EARLY DECREASED RESPIRATORY CHAIN CAPACITY IN RESUSCITATED EXPERIMENTAL SEPSIS IS A MAJOR CONTRIBUTOR TO LACTATE PRODUCTION.

ABSTRACT: Background : Increased plasma lactate levels in patients with sepsis may be due to insufficient oxygen delivery, but mitochondrial dysfunction or accelerated glycolysis may also contribute. We studied the effect of the latter on muscle metabolism by using microdialysis in a sepsis model with sustained oxygen delivery and decreased energy consumption or mitochondrial blockade. Methods : Pigs were subjected to continuous Escherichia coli infusion (sepsis group, n = 12) or saline infusion (sham group, n = 4) for 3 h. Protocolized interventions were applied to normalize the oxygen delivery and blood pressure. Microdialysis catheters were used to monitor muscle metabolism (naïve). The same catheters were used to block the electron transport chain with cyanide or the Na + /K + -ATPase inhibitor, ouabain locally. Results: All pigs in the sepsis group had positive blood cultures and a Sequential Organ Failure Assessment score increase by at least 2, fulfilling the sepsis criteria. Plasma lactate was higher in the sepsis group than in the sham group ( P < 0.001), whereas muscle glucose was lower in the sepsis group ( P < 0.01). There were no changes in muscle lactate levels over time but lactate to pyruvate ratio (LPR) was elevated in the sepsis versus the sham group ( P < 0.05). Muscle lactate, LPR, and glutamate levels were higher in the sepsis group than in the sham group in the cyanide catheters ( P < 0.001, all comparisons) and did not normalize in the former group. Conclusions: In this experimental study on resuscitated sepsis, we observed increased aerobic metabolism and preserved mitochondrial function. Sepsis and electron transport chain inhibition led to increased LPR, suggesting a decreased mitochondrial reserve capacity in early sepsis.

Case report: An unusual presentation of renal hypertension after damage control surgery.

INTRODUCTION AND IMPORTANCE: Hypertensive crisis may be a life-threatening condition to any patient and represents an even more serious condition in trauma patients following severe hemorrhage. CASE PRESENTATION: We present a case were surgical drape packing induced hypertensive crisis in a trauma patient, recently resuscitated from abdominal hemorrhage. CLINICAL DISCUSSION: We argue that direct compression of the kidney by the surgical drapes induced hypersecretion of renin with a mechanism equal to Page kidney. The hypertensive crisis as well as the hyperreninemia was resolved after removing the surgical drapes, and the patient's condition returned to normal without any sequelae. CONCLUSION: We encourage considering this unusual but important complication when packing of the abdomen has been carried out, and strongly recommend ruling out renin-mediated hypertension as a cause of post-operative hypertension in such cases.

[Rare but potentially life-threatening - Multisystem inflammatory syndrome in adults - a case description]. / Hyperinflammation hos vuxna med covid-19 ­ ovanligt men allvarligt.

Multisystem inflammatory syndrome in adults, MIS-A, is a rare but severe post-covid-19 immunologic complication. The presentation is similar to Multisystem inflammatory syndrome in children, MIS-C. Both MIS-A/C are life-threatening immunologic syndromes characterized by hypotension, skin rashes, myocardial affection, coagulopathy and GI symptoms.  Here we describe a case of MIS-A in a 35-year-old previously healthy female who, five weeks after a mild covid-19 infection, presented with a life-threatening immunological reaction. The patient made a swift recovery upon treatment with immunoglobulins, corticosteroids and an interleukin-1 receptor antagonist. We want to highlight the importance of immunological derangements following covid-19 infections in adults. We also present a treatment suggestion for MIS-A based on the management routine for MIS-C, which has been developed from international discussions and collaborations by pediatric rheumatologists in Sweden and around the world.

Intracranial Pressure Dynamics and Cerebral Vasomotor Reactivity in Coronavirus Disease 2019 Patient With Acute Encephalitis.

We describe the intracranial pressure dynamics and cerebral vasomotor reactivity in a coronavirus disease 2019 patient with acute encephalitis treated with cerebrospinal fluid drainage and therapeutic plasma exchange. DATA SOURCES: Coronavirus disease ICU, Uppsala University Hospital, Sweden. STUDY SELECTION: Case report. DATA EXTRACTION: Radiology, intracranial pressure, intracranial compliance (correlation between intracranial pressure amplitude and mean intracranial pressure), cerebral vasomotor reactivity (pressure reactivity index), arterial blood pressure, cerebrospinal fluid chemistry, and treatment. DATA SYNTHESIS: None. CONCLUSIONS: This is the first reported case of intracranial pressure monitoring in a patient with acute encephalitis following coronavirus disease 2019. Intracranial pressure data exhibited a high incidence of plateau waves with intracranial pressure insults above 40 mm Hg that required cerebrospinal fluid drainage. Intracranial compliance was low, and pressure reactivity was intact. It is probable that the combination of low intracranial compliance and intact pressure autoregulation explain the high degree of plateau intracranial pressure waves and intracranial pressure variability. This case illustrates that it could be of value to consider intracranial pressure monitoring in selected coronavirus disease 2019 patients with suspicion of increased intracranial pressure to be able to confirm and treat intracranial hypertension if needed. In this patient, therapeutic plasma exchange was safe and efficacious as the level of neuroinflammation decreased and the patient regained consciousness.

Rapid Bolus Administration Does not Increase The Extravasation Rate of Albumin: A Randomized Controlled Trial in The Endotoxemic Pig.

Some experimental data suggest that rapid bolus administration of albumin causes less plasma-expanding effects than slow, continuous infusion. To determine whether rapid bolus administration, in comparison with slow infusion, results in greater extravasation of albumin in experimental septic shock we performed a randomized controlled trial with 32 endotoxemic pigs. The animals were monitored and ventilated with standard intensive care equipment and given 10 mL × kg 5% albumin labeled with Technetium-99m, either as a rapid 15-min bolus (Bolus group, n = 16) or as a 2-h infusion (Infusion group, n = 16). Radioactivity was monitored in plasma, extracellular microdialysate, and urine for 6 h. Physiological parameters were monitored hourly. Radioactivity in the liver, spleen, kidney, and lung was analyzed post mortem.The plasma area under the curve activity0-6 h was 4.4 ±â€Š0.9 × 10 in the Bolus group and 4.4 ±â€Š1.1 × 10 counts × min × mL × h in the Infusion group. Blood hemoglobin levels increased in both groups, suggesting severe capillary leakage. Yet, there were no group differences in albumin radioactivity in plasma, muscle tissue, urine, or in the post-mortem analysis of the organs. Following albumin administration, circulatory and respiratory parameters were similar in the two groups.In conclusion, the present results suggest that albumin might be given as a bolus without leading to increased extravasation of albumin, in contrast to previous animal experiments in rodents.

Effects of tigecycline and doxycycline on inflammation and hemodynamics in porcine endotoxemia: a prospective, randomized, and placebo-controlled trial.

Antibiotics might, apart from an antimicrobial effect, also exert anti-inflammatory effects. The novel antibiotic tigecycline, potentially useful in septic shock from gram-negative multiresistant bacteria, is structurally related to antibiotics with known anti-inflammatory properties. However, its anti-inflammatory effects have not been previously explored in vivo. Using a sterile integrative porcine sepsis model, we investigated the anti-inflammatory and circulatory effects of tigecycline in comparison with doxycycline and placebo. Eighteen pigs were randomized to receive tigecycline 100 mg, doxycycline 200 mg, or placebo and subjected to 6-h endotoxin infusion at 0.5 µg kg(-1) h(-1). Markers of inflammation, nitric oxide production, vascular permeability, hemodynamics, organ dysfunction, tissue metabolism, and acid-base parameters were monitored. Peak plasma tumor necrosis factor-α was lower in the doxycycline group (P = 0.031) but not in the tigecycline group (P = 0.86) compared with placebo, with geometric mean plasma concentrations of 16, 79, and 63 ng mL(-1), respectively. Mean arterial pressure was higher 4 to 6 h in the tigecycline group, with values at 6 h of 107 ± 9 mmHg compared with the placebo and doxycycline groups (85 ± 27 mmHg and 90 ± 32 mmHg, respectively; P = 0.025). The white blood cell and the neutrophil granulocyte counts were less reduced in the doxycycline group but not in the tigecycline group at 4 to 6 h (P = 0.009 and P = 0.019, respectively). Other markers of inflammation, organ dysfunction, tissue metabolism, and acid-base parameters were unaffected by tigecycline. Consistent with known anti-inflammatory properties, doxycycline yielded decreased tumor necrosis factor-α levels. Tigecycline did not affect cytokine levels but counteracted hypotension and hypoperfusion.