DOCSLIB.ORG

Angiotensin II for the Emergency Physician Marianne C Wallis ‍ ,1 Jonathan H Chow,2 Michael E Winters,3 Michael T Mccurdy ‍ 4

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Angiotensin II for the Emergency Physician Marianne C Wallis ‍ ,1 Jonathan H Chow,2 Michael E Winters,3 Michael T Mccurdy ‍ 4 Practice review Emerg Med J: first published as 10.1136/emermed-2019-209062 on 19 February 2020. Downloaded from Angiotensin II for the emergency physician Marianne C Wallis ,1 Jonathan H Chow,2 Michael E Winters,3 Michael T McCurdy 4 1Division of Pulmonary and ABSTRact vasopressin and dopamine. Based on clinical guide- Critical Care, University of Refractory hypotension is one of the most common lines, norepinephrine is the first-line treatment for Maryland School of Medicine, Baltimore, Maryland, USA and difficult clinical problems faced by acute care distributive shock and is one of the most commonly 2Department of Anesthesia, clinicians, and it poses a particularly large problem to the used vasopressors for this indication. Its mechanism University of Maryland School of emergency physician when a patient in undifferentiated of action is by agonism of α1 receptors, which results Medicine, Baltimore, Maryland, shock arrives in the department. Angiotensin II (Ang- in smooth muscle contraction.1 Vasopressin is also USA 2) has been previously used as a vasopressor to 3Department of Emergency commonly used, particularly in profoundly hypoten- Medicine, University of combat shock; the feasibility of its clinical use has sive patients who require an adjunct to norepineph- Maryland School of Medicine, been reinvigorated after approval of a human synthetic rine. As the second- line vasopressor for the treatment Baltimore, Maryland, USA formulation of the medication by the US Food and Drug 4 of septic shock, it acts on vasopressin type 1 and Division of Pulmonary and Administration in 2017 and the European Medicines vasopressin type 2 receptors, leading to increased Critical Care, Department of Emergency Medicine, University Agency in 2019. A thorough literature search was water reabsorption in the kidneys and smooth of Maryland School of Medicine, completed, and in this review, we discuss the discovery muscle contraction in the vasculature.3 Epinephrine Baltimore, Maryland, USA and development of Ang-2, its complex mechanisms also targets the catecholamine axis and is a potent α1 of vasoconstriction, its potential adverse effects and agonist. Unlike norepinephrine, epinephrine also has Correspondence to its potential role in clinical practice for emergency agonistic effects on β receptors that increase chro- Dr Marianne C Wallis, University physicians. 1 of Maryland School of Medicine, notropy, inotropy and lusitropy in a dose- dependent 1 Baltimore, MD 21201, USA; manner. Dopamine, which has extremely limited use Mariannewallis@ gmail. com in septic shock, also exhibits dose-dependent action on the catecholamine axis, where it acts on Dopa- Protected by copyright. Received 27 August 2019 INTRODUCTION mine type 1 receptors at low doses, on receptors at Revised 23 January 2020 Humans have evolved multiple systems to autoreg- β1 intermediate doses, and on and Dopamine type 2 Accepted 25 January 2020 ulate blood pressure under conditions of stress, and α1 Published Online First the regulation of blood pressure relies on several receptors at high doses. The Surviving Sepsis Guide- 19 February 2020 complex pathways.1 Two of these axes have been lines recommend that it be used as a tertiary agent used regularly by clinicians for the past quarter only in highly selected patients with bradycardia and 3 century to treat the patient in shock: the cate- at low risk of developing tachydysrhythmias. Many cholamine axis (eg, norepinephrine and epineph- of these vasopressors share a quick onset of action, on the order of seconds to minutes, and short dura- rine) and the arginine–vasopressin system axis (eg, http://emj.bmj.com/ vasopressin). A third axis, the renin–angiotensin– tion of action (table 1). aldosterone system (RAAS), is intimately involved While there are physiological rationales for using in blood pressure regulation, and one of its main one vasopressor over another in various types of components is angiotensin II (Ang-2). The hormone shock, there is no evidence to show that one partic- was first identified and clinically administered in ular vasopressor is associated with better outcomes humans over 50 years ago, and a bovine formu- than another.4 While norepinephrine alone often lation of Ang-2 was used in the management of adequately corrects hypotension, all conventional on October 26, 2020 at SUNY Stony Brook NERL Consortia. hypotension for over 35 years.2 A human synthetic vasopressors at high doses and with prolonged version of Ang-2 was approved by the US Food and use have a variety of clinically significant adverse Drug Administration (FDA) in 2017 and by the effects (see table 2).1 Many clinicians commonly European Medicines Agency (EMA) in 2019 for start vasopressin as a second- line agent following the indication of distributive shock. It has not been norepinephrine, but there is no consensus on the widely used in the emergency department (ED), norepinephrine dose at which it should be initiated. but in an environment where the ED has become In the Vasopressin versus Norepinephrine Infusion so tightly integrated with other services, such as in Patients with Septic Shock trial, vasopressin did the operating room and intensive care unit (ICU), not significantly improve mortality when compared use of Ang-2 in the ED is foreseeable in the immi- with norepinephrine (28- day mortality, 35.4% nent future. Furthermore, especially in departments vasopressin vs 30.3% norepinephrine; p=0.26).4 where critically ill patients must wait for a signifi- Additionally, in 2016, the Effect of Early Vaso- © Author(s) (or their cant amount of time before being transferred to an pressin versus Norepinephrine on Kidney Failure employer(s)) 2020. No ICU, an understanding of Ang-2’s mechanism of commercial re-use . See rights in Patients with Septic Shock trial failed to demon- and permissions. Published action, pharmacokinetics and adverse effects will be strate a difference in benefit between vasopressin by BMJ. invaluable for the emergency medicine physician. and norepinephrine in preventing acute kidney 5 To cite: Wallis MC, injury (AKI) in patients with septic shock. Vaso- Chow JH, Winters ME, CURRENT CONVENTIONAL THERAPIES pressin use, unfortunately, does not eliminate, and et al. Emerg Med J Several vasopressors are available for use in the may even potentiate, some of the negative isch- 2020;37:717–721. ED: phenylephrine, norepinephrine, epinephrine, aemic effects of high-dose catecholamines.6 Wallis MC, et al. Emerg Med J 2020;37:717–721. doi:10.1136/emermed-2019-209062 717 Practice review Emerg Med J: first published as 10.1136/emermed-2019-209062 on 19 February 2020. Downloaded from of low renal perfusion, renin is secreted by the juxtaglomerular Table 1 Primary physiological systems involved in blood pressure apparatus of the kidney and cleaves angiotensinogen to Ang-1.9 autoregulation Endothelium- bound ACE, which is concentrated in the pulmo- Duration nary capillary network, converts Ang-1 to its most active form, System Receptor Onset of action Half- life Ang-2. The pleiotropic effects of Ang-2 result from its multiple Sympathetic sites of action (figure 1). Among a number of activities, Ang-2 Norepinephrine α and β adrenergic 1–2 min 1–2 min 2.5 min binds to angiotensin type 1 (AT1) receptors, causing release Epinephrine α and β adrenergic 1–2 min 1–2 min <5 min of calcium from the sarcoplasmic reticulum and activation of Dopamine α and β adrenergic, D1 and D2 5 min 10 min 2 min myosin light chain kinase, leading to smooth muscle contrac- Phenylephrine α adrenergic 30 s 10–15 min 2–3 hours 1 tion. In addition, agonism of AT1 receptors stimulates the release Arginine–vasopressin of the adrenocorticotropic hormone from the anterior pituitary Vasopressin V1 and V2 15 min 20 min <10 min gland; activates the sympathetic system, leading to the release Renin–angiotensin–aldosterone of catecholamines; and promotes salt and water reabsorption in 10 Angiotensin II AT1 and AT2 2–3 min 15 min 30 s the kidneys through multiple mechanisms. The renal effects of Ang-2 include direct activation of sodium and chloride reab- AT1, angiotensin type 1 receptor; AT2, angiotensin type 2 receptor; BP, blood pressure; D1, Dopamine type 1; D1, dopamine type 1; D2, dopamine 2; V1, vasopressin type 1; V2, sorption in the proximal tubules, aldosterone release from the vasopressin type 2. adrenal cortex to enhance sodium reabsorption in the convo- luted tubules and secretion of vasopressin from the posterior pituitary gland to increase free water retention in the collecting Similar to guideline-recommend ed approaches for treating 10 hypertension, a multimodal approach to treating hypotension ducts. All of these mechanisms work in concert to increase may render the ability to use lower doses of any given vaso- the mean arterial pressure (MAP) and the effective circulating pressor, which allows the clinician to maximise the efficacy of volume during hypovolaemia and relative vasodilatation. each medication while minimising the unwanted toxic effects of Through a separate mechanism, Ang-2 also plays an important each. role in the bradykinin pathway and regulates inflammatory states, particularly in the pulmonary system. Dysfunction in ACE results in excess Ang-1 accumulation, which then follows PHYSIOLOGY OF ANG-2 IN SHOCK a pathway that generates bradykinin.9 Hypotension, therefore, In an attempt to use a multimodal approach for the treatment results not only from diminished Ang-2- mediated vasoconstric- Protected by copyright. of shock, clinicians have
Load more

Recommended publications
  • Effects of Neuronal Nitric Oxide Synthase Signaling on Myocyte
    Effects of Neuronal Nitric Oxide Synthase Signaling on Myocyte Contraction during β- Adrenergic Stimulation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University By Lifei Tang Biophysics Graduate Program The Ohio State University 2013 Dissertation Committee: Dr. Mark T. Ziolo, PhD Advisor Dr. Brandon Biesiedecki, PhD Dr. Jonathan Davis, PhD Dr. Sandor Gyorke, PhD a Copyright by Lifei Tang 2013 i ABSTRACT Nitric oxide (NO) is known to be a key regulator of cardiac contraction. Within ventricular myocytes, NO is produced by two constitutively expressed NO synthase (NOS) isozymes, NOS1 and NOS3. It is well defined that NOS1 signaling results in positive inotropic and lusitropic effects under baseline conditions. This effect is largely due to the phosphorylation of phospholamban (PLB) at Ser16 by the cAMP-dependent protein kinase (PKA) up-regulating sarcoplasmic reticulum (SR) Ca2+ uptake. In addition, our lab also demonstrated that NOS1 increases ryanodine receptor (RyR) activity via S-nitrosylation up- regulating SR Ca2+ release. Physiologically, heart function is largely regulated by the β-adrenergic (β-AR) pathway leading to positive inotropy and lusitropy. Alterations in the β-AR pathway contribute to the contractile dysfunction, adverse remodeling, and arrhythmias in many cardiac diseases (i.e. heart failure (HF)). The purpose of this dissertation is to investigate the role of NOS1 signaling during β-AR stimulation. Previous studies have shown that NOS1 signaling contributes to the positive inotropy, but not lusitropy, during β-AR stimulation. Interestingly, unlike under baseline conditions, PLB phosphorylation is not altered in the condition of NOS1 deficiency (acute NOS1 inhibition or NOS1 knockout) during β-AR stimulation.
    [Show full text]
  • Simdax® Gives You Time When It's Needed Most1
    EASE THE CHALLENGE OF TREATING THE FAILING HEART SIMDAX® GIVES YOU TIME WHEN IT’S NEEDED MOST1 Reference: 1. Nieminen MS et al. Eur Heart J Suppl. 2017;19(suppl_C);C15-C21. SIMDAX® GIVES WITH THREE YOU TIME WHEN PHARMACOLOGICAL IT’S NEEDED MOST1 EFFECTS… SIMDAX® is the only inodilator2,3 to provide The clinical effects of SIMDAX® are mediated through:1 The unique triple mechanism sustained hemodynamic benefits3–8 and symptom • Increased cardiac contractility by calcium sensitization of action of levosimendan1 3–5,9,10 control to patients with acute heart failure, of troponin C and in need of inotropic therapy. • Vasodilation through the opening of potassium channels in the vasculature smooth muscle • Cardioprotection, anti-ischemic antistunning effects Cardioprotection Mitochondrial through the opening of mitochondrial potassium K channel opening channels in cardiomyocytes ATP levosimendan References: 1. Nieminen MS et al. Eur Heart J Suppl. 2017;19(suppl C);C15-C21. 2. Papp Z et al. Int J Cardiol. 2012; 159:82–87. 3. Nieminen Inotropy Vasodilation MS et al. Heart Lung Vessel. 2013;5(4):227–245. 4. Follath et al. Lancet. Cardiac Smooth muscle 2002;360:196–202. 5. Slawsky et al. Circulation. 2000;102:2222–2227. 6. Troponin C KATP channel Nieminen et al. J Am Coll Cardiol. 2000;36:1903–1912. 7. Kivikko et al. sensitization activation Circulation. 2003;107:81–86. 8. Lilleberg et al. Eur J Heart Fail. 2007;9:75– 82. 9. Mebazaa et al. JAMA. 2007;297:1883–1891. 10. Packer et al. JACC Heart Fail. 2013;1(2):103–111. Reference: 1.
    [Show full text]
  • Exogenous Cardiac Bridging Integrator 1 Benefits Mouse Hearts with Pre-Existing Pressure Overload-Induced Heart Failure
    ORIGINAL RESEARCH published: 24 June 2020 doi: 10.3389/fphys.2020.00708 Exogenous Cardiac Bridging Integrator 1 Benefits Mouse Hearts With Pre-existing Pressure Overload-Induced Heart Failure Jing Li1, Sosse Agvanian1, Kang Zhou1, Robin M. Shaw2 and TingTing Hong1,2,3* 1Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States, 2 Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, United States, 3 Department of Pharmacology & Toxicology, College of Pharmacy, University of Utah, Salt Lake City, UT, United States Background: Cardiac bridging integrator 1 (cBIN1) organizes transverse tubule (t-tubule) membrane calcium handling microdomains required for normal beat-to-beat contractility. cBIN1 is transcriptionally reduced in heart failure (HF). We recently found that cBIN1 pretreatment can limit HF development in stressed mice. Here, we aim to explore whether cBIN1 replacement therapy can improve myocardial function in continuously stressed hearts with pre-existing HF. Edited by: Ademuyiwa S. Aromolaran, Methods: Adult male mice were subjected to sham or transverse aortic constriction (TAC) Masonic Medical Research Institute surgery at the age of 8–10 weeks old. Adeno-associated virus 9 (AAV9) transducing cBIN1-V5 (MMRI), United States or GFP-V5 (3 × 1010 vg) was administered through retro-orbital injection at 5 weeks post- Reviewed by: Nikolaos G. Frangogiannis, TAC. Mice were followed by echocardiography to monitor cardiac function until 20 weeks Albert Einstein College of Medicine, after TAC. Overall survival, heart and lung weight (LW), and HF incidence were determined. United States Wayne Rodney Giles, In a second set of animals in which AAV9-cBIN1 pretreatment prevents HF, we recorded University of Calgary, Canada cardiac pressure-volume (PV) loops and obtained myocardial immunofluorescence imaging.
    [Show full text]
  • Beta-Arrestins in the Treatment of Heart Failure Related to Hypertension: a Comprehensive Review
    pharmaceutics Review Beta-Arrestins in the Treatment of Heart Failure Related to Hypertension: A Comprehensive Review Ahmed Rakib 1,†,‡ , Taslima Akter Eva 1,†, Saad Ahmed Sami 1 , Saikat Mitra 2, Iqbal Hossain Nafiz 3, Ayan Das 3, Abu Montakim Tareq 4 , Firzan Nainu 5 , Kuldeep Dhama 6 , Talha Bin Emran 7,* and Jesus Simal-Gandara 8,* 1 Department of Pharmacy, Faculty of Biological Sciences, University of Chittagong, Chittagong 4331, Bangladesh; [email protected] (A.R.); [email protected] (T.A.E.); [email protected] (S.A.S.) 2 Department of Pharmacy, Faculty of Pharmacy, University of Dhaka, Dhaka 1000, Bangladesh; [email protected] 3 Department of Biochemistry and Molecular Biology, Faculty of Biological Sciences, University of Chittagong, Chittagong 4331, Bangladesh; nafi[email protected] (I.H.N.); [email protected] (A.D.) 4 Department of Pharmacy, International Islamic University Chittagong, Chittagong 4318, Bangladesh; [email protected] 5 Faculty of Pharmacy, Hasanuddin University, Tamalanrea, Kota Makassar, Sulawesi Selatan 90245, Indonesia; fi[email protected] 6 Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly 243122, Uttar Pradesh, India; [email protected] 7 Department of Pharmacy, BGC Trust University Bangladesh, Chittagong 4381, Bangladesh 8 Nutrition and Bromatology Group, Department of Analytical and Food Chemistry, Faculty of Food Science and Technology, University of Vigo–Ourense Campus, E32004 Ourense, Spain * Correspondence: [email protected] (T.B.E.); [email protected] (J.S.-G.); Tel.: +880-1819-942214 (T.B.E.); +34-988-387-000 (J.S.G.) † These authors contributed equally to this work. Citation: Rakib, A.; Eva, T.A.; Sami, ‡ Present address: Department of Pharmaceutical Sciences, College of Pharmacy, The University of Tennessee S.A.; Mitra, S.; Nafiz, I.H.; Das, A.; Health Science Center, 881 Madison Ave, Memphis, TN 38163, USA.
    [Show full text]
  • Modulation of Calcium by Sympathetic Activation
    insight review articles after activating relaxes to a lower open probability, but can still be PKA can also modulate the open probability of RyR channels. In 2+ reactivated by a higher [Ca ]i (refs 79,80). Whether only one of these isolated single-channel recordings, PKA increased initial RyR open- 2+ is functionally relevant remains controversial, and few cellular ing during an abrupt [Ca ]i rise, but decreased the steady-state open 2+ 33 studies have addressed this unequivocally. But there is clearly some probability at a given [Ca ]i (ref. 80). In contrast, Marx et al. found refractoriness in cellular and local events of SR Ca2+ release44,75. that PKA enhanced the steady-state open probability of single RyRs Recovery of RyR availability occurs with two time constants: one fast in bilayers, and attributed this to the displacement of FKBP-12.6 (100–300 ms) and one very slow (several seconds). Inactivation of from the RyR. Moreover, they found that RyRs were RyRs may be important in minimizing inappropriate SR Ca2+ release hyperphosphorylated in heart failure, which could cause a diastolic events between heartbeats. In summary, it seems that both RyR inac- leak of SR Ca2+ and contribute to the reduced SR Ca2+ content in heart tivation and partial luminal depletion of SR Ca2+ (to reduce RyR failure (see above). But in more intact cellular systems, no effect of opening) both contribute to the turn-off of release. Coupled gating of PKA-dependent RyR phosphorylation could be detected on resting RyRs (so many gate as one) may also mean that a variant of stochastic SR Ca2+ leak (as Ca2+ sparks) in the absence of phospholamban (with attrition also contributes.
    [Show full text]
  • As a Calcium- Sensitizer
    BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Arch Dis Child Fetal Neonatal Ed Levosimendan Levosimendan is a phosphodiesterase III inhibitor as well as a “calcium-sensitizer.” As a calcium- sensitizer, it improves myocardial contractility by binding to Troponin C and stabilizing its interaction with calcium. Unlike other calcium sensitizers, that may worsen diastolic function, levosimendan also has lusitropic properties because its binding to Troponin C is dependent on cytosolic calcium concentrations. Additionally, its partial phosphodiesterase inhibition results in lusitropy and vasodilation. Myocardial contractility in the newborn is more dependent on calcium compared to adults.1 Thus, levosimendan may be useful in neonates. However, the effect of levosimendan may differ following asphyxia. In an asphyxiated piglet model, levosimendan increased cardiac output without an increase in carotid and mesenteric flow but with increased estimated PVR.2 In another asphyxiated piglet model, comparing milrinone and levosimendan (both combined with dopamine), milrinone increased mesenteric perfusion and reduced myocardial oxidative stress compared to levosimendan.3 There are case reports and small case series noting successful use of levosimendan in neonates, including those with PPHN.4,5 A recent case report of two neonates, levosimendan was chosen because the babies had risks or history of arrhythmia.4 Overall levosimendan carries a lower risk of arrhythmia, except in high doses in patients with myocardial ischemia.6 Special considerations Use of inotropes in infants of diabetic mothers with hypertrophic cardiomyopathy: Infants born to mothers with diabetes (IDM) may have hypertrophic cardiomyopathy and impaired cardiac output that must be considered when choosing vasoactive medications.
    [Show full text]
  • Cellular Mechanisms in Sympatho-Modulation of the Heart
    British Journal of Anaesthesia 93 (1): 34±52 (2004) DOI: 10.1093/bja/aeh159 Advance Access publication May 14, 2004 Cellular mechanisms in sympatho-modulation of the heart M. Zaugg1* and M. C. Schaub2 1Institute of Anaesthesiology, University Hospital Zurich, Switzerland. 2Institute of Pharmacology and Toxicology, University of Zurich, Switzerland *Corresponding author: Cardiovascular Anaesthesia Laboratory, Institute of Anaesthesiology, University Hospital Zurich, RaÈmistrasse 100, 8091 Zurich, Switzerland. E-mail: [email protected] Cardiovascular function relies on complex servo-controlled regulation mechanisms that involve both fast-acting feedback responses and long-lasting adaptations affecting the gene expression. The adrenergic system, with its speci®c receptor subtypes and intracellular signalling cascades provides the major regulatory system, while the parasympathetic system plays a minor role. At the molecular level, Ca2+ acts as the general signal trigger for the majority of cell activities including contraction, metabolism and growth. During recent years, important new results have emerged allowing an integrated view of how the multifarious Ca2+-signalling mechanisms transmit adrenergic impulses to intracellular target sites. These insights into cellular and molecular mechanisms are pivotal in improving pharmacological control of the sympathetic responses to surgical trauma and perioperative stress. They are examined in detail in this review, with particular emphasis being given to the differences in intracellular signalling between cardiomyocytes and vascular smooth muscle cells. Br J Anaesth 2004; 93: 34±52 Keywords: adrenergic receptor signalling; calcium, signalling; myocardial contractility; MAPK signalling; muscle, vascular smooth muscle regulation Heart function, in terms of contractile force (inotropy), molecular characteristics pertain to the human protein beating frequency (heart rate) and blood supply (vascular species.
    [Show full text]
  • Cardiovascular Physiology and Pharmacology
    Cardiovascular Physiology and Pharmacology Peter Paal MD, PD, MBA, EDAIC, EDIC Department of Anaesthesiology and Intensive Care Hospitallers Brothers Hospital, Paracelsus Medical University Salzburg, Austria Honorary Senior Clinical Lecturer, Barts Heart Centre, William Harvey Research Institute, Barts & The London School of Medicine&Dentistry, Queen Mary University of London NO COI CARDIOVASCULAR PHYSIOLOGY Myocardial contraction and Frank- Starling-Relationship Actin-Myosin-Filaments Troponin complex C = Ca2+ binding Protein I = Inhibits interaction between actin and myosin T = Tropomyosin-binding Frank–Starling law of the heart (Starling's law) Stroke volume ↑ in response to end- diastolic volume↑ Volume ↑ stretches ventricular wall more forceful contraction Mechanism: Stretching increases affinity of troponin C for calcium greater number of actin-myosin cross-bridges form Relation of resting sarcomere length on contractile force Maximal force is generated with an initial sarcomere length of 2.2 µm 100 (%) 50 Tension Tension 0 Sensitivity of myofilaments for Ca2+ 15 Control 10 Desensitization 5 % Cell shortening % Cell 0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Intracellular Ca2+ concentration (nM) Sensitivity of myofilaments for Ca2+ Sensitization 15 Control 10 5 % Cell shortening % Cell 0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Intracellular Ca2+ concentration (nM) Change of myofilament sensitivity to Ca2+ 1,2 1,0 0,8 0,6 Temperature a b Protons Force Development Force 0,4 ADP Phosphate 0,2 Relative Relative 0,0 8 7 6 pCa (–log[Ca]) The cardiac
    [Show full text]
  • UC San Diego UC San Diego Electronic Theses and Dissertations
    UC San Diego UC San Diego Electronic Theses and Dissertations Title Effects of viscogenic plasma expander on cardiac and vascular function Permalink https://escholarship.org/uc/item/8hh6r2dp Author Chatpun, Surapong Publication Date 2010 Peer reviewed|Thesis/dissertation eScholarship.org Powered by the California Digital Library University of California UNIVERSITY OF CALIFORNIA, SAN DIEGO Effects of Viscogenic Plasma Expander on Cardiac and Vascular Function A dissertation submitted in partial satisfaction of the requirements for the degree Doctor of Philosophy in Bioengineering by Surapong Chatpun Committee in charge: Professor Pedro Cabrales, Chair Professor Marcos Intaglietta Professor Paul Johnson Professor Kirk Peterson Professor Geert Schmid-SchÖenbein Professor Daniel Tartakovsky 2010 Copyright Surapong Chatpun, 2010 All rights reserved. The Dissertation of Surapong Chatpun is approved, and it is acceptable in quality and form for publication on microfilm and electronically: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Chair University of California, San Diego 2010 iii DEDICATION To my Parents and Family iv TABLE OF CONTENTS Signature Page…………………………………………………………………………. iii Dedication……………………………………………………………………………… iv
    [Show full text]
  • Neonatal Blood Pressure Support: the Use of Inotropes, Lusitropes, and Other Vasopressor Agents
    Neonatal Blood Pressure Support: The Use of Inotropes, Lusitropes, and Other Vasopressor Agents Shahab Noori, MD, Istvan Seri, MD, PhD* KEYWORDS Inotropes Lusitropes Vasopressors Hemodynamic Hypotension Shock The use of inotropes, lusitropes, and vasopressors is common in neonates with cardiovascular compromise.1,2 Although the understanding of cellular mechanisms of action of these medications is well founded,3,4 there is little information on their clin- ically relevant long-term benefits in the neonatal patient population.5–7 In addition, if not appropriately titrated, these medications may induce abrupt, excessive, and potentially harmful increases in blood pressure and systemic and organ blood flow.8–11 Thus, in addition to the cardiovascular compromise,10,11 treatment by sub- optimal administration of inotropes, lusitropes, and vasopressors may contribute to short- and long-term morbidities in critically ill preterm and term neonates.6 Prompt diagnosis of neonatal cardiovascular compromise by state-of-the-art hemodynamic monitoring of blood pressure and systemic and organ blood flow12 and careful titration of the vasoactive agents to the optimal hemodynamic response8,13 are thought to be of importance in decreasing mortality and morbidity associated with shock and its treatment in preterm and term neonates.14,15 Unfortunately, there is little evidence on what vasoactive medications to use in what patient and when, at what dose to start, how to titrate the drug, and what parameters to monitor.2,6,16 Because addressing these issues is only possible by opinion- and experience-based reasoning without much evidence at present, this article focuses on describing the documented, developmentally regulated hemodynamic actions of inotropes, lusitropes, and vasopressors, and their short-term hemodynamic bene- fits and risks.
    [Show full text]
  • Beat-To-Beat Period, Relaxation Time, and Partial Summation in A
    A CRITICAL CONTRACTION FREQUENCY IN LYMPHATIC VESSELS: TRANSITION TO A STATE OF PARTIAL SUMMATION A Thesis by JOSHUA KEITH MEISNER Submitted to the Office of Graduate Studies of Texas A&M University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE August 2006 Major Subject: Biomedical Engineering A CRITICAL CONTRACTION FREQUENCY IN LYMPHATIC VESSELS: TRANSITION TO A STATE OF PARTIAL SUMMATION A Thesis by JOSHUA KEITH MEISNER Submitted to the Office of Graduate Studies of Texas A&M University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Approved by: Chair of Committee, Christopher M. Quick Committee Members, Randolph H. Stewart John C. Criscione Head of Department, Gerard L. Coté August 2006 Major Subject: Biomedical Engineering iii ABSTRACT A Critical Contraction Frequency in Lymphatic Vessels: Transition to a State of Partial Summation. (August 2006) Joshua Keith Meisner, B.S., Texas A&M University Chair of Advisory Committee: Dr. Christopher M. Quick Although lymphatic vessel behavior is analogous to hearts (e.g. systole and diastole) and blood vessels (e.g. basal tone), hearts and blood vessels have fundamentally different contractile properties. While summation during contraction is minimized in the heart, summation is necessary for tonic contraction in blood vessels. Because lymphatic vessel behavior mimics cardiac and vascular behavior, we hypothesized that above a critical contraction frequency there is significant summation, evidenced by significantly increased diastolic active tension (i.e. basal tone). We used an isovolumic, controlled-flow preparation to examine the interaction of contraction cycle- time with contraction frequency. Using segments of isolated lymphatic vessels (~1 cm in length and 3-4 mm in diameter) from bovine mesentery, we measured transmural pressure and diameter for end-diastole and end-systole during spontaneous contractions for 10 volume steps.
    [Show full text]
  • Differential Regulation of Inotropy and Lusitropy in Overexpressed Gsα Myocytes Through Camp and Ca2+ Channel Pathways
    Differential regulation of inotropy and lusitropy in overexpressed Gsα myocytes through cAMP and Ca2+ channel pathways Song-Jung Kim, … , Charles J. Homcy, Stephen F. Vatner J Clin Invest. 1999;103(7):1089-1097. https://doi.org/10.1172/JCI4848. Article We investigated the mechanisms responsible for altered contractile and relaxation function in overexpressed Gsα myocytes. Although baseline contractile function (percent contraction) in Gsα mice was similar to that of wild-type (WT) 2+ 2+ mice, left ventricular myocyte contraction, fura-2 Ca transients, and Ca channel currents (ICa) were greater in Gsα mice in response to 10–8 M isoproterenol (ISO) compared with WT mice. The late phase of relaxation of the isolated myocytes and fura-2 Ca2+ transients was accelerated at baseline in Gsα but did not increase further with ISO.I n vivo measurements using echocardiography also demonstrated enhanced relaxation at baseline in Gsα mice. Forskolin and CaCl2 increased contraction similarly in WT and Gsα mice. Rp-cAMP, an inhibitor of protein kinase, blocked the increases in contractile response and Ca2+ currents to ISO in WT and to forskolin in both WT and Gsα. It also blocked the accelerated relaxation in Gsα at baseline but not the contractile response to ISO in Gsα myocytes. Baseline measurements of cAMP and phospholambation phosphorylation were enhanced in Gsα compared with WT. These data indicate that overexpression of Gsα accelerates relaxation at end diastolic but does not affect baseline systolic function in isolated myocytes. However, the enhanced responses to sympathetic stimulation partly reflect increased Ca2+ channel activity; i.e the cellular mechanisms mediating these effects appear to involve a cAMP-independent as well […] Find the latest version: https://jci.me/4848/pdf Differential regulation of inotropy and lusitropy in overexpressed Gsα myocytes through cAMP and Ca2+ channel pathways Song-Jung Kim,1 Atsuko Yatani,1 Dorothy E.
    [Show full text]