cytokine during a 2-h interval of direct hemoperfusion in septic patients with such condition.

PAF, rather than histamine, participates in mouse anaphylactic hypotension.

We determined the roles of platelet-activating factor (PAF) and histamine in anaphylactic hypotension in ovalbumin-sensitized anesthetized BALB/c mice. The effects of PAF and histamine on hemodynamic variables were studied by measuring the systemic arterial (Psa), portal venous (Ppv) and central venous (Pcv) pressures. Intravenous PAF evoked a biphasic Psa response, an initial rapid and transient drop followed by marked hypotension, accompanied by a decrease in Pcv. Histamine caused only mild systemic hypotension. Both agents similarly increased Ppv by approximately 4 cm H(2)O at high doses. After an injection of antigen, Psa initially increased slightly and then decreased from the baseline of 94 +/- 1 mm Hg to 46 +/- 1 mm Hg at 10 min after antigen administration, with Pcv decreasing by 2.5 cm H(2)O. Ppv increased by 3.5 cm H(2)O at 5 min after antigen injection. Pretreatment with either CV-6209 (PAF receptor antagonist, 1 mg/kg) or diphenhydramine (histamine H(1) receptor antagonist, 20 mg/kg) significantly attenuated an antigen-induced decrease in Psa. The inhibitory action of CV-6209 was greater than that of diphenhydramine, and the combination of these 2 antagonists almost completely inhibited the anaphylactic hypotension. In contrast, the antigen-induced increase in Ppv was attenuated by CV-6209 alone but augmented by diphenhydramine. It is concluded that anaphylactic hypotension is mainly mediated by PAF and, to a lesser extent, by histamine in anesthetized BALB/c mice.

Pyridoxalated haemoglobin polyoxyethylene conjugate, a nitric oxide scavenger, decreases dose-limiting hypotension associated with interleukin-2 (IL-2) therapy.

Interleukin-2 (IL-2), a cytokine that induces natural killer cells termed lymphokine-activated killer (LAK) cells, is in use as an anticancer agent. During IL-2 therapy, adverse effects, such as vasodilatation and hypotension, are common. Previous studies suggest that these effects are due to nitric oxide (NO). Therefore a model of IL-2-induced hyperdynamic response in sheep was developed to test the effect of pyridoxalated haemoglobin polyoxyethylene conjugate (PHP; a NO scavenger), which is currently in clinical development for the treatment of shock associated with systemic inflammatory response syndrome. Twelve female sheep were divided into four groups (n =3 per group): sham control (Ringer's lactate solution), PHP alone (20 mg x kg(-1) x h(-1) for 96 h), IL-2 alone (recombinant human IL-2; 1,440,000 units/kg intravenously every 8 h) and a combination of PHP and IL-2. All of the sheep received Ringer's lactate solution to maintain haematocrit at baseline levels. The sheep had free access to food and water. A fall in the mean arterial pressure and systemic vascular resistance index by 20% was observed in the IL-2 group, but not in the PHP+IL-2 group. The fluid requirement to maintain the haematocrit was higher in the IL-2 group (5 ml x kg(-1) x h(-1)) than in the PHP+IL-2 group (4 ml x kg(-1) x h(-1)). The sham group showed no changes in any of the parameters. Scavenging NO by PHP prevented the hyperdynamic reaction induced by IL-2 administration in sheep. This activity of PHP may prevent the early discontinuation of IL-2 therapy that results because of these adverse events.

Noradrenergic inhibition of TNF upregulation in hemorrhagic shock.

UNLABELLED: The early stress responses to hemorrhagic shock, trauma and endotoxicosis are associated with an early proinflammatory response characterized by increased gene expression of proinflammatory cytokines, PMN influx and accumulation in the lung and apoptosis. The central role of the neuroendocrine system in modulating these proinflammatory responses has been strongly suggested by recent studies. OBJECTIVES: To examine the role of noradrenergic innervation in modulating the early increase in lung and spleen content of TNF-alpha in response to fixed-pressure (40 mm Hg) hemorrhage in vivo. METHODS: Conscious unrestrained nonheparinized male Sprague-Dawley rats (n = 42) were randomized to receive intraperitoneally either 6-hydroxy-dopamine (6-OHDA; chemical sympathectomy, SNSx) or saline (0.3 ml) prior to undergoing hemorrhage followed by fluid resuscitation with lactated Ringer's solution. Animals were sacrificed at completion of the resuscitation period and tissue samples (lung and spleen) excised for determination of TNF-alpha content, myeloperoxidase activity and apoptosis. RESULTS: Hemorrhage resulted in an immediate marked elevation in circulating epinephrine and norepinephrine levels (10- and 2-fold, respectively), increasing their plasma ratio to 6:1. SNSx depleted tissue stores of norepinephrine (80%), did not alter basal plasma levels of epi- or norepinephrine or the hemorrhage-induced rise in epinephrine, but completely prevented the rise in circulating norepinephrine. Hemorrhage increased lung and spleen contents of TNF-alpha (55 and 72%, respectively). SNSx significantly enhanced the hemorrhage-induced rise in lung TNF in response to hemorrhage. CONCLUSIONS: These results show a suppressive role for noradrenergic innervation on the hemorrhage-induced increase in tissue TNF-alpha content in vivo. We speculate that the effects of norepinephrine are protective from tissue injury but are likely to contribute to the generalized immunosuppression following trauma.

Unintended immunomodulation: part I. Effects of common clinical conditions on cytokine biosynthesis.

Cytokines are low molecular weight proteins that act in an autocrine, paracrine and endocrine fashion to regulate and integrate immune effector cell function. Cytokine production is tightly controlled by a complex network of co-stimulatory and feedback loops. The systemic concentrations of some cytokines, most notably tumor necrosis factor and various interleukins, correlate with the extent of inflammation, and the severity of critical illness and patient outcome. Thus, cytokine expression is often monitored and/or manipulated as a therapeutic target in studies of sepsis and other inflammatory conditions. Unfortunately, some therapies designed to modify cytokine response have failed to improve outcomes in sepsis, and some of these therapies have actually been harmful. Several common clinical conditions, as well as, therapeutic interventions significantly influence cytokine expression. Furthermore, the magnitude and extent of these effects may be greater than those produced by immunomodulating therapies. In contrast, other conditions may not produce clinically significant changes in cytokine expression, and must simply be considered when interpreting studies designed to determine the effects of immunomodulation. Some conditions may even result in changes in the inflammatory response and may thus add to the inflammatory burden of a critically ill patient. This review provides intensivists and other clinicians with an overview of the effects of altered physiologic conditions on cytokine expression. This information is important so that studies measuring cytokines can be correctly interpreted and clinical circumstances in which cytokine manipulation is undesirable can perhaps be avoided.

Effect of profound normovolemic hypotension and moderate hypothermia on circulating cytokines and adhesion molecules.

Hypotension caused by hypovolemic, hemorrhagic shock induces disturbances in the immune system that may contribute to an increased susceptibility to sepsis. The effect of chemically induced hypotension on circulating cytokines and adhesion molecules has not been investigated yet. In 21 patients scheduled for resection of malignant choroidal melanoma of the eye the perioperative serum levels of the cytokines IL-1beta, IL-6, IL-10, TNF-alpha, and the adhesion molecules sE-Selectin and sICAM-1 were investigated. Moderate hypothermia of 32 degrees C was induced in all patients. In 14 patients profound hypotension (mean arterial blood pressure 35-40 mmHg, hypotension group) was induced by enalapril and nitroglycerin for a mean duration of 71 min. In 7 patients the tumor was not resectable, and hypotension was not induced (controls). We did not detect significant differences in serum levels of cytokines or sE-Selectin perioperatively in patients with profound hypotension compared with controls. In both groups IL-6 serum levels increased significantly and reached a maximum after rewarming (17 +/- 6 and 16 +/- 5 pg/dL, respectively, P < 0.001). IL-1beta, IL-10, and TNF-alpha did not change perioperatively in both groups. On the first postoperative day sICAM-1 serum levels were significantly increased in both groups (mean increase of 96 and 54 ng/mL, respectively, P < 0.01 and P < 0.05). We conclude from this study that profound normovolemic arterial hypotension does not seem to have effects on serum levels of circulating IL-1beta, IL-6, IL-10, TNF-alpha, and sE-Selectin. Perioperative moderate hypothermia may be the reason for the postoperative increase in sICAM-1 levels independent of the blood pressure.

Comparison of hypotensive response to aggregated IgG or to bacterial LPS in rats.

OBJECTIVE AND DESIGN: Rats treated with aggregated IgG (Aggr.) become "refractory" to the hypotensive action of a second dose of Aggr. The objective of this study was to assess the responsiveness of animals pretreated with Aggr. to bacterial LPS and vice versa. MATERIAL OR SUBJECTS: Female Wistar rats (250-300 g) were used. Each experiment was carried on at least 4 animals. TREATMENT: A human IgG preparation containing 30% aggregates (10-16 mg/100 g) or E. coli serotype 0111.B4 (0.005-mg/100 g) was administered i.v. Certain groups of animals were pretreated with 1 mg/100 g GdCl3 or with 10 mg/100 g pentoxyphylline (PTX). METHODS: Arterial blood pressure was monitored in the carotis-using a polyethylene cannula and an electronic tension meter. Tumor necrosis factor alpha (TNF-alpha) activity was estimated by the use of an L-929 cell cytotoxicity assay. RESULTS: Pretreatment of rats with a sublethal dose of LPS impaired the hypotensive reaction of the animals to Aggr. Rats male "refractory" to Aggr. reacted to the injection of LPS with hypotension and a second phase milder than in the controls. Hypotension could not be elicited by Aggr. in rats pretreated with GdCl3. The same pretreatment had no effect on the first phase of hypotension induced by intravenous injection of LPS, whilst a mitigation of the second phase was observed. Infusion of PTX immediately prior to Aggr. administration prevented the drop of blood pressure. A sizeable level of TNF-alpha was detected only later than blood pressure had reached its minimum level following Aggr. administration. CONCLUSIONS: Hypotension induced by LPS may involve a macrophage population broader than that responsible for the vascular action of Aggr. The data presented do not support a primary role for TNF-alpha in Aggr. induced hypotension.

Cytokine mRNA expression after transient and prolonged hypotension.

The role of cytokines in hemorrhagic shock remains controversial, with some studies showing an elevation of cytokines, whereas others do not. We thus analyzed the changes in tumor necrosis factor (TNF) activity and in mRNA of TNF alpha, interleukin-1beta (IL-1beta), and interleukin-6 (IL-6) after transient and prolonged hypotension. In the transient hypotension group (TH group), chronically cannulated rats were bled (20 ml/kg x 3 min) without fluid resuscitation. They showed transient hypotension, but their blood pressure (BP) quickly stabilized. In the prolonged hypotension group (PH group), the rats were bled and maintained at a mean BP of 40 mmHg for 60 min, and then were resuscitated with the shed blood and an equal volume of saline over 60 min. The serum TNF activity was measured by cytotoxicity against the L929 tumorigenic murine fibroblast. Messenger RNA of TNF alpha, IL-1beta, and IL-6 in liver was measured semi-quantitatively by high-performance liquid chromatography after reverse transcription and polymerase chain reaction. The increases in the TNF activity were not significant in either of the groups above the prehemorrhage levels, whereas mRNA of TNF alpha and IL-1beta showed a transient elevation in the TH group and a persistent elevation in the PH group. IL-6 mRNA did not increase significantly in the TH group, but did increase in the PH group. These results show that a large hemorrhage induces cytokine mRNA in the liver and also show the differences in the changes of cytokine mRNA after transient and prolonged hypotension.

Hypotension induces Fos immunoreactivity in NADPH-diaphorase positive neurons in the paraventricular and supraoptic hypothalamic nuclei of the rat.

Double staining for Fos and nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-D) was used to study the distribution of activated neurons that synthesize nitric oxide in the paraventricular (PVN) and supraoptic nuclei (SON) following hypotensive stimulation in conscious rats. Fos was detected in many magno- and parvocellular NADPH-D positive neurons in response to haemorrhage or drug-evoked hypotension using i.v. infusions of sodium nitroprusside. However, quantitative analysis did not reveal any differences in the number of Fos positive PVN neurons following either mode of stimulation. These results suggest that a subpopulation of hypothalamic NADPH-D positive neurons is activated following hypotensive challenge. This activation of NADPH-D neurons may occur indirectly through other CNS structures that influence the excitability of hypothalamic SON and PVN. Furthermore, the lack of a difference in activated neurons within the PVN following either haemorrhage or nitroprusside infusion suggests that while a drop in blood pressure causes activation of neurons that produce nitric oxide, a decrease in blood volume, which accompanies haemorrhage, does not.

Effects of trauma, duration of hypotension, and resuscitation regimen on cellular immunity after hemorrhagic shock.

OBJECTIVE: To determine the effects of: a) surgical trauma, b) crystalloid resuscitation, and c) different durations of hypotension on cellular immunity after hemorrhagic shock. DESIGN: Prospective, multiexperimental, randomized, controlled studies. SETTING: University research laboratory. SUBJECTS: Inbred C3H/HeN (endotoxin-sensitive) mice, aged 6 to 7 wks, weighing 18 to 23 g. INTERVENTIONS: Crystalloid resuscitation, with and without blood, after hemorrhage. MEASUREMENTS AND MAIN RESULTS: Mice which did or did not undergo laparotomy were subjected to hypotension of 35 mm Hg for 60 or 90 mins. Crystalloid resuscitation with and without blood was then provided. Animals were killed at 2 hrs after hemorrhage and cytokine concentrations in supernatants of splenocytes, splenic macrophages, and serum were assessed by bioassays. The cellular release of interleukin (IL)-2, IL-3, IL-6, tumor necrosis factor, and the splenocyte proliferative capacity were significantly and similarly depressed in all groups. Conversely, circulating IL-6 concentrations were significantly increased in all groups. CONCLUSIONS: Cellular immunity was depressed at 2 hrs after simple hemorrhage and no further depression occurred if hemorrhage was coupled with trauma, pure crystalloid resuscitation was provided, or the shock period was prolonged. Thus, the early immunodepression after hemorrhage was mainly dependent on the severity rather than the duration of shock, resuscitation regimen, or tissue trauma.

Defective macrophage antigen presentation following haemorrhage is associated with the loss of MHC class II (Ia) antigens.

Although recent studies indicate that severe and prolonged haemorrhage, despite adequate fluid resuscitation, induces profound depression of cell-mediated immunity, the mechanism of this remains unknown. Since macrophages (M phi) play a key role in the development of a competent immune response by the presentation of antigens, the study investigated (i) whether the capacity of the M phi to present antigen is altered even following mild hypotension, and (ii) what effects do different degrees of hypotension have on the M phi-mediated processes associated with antigen presentation (i.e. the expression Ia antigen, membrane-associated IL-1 or the secretion of IL-1). The results indicate that a minimal drop in blood pressure to approximately 50 mmHg (1 hr duration) was sufficient to depress M phi antigen presentation (AP). Similarly, even a transient hypotensive episode of 15 min duration at 35 mmHg was sufficient to produce a pronounced decline in AP. Decreased AP was observed as early as 12 hr after the haemorrhagic episode (35 mmHg; 1 hr) and remained detectable for at least 120 hr thereafter. The reductions in AP capacities were qualitatively similar in both peritoneal and splenic populations, and were not attributable to surgical stress, heparinization or ether anaesthesia. Determination of IL-1 production, as well as membrane-bound IL-1 levels, in these cell populations showed no significant difference from controls. However, a significant decrease was observed in the percentage of Ia antigen (MHC class II)-positive M phi, suggesting that reduced AP following haemorrhage may be related to the inability of these cells to express Ia.

Interaction of prostaglandins, activated complement, and granulocytes in clinical sepsis and hypotension.

Activated complement, thromboxane A2, prostacyclin, and activated granulocytes have been implicated in hemodynamic dysfunction after trauma, in sepsis, and in hypovolemic and septic shock. This study evaluated the interaction of plasma concentrations of complement components C3a and C5a, thromboxane B2 (TxB), prostaglandin 6-keto-F1 alpha (PGI), and granulocyte aggregation in clinical sepsis and hypotension. Forty-eight critically ill patients were followed clinically for as long as 10 days. Plasma C3a, C5a, TxB, and PGI were measured daily by the radioimmunoassay method. Granulocyte aggregation, the percentage of maximum aggregation of zymosan-activated plasma standard curves, was performed with patient plasma and normal human leukocytes. Patients were studied in four groups: group I, nonseptic, normotensive; group II, hypovolemic shock, group III, normotensive severe sepsis; and group IV, septic shock. Plasma from 12 normal adults was the control value. PGI, TxB, C3a, C5a, and granulocyte aggregation in patients were greater than that in the control subjects. Granulocyte aggregation was increased in groups III and IV versus groups I and II. C3a was increased in group IV versus groups II and III. C5a and TxB did not vary between groups. PGI was greatly increased in group IV compared with groups I through III. C3a and C5a decreased in nonsurvivors. PaO2/FiO2 ratios correlated directly with PGI and inversely with C3a and TxB/PGI. Plasma PGI and C3a are increased in septic shock. C3a and TxB/PGI imbalances are involved in hypovolemic and septic shock.