Guanylate cyclase inhibition by methylene blue as an option in the treatment of vasoplegia after a severe burn. A medical hypothesis

The oxygen dissociation curve of blood in COVID-19

COVID-19 hinders oxygen transport to the consuming tissues by at least two mechanisms: In the injured lung, saturation of hemoglobin is compromised, and in the tissues, an associated anemia reduces the volume of delivered oxygen. For the first problem, increased hemoglobin oxygen affinity [left shift of the oxygen dissociation curve (ODC)] is of advantage, for the second, however, the contrary is the case. Indeed a right shift of the ODC has been found in former studies for anemia caused by reduced cell production or hemolysis. This resulted from increased 2,3-bisphosphoglycerate (2,3-BPG) concentration. In three investigations in COVID-19, however, no change of hemoglobin affinity was detected in spite of probably high [2,3-BPG]. The most plausible cause for this finding is formation of methemoglobin (MetHb), which increases the oxygen affinity and thus apparently compensates for the 2,3-BPG effect. However, this "useful effect" is cancelled by the concomitant reduction of functional hemoglobin. In the largest study on COVID-19, even a clear left shift of the ODC was detected when calculated from measurements in fresh blood rather than after equilibration with gases outside the body. This additional "in vivo" left shift possibly results from various factors, e.g., concentration changes of Cl-, 2,3-BPG, ATP, lactate, nitrocompounds, glutathione, glutamate, because of time delay between blood sampling and end of equilibration, or enlarged distribution space including interstitial fluid and is useful for O2 uptake in the lungs. Under discussion for therapy are the affinity-increasing 5-hydroxymethyl-2-furfural (5-HMF), erythropoiesis-stimulating substances like erythropoietin, and methylene blue against MetHb formation.

Glutamine with probiotics attenuates intestinal inflammation and oxidative stress in a rat burn injury model through altered iNOS gene aberrant methylation

Severe burns may lead to intestinal inflammation and oxidative stress resulting in intestinal barrier damage and gut dysfunction. In the management of severe burns, therapies are needed to attenuate whole-body inflammatory responses and control the burden of oxidative stress. In this study, we evaluated the effects of oral glutamine (Gln) with probiotics on burn-induced intestinal inflammation and oxidative stress using a Wistar rat burn injury model. We then explored potential molecular mechanisms for the effects of glutamine and probiotics on intestinal tissue inflammation and oxidative stress. We found that glutamine and probiotics together significantly inhibited nitric oxide (NO) content; reduced levels of the inflammatory factors TNF-α, IL-6, and IL-8; and altered expression of oxidative stress factors including reactive oxygen species and superoxide dismutase. We found that the apoptotic proportion of intestinal epithelial cells in severely burned subjects was notably decreased following treatment with glutamine plus probiotics. We also found that glutamine and probiotics given together markedly reduced NO content by down-regulating the expression of iNOS in blood and intestinal tissue. These findings indicate that regulation of the iNOS gene plays a pivotal role in inflammation and oxidative stress in the response to severe burns in the Wistar rat. We then further investigated the mechanism by which combined therapy with glutamine and probiotics might reduce expression of iNOS and found that this treatment resulted in increased methylation of the iNOS gene. The methylation level of the iNOS gene was found to be regulated via differential expression of DNMT1 and Tet1. Collectively, our results suggest that combined therapy with glutamine and probiotics can markedly reduce the synthesis of NO, suppressing intestinal inflammation and oxidative stress in the Wistar rat burn injury model.

Methylene blue for burn-induced vasoplegia: case report and review of literature

We report the use of a single dose of methylene blue in a patient with burn-induced vasoplegia refractory to fluids, vasopressors, and steroids. Administration of methylene blue allowed for cessation of epinephrine infusion within 2 hours of administration, and reduction in excessive fluid resuscitation. The patient's clinical course continued for 2 months and was complicated by severe acute respiratory distress syndrome, pneumonia, septic shock, poor skin graft adherence, renal failure requiring continuous renal replacement therapy, cutaneous mucormycosis, and ultimately, withdrawal of care and death. Despite the eventual outcome, this is the longest reported survival following methylene blue administration for vasoplegia secondary to burn injury.

Update on Severe Burn Management for the Intensivist

Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients.

Attenuation of noise-induced hearing loss using methylene blue

The overproduction of reactive oxygen species (ROS) and reactive nitrogen species (RNS) has been known to contribute to the pathogenesis of noise-induced hearing loss. In this study, we discovered that in BALB/c mice pretreatment with methylene blue (MB) for 4 consecutive days significantly protected against cochlear injury by intense broad-band noise for 3 h. It decreased both compound threshold shift and permanent threshold shift and, further, reduced outer hair cell death in the cochlea. MB also reduced ROS and RNS formation after noise exposure. Furthermore, it protected against rotenone- and antimycin A-induced cell death and also reversed ATP generation in the in vitro UB-OC1 cell system. Likewise, MB effectively attenuated the noise-induced impairment of complex IV activity in the cochlea. In addition, it increased the neurotrophin-3 (NT-3) level, which could affect the synaptic connections between hair cells and spiral ganglion neurons in the noise-exposed cochlea, and also promoted the conservation of both efferent and afferent nerve terminals on the outer and inner hair cells. These findings suggest that the amelioration of impaired mitochondrial electron transport and the potentiation of NT-3 expression by treatment with MB have a significant therapeutic value in preventing ROS-mediated sensorineural hearing loss.

Arteriolar diameter and spontaneous vasomotion: importance of potassium channels and nitric oxide

Arterioles display cyclic variations in diameter, termed vasomotion initiated by smooth muscle cells (SMCs), but the endothelium should also be evaluated due to its modulatory role on vessel tone. Since nitric oxide (NO) and prostacyclin (PGI2) regulate SMC tone and activate K(+) currents, we have investigated their role on vasomotion, by observing effects of topical application of N(ω)-nitro-l-arginine (L-NA, NO synthesis inhibitor), glibenclamide (KATP channel inhibitor), sodium nitroprusside (SNP, NO donor), iloprost (PGI2 analogue) and methylene blue (MB, cGMP production inhibitor) on the cheek pouch preparation of anesthetized male hamsters. L-NA (10(-10)-10(-6)M) induced vasoconstriction, reduction and abolition of vasomotion. MB (10(-7) to 10(-5)M) reduced mean arteriolar diameter with no changes on vasomotion. In the presence of 10(-6)M of MB, addition of 10(-6)L-NA totally abolished vasomotion without further constriction. Glibenclamide (10(-6)M) in the presence of L-NA at equimolar concentration restored both vasomotion frequency and amplitude. This effect was not observed in the presence of TEA 5mM. SNP (10(-10)-10(-6)M) induced a dose-dependent increase of arteriolar diameter and decreased vasomotion. Iloprost (10(-12)-10(-6)M) induced a concentration dependent increase of arteriolar diameter, reduced vasomotion frequency, but in lower concentrations (10(-12)-10(-10)M) increased its amplitude and in higher concentrations (10(-9)-10(-6)M) decreased it. SNP and iloprost inhibited vasomotion at 10(-7)M; however, at this concentration SNP and iloprost induced an increment of 35% and 50% of the initial arteriolar diameter, respectively. In the presence of L-NA (10(-6)M), vasomotion was restored by SNP at 10(-10)M and iloprost 10(-12)M, which corresponded to 80% of the initial diameter value. Around the initial (control) arteriolar diameter value, vasomotion presented its highest frequencies and amplitudes. Cessation of vasomotion occurred with L-NA (10(-6)M) in the presence of SNP (10(-6)M) and iloprost (10(-7)M) when arteriolar diameter reached 150% and 120% of its initial value, respectively. In conclusion, the present study strongly suggests that vasomotion (1) is not solely related to vascular tone, (2) needs an interplay between vascular tone and membrane currents and (3) could be modulated by NO (but not cGMP) and KATP channels. In addition, our results point to the existence of dissociation between vasomotion frequency and amplitude.

Curbing inflammation in burn patients

Patients who suffer from severe burns develop metabolic imbalances and systemic inflammatory response syndrome (SIRS) which can result in multiple organ failure and death. Research aimed at reducing the inflammatory process has yielded new insight into burn injury therapies. In this review, we discuss strategies used to curb inflammation in burn injuries and note that further studies with high quality evidence are necessary.