Oxygen delivery in critical illness

Oxygen consumption is physiologically dependent on DO2 below the critical DO2. Thus, patients in overt shock have physiologic dependence of VO2 on DO2. The first priority of prevention and reversal of tissue hypoxia is to balance oxygen demand and oxygen supply. Pathologic dependence of VO2 on DO2 has not yet been demonstrated convincingly in critically ill patients. Furthermore, in our opinion, contradicting results of RCTs of supernormal DO2 versus normal DO2 do not support routine maintenance of supernormal levels of DO2. Finally, we suggest that intensivists continue to assess DO2 and VO2 carefully. Global assessment of VO2 and DO2 appears inadequate to detect occult tissue hypoxia in most critically ill patients. However, research focused on regional assessment such as gastric tonometer measurement of gastric mucosal PCO2 and pH provides opportunity for safe, convenient detection of occult tissue hypoxia in critically ill patients.     

Effect of bucladesine sodium on the plasma concentrations and urinary excretion of purine bases and uridine

To examine whether bucladesine sodium affects the plasma concentrations of purine bases (hypoxanthine, xanthine, and uric acid) and uridine, 100 mL of physiological saline containing bucladesine sodium (6 mg/kg weight) was administered intravenously to eight healthy subjects for 1 hour after overnight fast except for water. Blood was drawn 30 minutes before, and 30 minutes and 1 hour after the beginning of the infusion, and 1-hour urine was collected before and after the beginning of the infusion. Two weeks later, 100 mL of only physiological saline was administered under the same protocol. Bucladesine sodium decreased the plasma concentrations of hypoxanthine by 36% and by 37%, and of xanthine by 16% and 33%, and of uridine by 17% and 30%, 30 minutes and 1 hour after the beginning of the infusion, respectively, and increased the urinary excretion of hypoxanthine and uric acid by 140% and 30%, respectively, after the beginning of the infusion. However, it did not affect the plasma concentration of uric acid or the urinary excretion of xanthine, and the urinary excretion of uridine was less than 0.2 micromol/h before or after bucladesine sodium infusion. On the other hand, physiological saline alone did not affect any of the values described. These results suggest that bucladesine sodium acts on the secretory process of the renal transport of hypoxanthine, resulting in the increased urinary excretion of hypoxanthine, and further suggest that bucladesine sodium enhances the uptake of uridine in plasma to liver cells.     

Simultaneous determination of guanine, uric acid, hypoxanthine and xanthine in human plasma by reversed-phase high-performance liquid chromatography with amperometric detection

A reversed-phase high-performance liquid chromatographic method with amperometric detection is described for the separation and quantification of uric acid, guanine, hypoxanthine and xanthine. The isocratic separation of a standard mixture of the compounds was achieved in 5 min on a Spherisorb 5 C18 reversed-phase column, with a mobile phase of NaH2PO4 (300 mmol dm-3, pH 3.0)-methanol-acetonitrile-tetrahydrofuran (97.8 + 0.5 + 1.5 + 0.2). Uric acid, guanine, hypoxanthine and xanthine were completely separated, with detection limits in the range 2-20 pmol per injection. The effect of pH and the composition of the mobile phase on the separation are described. The hydrodynamic voltammograms of these compounds were recorded at a glassy carbon electrode. The linear range of the calibration graph for each compound was: uric acid, 1-5000 mumol dm-3; guanine, 0.5-2000 mumol dm-3; hypoxanthine, 0.1-500 mumol dm-3 and xanthine, 0.5-5000 mumol dm-3. The within- and between-day precision was good. The uric acid and hypoxanthine content in human plasma was measured using the proposed method. Good recoveries of uric acid (97.9-103%), hypoxanthine (98.0-99.2%), guanine (96.0-98.3%) and xanthine (96.0-102%) were obtained from human plasma. The results of electrochemical detection were in good agreement with those of UV detection.     

Simultaneous liquid chromatography of 5-fluorouracil, uridine, hypoxanthine, xanthine, uric acid, allopurinol, and oxipurinol in plasma

A reversed-phase "high-pressure" liquid-chromatographic method is described for simultaneous analysis for 5-fluorouracil, uridine, hypoxanthine, xanthine, uric acid, allopurinol, and oxipurinol. Separation was optimal with phosphate buffer (50 mmol/L, pH 4.60) as eluent. A simple acid extraction procedure yielded quantitative recoveries and permitted adequate separation for interfering peaks. Compounds were identified by their retention times, absorbance ratios, co-elution with standards, and enzymatic shifts. With a computerized integrator we quantitated these compounds in widely varying concentrations with a single injection. The limit of sensitivity was 0.1 mumol/L for the compounds studied. This method was applied to determine mean values for those compounds in normal human plasma. They are (in mumol/L): uric acid 276 (SD 55), hypoxanthine 0.46 (SD 0.21), xanthine 0.40 (SD 0.27), and uridine 4.50 (SD 1.70). Erythrocytes and platelets can continue to release hypoxanthine and xanthine into plasma or serum after a blood specimen has been drawn. We believe this explains the higher values previously reported for hypoxanthine and xanthine in serum.     

Inhibitory effects of plant growth regulators on xanthine oxidase

Several plant hormones and analogues were tested for their inhibitory effects on xanthine oxidase. The flavoprotein enzyme, xanthine oxidase, catalyses the oxidation of hypoxanthine to xanthine and then xanthine to uric acid which has lambda max 295 nm. Uric acid was thus the basis for a spectrophotometric assay of the activity of xanthine oxidase. The results showed that trans-zeatin displayed the strongest activity (IC50 = 23.5 muM) on xanthine oxidase inhibition, followed by indole-3-acrylic acid (IC50 = 136.0 muM) and then by the mixed isomers of zeatin (trans-zeatin and cis-zeatin) (IC50 = 198.65 muM). Trans-zeatin induced an uncompetitive inhibition of the enzyme with respect to the substrate xanthine and the apparent inhibition constant (Ki) was 5.09 muM. However, zeatin riboside was inactive. Since xanthine oxidase serum levels are increased in hepatitis, mild hepatic intoxication, tumours brain tissues, and DNA damage induced by cytotoxic agents, it is expected that trans-zeatin may be useful for the treatment of these diseases as well as gout which is caused by deposition of uric acid in the joints and oxidative damage of tissue caused by generation of superoxide anion radical.     

Evaluation of nitrogen dioxide scavengers during delivery of inhaled nitric oxide

Tissue hypoxia is an important cause for the development of multisystem organ failure in the critically ill. Achieving adequate haemodynamic support of oxygen demand is the mainstay of treatment in these patients. Controversies regarding therapeutic end-points do exist but in general maintaining oxygen delivery by ensuring adequate cardiac output, oxygen saturation and haemoglobin is important in the critically ill.     

Allopurinol, an inhibitor of xanthine oxidase, reduces uric acid levels and modifies the signs associated with copper deficiency in rats fed fructose

This study was designed to focus on the potential stress that xanthine oxidase could produce in copper-deficient rats fed fructose. Fructose consumption results in an excess production of uric acid due to an increased degradation of nucleotides. The enzyme xanthine oxidase catalyzes the oxidation of both hypoxanthine and xanthine. During the oxidation process free radicals are generated, which in turn, induce lipid peroxidation and premature death. Allopurinol -- a competitive inhibitor of xanthine oxidase -- could alleviate the combined effects of fructose feeding and copper deficiency. Twenty-five male rats were fed for 4 weeks from weaning a copper-deficient or adequate diet containing fructose. Twelve rats were given a daily oral dose of 5 mg allopurinol/100 g b.wt. Two copper-deficient rats that were not treated with allopurinol died prematurely during the fourth week of the study. No mortality occurred in the group of copper-deficient rats that had been treated with allopurinol. Anemia was alleviated by allopurinol, which in turn, could be responsible for improved growth rate. Allopurinol was effective in inhibiting xanthine oxidase activity in vivo as measured by the dramatic reduction of uric acid production. Lipid peroxidation, however, was not affected by allopurinol. It is concluded that the beneficial effects of allopurinol in copper deficiency do not appear to be related to prevention of oxygen radicals, but rather, to the protection against the catabolic destruction of purines, which in turn, increases nucleotide pool.     

A study of the 30 minutes following reperfusion after crystalloid and cold blood cardioplegia by enzymatic and metabolic analysis of coronary blood flow

Post-ischemic reperfusion phenomena were studied in two methods of myocardial protection: crystalloid cardioplegia (St Thomas n(o) 2) and cold blood cardioplegia (Buckherg) during cardiopulmonary bypass for human myocardial revascularisation. Myocardial protection was assessed on the course of hemodynamic parameters, reperfusion arrhythmias and biochemical analysis of the coronary flow after cross-clamp removal: creatine phosphokinase (CPK-MB) and nucleotide adenine metabolites (adenosine, inosine, hypoxanthine, xanthine and uric acid). The study was performed in two groups of 14 patients. Hemodynamic conditions were similar in both groups during reperfusion in order to avoid different coronary flow. Under these conditions, myocardial protection by cold blood cardioplegia reduced reperfusion arrhythmias, and resulted in a loss of CPK-MB release. Furthermore, cold blood cardioplegia provided protection of myocardial energy metabolism by reducing the loss of metabolites, purine bases and oxypurine bases into the coronary sinus. Our results also show that hypoxanthine is probably the final product of ATP degradation in human myocardial tissue.     

Physiologic profiles in circulatory support and management of the critically ill

An automated system has been developed for measuring hemodynamic, oxygen transport and tissue utilization functions. Rapid measurement and data analysis of physiologic profiles by paramedical personnel allow prompt evaluation of altered cardiovascular function. Evaluation of physiologic function allows therapeutic interventions to be instituted on a timely basis, appropriately directed toward improvement of the measured cardiovascular abnormalities. Physiologic profile studies were performed on 1016 occasions in 580 patients during a three-year period and form the basis of this report. Although utilized on hospitalized patients, there are implications for use in evaluating and treating all critically ill patients.     

Dexamethasone and interleukin-1 potently synergize to stimulate the production of granulocyte colony-stimulating factor in differentiated THP-1 cells

Oxygen free radical generation by xanthine oxidase (XO) is a possible mechanism in the injury following reperfusion of transplanted organs. This study was undertaken to investigate XO in human lung, and to investigate whether XO is released into the blood stream during the immediate postoperative period after lung transplantation. XO activity was measured in healthy human lung tissue, and XO protein and the adenine nucleotide catabolic products hypoxanthine, xanthine and uric acid were analysed in the plasma samples collected during human heart-lung transplantation (n=4), double lung transplantation (n=2), and single lung transplantation (n=1). Neutrophil degranulation was assessed by plasma lactoferrin measurements. The results indicated that XO activity (detection limit 5 pmol x min(-1) x mg(-1) protein) and protein (detection limit 5 ng x mg-1 protein) were undetectable in the lungs of five healthy individuals. Similarly, no XO protein could be found in the plasma samples from the right ventricle or left atrium during and after the transplantation in any of the cases. Plasma xanthine and hypoxanthine concentrations were elevated 2-10 fold immediately after the reperfusion of the transplant, indicating washout of high-energy phosphate degradation products from the ischaemic lung. Plasma uric acid decreased rather than increased immediately after the surgery and during the following 24 h. Lactoferrin was elevated during the surgery. In conclusion, these results show that XO activity in human lung is low, it is not released into the blood stream during human heart-lung transplantation, and it is unlikely to contribute to postoperative complications in these patients.     

Ogilvie''s syndrome: a new approach to an old problem

The effect of glucose infusion on renal handling of purine bases and oxypurinol was examined in 6 normal subjects. Five hundred milliliters of 1.1 M glucose solution were administered intravenously in 1 h. Fractional clearances of uric acid, xanthine and oxypurinol were significantly increased during glucose infusion, but that of hypoxanthine was not changed, while a 1-hour infusion of 500 ml of 1.1 M mannitol had no effect on the fractional clearances of purine bases and oxypurinol. These data indicate that the effect of glucose infusion on the renal clearances of uric acid, xanthine and oxypurinol was not related to osmotic diuresis but induced by glycosuria and/or hyperglycemia. Accordingly, the glycosuria- and/or hyperglycemia-induced decrease in the biological half-life of oxypurinol must be considered in the administration of allopurinol to gouty patients with uncontrolled diabetes mellitus.     

Reperfusion injury as the mechanism of brain damage after perinatal asphyxia

Upon reperfusion of ischemic tissues, reactive oxygen metabolites are generated and are responsible for much of the organ damage. Experimental studies have revealed two main sources of these metabolites: 1) the oxidation of hypoxanthine to xanthine and on to uric acid by the oxidase form of xanthine oxidoreductase and 2) neutrophils accumulating in ischemic and reperfused tissue. Blocking either source will reduce reperfusion damage in a number of experimental situations. Although xanthine oxidoreductase activity may be unmeasurably low in organs other than liver and intestine, it may be involved in reperfusion injury elsewhere because of its localization in capillary endothelial cells. Time course considerations suggest that substrate accumulation and NADH inhibition of dehydrogenase activity may be more important in the pathogenesis than conversion of xanthine dehydrogenase into the oxidase form. Neutrophil accumulation may be partly due to oxidants in the first place, suggesting a link between the two sources of reactive oxygen metabolites. In the clinical context, many of the sequelae of perinatal asphyxia may be accounted for by reperfusion damage to organs such as brain, kidney, heart, liver, and lungs. During asphyxia, substrates of xanthine oxidase accumulate, upon resuscitation the cosubstrate oxygen is introduced, and evidence for oxidant production and effects has been obtained. In the pathogenesis of brain damage after asphyxia, both microvascular injury and parenchymal cell damage are important. Oxygen metabolites are involved in the former, but in the latter process their role is less clear because ischemia-reperfusion triggers not only oxidant production but many other phenomena, including gene activation, ATP depletion, glutamate accumulation, and increase of intracellular calcium. A severe insult results in cell necrosis, but more moderate asphyxia may cause delayed neuronal death through apoptosis. The time course of the changes in high energy phosphates as well as of selective neuronal death suggest that in the first hours of life there is a "therapeutic window," with future possibilities for prevention of permanent damage.     

The use of computed tomography in stereotaxic operations in dyskinesia patients

The pool of free purine derivatives and activities of the key enzymes of purine metabolism (adenosine deaminase, purine nucleoside phosphorylase, and 5'-nucleotidase) in lymphocytes, erythrocytes, and epidermis homogenates were measured in 20 normal subjects and 15 patients with psoriasis by high-performance liquid chromatography. The levels of AMP, GMP, and IMP purine monophosphates are decreased in the epidermis and red cells of psoriasis patients, whereas the final products of hypoxanthine, xanthine, and uric acid metabolism are accumulating, and the activities of ADA and PNP are increased double in the skin, all this indicating purine derivatives catabolism.     

Simultaneous measurement of allantoin, uric acid, xanthine and hypoxanthine in blood by high-performance liquid chromatography

A high-performance liquid chromatographic method for determining catabolism products of nucleic acids and purines, such as oxypurines (i.e. uric acid, xanthine and hypoxanthine) and allantoin in the blood plasma of ruminants was developed. The plasma was deproteinized with 10% trichloroacetic acid. The method enabled determination of oxypurines without derivatization. Allantoin was determined after conversion with 2,4-dinitrophenylhydrazine to a hydrazone (GLX-DNPH). Separation of converted allantoin, uric acid, xanthine and hypoxanthine derivatives was carried out using two reversed-phase C18 columns. The combination of pre-column derivatization and gradient elution with monitoring of the effluent at 205, 254 and 360 nm provides a simple and selective analytical tool for studying oxypurines and allantoin in plasma. The total run time of the HPLC analysis was 60 min. The recovery of the purine derivatives (i.e. oxypurines and allantoin) added to the plasma was between 95 and 106%. Purine derivatives were stable when the processed samples were stored for 7 days at -10 degrees C. The low values of the intra-assay coefficient of variations (2.5-4.6%) and the low values of the detection limits (0.187-0.004 nmol) point to the satisfactory precision and sensitivity of the method.     

Effect of morphine on striatal dopamine metabolism and ascorbic and uric acid release in freely moving rats

Recent ex vivo findings have shown that morphine increases dopamine (DA) and xanthine oxidative metabolism and ascorbic acid (AA) oxidation in the rat striatum. In the present study, we evaluated the effects of subcutaneous daily morphine (20 mg/kg) administration on DA, dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), AA and uric acid in the striatum of freely moving rats using microdialysis. Dialysates were assayed by high performance liquid chromatography with electrochemical detection. On the first day, morphine administration caused a significant increase in extracellular DA, DOPAC, HVA, AA and uric acid concentrations over a 3 h period after morphine. In all treated rats (n = 7), individual concentrations of DOPAC + HVA were directly correlated with individual AA and uric acid concentrations. Last morphine administration on the 4th day increased DOPAC, HVA, AA and uric acid concentrations but failed to increase those of DA. Individual DOPAC + HVA concentrations were still directly correlated with individual AA and uric acid concentrations. These results suggest that systemic morphine increases both striatal DA release and DA and xanthine oxidative metabolism. Only the former effect undergoes tolerance. The increase in DA oxidative metabolism is highly correlated with that of xanthine. The subsequent enhancement in reactive oxygen species production may account for the increase in extracellular AA.     

Measurement of uric acid as a marker of oxygen tension in the lung

Changes in O2 tension such as those associated with hypoxic ischemia or hyperoxia may potentially modulate purine nucleotide turnover and production of associated catabolites. We used an isolated perfused rat lung preparation to evaluate the effect of O2 tension on pulmonary uric acid production. Three O2 concentrations (21%, normoxia; 95%, hyperoxia; 0%, hypoxia) were utilized for both pulmonary ventilation and equilibration of recirculating perfusate. All gas mixtures contained 5% CO2 and were balanced with N2. We used Certified Virus Free Sprague-Dawley male rats weighting 250-300 g, four to five rats in each exposure regimen. After a 10-min equilibration period, we measured uric acid levels at 0 and 60 min in lung perfusate and at 60 min in lung tissue. After 60 min of ventilation/perfusion, we observed significant uric acid accumulation in both lung tissue (25-60%) and perfusate (8- to 10-fold) for all three O2 regimens. However, hypoxia produced substantially greater net uric acid concentrations (net = the difference between zero and 60 min) than either normoxia or hyperoxia (1.5-fold in lung tissue, and 2-fold in perfusate, respectively). The data suggest that pulmonary hypoxia results in greater purine catabolism leading to increased uric acid production. Vascular space uric acid, as measured in the recirculating perfusate, was proportional to lung weight changes (r = 0.99) with hypoxia exhibiting the greatest values, possibly reflecting a linkage between tissue perturbation and uric acid release. Thus, measurement of uric acid may serve as a useful marker of adenine nucleotide turnover and lung injury.     

What changes drug metabolism in critically ill patients? Two preliminary studies in isolated human hepatocytes

The metabolism of many drugs is abnormal in the critically ill patient. The causes of this are unknown, and investigation in patients is difficult. We therefore used isolated, cultured human hepatocytes to study the effects of hypoxia and induction on cytochrome P450 3A, the cytochrome responsible for the metabolism of many drugs. When hepatocytes were exposed to 5% oxygen, the amount of 3A produced, after induction with rifampicin, was five to 10 times less than the amount produced in 21% oxygen. In another study, we exposed isolated hepatocytes for 4 days to serum from five critically ill patients or from volunteers. At the end of this time, the functional ability of the hepatocytes to glucuronidate 14C progesterone was measured. Four of the five patients had a substance in their plasma that reduced the ability of the hepatocytes to glucuronidate progesterone. The nature of this substance and the reason that the serum from the fifth patient did not affect metabolism are unknown. This model is able to simulate the abnormalities which occur in critically ill patients. Further studies are needed to explain our observations and to identify the substances in the serum from critically ill patients that alter drug metabolism.     

Comparison of high-performance liquid chromatographic serum profiles of humans and dogs

The sera of 30 healthy male beagles were analyzed by reversed-phase high-performance liquid chromatography. The profiles were compared with those obtained from the sera of 30 healthy human donors. The chromatograms of each group were very reproducible; however, there were characteristic differences between the two groups. The compounds observed in both the human and canine profiles were identified as creatinine, uric acid, tyrosine, hypoxanthine, xanthine, kynurenine, inosine and tryptophan. Compounds present only in the canine profiles were identified as cytindine, riboflavin and 5-methyl-cytidine. Compounds present only in the human profiles include uridine, guanosine, hippuric acid and the dietary dependent compounds theobromine and caffeine. The compounds present in both human and canine sera were quantitated and compared statistically. The amounts of these compounds were very similar, except for uric acid.     

Xanthine urolithiasis in a dachshund

Calculi were located in the kidneys, the ureters and the bladder of a two-year-old male dachshund. The yellow-greenish calculi developed as a result of impaired transformation of xanthine to uric acid resulting in an increased concentration of xanthine in the urine. The cause of the impaired catabolism of xanthine was probably a disorder of the xanthine oxidase enzyme, which catalyses the transformation of xanthine to uric acid.     

Complications of treadmill testing

OBJECTIVE: To illustrate the possible role of cerebral oximetry and stroke distance as measured by Doppler ultrasound in monitoring the critically ill patient non-invasively in the emergency department. METHODS: Five critically ill patients were monitored with either cerebral oximetry or both cerebral oximetry and stroke distance (the distance travelled by blood in the aorta with each ventricular contraction), as measured by Doppler ultrasound of the aortic arch. CONCLUSIONS: Stroke distance as measured by Doppler ultrasound was a good clinical indication of reduced stroke volume and hence of cardiac output. Cerebral oximetry appears to be a useful measure of tissue hypoxia in patients in whom pulse oximetry is either unrecordable or unreliable.