La sclérose en plaques (SEP) est une maladie inflammatoire démyélinisante et neurodégénérative du système nerveux central (SNC). Les cellules T activées qui expriment le PD-1 sont inhibées via l’interaction avec l’un des ligands: PD-L1 ou PD-L2. Des études effectuées chez le modèle murin de la SEP, l’encéphalomyélite auto-immune expérimentale (EAE), ont démontré que l’interaction du PD-1 avec ses ligands contribue à atténuer la maladie. Toutefois, le rôle du PD-1 et de ses ligands dans la pathogenèse de la SEP chez l’humain et dans le modèle murin n’a pas été complètement élucidé. Nous avons déterminé que plusieurs cellules du SNC humain peuvent exprimer les ligands du PD-1. Les astrocytes, les microglies, les oligodendrocytes et les neurones expriment faiblement le PD-L1 dans des conditions basales mais augmentent de façon significative cette expression en réponse à des cytokines inflammatoires. Le blocage de l’expression du PD-L1 par les astrocytes à l’aide de siRNA spécifiques mène à l’augmentation significative des réponses des cellules T CD8+ (prolifération, cytokines, enzymes lytiques). Nos résultats établissent ainsi que les cellules gliales humaines peuvent exprimer des niveaux suffisants de PD-L1 en milieu inflammatoire pour inhiber les réponses des cellules T CD8+. Notre analyse de tissus cérébraux post-mortem par immunohistochimie démontre que dans les lésions de la SEP les niveaux de PD-L1 sont significativement plus élevés que dans les tissus de témoins; les astrocytes et les microglies/macrophages expriment le PD-L1. Cependant, plus de la moitié des lymphocytes T CD8+ ayant infiltré des lésions de SEP n’expriment pas le récepteur PD-1. Au cours du développement de l’EAE, les cellules du SNC augmentent leur niveau de PD-L1. Le PD-1 est fortement exprimé par les cellules T dès le début des symptômes, mais son intensité diminue au cours de la maladie, rendant les cellules T insensibles au signal inhibiteur envoyé par le PD-L1. Nous avons observé que les cellules endothéliales humaines formant la barrière hémato-encéphalique (BHE) expriment de façon constitutive le PD-L2 mais pas le PD-L1 et que l’expression des deux ligands augmente dans des conditions inflammatoires. Les ligands PD-L1 et PD-L2 exprimés par les cellules endothéliales ont la capacité de freiner l’activation des cellules T CD8+ et CD4+, ainsi que leur migration à travers la BHE. L’endothélium du cerveau des tissus normaux et des lésions SEP n’exprime pas des taux détectables de PD-L1. En revanche, tous les vaisseaux sanguins des tissus de cerveaux normaux sont positifs pour le PD-L2, alors que seulement la moitié de ceux-ci expriment le PD-L2 dans des lésions SEP. Nos travaux démontrent que l’entrée des cellules T activées est contrôlée dans des conditions physiologiques grâce à la présence du PD-L2 sur la BHE. Cependant, l’expression plus faible du PD-L2 sur une partie des vaisseaux sanguins dans les lésions SEP nuit au contrôle de la migration des cellules immunes. De plus, une fois dans le SNC, les cellules T CD8+ étant dépourvues du PD-1 ne peuvent recevoir le signal inhibiteur fourni par le PD-L1 fortement exprimé par les cellules du SNC, leur permettant ainsi de rester activées. / Multiple sclerosis (MS) is an inflammatory, demyelinating and neurodegenerative disease of the central nervous system (CNS). Responses of activated T cells are suppressed upon engagement of the receptor programmed cell death-1 (PD-1) with its ligands (PD-L1 and PD-L2). Experiments using the mouse model of MS, experimental autoimmune encephalomyelitis (EAE), have demonstrated that the PD-1/PD-Ls interaction contributes to attenuate disease severity. However, the expression and the role of PD-1 and PD-Ls have been partially documented in inflammatory murine models and human CNS data are still incomplete. We determined that primary cultures of human astrocytes, microglia, oligodendrocytes, or neurons expressed low or undetectable PD-L1 levels under basal conditions, but inflammatory cytokines significantly induced such expression, especially on astrocytes and microglia. Blocking PD-L1 expression in astrocytes using specific siRNA in co-culture led to significantly increased CD8 T cell responses (proliferation, cytokines, lytic enzyme). Thus, our results establish that inflamed human glial cells can express sufficient and functional PD-L1 to inhibit CD8 T cell responses. Extensive immunohistochemical analysis of post-mortem brain tissues demonstrated a significantly greater PD-L1 expression in MS lesions compared to control tissues, which co-localized with astrocyte and microglia/macrophage cell markers. However, more than half of infiltrating CD8 T lymphocytes in MS lesions did not express PD-1, the cognate receptor. Similar results were obtained in EAE mice. Even though CNS cells expressed PD-L1 at the peak of the disease, PD-1 intensity on infiltrating T cells decreased throughout EAE disease development. This reduction of PD-1 level on activated T cells prevented these cells to receive PD-L1 inhibitory signal. We also investigated whether human brain endothelial cells (HBECs), which form the blood brain barrier (BBB), can express PD-L1 or PD-L2 and thereby modulate T cells. HBECs expressed PD-L2 under basal conditions, whilst PD-L1 was not detected. Both ligands were up-regulated under inflammatory conditions. Blocking PD-L1 and PD-L2 led to increased transmigration and enhanced responses by human CD8 T cells in co-culture assays. Similarly, PD-L1 and PD-L2 blockade significantly increased CD4 T cell transmigration. Brain endothelium in normal tissues and MS lesions did not express detectable PD-L1; in contrast, all blood vessels in normal brain tissues were PD-L2-positive, while only about 50% expressed PD-L2 in MS lesions. Therefore, our results demonstrate that under basal conditions, PD-L2 expression by HBECs impedes the migration of activated immune T cells through the BBB, and inhibits their activation. However, such impact is impaired in MS lesions due to down-regulation of PD-L2 levels on the endothelium. The majority of infiltrating CD8 T cells is devoid of PD-1, thus insensitive to PD-L1 inhibitory signal providing by CNS cells once they have entered the CNS.

En dépit de nombreux essais thérapeutiques, les syndromes septiques sont la première cause de mortalité en service de soins intensifs. La population septique étant très hétérogène, une meilleure caractérisation des patients serait essentielle afin de mieux individualiser et cibler les thérapeutiques potentiellement bénéfiques. Une approche multiparamétrique de l’utilisation des biomarqueurs est une alternative qui viserait à appréhender la situation de manière plus globale. Notre travail s’inscrit dans ce contexte au travers de l’étude plus spécifique de la défaillance des systèmes cardio-vasculaire et immunitaire. Au-delà de la confirmation de l’intérêt des biomarqueurs présentement étudiés (prohormones cardio-vasculaires et PD-1) dans la prédiction de la mortalité et du risque d’infections nosocomiales, nos résultats apportent des éléments nouveaux. Nous avons montré que (1) la sur-expression des molécules PD-1 est associée à l’énergie leucocytaire, (2) un même biomarqueur peut apporter une information différente au cours du temps, (3) l’information apportée par l’analyse simultanée de deux biomarqueurs est supérieure à celle de la somme de leurs valeurs individuelles, et (4) l’expression dynamique d’un biomarqueur est meilleure que son expression à un temps donné. Au total, notre travail illustre l’intérêt potentiel d’un panel de biomarqueurs pour mieux appréhender la complexité des états septiques et leur rapide évolution. Il reste néanmoins à développer des outils biostatistiques capables de donner au clinicien une vision globale en temps réel des processus en cours. Cela constituera une étape clé pour mieux stratifier et cibler les prochains essais cliniques dans le domaine. / Septic syndromes remain the leading cause of death in the intensive care units despite numerous clinical trials. Septic patients constitute a very heterogeneous population. Therefore improved characterisation of patients in order to better target and personalize potential new therapeutics is highly desirable. A multiparametric biomarker-based approach could be an attractive alternative to obtain a global view of the pathophysiologic situation. In this context, we worked specifically on cardio-vascular and immune dysfunctions. We first confirmed the predictive value of biomarkers for mortality or nosocomial infections, and showed new elements. We observed that (1) PD-1 overexpression is associated with leukocyte anergy, (2) one biomarker could give different information over time, (3) information provided by the association of two biomarkers is more interesting than the addition of their individual values, and (4) dynamic expression of one biomarker is more informative than its expression at a given time point. Finally, our results illustrate the potential interest of biomarker panels to improve our understanding of the septic syndrome complexity and to reflect their rapid evolution. Consequently, next step will depend on our capacity to develop biostatistic tools that enable clinicians to get, in real time, a global view of the process over time. This key step is likely necessary to decrease the heterogeneity of septic patient population in order to better stratify and target next clinical trials in the field.

Le présent travail s’intéresse à l’électro-dépôt et à la caractérisation des nanofilms Pt/Pd(hkl) ainsi que leurs propriétés en relation avec le stockage d’hydrogène. Les effets de taille nanométrique, de l’épaisseur et de l’orientation cristallographique du substrat ont été étudiés.En comparant les films Pd/Pt(111) et Pd/Pt(100), des caractéristiques distinctes ont été observées aussi bien pour les courbes d’électro-dépôt que durant les caractérisations électrochimiques et par AFM ex situ. Les dépôts Pd/Pt(100) ont montré la présence d’un dépôt en sous tension jusqu’à deux couches atomiques, ce qui est assez inhabituel. Les films plus épais montrent la présence de pyramides à base carrée alignées sur l’orientation (100) du substrat. Au contraire, seule la première couche de Pd/Pt(111) se dépose en sous-tension et le dépôt présente un caractère pseudomorphe jusqu’à 10 couches complètes.L’absorption d’hydrogène dans les nanofilms de Pd/Pt(100) a été étudiée avec une méthode « classique » dans une solution d’acide sulfurique. Nous avons développé une nouvelle méthode recourant à une électrode tournante à ménisque suspendu pour mesurer l’insertion d’hydrogène dans les films les plus minces de Pd/Pt(111), où l’insertion d’hydrogène et le dégagement de H2(g) ne sont pas bien séparés.Les isothermes d’insertion d’hydrogène présentent des points communs entre les deux systèmes, comme la réduction du taux maximal d’insertion (H/Pd)max comparé au Pd massif, valeur qui décroît avec la réduction d’épaisseur. La largeur de la région biphasique décroît aussi avec la réduction d’épaisseur de film et présent une pente. Cette pente a été attribuée à la présence de sites d’insertion non-équivalents résultant des contraintes induites par le substrat. Cependant, pour Pd/Pt(100), la pente est moins prononcée et la valeur de (H/Pd)max décroît plus rapidement avec l’épaisseur. Sa valeur pour Pd5ML/Pt(100) est à peine supérieure au taux d’insertion αmax du Pd massif. / The present work focuses on the electro-deposition and characterization of Pd/Pt(hkl) nanofilms and on their properties concerning hydrogen storage. The effects of the nanometric size, of the thickness and of the substrate’s orientation have been studied.Comparing Pd/Pt(111) and Pd/Pt(100) films, distinct features were observed either in the electrodeposition curve or in the electrochemical and ex situ AFM characterizations. Pd/Pt(100) deposits have shown the presence of an UPD process up to two layers, which is a quite uncommon phenomenon. Thicker films show the presence of square based pyramids, following the substrate’s (100) orientation. On the contrary, only the first layer is Under Potentially Deposited in Pd/Pt(111) films and the deposit presents a pseudomorphic character up to about 10 complete layers.Hydrogen absorption into the Pd/Pt(100) nanofilms was studied following a “classical” method in sulphuric acid medium. We have developed a new method using the hanging meniscus rotating disk electrode (HMRDE) to measure the hydrogen insertion into ultra-thin Pd/Pt(111) films, where H insertion and HER (Hydrogen Evolution Reaction) are not well separated. The hydrogen insertion isotherms present some common points between the two studied systems, like smaller value of the maximum hydrogen insertion rate (H/Pd)max compared to bulk Pd, value which decreases with the decrease of the thickness. The two-phase region width decreases with film thickness as well and presents a slope. Such slope has been attribtued to the presence of non-equivalent insertion sites due to substrate induced constraints. Nevertheless, for Pd/Pt(100) the slope is less pronounced and (H/Pd)max value decreases more rapidly with thickness. Its value in correspondence of Pd5ML/Pt(100) is only slightly higher than the αmax insertion rate of bulk Pd.

Une des stratégies pour limiter les neutropénies induites par la chimiothérapie est l’utilisation de granulocyte-colony stimulating factor (G-CSF). Nous avons développé, par une approche de population, un nouveau modèle pharmacocinétique/pharmacodynamique capable de décrire la cinétique des neutrophiles des patients traités au carboplatine, qu’ils aient ou non reçu du G-CSF. Les simulations réalisées à partir de ce modèle ont montré que le G-CSF n’était pas bénéfique chez tous les patients et que la formulation à action longue semblerait plus efficace que les autres formulations. Nous avons également établi des règles de décision permettant d’une part de prédire le risque de neutropénie sévère, et d’autre part d’identifier précocement les patients pour lesquels le G-CSF peut avoir un effet bénéfique. / Granulocyte colony-stimulating factor (G-CSF) is often used in cancer patients receiving cytotoxic drugs to prevent or reduce high grade neutropenia. We developed a new population pharmacokinetic/pharmacodynamic model to describe neutrophil time-course in carboplatin-treated patients, whether or not they received G-CSF. Model simulations showed that G-CSF was not as beneficial as expected in some patients and that the onceper- cycle formulation was more efficient than other formulations. Model-based decision rules were also built to anticipate prolonged high grade neutropenia and early identify patients for whom G-CSF was beneficial.

6 Abstract The first part of this Thesis describes the preparation of a novel phosphanyl-ferrocene amine, Ph2PfcCH2NH2 (1; fc = 1,1'-ferrocendiyl) in two steps from the known aldehyde Ph2PfcCHO. An oxime Ph2PfcCH=NHOH was prepared firstly by a condensation reaction, and subsequently treated with Li[AlH4] to give the desired amine. The amine was converted into its more stable hydrochloride salt, Ph2PfcCH2NH3Cl. Derivatization of amine 1 was examined through the preparation of a series of phosphanyl-urea ligands Ph2PfcCH2NHC(E)NR1 R2 . Some of these compounds were also prepared via an alternative method employing reductive amination reaction. These donors and their Pd(II) complexes were evaluated in Pd-catalyzed reaction of arylbromides with K4[Fe(CN)6] in order to prepare corresponding benzonitrile derivatives using aqueous reaction solvents. The reaction proceeds with excellent yields and purity when 1 mol.% of Pd- catalyst is used (at 100 řC for 3 hours), especially for electron-rich bromobenzenes. Substrates with electron-withdrawing substituents react significantly slower and corresponding hydrolytic products (benzamides) are isolated. The coordination properties of phosphanyl-amine 1 were examined towards Cu(I) ions. Thus, reaction of 1 with [Cu(MeCN)4][BF4] provided bis-chelate complex [Cu(1- κ2...

Des lots de scintillateurs orthosilicates et grenats dope terres rares ont été cristallisés par les méthodes micro-pulling down (μ-PD) et Czochralski. Pour la première fois des fibres Lu2xGd2 2xSiO5 dopées Ce (LGSO:Ce) (x = 0.5) ont été tirées par la méthode micro-pulling down (μ-PD). Dans le but de déterminer la concentration optimale de l'ion activateur avec les meilleurs paramètres de scintillation, la concentration du cérium dans le liquide a été variée dans l'intervalle 0.01-1.5 at%. La distribution spatiale des cations le long des cristaux LGSO :Ce tirés par la méthode de la micro-pulling down a été étudiée par microscopie à champ proche et microscopie Confocale à travers l'excitation du Ce3+ sur les sites cristallographiques du CeO6. Des fibres de composition Lu3A15O12 (LuAG) non dopées et dopées Ce3+ et Pr3+, des matrices mixtes (Lu, Y)3A15O12 (LuYAG) et Y3A15O12 (YAG) dopés Ce3+ ont été fabriqués pour évaluer les possibilités de développer un calorimètre dual-readout pour fonctionner dans le Grand collisionneur de hadrons du CERN. Les cristaux LuAG ont été choisis dans le but de détecter la scintillation (ion activateur) et les radiations Chernkov. Pour confirmer l'amélioration de la qualité des fibres cristallines à travers les conditions de croissance cristalline, nous avons réalisé des mesures d'atténuation le long des fibres. La bonne reproductivité des fibres a été vérifiée par des tests faisceau en conditions de calorimètre. Nous avons étudié la structure et la scintillation dans les cristaux appartenant à la solution solide Y3(Al1-xGax)5O12 :Ce. Les cristaux ont été tirés à partir de l'état liquide par la méthode Czochralski. La distribution des cations de la matrice a été étudiée. L'effet de la substitution du Al/Ga dans Y3(Al1-xGax)5O12 :Ce sur le rendement de scintillation a été déterminé. Le rendement de scintillation a atteint 130 % par rapport au grenat aluminium-yttrium dopé Ce. L'évolution des propriétés de luminescence en fonction de la substitution al/Ga a été étudiée / A set of rare earth orthosilicate and garnet scintillators were grown by the micropulling down (μ-PD) and Czochralski methods. Ce-doped Lu2xGd2 2xSiO5 (LGSO:Ce) fibers were grown by the micro-pulling down (μ-PD) method for the first time. In order to determine the optimal activator concentration with regard to the best scintillating parameters, cerium concentration in the melt was varied within 0.01-1.5 at.%. A set of results on optical and scintillation characteristics of the grown fibers with the different activator content was determined and discussed. Distribution of Gd3+ and Ce3+ in LGSO:Ce structure was compared to the Czochralski grown crystals. Spatial distribution of cations across LGSO:Ce scintillation shaped crystals grown by the micro-pulling-down method is studied using wide-field microscopy under simultaneous excitation of both cerium-related centers and confocal microscopy under selective excitation of Ce3+ in CeO6 crystallographic sites. Undoped fibers of Lu3Al5O12 (LuAG) and doped by Ce3+, Pr3+, mixed (Lu,Y)3Al5O12 (LuYAG) and Y3Al5O12 (YAG) both doped by Ce3+ were produced to evaluate a possibility of their potential use in the new dual-calorimeter planned to operate in the upgraded Large Hadron Collider in CERN. The choice of grown crystals was made to detect scintillation (activated materials) and Cherenkov radiation (LuAG). Growth conditions for the improvement of fibers quality were selected basing on measurements of attenuation length of the fibers. The activator segregation coefficient in LuAG:Ce and LuYAG:Ce fibers was evaluated by the cathodoluminescence measurements. The effect of annealing and radiation damage was studied. The good productivity of the grown fibers was verified on the test beam calorimeter. Structure and scintillation yield of Y3(Al1 xGax)5O12:Ce solid solution crystals are studied. Crystals are grown from melt by the Czochralski method. Distribution of host cations in crystal lattice is determined. The trend of light output at Al/Ga substitution in Y3(Al1-xGax)5O12:Ce is determined. Light output in mixed crystals reaches 130% comparative to Ce-doped yttrium–aluminum garnet. The evolution of luminescence properties at Al/Ga substitution is studied

Epithelial ovarian cancer is the sixth most common tumor disease among women and it is the leading cause of death from all types of gynecologic malignancies. The current standart of care consist of debulking surgery followed by platinum-taxane chemotherapy. Althought some patients benefit from the treatment, most eventually experience platinum-resistance and die from this disease. Immunotherapy based on application of immune checkpoint blockers represents a new treatment strategy in different cancer malignancies. However, emerging clinical data show only limited clinical efficacy of these agents in ovarian cancer patients with objective response rates of 10-15%. Therefore there is a strong need to identify a potential biomarkers, which allows to identify the group of patients, who will benefit the most from this costly treatment. The aim of my diploma thesis was to characterize the prognostic and predictive role of the immune checkpoints within the retrospective and prospective cohort of patients with high-grade serous ovarian cancer (HGSOC). Our study follows, that the expression of PD-L1 molecule and high frequencies of PD-1+ tumor infiltrating lymphocytes (TILs) in tumor microenviroment is significantly correlated with a better prognosis of patients with HGSOC. Moreover, PD-L1 and PD-1...

Chez les patients, la tumeur développe une immunosuppression qui compromet les capacités des effecteurs de l’immunité à réagir. Longtemps décriée, l’immunothérapie est considérée aujourd’hui comme une thérapie à part entière avec la chirurgie, la chimiothérapie et la radiothérapie. Parmi les premières immunothérapies développées dans les années 1990, l’IL-2 forte dose fut approuvée dans le traitement du mélanome et du cancer du rein métastatiques. Cependant, sa forte toxicité et la faible proportion de patients répondeurs ont limité son usage clinique. Une autre cytokine, l’IL-15, apparaît prometteuse dans le traitement des cancers pour son activité similaire à l’IL-2 sans ses facteurs limitants. Cependant, seule, son activité anti-tumorale n’est pas optimale du fait de sa courte demi-vie ou encore de l’affinité intermédiaire de liaison à son récepteur βγ. Différentes stratégies ont été mises au point pour améliorer l’efficacité de l’IL-15, notamment, sa stabilisation à travers l’association avec sa chaine de haute affinité IL-15Rα. Une molécule de fusion associant de manière covalente la partie sushi+ de l’IL-15Rα avec l’IL-15 humaine a été développée : le RLI. Au cours de cette thèse, nous avons étudié chez la souris, le potentiel thérapeutique de cette molécule dans le traitement des cancers solides. Nous avons ainsi mis en évidence une activité anti-tumorale du RLI et une association synergique avec un anticorps monoclonal anti-PD-1. / In cancer patients the immune system is compromised by the tumor and its microenvironment. In recent decades the role of the immune system in tumor control has been controversial, though today cancer treatments that modulate immunity are a reality. Immunotherapy is a unique therapy adding to pre-existing methods of cancer control: surgery, chemotherapy and radiotherapy. In the 1990’s, high dosing of IL-2 was the first immunotherapy approved by the FDA to treat metastatic melanoma and renal carcinoma, however high toxicities and low responder rates have limited its clinical use. IL-15 is another promising cytokine therapy. The similar properties with IL-2 and differences in terms of toxicities and Treg induction make IL-15 an attractive potential therapy. Nonetheless, the short half-life and intermediate affinity for its receptor βγ compromise its efficacy. Different strategies have been developed to facilitate IL-15 therapeutic bioactivity. IL-15Rα as a chaperon molecule allows stability of IL-15 in vivo. RLI is a fusion molecule that covalently links sushi+IL-15Rα, the binding domain of its high affinity receptor and a recombinant human IL-15. We have studied the therapeutic potential of RLI in mouse tumor models. Our results show anti-tumor activities of RLI and synergistic combination with anti-PD-1, a monoclonal antibody.

Introdução: A administração de morfina através de bomba de infusão controlada pelo paciente (ACP) no tratamento da dor pós-cirurgica e traumática tem-se mostrado promissora e faz parte da rotina terapêutica de muitos hospitais. No entanto, doses altas ou repetidas deste opióide estão associadas a efeitos adversos dose dependentes, dentre eles, a depressão respiratória. No caso de pacientes submetidos a cirurgias de tórax, além da analgesia pós-operatória, devem também ser considerados como parâmetros relevantes a anestesia regional (intratecal) no intra-operatório, a qual pode contribuir para melhora da função pulmonar pós-operatória e extubação precoce no pós-operatório e a circulação extracorpórea (CEC), potencial fator de alteração na cinética de fármacos. Objetivos: Investigar a influência da morfina intratecal e da circulação extracorpórea (CEC) sobre o consumo de morfina ACP, área sob a curva e escores de dor no período pós-operatório, bem como propor modelo farmacocinético-farmacodinâmico (PK-PD) para correlação dessas variáveis. Adicionalmente, foi desenvolvido método analítico para quantificação da morfina plasmática. Métodos: 59 pacientes submetidos à cirurgia eletiva de revascularização com CEC e sem CEC, na presença ou não de morfina intratecal intra-operatória foram distribuídos em grupos com base na combinação das intervenções acima mencionadas. No período pós-operatório, todos os pacientes receberam bolus IV de 1mg de morfina, e então o dispositivo ACP foi instalado na unidade de terapia intensiva, através de cateter venoso após a extubação orotraqueal. A morfina ACP foi liberada através de livre demanda solicitada pelo paciente (bolus de 1 mg), lock-out de 5 min até 36 horas do pós-operatório. Coletaram-se amostras seriadas de sangue de cateter venoso no período (3,6,12,18,24,36 horas) e a morfina plasmática foi determinada através da cromatografia líquida - espectrometria de massas (LC-MS/MS ESI+) após a purificação das amostras de plasma. A intensidade da dor foi monitorada no mesmo período pela escala análoga visual (EAV). A modelagem PK-PD foi investigada pelo GraphPad Prism 5.0. Resultados: O consumo de morfina e a intensidade da dor diferiram entre os grupos. O modelo do EMAX e a curva de histerese foram propostos pela modelagem PK-PD. Conclusões: O método analítico mostrou-se adequado na determinação da morfina plasmática. O consumo de morfina os escores de dor EAV no pós-operatório diferiram pela comparação dos grupos de pacientes investigados. Menores doses de morfina ACP foram requeridas pelos pacientes que receberam morfina intratecal intra-operatória. Demonstrou-se através do modelo do EMAX correlação não linear entre os parâmetros consumo de morfina e AUC0-36, e curva de histerese foi obtida quando se plotou consumo de morfina versus escore de dor. / Introduction: Morphine administration using patient controlled analgesia (PCA) for treatment of post surgical and traumatic pain has been a current practice in many hospitals. However, large or repeated doses of this opioid are associated to dose dependent adverse events, including, respiratory depression. Considering patients submitted to thoracic surgery, in addition to the postoperatory analgesia, two other relevant parameters must be considered: regional anesthesia (intrathecal) in the intra-operatory period, which should contribute to the respiratory function improvement and decrease in the extubation time; and the cardiopulmonary bypass (OPCAB), that potentially alters the drugs\' kinetics. Objectives: To investigate the influence of intrathecal morphine administration and cardiopulmonary bypass (OPCAB) in the morphine PCA drug requirements, area under the curve of morphine plasma concentration versus time and pain scores in the postoperative period, and to choose a pharmacokinetic-pharmacodynamic model to correlate these variables. In addition, an analytical method was developed to quantify morphine in plasma. Methods: 59 patients submitted to elective coronary artery bypass grafting (CABG) with (CPB) and without cardiopulmonary bypass (OPCAB), with and without intrathecal morphine in the intra-operative period were distributed by the combination of the above mentioned interventions. In the postoperative period, all the patients were given an IV bolus of 1mg of morphine, and then PCA device was installed in the intensive care unit by a venous catheter after the orotracheal extubation. Morphine PCA was delivered on demand (boluses of 1 mg), lock-out of 5 min until 36 hours of the postoperative period. A serial of blood samples were collected from venous catheter of patients at the postoperative period (3,6,12,18,24,36 hrs) and morphine plasma concentrations were determined by Liquid Chromatography-Mass Spectrometry ((LC-MS/MS ESI+)) after the purification of plasma samples. Pain scores were monitored during the same period by a visual analogue scale, VAS or 1-2-3 pain scale. PK-PD modeling was investigated by applying the GraphPad Prism 5.0. Results: Drug dose requirements and analgesia were significant different in patients of groups investigated. EMAX model and the hysteresis curve were proposed by PK-PD modeling to correlate drug requirements and AUC 0-36 or VAS. Conclusions: LC-MS/MS (ESI+) method was adequate for drug measurements in plasma. Morphine dose requirements and analgesia were different by comparison of groups. Lower doses of morphine by PCA were required for the groups that have received intrathecal morphine intraoperatively. It was demonstrated a non linear correlation between parameters by EMAX model when drug requirements and AUC0-36 were plotted, and the hysteresis curve was obtained when analgesia dose requirements was plotted against pain score.

Introdução: A administração de morfina através de bomba de infusão controlada pelo paciente (ACP) no tratamento da dor pós-cirurgica e traumática tem-se mostrado promissora e faz parte da rotina terapêutica de muitos hospitais. No entanto, doses altas ou repetidas deste opióide estão associadas a efeitos adversos dose dependentes, dentre eles, a depressão respiratória. No caso de pacientes submetidos a cirurgias de tórax, além da analgesia pós-operatória, devem também ser considerados como parâmetros relevantes a anestesia regional (intratecal) no intra-operatório, a qual pode contribuir para melhora da função pulmonar pós-operatória e extubação precoce no pós-operatório e a circulação extracorpórea (CEC), potencial fator de alteração na cinética de fármacos. Objetivos: Investigar a influência da morfina intratecal e da circulação extracorpórea (CEC) sobre o consumo de morfina ACP, área sob a curva e escores de dor no período pós-operatório, bem como propor modelo farmacocinético-farmacodinâmico (PK-PD) para correlação dessas variáveis. Adicionalmente, foi desenvolvido método analítico para quantificação da morfina plasmática. Métodos: 59 pacientes submetidos à cirurgia eletiva de revascularização com CEC e sem CEC, na presença ou não de morfina intratecal intra-operatória foram distribuídos em grupos com base na combinação das intervenções acima mencionadas. No período pós-operatório, todos os pacientes receberam bolus IV de 1mg de morfina, e então o dispositivo ACP foi instalado na unidade de terapia intensiva, através de cateter venoso após a extubação orotraqueal. A morfina ACP foi liberada através de livre demanda solicitada pelo paciente (bolus de 1 mg), lock-out de 5 min até 36 horas do pós-operatório. Coletaram-se amostras seriadas de sangue de cateter venoso no período (3,6,12,18,24,36 horas) e a morfina plasmática foi determinada através da cromatografia líquida - espectrometria de massas (LC-MS/MS ESI+) após a purificação das amostras de plasma. A intensidade da dor foi monitorada no mesmo período pela escala análoga visual (EAV). A modelagem PK-PD foi investigada pelo GraphPad Prism 5.0. Resultados: O consumo de morfina e a intensidade da dor diferiram entre os grupos. O modelo do EMAX e a curva de histerese foram propostos pela modelagem PK-PD. Conclusões: O método analítico mostrou-se adequado na determinação da morfina plasmática. O consumo de morfina os escores de dor EAV no pós-operatório diferiram pela comparação dos grupos de pacientes investigados. Menores doses de morfina ACP foram requeridas pelos pacientes que receberam morfina intratecal intra-operatória. Demonstrou-se através do modelo do EMAX correlação não linear entre os parâmetros consumo de morfina e AUC0-36, e curva de histerese foi obtida quando se plotou consumo de morfina versus escore de dor. / Introduction: Morphine administration using patient controlled analgesia (PCA) for treatment of post surgical and traumatic pain has been a current practice in many hospitals. However, large or repeated doses of this opioid are associated to dose dependent adverse events, including, respiratory depression. Considering patients submitted to thoracic surgery, in addition to the postoperatory analgesia, two other relevant parameters must be considered: regional anesthesia (intrathecal) in the intra-operatory period, which should contribute to the respiratory function improvement and decrease in the extubation time; and the cardiopulmonary bypass (OPCAB), that potentially alters the drugs\' kinetics. Objectives: To investigate the influence of intrathecal morphine administration and cardiopulmonary bypass (OPCAB) in the morphine PCA drug requirements, area under the curve of morphine plasma concentration versus time and pain scores in the postoperative period, and to choose a pharmacokinetic-pharmacodynamic model to correlate these variables. In addition, an analytical method was developed to quantify morphine in plasma. Methods: 59 patients submitted to elective coronary artery bypass grafting (CABG) with (CPB) and without cardiopulmonary bypass (OPCAB), with and without intrathecal morphine in the intra-operative period were distributed by the combination of the above mentioned interventions. In the postoperative period, all the patients were given an IV bolus of 1mg of morphine, and then PCA device was installed in the intensive care unit by a venous catheter after the orotracheal extubation. Morphine PCA was delivered on demand (boluses of 1 mg), lock-out of 5 min until 36 hours of the postoperative period. A serial of blood samples were collected from venous catheter of patients at the postoperative period (3,6,12,18,24,36 hrs) and morphine plasma concentrations were determined by Liquid Chromatography-Mass Spectrometry ((LC-MS/MS ESI+)) after the purification of plasma samples. Pain scores were monitored during the same period by a visual analogue scale, VAS or 1-2-3 pain scale. PK-PD modeling was investigated by applying the GraphPad Prism 5.0. Results: Drug dose requirements and analgesia were significant different in patients of groups investigated. EMAX model and the hysteresis curve were proposed by PK-PD modeling to correlate drug requirements and AUC 0-36 or VAS. Conclusions: LC-MS/MS (ESI+) method was adequate for drug measurements in plasma. Morphine dose requirements and analgesia were different by comparison of groups. Lower doses of morphine by PCA were required for the groups that have received intrathecal morphine intraoperatively. It was demonstrated a non linear correlation between parameters by EMAX model when drug requirements and AUC0-36 were plotted, and the hysteresis curve was obtained when analgesia dose requirements was plotted against pain score.