Sepsis-induced cholestasis

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Serum uric acid, creatinine, and the assessment of antioxidant capacity in critical illness

No Abstract - The letter addresses the issue of low plasma urate as a marker of impaired antioxidant capacity in critical illness

Parenteral Nutrition in Liver Resection

Albeit a very large number of experiments have assessed the impact of various substrates on liver regeneration after partial hepatectomy, a limited number of clinical studies have evaluated artificial nutrition in liver resection patients. This is a peculiar topic because many patients do not need artificial nutrition, while several patients need it because of malnutrition and/or prolonged inability to feeding caused by complications. The optimal nutritional regimen to support liver regeneration, within other postoperative problems or complications, is not yet exactly defined. This short review addresses relevant aspects and potential developments in the issue of postoperative parenteral nutrition after liver resection

Co-variation of plasma sodium, taurine and other amino acid levels in critical illness

This study investigates the relationship between changes in plasma sodium and changes in amino acid levels in a patient with post-traumatic sepsis and prolonged critical illness. Ninety-two consecutive measurements were performed at regular intervals over a period of many weeks; these consisted in the determination of full amino-acidograms, plasma sodium and complementary variables. A unique, highly significant inverse correlation between taurine and plasma sodium was found (r(2) = 0.48, p < 0.001). All other amino acids were unrelated, or much more weakly related, to sodium. Taurine was also strongly and directly related to phosphoethanolamine, glutamate and aspartate. Changes in sodium and in levels of these amino acids explained up to 86% of the variability of taurine. Besides, levels of these amino acids maintained a high degree of co-variation, remaining reciprocally related one to each other, directly, with r(2) ranging between 0.33 and 0.59 (p < 0.001 for all). There were similar findings for beta-alanine, which however was measured inconsistently. These data provide gross clinical evidence of a specific link binding plasma sodium and taurine levels, and may be consistent with occurrence of opposite and interdependent shifts of sodium and taurine between intravascular and extravascular space, to maintain osmoregulation. Co-variation of taurine with the other amino acids may be related to the same phenomenon, and/or to similarities in transport systems and chemical structure, or true metabolic interactions

Patterns of correlation of plasma ceruloplasmin in sepsis

Background. In sepsis, plasma ceruloplasmin (Cp, mg/L) is known to increase as part of the acute phase response. However, there is poor knowledge of the patterns of increase and correlation with changes in other biochemical variables, and our study has been performed to investigate this aspect. Materials and methods. A total of 213 simultaneous measurements of Cp and other acute phase proteins, biochemical variables, and amino acids were performed on nine patients with severe sepsis, and processed by regression analysis. Results. Mean Cp was 478 +/- 119 mg/L (median 488, range 242-784). Significant direct correlations between Cp and C-reactive protein, alpha-1-antitrypsin and alpha-2-macroglobulin (P < 0.001 for all) were all simultaneously influenced by the level of alkaline phosphatase, which was an independent determinant of increased Cp (P < 0.001). Cp increased further with decreasing plasma pH and increasing triglyceride, taurine levels, and distance from the onset of sepsis (P < 0.001 for all). The maximum increases in Cp were associated with the presence of cholestasis, increasing triglyceride levels, and metabolic acidosis. With regard to septic liver dysfunction, while signs of cholestasis were mostly reflected in greater increases in Cp, increasing bilirubin in the presence of normal alkaline phosphatase was mostly correlated with abnormal increases in cyst(e)ine, cystathionine, and tyrosine levels. Conclusions. These data characterize the patterns of correlation of Cp within the biochemical abnormalities of sepsis, and may provide new insights into the pathophysiology of septic hepatobiliary dysfunction

Epinephrine induces tissue perfusion deficit in porcine endotoxin shock: evaluation by regional CO2 content gradients and lactate-to-pyruvate ratio

Epinephrine is widely used as a vasoconstrictor or inotrope in shock, although it may typically induce or augment lactic acidosis. Ongoing debate addresses the question of whether hyperlactatemia per se is a sign of tissue perfusion deficit or aerobic glycolysis. We wanted to test the hypothesis that epinephrine has selective detrimental effects on visceral perfusion and metabolism. We performed rigorous regional venous blood gas analyses as well as intraperitoneal microdialysis. We used a mathematical model to calculate regional arteriovenous CO2 content gradients and estimated the magnitude of the Haldane effect in a porcine model of prolonged hypotensive shock induced by endotoxin infusion (mean arterial blood pressure 70 mmHg for 4 h. Epinephrine caused systemic hyperlactatemia and acidosis. Importantly, both systemic and regional venous lactate-to-pyruvate ratios increased. Epinephrine was associated with decreasing portal blood flow despite apparently maintained total splanchnic blood flow. Epinephrine increased gastric venous-to-arterial PCO2 gradients and CO2 content gradients with decreasing magnitude of the Haldane effect, and the regional gastric respiratory quotient remained higher after epinephrine as opposed to norepinephrine infusion. In addition, epinephrine induced intraperitoneal lactate and glycerol release. We did not observe these adverse hemodynamic or metabolic changes related to norepinephrine with the same arterial pressure goal. We conclude that high CO2 content gradients with decreasing magnitude of the Haldane effect pinpoint the most pronounced perfusion deficiency to the gastric wall when epinephrine, as opposed to norepinephrine, is used in experimental endotoxin shock

Total Vascular Exclusion: indications, techniques and results

The book chapter describes the indications, technical modalities and multiple issues related to the performance of total vascular exclusion during liver resection