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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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2
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Xu OW, Wang J, Alston TA. James Watt, of Steam Engine Fame, Offered Inhaled Carbon Monoxide for Putative Therapeutic Action. Anesth Analg 2024:00000539-990000000-00795. [PMID: 38507520 DOI: 10.1213/ane.0000000000006955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
James Watt (1736-1819) is remembered as a steam engine innovator and industrial magnate. A polymath, he was also a hands-on contributor to the Medical Pneumatic Institution of Thomas Beddoes. Watt recruited Humphry Davy, who there discovered analgesic action of inhaled nitrous oxide in 1799. Watt also built pneumatic equipment, and he introduced a gas mixture, dubbed hydro-carbonate, as a medical tonic. The bioactive component was carbon monoxide, a readily-lethal inhibitor of the transport and utilization of respiratory oxygen. Despite appreciable toxicity, carbon monoxide is an endogenous product of heme catabolism, and low doses of the gas are under laboratory investigation for therapeutic purposes. However, Watt's hydro-carbonate constituted a setback in the development of pharmacologically useful gases.
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Affiliation(s)
- Olivia W Xu
- From the Undergraduate College of Arts and Sciences, New York University, New York, New York
| | - Jingping Wang
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School at the Massachusetts General Hospital, Boston, Massachusetts
| | - Theodore A Alston
- College of Professional Studies, Northeastern University, Boston, Massachusetts
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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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4
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Dent MR, Rose JJ, Tejero J, Gladwin MT. Carbon Monoxide Poisoning: From Microbes to Therapeutics. Annu Rev Med 2024; 75:337-351. [PMID: 37582490 PMCID: PMC11160397 DOI: 10.1146/annurev-med-052422-020045] [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] [Indexed: 08/17/2023]
Abstract
Carbon monoxide (CO) poisoning leads to 50,000-100,000 emergency room visits and 1,500-2,000 deaths each year in the United States alone. Even with treatment, survivors often suffer from long-term cardiac and neurocognitive deficits, highlighting a clear unmet medical need for novel therapeutic strategies that reduce morbidity and mortality associated with CO poisoning. This review examines the prevalence and impact of CO poisoning and pathophysiology in humans and highlights recent advances in therapeutic strategies that accelerate CO clearance and mitigate toxicity. We focus on recent developments of high-affinity molecules that take advantage of the uniquely strong interaction between CO and heme to selectively bind and sequester CO in preclinical models. These scavengers, which employ heme-binding scaffolds ranging from organic small molecules to hemoproteins derived from humans and potentially even microorganisms, show promise as field-deployable antidotes that may rapidly accelerate CO clearance and improve outcomes for survivors of acute CO poisoning.
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Affiliation(s)
- Matthew R Dent
- Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; ,
| | - Jason J Rose
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA; ,
| | - Jesús Tejero
- Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; ,
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark T Gladwin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA; ,
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5
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Could your acute stroke patient be carbon monoxide poisoning? Acta Neurol Belg 2022:10.1007/s13760-022-02038-4. [PMID: 35881307 DOI: 10.1007/s13760-022-02038-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/14/2022] [Indexed: 11/01/2022]
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Romano G, Insero G, Marrugat SN, Fusi F. Innovative light sources for phototherapy. Biomol Concepts 2022; 13:256-271. [DOI: 10.1515/bmc-2022-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/03/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
The use of light for therapeutic purposes dates back to ancient Egypt, where the sun itself was an innovative source, probably used for the first time to heal skin diseases. Since then, technical innovation and advancement in medical sciences have produced newer and more sophisticated solutions for light-emitting sources and their applications in medicine. Starting from a brief historical introduction, the concept of innovation in light sources is discussed and analysed, first from a technical point of view and then in the light of their fitness to improve existing therapeutic protocols or propose new ones. If it is true that a “pure” technical advancement is a good reason for innovation, only a sub-system of those advancements is innovative for phototherapy. To illustrate this concept, the most representative examples of innovative light sources are presented and discussed, both from a technical point of view and from the perspective of their diffusion and applications in the clinical field.
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Affiliation(s)
- Giovanni Romano
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence , Viale G. Pieraccini 6 , 50139 Florence , Italy
| | - Giacomo Insero
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence , Viale G. Pieraccini 6 , 50139 Florence , Italy
- National Research Council, National Institute of Optics (CNR-INO) , Via Carrara 1 , 50019 Sesto Fiorentino , FI , Italy
| | - Santi Nonell Marrugat
- Institut Quimic de Sarria, Universidad Ramon Llull , Via Augusta 390 , 08017 Barcelona , Spain
| | - Franco Fusi
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence , Viale G. Pieraccini 6 , 50139 Florence , Italy
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Liu CC, Hsu CS, He HC, Cheng YY, Chang ST. Effects of intravascular laser phototherapy on delayed neurological sequelae after carbon monoxide intoxication as evaluated by brain perfusion imaging: A case report and review of the literature. World J Clin Cases 2021; 9:3048-3055. [PMID: 33969090 PMCID: PMC8080739 DOI: 10.12998/wjcc.v9.i13.3048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/21/2020] [Accepted: 12/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Delayed neurological sequelae (DNS) caused by carbon monoxide (CO) intoxication poses considerable treatment challenges for clinical practitioners. In this report, we used nuclear medicine imaging and the Mini-Mental State Examination (MMSE) to evaluate the effectiveness of intravascular laser irradiation of blood (ILIB) therapy for the management of DNS.
CASE SUMMARY A 51-year-old woman presented to our medical center experiencing progressive bradykinesia, rigidity of limbs, gait disturbance, and cognitive impairment. Based on her neurological deficits, laboratory tests and imaging findings, the patient was diagnosed with delayed neurological sequelae of CO intoxication. She received intensive rehabilitation and ILIB therapy during 30 sessions over 2 mo after diagnosis. Brain single-photon emission computed tomography was performed both prior to and after ILIB therapy. The original hypoperfusion area in bilateral striata, bilateral frontal lobe, right parietal lobe, and bilateral cerebellum showed considerable improvement after completion of therapy. The patient’s MMSE score also increased markedly from 6/30 to 25/30. Symptoms of DNS became barely detectable, and the woman was able to carry out her daily living activities independently.
CONCLUSION ILIB therapy could facilitate recovery from delayed neurological sequelae in patients with CO intoxication, as demonstrated by improved cerebral blood flow and functional outcomes in our patient.
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Affiliation(s)
- Chuan-Ching Liu
- Department of Physical Medicine and Rehabilitation, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Chun-Sheng Hsu
- Department of Physical Medicine and Rehabilitation, Taichung Veterans General Hospital, Taichung 407, Taiwan
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Rehabilitation Science, Jenteh Junior College of Medicine, Nursing and Management, Miaoli 356, Taiwan
| | - Hsin-Chen He
- Department of Physical Medicine and Rehabilitation, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Yuan-Yang Cheng
- Department of Physical Medicine and Rehabilitation, Taichung Veterans General Hospital, Taichung 407, Taiwan
- School of Medicine, National Yang-Ming University, Taipei 112, Taiwan
- Center for Geriatrics and Gerontology, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Shin-Tsu Chang
- Department of Physical Medicine and Rehabilitation, Taichung Veterans General Hospital, Taichung 407, Taiwan
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
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8
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Zazzeron L, Fischbach A, Franco W, Farinelli WA, Ichinose F, Bloch DB, Anderson RR, Zapol WM. Phototherapy and extracorporeal membrane oxygenation facilitate removal of carbon monoxide in rats. Sci Transl Med 2020; 11:11/513/eaau4217. [PMID: 31597752 DOI: 10.1126/scitranslmed.aau4217] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 04/02/2019] [Accepted: 09/18/2019] [Indexed: 11/02/2022]
Abstract
Inhaled carbon monoxide (CO) displaces oxygen from hemoglobin, reducing the capacity of blood to carry oxygen. Current treatments for CO-poisoned patients involve administration of 100% oxygen; however, when CO poisoning is associated with acute lung injury secondary to smoke inhalation, burns, or trauma, breathing 100% oxygen may be ineffective. Visible light dissociates CO from hemoglobin. We hypothesized that the exposure of blood to visible light while passing through a membrane oxygenator would increase the rate of CO elimination in vivo. We developed a membrane oxygenator with optimal characteristics to facilitate exposure of blood to visible light and tested the device in a rat model of CO poisoning, with or without concomitant lung injury. Compared to ventilation with 100% oxygen, the addition of extracorporeal removal of CO with phototherapy (ECCOR-P) doubled the rate of CO elimination in CO-poisoned rats with normal lungs. In CO-poisoned rats with acute lung injury, treatment with ECCOR-P increased the rate of CO removal by threefold compared to ventilation with 100% oxygen alone and was associated with improved survival. Further development and adaptation of this extracorporeal CO photo-removal device for clinical use may provide additional benefits for CO-poisoned patients, especially for those with concurrent acute lung injury.
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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
| | - Anna Fischbach
- 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
- Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - William A Farinelli
- Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Fumito Ichinose
- 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
| | - Donald B Bloch
- 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.,Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - R Rox Anderson
- Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Warren M Zapol
- 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.
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9
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Li J, Jia M, Chen G, Nie S, Zheng C, Zeng W, Xu Y, Wang C, Cao X, Liu Q. Involvement of p38 mitogen‐activated protein kinase in altered expressions of AQP1 and AQP4 after carbon monoxide poisoning in rat astrocytes. Basic Clin Pharmacol Toxicol 2019; 125:394-404. [PMID: 31063681 DOI: 10.1111/bcpt.13247] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/28/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Jinlan Li
- Department of Neurology Enshi Tujia and Miao Autonomous Prefecture Center Hospital Enshi China
| | - Min Jia
- Department of Neurology Enshi Tujia and Miao Autonomous Prefecture Center Hospital Enshi China
| | - Guiqin Chen
- Department of Neurology Renmin Hospital of Wuhan University Wuhan China
| | - Shuke Nie
- Department of Neurology Renmin Hospital of Wuhan University Wuhan China
| | - Cong Zheng
- Department of Neurology, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Weiqi Zeng
- Department of Neurology, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Yan Xu
- Department of Neurology, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Congping Wang
- Department of Neurology Enshi Tujia and Miao Autonomous Prefecture Center Hospital Enshi China
| | - Xuebing Cao
- Department of Neurology, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Qunhui Liu
- Department of Neurology Enshi Tujia and Miao Autonomous Prefecture Center Hospital Enshi China
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Simonsen C, Magnusdottir SO, Andreasen JJ, Rohde MC, Kjærgaard B. ECMO improves survival following cardiogenic shock due to carbon monoxide poisoning - an experimental porcine model. Scand J Trauma Resusc Emerg Med 2018; 26:103. [PMID: 30466470 PMCID: PMC6251161 DOI: 10.1186/s13049-018-0570-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 11/14/2018] [Indexed: 12/16/2022] Open
Abstract
Background Severe intoxication with carbon monoxide (CO) is extremely lethal and causes numerous deaths due to cardiac or respiratory failure. Conventional intensive treatment may not be sufficient. The aim of this study was to investigate the treatment effect of extracorporeal veno-arterial extracorporeal membrane oxygenation (ECMO) following severe CO poisoning in an experimental porcine model. Methods A total of twelve pigs were anaesthetized, routinely monitored and intoxicated by inhalation of CO until the beginning of cardiac failure and randomized to a treatment (ventilator using an FiO2 of 100% or ECMO). In the case of cardiac arrest, advanced resuscitation using standard guidelines was performed for at least 10 min. ECMO was also initiated in the ventilation group if the return of spontaneous circulation did not occur within 10 min. Lung tissue biopsies were obtained before and after CO intoxication. Results All animals in the ECMO group survived; however, one had to be resuscitated due to cardiac arrest. A single animal survived in the ventilator group, but five animals suffered from cardiac arrest at an average of 11.8 min after initiation of treatment. Conventional resuscitation failed in these animals, but four animals were successfully resuscitated after the establishment of ECMO. A significant decrease was noticed in PO2 with increasing HbCO, but there was no increase in pulmonary vascular resistance. No differences in H&E-stained lung tissue biopsies were observed. Conclusions The use of ECMO following severe CO poisoning greatly improved survival compared with conventional resuscitation in an experimental porcine model. This study forms the basis for further research among patients.
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Affiliation(s)
- Carsten Simonsen
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000, Aalborg, Denmark.
| | - Sigridur O Magnusdottir
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000, Aalborg, Denmark.,Biomedical Research Laboratory, Aalborg University Hospital North, Ladegårdsgade 3, 9000, Aalborg, Denmark
| | - Jan J Andreasen
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000, Aalborg, Denmark
| | - Marianne Cathrine Rohde
- Department of Forensic Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Benedict Kjærgaard
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000, Aalborg, Denmark.,Biomedical Research Laboratory, Aalborg University Hospital North, Ladegårdsgade 3, 9000, Aalborg, Denmark
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11
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Abstract
BACKGROUND Carbon monoxide (CO) poisoning is a common cause of poison-related mortality. CO binds to hemoglobin in the blood to form carboxyhemoglobin (COHb), impairing oxygen delivery to peripheral tissues. Current treatment of CO-poisoned patients involves oxygen administration to rapidly remove CO and restore oxygen delivery. Light dissociates CO from COHb with high efficiency. Exposure of murine lungs to visible laser-generated light improved the CO elimination rate in vivo. The aims of this study were to apply pulmonary phototherapy to a larger animal model of CO poisoning, to test novel approaches to light delivery, and to examine the effect of chemiluminescence-generated light on the CO elimination rate. METHODS Anesthetized and mechanically ventilated rats were poisoned with CO and subsequently treated with air or oxygen combined with or without pulmonary phototherapy delivered directly to the lungs of animals at thoracotomy, via intrapleural optical fibers or generated by a chemiluminescent reaction. RESULTS Direct pulmonary phototherapy dissociated CO from COHb reducing COHb half-life by 38%. Early treatment with phototherapy in critically CO poisoned rats improved lactate clearance. Light delivered to the lungs of rats via intrapleural optical fibers increased the rate of CO elimination without requiring a thoracotomy, as demonstrated by a 16% reduction in COHb half-life. Light generated in the pleural spaces by a chemiluminescent reaction increased the rate of CO elimination in rats breathing oxygen, reducing the COHb half-life by 12%. CONCLUSIONS Successful application of pulmonary phototherapy in larger animals and humans may represent a significant advance in the treatment of CO-poisoned patients.
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12
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Bhagwat S, Bruxner G. 'Not quite out of the woods': potential for misdiagnosis of delayed neurologic syndrome of carbon monoxide poisoning as relapse of mental illness. Australas Psychiatry 2017; 25:494-496. [PMID: 28836814 DOI: 10.1177/1039856217726695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The aim of this paper is to provide an overview of the delayed neurologic syndrome of carbon monoxide poisoning and its clinical importance in psychiatric settings. METHOD A brief review of carbon monoxide poisoning is presented with a focus on the delayed neurologic syndrome and a case of deliberate self- poisoning is described. RESULTS As in the case described, the delayed manifestations of carbon monoxide poisoning can resemble a relapse of psychiatric illness. CONCLUSIONS In cases of carbon monoxide poisoning it is important to consider the delayed neurologic syndrome as misdiagnosis could lead to inappropriate treatment and worsened outcome.
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Affiliation(s)
- Samir Bhagwat
- Psychiatry Registrar, Redcliffe-Caboolture Mental Health Service Caboolture Hospital, Caboolture, QLD, Australia
| | - George Bruxner
- Visiting Psychiatrist and Clinical Lead, Redcliffe-Caboolture Consultation-Liaison Psychiatry Service, Caboolture, QLD, Australia
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13
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Rose JJ, Wang L, Xu Q, McTiernan CF, Shiva S, Tejero J, Gladwin MT. Carbon Monoxide Poisoning: Pathogenesis, Management, and Future Directions of Therapy. Am J Respir Crit Care Med 2017; 195:596-606. [PMID: 27753502 PMCID: PMC5363978 DOI: 10.1164/rccm.201606-1275ci] [Citation(s) in RCA: 357] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 10/14/2016] [Indexed: 02/06/2023] Open
Abstract
Carbon monoxide (CO) poisoning affects 50,000 people a year in the United States. The clinical presentation runs a spectrum, ranging from headache and dizziness to coma and death, with a mortality rate ranging from 1 to 3%. A significant number of patients who survive CO poisoning suffer from long-term neurological and affective sequelae. The neurologic deficits do not necessarily correlate with blood CO levels but likely result from the pleiotropic effects of CO on cellular mitochondrial respiration, cellular energy utilization, inflammation, and free radical generation, especially in the brain and heart. Long-term neurocognitive deficits occur in 15-40% of patients, whereas approximately one-third of moderate to severely poisoned patients exhibit cardiac dysfunction, including arrhythmia, left ventricular systolic dysfunction, and myocardial infarction. Imaging studies reveal cerebral white matter hyperintensities, with delayed posthypoxic leukoencephalopathy or diffuse brain atrophy. Management of these patients requires the identification of accompanying drug ingestions, especially in the setting of intentional poisoning, fire-related toxic gas exposures, and inhalational injuries. Conventional therapy is limited to normobaric and hyperbaric oxygen, with no available antidotal therapy. Although hyperbaric oxygen significantly reduces the permanent neurological and affective effects of CO poisoning, a portion of survivors still have substantial morbidity. There has been some early success in therapies targeting the downstream inflammatory and oxidative effects of CO poisoning. New methods to directly target the toxic effect of CO, such as CO scavenging agents, are currently under development.
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Affiliation(s)
- Jason J. Rose
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine
| | - Ling Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine
| | - Qinzi Xu
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
| | | | - Sruti Shiva
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Department of Pharmacology and Chemical, and
- Center for Metabolism and Mitochondrial Medicine, University of Pittsburgh, Pennsylvania
| | - Jesus Tejero
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine
| | - Mark T. Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine
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14
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Azarov I, Wang L, Rose JJ, Xu Q, Huang XN, Belanger A, Wang Y, Guo L, Liu C, Ucer KB, McTiernan CF, O'Donnell CP, Shiva S, Tejero J, Kim-Shapiro DB, Gladwin MT. Five-coordinate H64Q neuroglobin as a ligand-trap antidote for carbon monoxide poisoning. Sci Transl Med 2016; 8:368ra173. [PMID: 27928027 PMCID: PMC5206801 DOI: 10.1126/scitranslmed.aah6571] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/16/2016] [Indexed: 12/11/2022]
Abstract
Carbon monoxide (CO) is a leading cause of poisoning deaths worldwide, with no available antidotal therapy. We introduce a potential treatment paradigm for CO poisoning, based on near-irreversible binding of CO by an engineered human neuroglobin (Ngb). Ngb is a six-coordinate hemoprotein, with the heme iron coordinated by two histidine residues. We mutated the distal histidine to glutamine (H64Q) and substituted three surface cysteines with less reactive amino acids to form a five-coordinate heme protein (Ngb-H64Q-CCC). This molecule exhibited an unusually high affinity for gaseous ligands, with a P50 (partial pressure of O2 at which hemoglobin is half-saturated) value for oxygen of 0.015 mmHg. Ngb-H64Q-CCC bound CO about 500 times more strongly than did hemoglobin. Incubation of Ngb-H64Q-CCC with 100% CO-saturated hemoglobin, either cell-free or encapsulated in human red blood cells, reduced the half-life of carboxyhemoglobin to 0.11 and 0.41 min, respectively, from ≥200 min when the hemoglobin or red blood cells were exposed only to air. Infusion of Ngb-H64Q-CCC to CO-poisoned mice enhanced CO removal from red blood cells, restored heart rate and blood pressure, increased survival, and was followed by rapid renal elimination of CO-bound Ngb-H64Q-CCC. Heme-based scavenger molecules with very high CO binding affinity, such as our mutant five-coordinate Ngb, are potential antidotes for CO poisoning by virtue of their ability to bind and eliminate CO.
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Affiliation(s)
- Ivan Azarov
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Ling Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Jason J Rose
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Qinzi Xu
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Xueyin N Huang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Andrea Belanger
- Department of Physics, Wake Forest University, Winston-Salem, NC 27109, USA
| | - Ying Wang
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Lanping Guo
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Chen Liu
- Department of Physics, Wake Forest University, Winston-Salem, NC 27109, USA
| | - Kamil B Ucer
- Department of Physics, Wake Forest University, Winston-Salem, NC 27109, USA
| | - Charles F McTiernan
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Christopher P O'Donnell
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Sruti Shiva
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Center for Metabolism and Mitochondrial Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Jesús Tejero
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Daniel B Kim-Shapiro
- Department of Physics, Wake Forest University, Winston-Salem, NC 27109, USA
- Translational Science Center, Wake Forest University, Winston-Salem, NC 27109, USA
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15261, USA.
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
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15
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Rose JJ, Xu Q, Wang L, Gladwin MT. Shining a Light on Carbon Monoxide Poisoning. Am J Respir Crit Care Med 2016; 192:1145-7. [PMID: 26568235 DOI: 10.1164/rccm.201508-1579ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jason J Rose
- 1 Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute University of Pittsburgh Pittsburgh, Pennsylvania and.,2 Division of Pulmonary, Allergy and Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Qinzi Xu
- 2 Division of Pulmonary, Allergy and Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Ling Wang
- 1 Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute University of Pittsburgh Pittsburgh, Pennsylvania and.,2 Division of Pulmonary, Allergy and Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
| | - Mark T Gladwin
- 1 Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute University of Pittsburgh Pittsburgh, Pennsylvania and.,3 Department of Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
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16
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Zazzeron L, Liu C, Franco W, Nakagawa A, Farinelli WA, Bloch DB, Anderson RR, Zapol WM. Pulmonary Phototherapy for Treating Carbon Monoxide Poisoning. Am J Respir Crit Care Med 2016. [PMID: 26214119 DOI: 10.1164/rccm.201503-0609oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Carbon monoxide (CO) exposure is a leading cause of poison-related mortality. CO binds to Hb, forming carboxyhemoglobin (COHb), and produces tissue damage. Treatment of CO poisoning requires rapid removal of CO and restoration of oxygen delivery. Visible light is known to effectively dissociate CO from Hb, with a single photon dissociating one CO molecule. OBJECTIVES To determine whether illumination of the lungs of CO-poisoned mice causes dissociation of COHb from blood transiting the lungs, releasing CO into alveoli and thereby enhancing the rate of CO elimination. METHODS We developed a model of CO poisoning in anesthetized and mechanically ventilated mice to assess the effects of direct lung illumination (phototherapy) on the CO elimination rate. Light at wavelengths between 532 and 690 nm was tested. The effect of lung phototherapy administered during CO poisoning was also studied. To avoid a thoracotomy, we assessed the effect of lung phototherapy delivered to murine lungs via an optical fiber placed in the esophagus. MEASUREMENTS AND MAIN RESULTS In CO-poisoned mice, phototherapy of exposed lungs at 532, 570, 592, and 628 nm dissociated CO from Hb and doubled the CO elimination rate. Phototherapy administered during severe CO poisoning limited the blood COHb increase and improved the survival rate. Noninvasive transesophageal phototherapy delivered to murine lungs via an optical fiber increased the rate of CO elimination while avoiding a thoracotomy. CONCLUSIONS Future development and scaling up of lung phototherapy for patients with CO exposure may provide a significant advance for treating and preventing CO poisoning.
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Affiliation(s)
- Luca Zazzeron
- 1 Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care, and Pain Medicine
| | - Chen Liu
- 1 Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care, and Pain Medicine
| | - Walfre Franco
- 2 Wellman Center for Photomedicine, Department of Dermatology, and
| | - Akito Nakagawa
- 1 Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care, and Pain Medicine
| | | | - Donald B Bloch
- 1 Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care, and Pain Medicine.,3 Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - R Rox Anderson
- 2 Wellman Center for Photomedicine, Department of Dermatology, and
| | - Warren M Zapol
- 1 Anesthesia Center for Critical Care Research of the Department of Anesthesia, Critical Care, and Pain Medicine
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