Immunomodulation in the critically ill

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Immunomodulation in the critically ill N.R. Webster, H.F. Galley British Journal of Anaesthesia Volume 103, Issue 1, Pages 70-81 (July 2009) DOI: 10.1093/bja/aep128 Copyright © 2009 British Journal of Anaesthesia Terms and Conditions

Fig 1 A diagram showing the intracellular signalling pathways and how an external inflammatory stimulus can induce cytokine synthesis. Bacterial products (lipopolysaccharide, LPS, and peptidoglycan, PG) bind to specific cell surface receptors (toll-like receptors, TLRs) and induce a downstream signalling pathway within the cell. The first induced complex is an adaptor molecule such as myeloid differentiation factor (MyD) 88, and a serine/threonine innate immunity kinase such as IL-1 receptor accessory protein kinase (IRAK). The activated TLR complex in turn activates the NFκB-inducing kinase (NIK) complex in a step mediated by TNF-receptor-associated factor (TRAF6). The NIK complex then causes the release of the inhibitory subunit (IB) of NFκB. NF-κB then moves to the nucleus, where it can activate target genes, resulting in enhanced production of pro- and anti-inflammatory cytokines. (Reproduced with the kind permission of the Royal College of Surgeons of Edinburgh.)13 British Journal of Anaesthesia 2009 103, 70-81DOI: (10.1093/bja/aep128) Copyright © 2009 British Journal of Anaesthesia Terms and Conditions

Fig 2 Superimposed on Figure 1 are the various sites at which immunotherapy can be altered by modification of the signalling pathway. British Journal of Anaesthesia 2009 103, 70-81DOI: (10.1093/bja/aep128) Copyright © 2009 British Journal of Anaesthesia Terms and Conditions

Fig 3 The two phases of sepsis—an early pro-inflammatory phase follows onto a later anti-inflammatory phase. An ideal response occurs when these two phases are balanced (a). When there is an exaggerated early response, early mortality associated with shock may be the result; when there is an excessive later response, then immunoparalysis or immunosuppression may occur with later onset infections and multi-organ failure (b). British Journal of Anaesthesia 2009 103, 70-81DOI: (10.1093/bja/aep128) Copyright © 2009 British Journal of Anaesthesia Terms and Conditions