SIRS / MODS: From Molecular Basis to Surgical Practices in...

SIRS / MODS: From Molecular SIRS / MODS: From Molecular Basis to Surgical Practices in 2008Basis to Surgical Practices in 2008

Somkiat Wattanasirichaigoon, MD, FRCSTProfessor of Surgery

Dean, Faculty of Medicine, Srinakharinwirot UniversityEmail: [email protected]

Mortality rate in septic patientsMortality rate in septic patients

Shock and SIRS: UpdatedShock and SIRS: Updated

• The anti-thrombin activity is considered to be the most useful predictor of organ dysfunction. (J Trauma. 2007 Nov;63(5):1093-8.)

• The Emergency Department is well placed to improve this outcome by earlier detection and the use of goal directed therapy. (Emerg Med J. 2008 Jan;25(1):11-4.)

The MEDS score was calculated by recording the following:The MEDS score was calculated by recording the following:

1.presence of terminal illness, 2.tachypnea or hypoxemia, 3.septic shock, 4.platelet count <150,000 cells/mm, 5.band count as a >5% of total white blood cell count, 6.age >65 yrs, 7.lower respiratory infection, 8.nursing home residence, 9.altered mental status.

The MEDS score accurately predicts 28-day mortality in patients who present to the emergency department with systemic inflammatory response syndrome and who are admitted to the hospital. Crit Care Med. 2007 Dec 12 [Epub ahead of print]

Conceptual FrameworkConceptual Framework

SepsisSepsis

Fever Leukocytosis

Systemiccirculation

Iceberg

SepsisSepsis

Inflammatory responseInflammatory response

Fever Leukocytosis

HPA axisstimulation

Immuneactivation

Systemiccirculation

Mediators

Anterior Pituitary gland.• CRH• ACTH• Cortisol/Glucocorticoid• MIF• TRH, TSH• GH• Somatostatin• Sex hormone• Prolactin• Endogenous opioids

Posterior Pituitary gland• Arginine vasopressin• Oxytocin

Autonomic system• Catecholamines• Aldosterone• Renin/Angiotensin• Insulin• Glucagon

Cytokine• TNF-α• IL-1• IL-2• IL-4• IL-8• IL-10• IL-12• IL-13• IFN-γ• GM-CSF

Acute phaseprotein

• Complement proteins • Coagulation proteins• Proteinase inhibitors• Metal-binding proteins• Major APRs: CRP, serum amyloid A, amyloid P • Negative APRs: Albumin, transferrin, ApoAI• others: lipopolysaccharide-binding protein

Tc NK

TH

cytokines

macrophage granulocyte

cytokines

APC

Ts

B

K Antibody-Dependent cytotoxic cell

antibody

antigenรูปที่ 15.7

Intracellular signalingIntracellular signaling• via Tyrosine kinase• 5 pathways

– 3 pathways via second messenger: cAMP, cGMP, phospholipid/calcium

– 2 direct signalling pathways: Ras, Raf, MAPK and JAK/STAT

• Heat shock protein

OutlineOutline

•• Heat shock proteinHeat shock protein

•• Free radicalsFree radicals

•• Nitric oxideNitric oxide

•• Endothelial dysfunctionEndothelial dysfunction

Heat shock proteinHeat shock protein

Intracellular Hsps function as molecular Intracellular Hsps function as molecular chaperones:chaperones:1.governing protein assembly, folding, or transport 2.anti-apoptotic regulators of cell signalling pathways leading to cell death. 3.an anti-inflammatory role in various inflammatory conditions such as

• Infection• ischemia/reperfusion injury, • cardiovascular diseases.

Inflamm Allergy Drug Targets. 2007 Jun;6(2):91-100.

Role of heat shock protein (Hsps)

Inflamm Allergy Drug Targets. 2007 Jun;6(2):91-100.

Hsp induction

After injury

Extracellular Hsps

Danger signals

Activate innate immunityProtect cells against

noxious stimulus

Mol

ecul

ar c

hape

rone

s•Assembly

•Folding

•Transport

Anti-apoptotic regulators

Intracellular Hsps

Anti-inflammatory actions

Before injury

Heat shock proteinHeat shock protein

British Journal of Pharmacology 2002; 135: 1776 -1782.

Ischemic heart disease

reactive oxygen species (ROS)

Antioxidant enzyme activities do not seem to be implicated in this

cardio-protective mechanism.

HS-induced cardioprotection

protein synthesis and protein transport across membranes

cellular homeostatic functions cellular response to stress

signal transduction gene expression

enhance antigen presentation to T lymphocytes

HSPs displayed on the surface of cells are important in targeting cytotoxic cells

cytokine

Hsps

Free radicalsFree radicals

Shock : syndrome of Shock : syndrome of

mitochondrial dysfunctionmitochondrial dysfunction

Mitochondria- cellular organelle involve multiple area

of metabolism; oxidation-reduction signalling

- key function of energy production (ATP)

- calcium homeostasis

cell membraneglucose

glucose

fatty acid

fatty acid

cytoplasmmitochondriamitochondria

EM-pathway

NADH+

ATP

pyruvate

pyruvate

fatty acyl coA

fatty acyl coA

acetyl coA

Citric acid

cycle

2e-

NADH

nH+H

2O

1 O22

O2

ATPADP + Pi

ATP ADP + Pi

nH+

Cyt C

Q

2e-

2e-

NAD+ + H+

FADH+ + H+

FADH2NADH

2H+ + 1/2 O2

H2O

Com

plex I

Com

plex II

Com

plex III Com

plex IV

Inter-

membrane

space

Inner

membrane

Matrix

pH 8

H+

H+H+ H+

NADHdehydrogenase

b-c1complex

Cytochromeoxidase

ADP

+ Pi

ATP

Com

plex V

ATP synthetase

Mitochondrial cristae

Mitochondria

2 ATP4 e-

Water

H2O

O2-

H2O2

SuperoxideAnion

e- HydroperoxylRadical

OH•HO

2•

e-

e-e-

HydrogenPeroxide

HydroxylRadical

UNIVALENT LEAK

SuperoxideDismutase

Catalase/Peroxidase

2 ATP4 e-

2 NADH

2 NAD+

CytochromeComplex

Ubiquinone Cyt. C

ELECTRON TRANSPORT CHAIN

CytochromeComplex

CytochromeComplex

4 e- 4 e-2 ATP

O2

Oxygen

UNIVALENT LEAKUNIVALENT LEAK

NF-κB

activation

TLR4

activation

IκB kinase

activation

Ku DNA

Repair protein

Nuclear translocation

(anti-apoptosis)Inflammation,

Immune response

Adhesion

molecules

Chemokines

Autocrine

growth factor

Acute phase

proteinNOS

Cell cycle

control

ROSROS

Endogenous

antioxidant Oxidant

Intracellular

redox imbalance

Intervention with

exogenous

antioxidants

Normal human mitochondria

Inner membrane:“OXPHOS”(oxidative phosphorylation)mt energy-generating apparatus

Disorders of MitochondriaDisorders of Mitochondria

Abnormal mitochondriaAbnormal mitochondria

-- increased numbersincreased numbers-- abnormal shapeabnormal shape-- vary in sizesvary in sizes

Ragged red fiber (GomoriRagged red fiber (Gomori--Trichrome staining)Trichrome staining)

Mitochondrial dyfunction in shock

BLMicrovascular compensation

Microvascular decompensation

%

0

20

40

60

80

100

MTT-FZ

*

*

ATP

*

Mitochondrial dysfunction in shock

BLMicrovascular compensation

Microvascular decompensation

%

0

20

40

60

80

100

MTT-FZ

*

*

ATP

*

120

GSH

Mitochondria in Trauma and Shock

Hemorrhagic shock

Hypoxia

Traumatic injury

Septic shock

Burns

Ischemia

Acute toxicity

Production of ROS

Oxidative damage

to DNA, protein

Loss of function

NO inactivation

Endothelial compromise

Microcirculation disturbance

Nitric oxideNitric oxide

Nitric oxide

lumen

vasc

ular

wal

l

adve

ntiti

am

edia

intim

a

endothelial

platelets, lymphocytes, granulocytes,monocytes

endothelial cellsinternal elastic lamina

smooth muscle cellextermal elastic lamina

smooth muscle cells

interstitial cells

nearby airway, gut

epithelial cells

lumen

macrophages,neutrophils,

microbes

NANC nerve fibers,mast cells,fibroblasts

NITRIC OXIDE

neuron

astrocyte

-30 0 30 60 90 1200

20

40

60

80

100

120

Buffer NO donor

A* * *

-30 0 30 60 90 120

0

20

40

60

80

100

120

Buffer

cNOS inhibitor

B

Ischemia Reperfusion

** *

†† †

γ

γ γ

Mucosal blood flow (mL/min/100g)Mucosal blood flow (mL/min/100g)

SMA occlusion / reperfusion SMA occlusion / reperfusion

0

10

20

30

40

50

60 Buffer

Cle

aran

ce (n

l/min

/cm

2 ) ** *A

* *

†

*

NO donor

BL I-30 I-60 R-30 R-60

SMA occlusion / reperfusion

0

20

40

60

80

100

Buffer

Cle

aran

ce (n

l/min

/cm

2 ) **

*

** **

B L-NAME (cNOS inh) †

† †

*

Am J Respir Crit Care Med 2002; 166: 1197-1205.

An analysis of the clinical trials showed that anti-

inflammatory agents were also significantly more

efficacious in septic patients with higher risk of death

(p =0.002) and were harmful in those with low risk.

High dose steroid = iNOS inhibitors

Compensatorystate

Decompensatorystate

cNOS

Microvascular dilatation

NO

iNOScNOS

NO

free radicals

O2+

ONOO.

Host defenseNormal

Host defense

Endothelial cell dysfunction

Inhibit Tyrosine kinase

Vascular hyporesponsibility

“No flow” phenomenon

IL-1, TNF-α, etc.

LPS/Toxin

Sepsis/Septicemia

Compensatorystate

Decompensatorystate

cNOS


NO

iNOScNOS

NO

free radicals

O2+

ONOO.

Host defenseNormal

Host defense





IL-1, TNF-α, etc.

LPS/Toxin

Sepsis/Septicemia

• Mitochondrial dysfunction• Cytopathic hypoxia

Peroxynitrite: An aggressive oxidant

NONONONOSNOSNOS vasodilation

OH OHNO2

tyrosine residuetyrosine residue 33--NTNT

irrev. Rxirrev. Rx

ONOOONOO--

+ O2-. diffusion rate lim.diffusion rate lim.Bimol. Reaction

2X1010 M-1s-1

Appearance of protein 3NT

60 min: splanchnic artery occlusionshock

5 days: gentamicin-induced renal injury

4 h: carrageenan-induced pleurisy

35 days:collagen-induced arthritis

Pharm Rev 2001;53(1):135-159

Endothelial dysfunctionEndothelial dysfunction

SepsisSepsis

Inflammatory responseInflammatory response

Acute phaseprotein

EndocrineResponse

ImmuneResponse

•Arachidonic acid metabolism: PG, TXA2 , LTD4

•Kallikrein-kinin system

•Serotonin•Histamine

• Lower blood pressure• Cardiac depressant• ARDS• Renal failure• Brain anoxia

Endothelial cell Response

CytokinesVasoactive agents Prostaglandins

CoagulationComplement

• Nitric oxide• Endothelin• Platelet-activating factors• Atrial natriuretic peptides

Adhesion molecules

Mediators

Hemorrhage

Burns, GI loss

Hypovolemia

Ischemia, Arrhythmia

Vascular damage

Cardiac failure

Pulmonary embolism

Vascular occlusion

Systemic endotoxemia

Gut mucosal injury Reduced hepatic

RE function

Sepsis / Injury

Release of endogenous endotoxin

Microcirculatory disturbances

Cellular dysfunction

Cell death

Point of no return

Calcium inflow

Other mediators

Cellular and humoral activation

TNF / IL-1

splanchnic blood flow

Leukocyte : good, bad and Leukocyte : good, bad and

ugly roleugly role

Tissue

Blood lymphocytepool

HEV

Efferentlymphatic

Thoracic duct

Lymph node

Afferentlymphatic

spleen

รูปที่ 15.2

WHO definition of MSWHO definition of MS•• Presence of insulin resistancePresence of insulin resistance

–– Type 2 diabetesType 2 diabetes

–– Impaired fasting glucoseImpaired fasting glucose

–– Impaired GTImpaired GT

•• Plus any two of the followingPlus any two of the following

–– High BPHigh BP (140/90 mm Hg)(140/90 mm Hg)

–– High TG or low HDLHigh TG or low HDL (TG> 150 mg/dl; HDL< 35 mg/dL in men or 40 mg/dL in (TG> 150 mg/dl; HDL< 35 mg/dL in men or 40 mg/dL in

women)women)

–– Obesity Obesity (BMI > 30 kg/m(BMI > 30 kg/m2 2 and/or waist hip ratio >0.9 in men or 0.85 in women)and/or waist hip ratio >0.9 in men or 0.85 in women)

–– Microalbuminuria Microalbuminuria >20 >20 µµg/ming/min

Metabolic SyndromeMetabolic Syndrome

Obese man: • Android obesity• Apple

Obese woman: • Gynecoid obesity• Pear

Metabolic SyndromeMetabolic Syndrome

Pathogenesis of Pathogenesis of cardiovascular diseasecardiovascular disease

Hyperinsulinemia

Small LDL particles

Elevated apolipoprotein Bconcentrations

Theatherogenic

metabolictriad

Theatherogenic

metabolictriad

20-fold increasein IHD risk

20-fold increasein IHD risk

Abdominal obesity+ low HDLAbdominal obesityAbdominal obesity+ low HDL+ low HDL

Atherogenic features of the metabolic syndrome:

Adapted from Lamarche B et al.

JAMA (1998) 279:1955-1961

Oxidized LDL

Insulin Resistance SyndromeInsulin Resistance Syndrome

Microalbuminuria

Hypertension

Central/abdominal obesity

Coronary heart

disease

Dyslipidemia

Type 2 diabetes

Hyperinsulinemia

Groop Groop et alet al. Front Horm Res 1997; . Front Horm Res 1997; 2222:131:131––156.156.

InsulinInsulinresistanceresistancesyndromesyndrome

Pathogenesis of cardiovascular diseasePathogenesis of cardiovascular disease

InflammationInflammation

AtherosclerosisAtherosclerosis

ThrombosisThrombosis


NO NO

free radicals

O2+

ONOO.

Host defenseNormal

Host defense





IL-1, TNF-α, etc.

Adipocyte

Obesity/Metabolic syndrome

Compensatorystate

cNOS

Decompensatorystate

iNOScNOS

Free flowing

Blood flowBlood flow

Selectins (P-, E-, L-)

PECAM-1 β1-Integrins (VLA-4)

ICAMsVCAMs

β2-Integrins

Blood flowBlood flow

Selectins (P-, E-, L-)

PECAM-1 β1-Integrins (VLA-4)

ICAMsVCAMs

β2-Integrins

The multistep model of leukocyte-endothelial interactions and leukocyte migration

RollingRolling

AdhesionAdhesion

EmigrationEmigration

MicroangiopathyMicroangiopathy

NormalNormal Diabetes mellitusDiabetes mellitus

Scanning electronmicrograph, showing leucocytes adhering to the wall of a venule in inflamed tissue

Scanning EM: Scanning EM:

normal endothelial cell junctionnormal endothelial cell junction

Scanning EM:

1 minute after substance P

Plasma Membrane

NeutrophilCytoplasmLysosome

Hexose Monophosphate Shunt

NADP NADPH

NADPH Oxidase

e-

O2

O2

O2-

H2O2 Cl-HOCl

H2O

MyeloperoxidaseMyeloperoxidase

Capillary networks Capillary networks

HeartBrain

Lung Renal Gut SkinMuscle

Capillary networks Capillary networks

SkinMuscle

Edema

Gut

•• Second hit injurySecond hit injury•• Bacterial Bacterial translocationtranslocation

•• NonNon--functionfunction

Renal

Renal failureRenal failure

Lung

ARDSARDS

DeathDeath HeartBrain

ConfusionConfusion

Pump failurePump failure

Red

blood

cell

Alveolus CapillaryDiffusion

Diffusion

Oxygen

Carbon dioxide

Capillary endothelium

Capillary basement membraneInterstitial space

Epithelial basement membrane

Alveolar epithelium

Fluid and surfactant layer

Gas ExchangeGas Exchange

White blood cell

AlveolusAlveolus CapillaryCapillary




Alveolar epithelium


BronchoBroncho--alveolar lavage (BAL)alveolar lavage (BAL)

White blood cell

emigration





Alveolar epithelium


BronchoBroncho--alveolar lavage (BAL)alveolar lavage (BAL)

White blood cell

emigration





Alveolar epithelium


LeukocyteLeukocyte--Endothelium InteractionEndothelium Interaction

WBCWBC count in count in BALBAL fluid in control vs CBDDfluid in control vs CBDD,,

challenged with varied doses of LPSchallenged with varied doses of LPS

0

5000

10000

15000

20000

cells/cu mm

saline LPS(0.25 mg/kg)

LPS(1.25 mg/kg)

saline LPS LPS(0.25 mg/kg)(1.25 mg/kg)

SHAMSHAM CBDDCBDD

DEADDEAD

*p<0.001

LungLung

Sham + LPSSham + LPS

CBDD + LPS CBDD + LPS

Note: Note: CBDD CBDD == common bile duct divisioncommon bile duct division

MucosalMucosal--toto--serosal clearance inserosal clearance incontrol vs CBDDcontrol vs CBDD,,

challenged with varied doses of LPSchallenged with varied doses of LPS

0

2

4

6

8

10

12

14

16

18

saline LPS(0.25 mg/kg)

LPS(1.25 mg/kg)

saline LPS LPS

nL/min/cm2

(0.25 mg/kg) (1.25 mg/kg)

SHAMSHAM CBDDCBDD

DEADDEAD

* p<0.001

Sham + LPSSham + LPS

CBDD + LPS CBDD + LPS

IntestineIntestine

Note: Note: CBDD CBDD == common bile duct divisioncommon bile duct division

Frontier in Septic ShockFrontier in Septic Shock

• Mitochondrial dysfunction

• Activated Protein C (APC)

• Cytopathic hypoxia

Procalcitonin and C-reactive protein as markers of systemic inflammatory response syndrome severity in critically ill children. Intensive Care Med. 2007 Jun;33(6):1108-9.

Inflammatory markers in patients with severe burn injury. What is the best indicator of sepsis? Burns. 2007 Nov;33(7):939-40; author reply 941-2.

Procalcitonin in the diagnosis of inflammation in intensive care units. Clin Biochem. 2006 Dec;39(12):1138-43. Epub 2006 Sep 14.

ProcalcitoninProcalcitonin

http://www.ncbi.nlm.nih.gov/pubmed/17644262?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/pubmed/17644262?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

CYTOPATHIC HYPOXIACYTOPATHIC HYPOXIA

Measurement of Tissue OMeasurement of Tissue O22 ConsumptionConsumption

SLOPE = Oxygen Consumption

100 % Oxygen in Bufferwith temp 370C

Ieal mucosal strip 2 x 3 mm (normal)

Measurement of Tissue OMeasurement of Tissue O22 ConsumptionConsumption

Poor Oxygen Consumption

100 % Oxygen in Bufferwith temp 370C

Ieal mucosal strip, LPS 5 mg/kg iv 24 h.

Tissue hypoperfusion/hypoxia

GUT

Microcirculationfailure

Macrophage(inflammatory)

response

Organ dysfunction

Bacterial translocation

Multiple organ failure (MOF)

Barrierfailure

Endothelial-leukocyte

interaction

Free radicals formationCytokine, PAF, PGs

Complement

activation (priming)

Hemorrhagic shock/Mesenteric ischemia

microbialproducts

endothelium

leukocyterecruitment

macrophage

C3aC5a

IL-4TH0

mast cell TH2

TH1selection of

response mode

NKTNF-αIL-12

IL-10

IFN-γ

IFN-γ

TNF-α

tissue cells

TNF-αIL-1

chemokines

CK

Endothelial cell damage

Coagulation cascade

contact system

Granulocytes

O2 radicals, Eicosanoids,

Protease, PAF

Cell adherenceCoagulation

Factor Xlla kinins

Macrophages

MODERN THEORY

Complement

C5a

Tumor necrosis factor

IL-6

Tachycardia, hypotension

fever, hypothermia,

multiple organ dysfunction

Vasomotor effects

This is not the end. This is not the end. It is not even the It is not even the beginning of the end.beginning of the end.But it is, perhaps, the But it is, perhaps, the end of the beginning.end of the beginning.

Winston Churchill.Winston Churchill.

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