1. Editorial II British Journal of Anaesthesia
R.C. Baker, M.A. Armstrong, S.J. Allen, W.T. McBride 
British Journal of Anaesthesia 
Volume 88, Issue 3, Pages (March 2002)
DOI: /bja/
Copyright © 2002 British Journal of Anaesthesia Terms and Conditions

2. Fig. 1
Conceptualized diagram representing two patients undergoing a simultaneous inflammatory insult of identical intensity, such as major cardiovascular surgery. Patient 1 has normal preoperative renal function and patient 2 has chronic renal impairment. (Time A) During the initial phase of the insult in both patients, local cytokine production spills into the systemic compartment. In patients 1 and 2 this is countered by two strategies: strategy 1 is renal excretion of proinflammatory cytokines; strategy 2 consists of anti-inflammatory mechanisms that are constitutively active in plasma. The notional quantity of proinflammatory cytokines safely controlled by these plasma anti-inflammatory mechanisms is represented by the box labelled ‘Safe systemic cytokine capacity’. To compensate for a defect in strategy 1, patient 2 has preoperatively developed strategy 2, as indicated by an increased safe systemic cytokine capacity. At this time point, organs in both patients are still ‘safe’. (Time B) In both patients, the kidneys undergo significant injury. This may be due either to the inflammatory response itself or to an additional hypotensive episode. Strategy 1 has now been knocked out and if the spillover of inflammatory mediators continues at a constant rate, strategy 2 is in danger of being overwhelmed, resulting in multiple organ failure (MOF). However, because patient 2 has compensated for a defective strategy 1 preoperatively by the use of the more effective strategy 2 (box labelled ‘Increased safe systemic cytokine capacity’), the impact of acute renal failure on inflammatory-mediated organ failure may be delayed. (Time C) The safe systemic cytokine capacity has been exceeded in both patients and proinflammatory mediators can have deleterious effects on other organs. Patients with normal renal function preoperatively who develop acute renal failure in the presence of an ongoing inflammatory response are at particular risk of multiple organ failure.
British Journal of Anaesthesia  , DOI: ( /bja/ )
Copyright © 2002 British Journal of Anaesthesia Terms and Conditions