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Wang Y, Yu Q, Tian Y, Ren S, Liu L, Wei C, Liu R, Wang J, Li D, Zhu K. Unraveling the impact of nitric oxide, almitrine, and their combination in COVID-19 (at the edge of sepsis) patients: a systematic review. Front Pharmacol 2024; 14:1172447. [PMID: 38318311 PMCID: PMC10839063 DOI: 10.3389/fphar.2023.1172447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 12/27/2023] [Indexed: 02/07/2024] Open
Abstract
Introduction: During the coronavirus disease 2019 (COVID-19) pandemic, a large number of critically ill and severe COVID-19 patients meet the diagnostic criteria for sepsis and even septic shock. The treatments for COVID-19 patients with sepsis are still very limited. For sepsis, improving ventilation is one of the main treatments. Nitric oxide (NO) and almitrine have been reported to improve oxygenation in patients with "classical" sepsis. Here, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of NO, almitrine, and the combination of both for COVID-19 (at the edge of sepsis) patients. Method: A systematic search was performed on Embase, PubMed, the Cochrane Library, the Web of Science, Wanfang Data, and China National Knowledge Infrastructure. Randomized clinical trials, cohort studies, cross-sectional studies, case-control studies, case series, and case reports in COVID-19 patients with suspected or confirmed sepsis were performed. Study characteristics, patient demographics, interventions, and outcomes were extracted from eligible articles. Results: A total of 35 studies representing 1,701 patients met eligibility criteria. Inhaled NO did not affect the mortality (OR 0.96, 95% CI 0.33-2.8, I2 = 81%, very low certainty), hospital length of stay (SMD 0.62, 95% CI 0.04-1.17, I2 = 83%, very low certainty), and intubation needs (OR 0.82, 95% CI 0.34-1.93, I2 = 56%, very low certainty) of patients with COVID-19 (at the edge of sepsis). Meanwhile, almitrine did not affect the mortality (OR 0.44, 95% CI 0.17-1.13, low certainty), hospital length of stay (SMD 0.00, 95% CI -0.29-0.29, low certainty), intubation needs (OR 0.94, 95% CI 0.5-1.79, low certainty), and SAEs (OR 1.16, 95% CI 0.63-2.15, low certainty). Compared with pre-administration, the PaO2/FiO2 of patients with NO (SMD-0.87, 95% CI -1.08-0.66, I2 = 0%, very low certainty), almitrine (SMD-0.73, 95% CI-1.06-0.4, I2 = 1%, very low certainty), and the combination of both (SMD-0.94, 95% CI-1.71-0.16, I2 = 47%, very low certainty) increased significantly. Conclusion: Inhaled NO, almitrine, and the combination of the two drugs improved oxygenation significantly, but did not affect the patients' mortality, hospitalization duration, and intubation needs. Almitrine did not significantly increase the patients' SAEs. Well-designed high-quality studies are needed for establishing a stronger quality of evidence. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=367667, identifier CRD42022367667.
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Affiliation(s)
- Ying Wang
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, Jilin, China
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Qian Yu
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, Jilin, China
| | - Yuan Tian
- Department of Nutrition and Food Hygiene, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Shiying Ren
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Liping Liu
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Chaojie Wei
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Renli Liu
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Jing Wang
- Department of Pharmacy, Siping Tumor Hospital, Siping, Jilin, China
| | - Dong Li
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Kun Zhu
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, Jilin, China
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Trachsel S, Hambraeus-Jonzon K, Bergquist M, Martijn C, Chen L, Hedenstierna G. No redistribution of lung blood flow by inhaled nitric oxide in endotoxemic piglets pretreated with an endothelin receptor antagonist. J Appl Physiol (1985) 2014; 118:768-75. [PMID: 25549764 DOI: 10.1152/japplphysiol.00591.2014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Inhaled nitric oxide (INO) improves ventilation-perfusion matching and alleviates pulmonary hypertension in patients with acute respiratory distress syndrome. However, outcome has not yet been shown to improve, and nonresponse is common. A better understanding of the mechanisms by which INO acts may guide in improving treatment with INO in patients with severe respiratory failure. We hypothesized that INO may act not only by vasodilation in ventilated lung regions, but also by causing vasoconstriction via endothelin (ET-1) in atelectatic, nonventilated lung regions. This was studied in 30 anesthetized, mechanically ventilated piglets. The fall in oxygenation and rise in pulmonary artery pressure during a sepsislike condition (infusion of endotoxin) were blunted by INO 40 ppm. Endotoxin infusion increased serum ET-1, and INO almost doubled the ratio between mRNA expression of endothelin receptor A (mediating vasoconstriction) and B (mediating vasodilation and clearance of ET-1) (ET-A/ET-B) in atelectatic lung regions. INO caused a shift in blood flow away from atelectatic lung regions in the endotoxemic piglets, but not during ET receptor antagonism. We conclude that INO in short-term experiments, in addition to causing selective pulmonary vasodilation in ventilated lung regions, increases the ET-A/ET-B mRNA expression ratio in lung tissue. This might augment the vasoconstriction in atelectatic lung regions, enhancing the redistribution of pulmonary blood flow to ventilated lung regions which are reached by INO. Such vasoconstriction may be an important additional factor explaining the effect of INO.
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Affiliation(s)
- Sebastien Trachsel
- Department of Medical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden; University Department of Anesthesiology and Pain Medicine, University Hospital, Inselspital, Bern, Switzerland
| | - Kristina Hambraeus-Jonzon
- Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Bergquist
- Department of Medical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
| | - Cecile Martijn
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Luni Chen
- Department of Medical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden; Karolinska Institutet, Solna, Sweden
| | - Göran Hedenstierna
- Department of Medical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden;
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Protective effects of endothelin-A receptor antagonist BQ123 against LPS-induced oxidative stress in lungs. Pharmacol Rep 2011; 63:494-500. [PMID: 21602605 DOI: 10.1016/s1734-1140(11)70516-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 10/25/2010] [Indexed: 12/22/2022]
Abstract
The aim of this study was to assess whether endothelin-A receptor (ET(A)-R) blocker, BQ123, influences lung edema, lipid peroxidation TBARS), hydrogen peroxide (H(2)O(2)), TNF-α concentration or the glutathione redox system in the lung homogenates obtained from LPS-induced endotoxic shock rats. The study was performed on male Wistar rats (n = 6 per group) divided into groups: (1) saline, (2) LPS (15 mg/kg)-saline, (3) BQ123 (0.5 mg/kg)-LPS, (4) BQ123 (1 mg/kg)-LPS. The ET(A)-R antagonist was injected intravenously 30 min before LPS administration. Five hours after saline or LPS administration, animals were sacrificed and lungs were isolated for indices of lung edema, oxidative stress and TNF-α concentration. Injection of LPS alone resulted in lung edema development and a marked increase in TNF-α (p < 0.02), TBARS (p < 0.02), and H(2)O(2) (p < 0.01) concentrations as well as a depletion of total glutathione (p < 0.01). Administration of BQ123 (1 mg/kg), before LPS challenge, led to a significant reduction in TNF-α and H(2)O(2) concentrations (p < 0.05) and elevation of both total glutathione and the GSH/GSSG ratio (p < 0.05). However, it did not prevent LPS-induced TBARS increase and lung edema formation. Interestingly, a lower dose of BQ123 was much more effective in decreasing H(2)O(2), TBARS, as well as TNF-α levels (p < 0.02, p < 0.05, p < 0.05, respectively). That dose was also effective in prevention of lung edema development (p < 0.01). Taken together, the obtained results indicate that BQ123 is highly effective in decreasing LPS-induced oxidative stress in lungs. Moreover, the dose of 0.5 mg/kg of the antagonist showed to be more effective in decreasing free radical generation and lung edema in endotoxemic rats.
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Applying gases for microcirculatory and cellular oxygenation in sepsis: effects of nitric oxide, carbon monoxide, and hydrogen sulfide. Curr Opin Anaesthesiol 2009; 22:168-76. [PMID: 19390245 DOI: 10.1097/aco.0b013e328328d22f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Nitric oxide, carbon monoxide, and hydrogen sulfide (H2S) are gases that have received attention as signaling molecules regulating many biological processes. All of them were reported to have beneficial effects in inflammatory states, in particular for microcirculatory perfusion and tissue energy balance. Thus, this review will highlight the most important results with a focus on resuscitated, clinically relevant experimental models and, if available, human studies. RECENT FINDINGS There is ample evidence that nitric oxide, carbon monoxide, and H2S may exert cytoprotective effects in shock states due to their vasomotor, antioxidant, and anti-inflammatory properties as well as their potential to induce a hibernation-like metabolic state called 'suspended animation' resulting from inhibition of cytochrome-c-oxidase. It must be emphasized, however, that the three molecules may also be cytotoxic, not only because of their inhibition of cellular respiration but also because of their marked pro-inflammatory effects. SUMMARY It is still a matter of debate whether manipulating nitric oxide, carbon monoxide, or H2S tissue concentrations, either by using the inhaled gas itself or by administering donor molecules or inhibitors of their endogenous production, is a useful therapeutic approach to improve microcirculatory blood flow, tissue oxygenation, and cellular respiration. This is mainly due to their 'friend and foe character' documented in various experimental models, but also to the paucity of data from long-term, resuscitated large animal experiments that fulfil the criteria of clinically relevant models.
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Opal SM, LaRosa SP. Year in review 2008: Critical Care--sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:224. [PMID: 19886974 PMCID: PMC2784335 DOI: 10.1186/cc7945] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The present report highlights the most important papers appearing in Critical Care and other major journals about severe sepsis, the systemic inflammatory response and multiorgan dysfunction over the past year. A number of these clinical and laboratory studies will have a considerable impact on the sepsis research agenda for years to come. The steroid controversy, the debate over tight glycemic control, the colloid versus crystalloid issue, the value of selective decontamination of the digestive tract, the enlarging role of biomarkers, the value of genomics and rapid diagnostic techniques have all been prominently featured in recent publications. Basic research into novel predictive assays, genetic polymorphisms, and new molecular methods to risk-stratify and to determine treatment options for sepsis have occupied much of the Critical Care publications relating to sepsis pathophysiology in 2008. We will attempt to briefly summarize what we consider to be the most significant contributions to the sepsis literature over the last year, and their likely ramifications in the future, for critical care clinicians, clinical investigators and basic researchers alike.
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Affiliation(s)
- Steven M Opal
- Department of Medicine, Infectious Disease Division, Memorial Hospital of RI, The Warren Alpert Medical School of Brown University, 111 Brewster Street, Pawtucket, RI 02860, USA.
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