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Zazzeron L, Franco W, Anderson R. Carbon monoxide poisoning and phototherapy. Nitric Oxide 2024; 146:31-36. [PMID: 38574950 PMCID: PMC11197981 DOI: 10.1016/j.niox.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/18/2024] [Accepted: 04/01/2024] [Indexed: 04/06/2024]
Abstract
Carbon monoxide (CO) poisoning is a leading cause of poison-related morbidity and mortality worldwide. By binding to hemoglobin and other heme-containing proteins, CO reduces oxygen delivery and produces tissue damage. Prompt treatment of CO-poisoned patients is necessary to prevent acute and long-term complications. Oxygen therapy is the only available treatment. Visible light has been shown to selectively dissociate CO from hemoglobin with high efficiency without affecting oxygen affinity. Pulmonary phototherapy has been shown to accelerate the rate of CO elimination in CO poisoned mice and rats when applied directly to the lungs or via intra-esophageal or intra-pleural optical fibers. The extracorporeal removal of CO using a membrane oxygenator with optimal characteristic for blood exposure to light has been shown to accelerate the rate of CO illumination in rats with or without lung injury and in pigs. The development of non-invasive techniques to apply pulmonary phototherapy and the development of a compact, highly efficient membrane oxygenator for the extracorporeal removal of CO in humans may provide a significant advance in the treatment of CO poisoning.
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Affiliation(s)
- Luca Zazzeron
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA.
| | - Walfre Franco
- Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, MA, USA; Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Rox Anderson
- Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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Vlcek P, Monkova I, Nerandzic Z, Lippert-Grüner M. Delayed encephalopathy after acute carbon monoxide poisoning: a case study. Brain Inj 2024; 38:331-336. [PMID: 38308510 DOI: 10.1080/02699052.2024.2311339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
Delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) is a relatively rare inflammatory-associated neurometabolic complication. In this article, we present a case report of a 50-year-old male patient with a history of carbon monoxide poisoning. This acute poisoning, although successfully controlled during a stay in the intensive care unit of a local hospital, later led to persistent neurological symptoms. The patient was then treated in the inpatient unit of the rehabilitation clinic, where cognitive deterioration began to develop 20 days after admission. Subsequent examination using EEG and magnetic resonance imaging confirmed severe encephalopathy later complicated by SARS-CoV-2 infection with fatal consequences due to bronchopneumonia. Because currently there are no approved guidelines for the management of DEACMP, we briefly discuss the existing challenges for future studies, especially the application of rational immunosuppressive therapy already in the acute treatment phase of CO poisoning, which could prevent the development of a severe form of DEACMP.
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Affiliation(s)
- Premysl Vlcek
- Department of Rehabilitation, Third Faculty of Medicine, Charles University, Prague, Czech Republic
- National Institute of Mental Health, Klecany, Czech Republic
| | - Ivana Monkova
- Department of Rehabilitation, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zoran Nerandzic
- Department of Rehabilitation, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marcela Lippert-Grüner
- Department of Rehabilitation, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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3
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Parker AL, Johnstone TC. Carbon monoxide poisoning: A problem uniquely suited to a medicinal inorganic chemistry solution. J Inorg Biochem 2024; 251:112453. [PMID: 38100903 DOI: 10.1016/j.jinorgbio.2023.112453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/30/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023]
Abstract
Carbon monoxide poisoning is one of the most common forms of poisoning in the world. Although the primary mode of treatment, oxygen therapy, is highly effective in many cases, there are instances in which it is inadequate or inappropriate. Whereas oxygen therapy relies on high levels of a low-affinity ligand (O2) to displace a high-affinity ligand (CO) from metalloproteins, an antidote strategy relies on introducing a molecule with a higher affinity for CO than native proteins (Kantidote,CO > Kprotein,CO). Based on the fundamental chemistry of CO, such an antidote is most likely required to be an inorganic compound featuring an electron-rich transition metal. A review is provided of the protein-, supramolecular complex-, and small molecule-based CO poisoning antidote platforms that are currently under investigation.
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Affiliation(s)
- A Leila Parker
- Department of Chemistry and Biochemistry, University of California Santa Cruz, Santa Cruz, California 95064, United States
| | - Timothy C Johnstone
- Department of Chemistry and Biochemistry, University of California Santa Cruz, Santa Cruz, California 95064, United States..
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Hoffman KR, Diehl A, Paul E, Butt W, Burrell AJC. Shedding light on carboxyhaemoglobin in extracorporeal membrane oxygenation. Crit Care 2023; 27:384. [PMID: 37789436 PMCID: PMC10548643 DOI: 10.1186/s13054-023-04671-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/28/2023] [Indexed: 10/05/2023] Open
Affiliation(s)
- Kenneth R Hoffman
- Intensive Care Unit, Alfred Hospital, Melbourne, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Arne Diehl
- Intensive Care Unit, Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Warwick Butt
- Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
- Department of Critical Care, Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Paediatric Intensive Care, Murdoch Children's Research Institute, Melbourne, Australia
| | - Aidan J C Burrell
- Intensive Care Unit, Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Etim E, Goulopoulos A, Fischbach A, Franco W. Design Optimization of a Phototherapy Extracorporeal Membrane Oxygenator for Treating Carbon Monoxide Poisoning. Bioengineering (Basel) 2023; 10:969. [PMID: 37627854 PMCID: PMC10451272 DOI: 10.3390/bioengineering10080969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
We designed a photo-ECMO device to speed up the rate of carbon monoxide (CO) removal by using visible light to dissociate CO from hemoglobin (Hb). Using computational fluid dynamics, fillets of different radii (5 cm and 10 cm) were applied to the square shape of a photo-ECMO device to reduce stagnant blood flow regions and increase the treated blood volume while being constrained by full light penetration. The blood flow at different flow rates and the thermal load imposed by forty external light sources at 623 nm were modeled using the Navier-Stokes and convection-diffusion equations. The particle residence times were also analyzed to determine the time the blood remained in the device. There was a reduction in the blood flow stagnation as the fillet radii increased. The maximum temperature change for all the geometries was below 4 °C. The optimized device with a fillet radius of 5 cm and a blood priming volume of up to 208 cm3 should decrease the time needed to treat CO poisoning without exceeding the critical threshold for protein denaturation. This technology has the potential to decrease the time for CO removal when treating patients with CO poisoning and pulmonary gas exchange inhibition.
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Affiliation(s)
- Edidiong Etim
- Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, MA 01854, USA
| | - Anastasia Goulopoulos
- Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, MA 01854, USA
| | - Anna Fischbach
- Department of Anesthesiology, University Hospital, 52074 Aachen, Germany
| | - Walfre Franco
- Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, MA 01854, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
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Goulopoulos A, Etim E, Korupolu S, Farinelli W, Sierra H, Anderson RR, Fischbach A, Franco W. Optical, flow, and thermal analysis of a phototherapy extracorporeal membrane oxygenator for treating carbon monoxide poisoning. Lasers Surg Med 2023; 55:390-404. [PMID: 36883985 DOI: 10.1002/lsm.23649] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/09/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenators (ECMO) are currently utilized to mechanically ventilate blood when lung or lung and heart function are impaired, like in cases of acute respiratory distress syndrome (ARDS). ARDS can be caused by severe cases of carbon monoxide (CO) inhalation, which is the leading cause of poison-related deaths in the United States. ECMOs can be further optimized for severe CO inhalation using visible light to photo-dissociate CO from hemoglobin (Hb). In previous studies, we combined phototherapy with an ECMO to design a photo-ECMO device, which significantly increased CO elimination and improved survival in CO-poisoned animal models using light at 460, 523, and 620 nm wavelengths. Light at 620 nm was the most effective in removing CO. OBJECTIVE The aim of this study is to analyze the light propagation at 460, 523, and 620 nm wavelengths and the 3D blood flow and heating distribution within the photo-ECMO device that increased CO elimination in CO-poisoned animal models. METHODS Light propagation, blood flow dynamics, and heat diffusion were modeled using the Monte Carlo method and the laminar Navier-Stokes and heat diffusion equations, respectively. RESULTS Light at 620 nm propagated through the device blood compartment (4 mm), while light at 460 and 523 nm only penetrated 48% to 50% (~2 mm). The blood flow velocity in the blood compartment varied with regions of high (5 mm/s) and low (1 mm/s) velocity, including stagnant flow. The blood temperatures at the device outlet for 460, 523, and 620 nm wavelengths were approximately 26.7°C, 27.4°C, and 20°C, respectively. However, the maximum temperatures within the blood treatment compartment rose to approximately 71°C, 77°C, and 21°C, respectively. CONCLUSIONS As the extent of light propagation correlates with efficiency in photodissociation, the light at 620 nm is the optimal wavelength for removing CO from Hb while maintaining blood temperatures below thermal damage. Measuring the inlet and outlet blood temperatures is not enough to avoid unintentional thermal damage by light irradiation. Computational models can help eliminate risks of excessive heating and improve device development by analyzing design modifications that improve blood flow, like suppressing stagnant flow, further increasing the rate of CO elimination.
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Affiliation(s)
- Anastasia Goulopoulos
- Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Edidiong Etim
- Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Sandeep Korupolu
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William Farinelli
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Heidy Sierra
- Department of Electrical and Computer Engineering, University of Puerto Rico, Mayaguez, Puerto Rico
| | - R Rox Anderson
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Fischbach
- Department of Anesthesiology, University Hospital, Aachen, Germany
| | - Walfre Franco
- Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, Massachusetts, USA.,Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Fichtner A, Eichhorn L. [Carbon monoxide intoxication-New aspects and current guideline-based recommendations]. DIE ANAESTHESIOLOGIE 2022; 71:801-810. [PMID: 35925170 DOI: 10.1007/s00101-022-01149-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
Carbon monoxide poisoning is a common and potentially life-threatening intoxication, showing an interindividual variety of unspecific symptoms as well as late neurological and other sequelae. Two new German guidelines (S2k guidelines diagnosis and treatment of carbon monoxide poisoning as well as S3 guidelines oxygen therapy in the acute care of adult patients) focus on current evidence-based information on diagnostics as well as therapeutic options with considerable uncertainty remaining. This review summarizes current information and presents a flow scheme for daily practical use.
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Affiliation(s)
- A Fichtner
- Notfall- und OP-Management, Kreiskrankenhaus Freiberg, Donatsring 20, 09599, Freiberg, Deutschland.
| | - L Eichhorn
- Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinikum Bonn/Rhein-Sieg, Bonn, Deutschland
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Fischbach A, Traeger L, Farinelli WA, Ezaka M, Wanderley HV, Wiegand SB, Franco W, Bagchi A, Bloch DB, Anderson RR, Zapol WM. Hyperbaric phototherapy augments blood carbon monoxide removal. Lasers Surg Med 2021; 54:426-432. [PMID: 34658052 DOI: 10.1002/lsm.23486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/23/2021] [Accepted: 10/06/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Carbon monoxide (CO) poisoning is responsible for nearly 50,000 emergency department visits and 1200 deaths per year. Compared to oxygen, CO has a 250-fold higher affinity for hemoglobin (Hb), resulting in the displacement of oxygen from Hb and impaired oxygen delivery to tissues. Optimal treatment of CO-poisoned patients involves the administration of hyperbaric 100% oxygen to remove CO from Hb and to restore oxygen delivery. However, hyperbaric chambers are not widely available and this treatment requires transporting a CO-poisoned patient to a specialized center, which can result in delayed treatment. Visible light is known to dissociate CO from carboxyhemoglobin (COHb). In a previous study, we showed that a system composed of six photo-extracorporeal membrane oxygenation (ECMO) devices efficiently removes CO from a large animal with CO poisoning. In this study, we tested the hypothesis that the application of hyperbaric oxygen to the photo-ECMO device would further increase the rate of CO elimination. STUDY DESIGN/MATERIAL AND METHODS We developed a hyperbaric photo-ECMO device and assessed the ability of the device to remove CO from CO-poisoned human blood. We combined four devices into a "hyperbaric photo-ECMO system" and compared its ability to remove CO to our previously described photo-ECMO system, which was composed of six devices ventilated with normobaric oxygen. RESULTS Under normobaric conditions, an increase in oxygen concentration from 21% to 100% significantly increased CO elimination from CO-poisoned blood after a single pass through the device. Increased oxygen pressure within the photo-ECMO device was associated with higher exiting blood PO2 levels and increased CO elimination. The system of four hyperbaric photo-ECMO devices removed CO from 1 L of CO-poisoned blood as quickly as the original, normobaric photo-ECMO system composed of six devices. CONCLUSION This study demonstrates the feasibility and efficacy of using a hyperbaric photo-ECMO system to increase the rate of CO elimination from CO-poisoned blood. This technology could provide a simple portable emergency device and facilitate immediate treatment of CO-poisoned patients at or near the site of injury.
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Affiliation(s)
- Anna Fischbach
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical, Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lisa Traeger
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical, Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William A Farinelli
- Department of Biomedical Engineering, University of Massachusetts, Lowell, Massachusetts, USA
| | - Mariko Ezaka
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical, Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hatus V Wanderley
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical, Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steffen B Wiegand
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical, Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Walfre Franco
- Department of Biomedical Engineering, University of Massachusetts, Lowell, Massachusetts, USA.,Wellman Center for Photomedicine, Department of Dermatology, General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Arayna Bagchi
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical, Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Donald B Bloch
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical, Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - R Rox Anderson
- Wellman Center for Photomedicine, Department of Dermatology, General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Warren M Zapol
- Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical, Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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