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Vassalos A, Peng E, Young D, Walker S, Pollock J, MacArthur K, Lyall F, Danton MHD. Pre-operative sildenafil and pulmonary endothelial-related complications following cardiopulmonary bypass: a randomised trial in children undergoing cardiac surgery*. Anaesthesia 2011; 66:472-80. [DOI: 10.1111/j.1365-2044.2011.06702.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
AIMS AND OBJECTIVES This paper, therefore, aimed to review published literature in this area of pharmacological exploitation, to look at the therapeutic applications and clinical relevance and, by so doing, provide an accessible source for nurses to gain insight into the role of nitric oxide in the clinical setting. BACKGROUND Nitric oxide is a chemical mediator fundamental in the maintenance of adequate tissue perfusion and effective cardiovascular function; a major endogenous regulator of vascular tone. The use of nitrates are well established as pharmacological agents but it is only recently that it has been recognized that they act as a source of nitric oxide. Although widely addressed within the medical literature, there appears to be a paucity of nursing literature that explores either its physiological action, or its relevance to nursing practice. CONCLUSIONS This literature review provides an overview of the use of nitric oxide and its implications for nursing practice and patient outcomes. RELEVANCE TO CLINICAL PRACTICE Knowledge of nitric oxide and its action is pertinent to nurses across diverse specialities. It helps in understanding the principles of many nitrogen-derived medications which nurses administer to their patients on a daily basis. In terms of oral medication, this is demonstrated by greater insights into the action of nitrates, the appreciation of surprising developments in medications such as sildenafil and the development of new drug opportunities such as nitric oxide-non-steroidal anti-inflammatory drugs. Equally, the use of inhaled nitric oxide therapy in adult and neonatal critical care units appears to be an increasingly valuable source of treatment. A particular research challenge is found in the attempt at nitric oxide inhibition in the management of septic shock. The authors argue that understanding such esoteric areas of therapeutic developments is increasingly to be part of the repertoire of knowledge and skills for nurses in the 21st century.
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Maruyama J, Jiang BH, Maruyama K, Takata M, Miyasaka K. Prolonged nitric oxide inhalation during recovery from chronic hypoxia does not decrease nitric oxide-dependent relaxation in pulmonary arteries. Chest 2005; 126:1919-25. [PMID: 15596693 DOI: 10.1378/chest.126.6.1919] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To investigate the effects of long-term nitric oxide (NO) inhalation on the recovery process of right ventricular hypertrophy (RVH) and functional alterations in the NO-cyclic guanosine monophosphate (cGMP) relaxation pathway in rat conduit pulmonary arteries (PAs) in established chronic hypoxic pulmonary hypertension. MATERIALS AND METHODS A total of 35 rats were exposed to chronic hypobaric hypoxia (380 mm Hg, 10% oxygen), and 39 rats were exposed to air for 10 days. Both groups were then exposed to 3 or 10 days of NO 10 ppm, NO 40 ppm, or air (control groups for each NO concentration), resulting in a total of 16 groups. Acetylcholine- and sodium nitroprusside (SNP)-induced relaxation were evaluated in precontracted PA rings. RVH was assessed by heart weight ratio of right ventricle to left ventricle plus septum. RESULTS NO inhalation had no effect on either the regression of RVH or the recovery process of impaired relaxation induced by acetylcholine or SNP in a endothelium-intact hypertensive conduit extrapulmonary artery or intrapulmonary artery (IPA). In a normal endothelium-intact conduit IPA, 40 ppm NO inhalation for 10 days partially augmented SNP-induced relaxation, but not that induced by acetylcholine. CONCLUSION Continuous NO inhalation did not affect the regression process of either established RVH or the impaired endogenous NO-cGMP relaxation cascade in a conduit PA in rats during the recovery period after chronic hypoxia.
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Affiliation(s)
- Junko Maruyama
- Department of Physiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
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Abstract
The discovery in 1989 of sildenafil, a highly selective inhibitor of phosphodiesterase-5 (PDE-5), was the result of extensive research on chemical agents targeting PDE-5 that might potentially be useful in the treatment of coronary heart disease. Initial clinical studies on sildenafil in the early 1990s were not promising with respect to its antianginal potential. However, the incidental discovery of its antiimpotence effect led to its approval of for the treatment of erectile dysfunction. Thereafter, several reports of adverse cardiac events in patients on sildenafil raised concerns about its safety in cardiovascular disorders. Novel therapeutic indications are emerging for sildenafil with the recent discovery that PDE-5 is expressed in various other tissues such as the arterial vasculature, including pulmonary and coronary arteries, venous vasculature, skeletal muscles, platelets, and visceral and tracheobronchial muscles. In this review we briefly summarize the pharmacology of sildenafil and the current available evidence on its potential therapeutic applications in cardiovascular disorders.
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Affiliation(s)
- Shahzad G Raja
- Department of Paediatric Cardiac Surgery, Alder Hey Children's Hospital, West Derby, Liverpool, United Kingdom.
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Macrae DJ, Field D, Mercier JC, Møller J, Stiris T, Biban P, Cornick P, Goldman A, Göthberg S, Gustafsson LE, Hammer J, Lönnqvist PA, Sanchez-Luna M, Sedin G, Subhedar N. Inhaled nitric oxide therapy in neonates and children: reaching a European consensus. Intensive Care Med 2004; 30:372-80. [PMID: 14722629 DOI: 10.1007/s00134-003-2122-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2003] [Accepted: 12/01/2003] [Indexed: 10/26/2022]
Abstract
Inhaled nitric oxide (iNO) was first used in neonatal practice in 1992 and has subsequently been used extensively in the management of neonates and children with cardiorespiratory failure. This paper assesses evidence for the use of iNO in this population as presented to a consensus meeting jointly organised by the European Society of Paediatric and Neonatal Intensive Care, the European Society of Paediatric Research and the European Society of Neonatology. Consensus Guidelines on the Use of iNO in Neonates and Children were produced following discussion of the evidence at the consensus meeting.
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Affiliation(s)
- Duncan J Macrae
- Royal Brompton Hospital, Sydney Street, SW3 6NP London, U.K.
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Gao Y, Dhanakoti S, Trevino EM, Wang X, Sander FC, Portugal AD, Raj JU. Role of cGMP-dependent protein kinase in development of tolerance to nitric oxide in pulmonary veins of newborn lambs. Am J Physiol Lung Cell Mol Physiol 2003; 286:L786-92. [PMID: 14660486 DOI: 10.1152/ajplung.00314.2003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Continuous exposure to nitrovasodilators and nitric oxide induces tolerance to their vasodilator effects in vascular smooth muscle. This study was done to determine the role of cGMP-dependent protein kinase (PKG) in the development of tolerance to nitric oxide. Isolated fourth-generation pulmonary veins of newborn lambs were studied. Incubation of veins for 20 h with DETA NONOate (DETA NO; a stable nitric oxide donor) significantly reduced their relaxation response to the nitric oxide donor and to beta-phenyl-1,N2-etheno-8-bromo-cGMP (8-Br-PET-cGMP, a cell-permeable cGMP analog). Incubation with DETA NO significantly reduced PKG activity and protein and mRNA levels in the vessels. These effects were prevented by 1H-(1,2,4)oxadiazolo(4,3-a)quinoxalin-1-one (an inhibitor of soluble guanylyl cyclase) and Rp-8-Br-PET-cGMPS (an inhibitor of PKG). A decrease in PKG protein and mRNA levels was also observed after continuous exposure to cGMP analogs. The PKG inhibitor abrogated these effects. The decrease in cGMP-mediated relaxation and in PKG activity caused by continuous exposure to DETA NO was not affected by KT-5720, an inhibitor of cAMP-dependent protein kinase. Prolonged exposure to 8-Br-cAMP (a cell-permeable cAMP analog) did not affect PKG protein level in the veins. These results suggest that continuous exposure to nitric oxide or cGMP downregulates PKG by a PKG-dependent mechanism. Such a negative feedback mechanism may contribute to the development of tolerance to nitric oxide in pulmonary veins of newborn lambs.
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Affiliation(s)
- Yuansheng Gao
- Harbor-UCLA Medical Center, Research and Education Institute, 1124 W. Carson St., RB-1, Torrance, CA 90502, USA.
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Abstract
Inhaled nitric oxide (NO) clearly decreased pulmonary vascular resistance in pediatric patients with pulmonary hypertension, regardless of the underlying origin of the pulmonary hypertension. In persistent pulmonary hypertension of the neonate (PPHN) and CHD, the use of inhaled NO appears to improve the outcome of these patients. In acute respiratory distress syndrome (ARDS) and surfactant deficiency the role of inhaled NO therapy remains unclear. The use of inhaled NO is safe in a carefully monitored setting with a delivery system designed to minimize the generation of NO2.
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Affiliation(s)
- L D Nelin
- Section of Neonatology, Medical College of Wisconsin, Milwaukee, USA
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Francoe M, Troncy E, Blaise G. Inhaled nitric oxide: technical aspects of administration and monitoring. Crit Care Med 1998; 26:782-96. [PMID: 9559620 DOI: 10.1097/00003246-199804000-00033] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Clinical applications of inhaled nitric oxide (NO) therapy resulted in the development of delivery systems and monitoring devices applicable to routine clinical care. This article presents the various components necessary for an adequate clinical use of inhaled NO, and discusses the NO gas mixture cylinders, inhaled NO delivery techniques and specifications, monitoring devices, and ending with an exhaustive description of the scavengers of nitrogen oxides (NOx). DATA SOURCES Computerized search (CURRENT CONTENTS, MEDLINE) of published original research and review articles (approximately 200), conference abstracts and compendiums up to May 1997 (approximately 50), personal files, and contact with expert informants. STUDY SELECTION Technical, experimental, and clinical reports were selected from the recent English, French, German, and Spanish literature, if pertinent to the administration or monitoring of inhaled NO. DATA EXTRACTION The authors extracted all applicable data. DATA SYNTHESIS The production of NO gas mixture cylinders must be certified with respect to gas purity, stability, and concentration (limits between 100 and 1000 ppm), guaranteed calibration, and specific color. An ideal inhaled NO delivery device requires a synchronized delivery, a minimal production of nitrogen dioxide (NO2), and should be simple to use (verification, calibration, convenient flushing, cylinder change possible while in use and a simple alarm setting) with full information (high and low alarms and available precision monitoring of NO, NO2, and O2). Emergency and transport systems must be readily available. The choice of the monitoring device (chemiluminescence or electrochemistry) should be made based on the knowledge of their strength and weakness for a particular clinical application. Finally, scavengers of NOx should be used with caution until specific filters are proven safe and effective. CONCLUSIONS The great expectancies generated by inhaled NO action have led researchers to design personal inhaled NO delivery systems, but only with mitigated results. At present, medical companies are finding a financial interest in designing a delivery system which will suit the needs of clinicians and this, along with official governmental approval, will only then permit the use of inhaled NO safely and on a larger scale.
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Affiliation(s)
- M Francoe
- Department of Anesthesia, Centre Hospitalier de l'Université de Montréal, Pavillon Notre-Dame, PQ, Canada
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Cuthbertson BH, Dellinger P, Dyar OJ, Evans TE, Higenbottam T, Latimer R, Payen D, Stott SA, Webster NR, Young JD. UK guidelines for the use of inhaled nitric oxide therapy in adult ICUs. American-European Consensus Conference on ALI/ARDS. Intensive Care Med 1997; 23:1212-8. [PMID: 9470075 DOI: 10.1007/s001340050488] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Although unlicensed, inhaled nitric oxide (NO) therapy is now widely used in the United Kingdom. Our aim was to produce guidelines for the clinical application of inhaled NO in adult intensive care practice, based upon the current level of published information. METHODS The published data regarding the use of inhaled NO in the acute respiratory distress syndrome and right-sided cardiac failure was presented, analysed and discussed. Recommendations based on these data as well as on current experience in the United Kingdom were formulated. DESIGN An expert group comprising intensive care specialists from within the United Kingdom, representatives from the European Society of Intensive Care Medicine and the Society of Critical Care Medicine and individuals from the Departments of Health and Industry related to the field was assembled. RESULTS United Kingdom guidelines for the indications, contraindications, dose, delivery, monitoring and scavenging of inhaled NO therapy were produced. CONCLUSIONS The need for additional quality research to establish evidence of efficacy and safety was emphasized. The guidelines are designed to act within the context of current practice and knowledge and should be revised as further data emerge.
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Affiliation(s)
- B H Cuthbertson
- Anaesthesia and Intensive Care, Institute of Medical Sciences, Medical School, University of Aberdeen, Scotland.
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Dinh-Xuan AT, Brunet F, Dhainaut JF. The use, and misuse, of exogenous endothelial-derived vasodilators in acute respiratory failure. Intensive Care Med 1997; 23:1110-8. [PMID: 9434915 DOI: 10.1007/s001340050466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- A T Dinh-Xuan
- Department of Physiology, Cochin University Hospital, Paris, France
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Combes X, Mazmanian M, Gourlain H, Hervé P. Effect of 48 hours of nitric oxide inhalation on pulmonary vasoreactivity in rats. Am J Respir Crit Care Med 1997; 156:473-7. [PMID: 9279226 DOI: 10.1164/ajrccm.156.2.9601056] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Nitric oxide (NO) has been shown to down regulate its own synthesis in vitro. We tested the hypothesis that NO inhalation (30 ppm under normoxic conditions) could decrease the release of endogenous endothelial NO, and thus alter pulmonary vasoreactivity. Pulmonary vasoreactivity was assessed in isolated perfused rat lungs immediately or 6 h after a 48 h NO inhalation period, and compared with a control group. NO inhalation resulted in an increase in pulmonary vasoconstrictor reactivity to angiotensine II and U-46619, a reduction in the potentiation by the eNOS inhibitor L-NAME of the angiotensine II response, a decrease in endothelium-dependent vasodilation to arginine vasopressin, whereas non-endothelium-dependent vasodilation to sodium nitroprusside remained unaltered. These alterations returned to control values in the group studied 6 h after the end of NO inhalation, and were not prevented by inhibition of the prostanoid synthesis, or by pretreatment with the endothelin receptors antagonist Bosentan. These results indicate that NO inhalation over 2 d induces a reversible alteration of pulmonary vasoreactivity in relationship with a decrease in endogenous NO release. Inhibition of eNOS could be involved.
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Affiliation(s)
- X Combes
- Laboratoire de Chirurgie Experimentale, Hôpital Marie Lannelongue, Université de Paris Sud, Le Plessis-Robinson, France
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Haraldsson A, Kieler-Jensen N, Ricksten SE. Inhaled prostacyclin for treatment of pulmonary hypertension after cardiac surgery or heart transplantation: a pharmacodynamic study. J Cardiothorac Vasc Anesth 1996; 10:864-8. [PMID: 8969392 DOI: 10.1016/s1053-0770(96)80047-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To study the effects of incremental concentrations of inhaled aerosolized prostacyclin (PGI2) on pulmonary and systemic hemodynamics after cardiac surgery or heart transplantation. DESIGN Pharmacodynamic dose-response study. SETTING Cardiothoracic intensive care unit (ICU) at a university hospital. PARTICIPANTS Nine patients with pulmonary hypertension after cardiac surgery or heart transplantation and an elevated pulmonary vascular resistance (PVR) (> 20 dynes.sec.cm-5) treated in the ICU with inotropic support were studied. INTERVENTIONS Inhaled prostacyclin was administered at concentrations of 2.5, 5.0, and 10.0 micrograms/mL using conventional systems for nebulization. MEASUREMENTS AND MAIN RESULTS Pulmonary and systemic hemodynamics as well as right ventricular (RV) function variables (n = 3) were measured before, during, and 10 and 20 minutes after inhalation of PGI2. Inhaled PGI2 induced a dose-dependent decrease in PVR and the transpulmonary gradient (which decreased by -29% and -26%, respectively) at an inhaled concentration of 10 micrograms/mL. Inhaled PGI2 caused no changes in systemic vascular resistance. Central venous pressure decreased during PGI2 inhalation with no change in stroke volume, indicating an improvement in RV performance, which was particularly obvious in one patient with RV failure after heart transplantation. Twenty minutes after discontinuation of inhaled PGI2, hemodynamic variables returned to baseline. CONCLUSIONS Inhaled PGI2 induces a dose-dependent selective pulmonary vasodilation and may improve RV performance after cardiac surgery complicated by pulmonary hypertension and RV failure.
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Affiliation(s)
- A Haraldsson
- Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
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Goldman AP, Haworth SG, Macrae DJ. Does inhaled nitric oxide suppress endogenous nitric oxide production? J Thorac Cardiovasc Surg 1996; 112:541-2. [PMID: 8751526 DOI: 10.1016/s0022-5223(96)70285-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- A P Goldman
- Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, United Kingdom
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Abstract
Inhaled nitric oxide is rapidly gaining popularity as a selective pulmonary vasodilator in patients with acute lung injury and pulmonary hypertension. The development of nitric oxide as a drug has bypassed the usual regulatory and commercial processes, and as a result clinicians have devised a wide range of delivery and monitoring systems. This review describes these systems, and discusses their advantages, disadvantages and safety. The monitoring of nitric oxide metabolites is also discussed.
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Affiliation(s)
- J D Young
- Nuffield Department of Anaesthetics, The Radcliffe Infirmary, Oxford, UK
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De Man JG, Boeckxstaens GE, De Winter BY, Moreels TG, Herman AG, Pelckmans PA. Inhibition of non-adrenergic non-cholinergic relaxations by nitric oxide donors. Eur J Pharmacol 1995; 285:269-74. [PMID: 8575513 DOI: 10.1016/0014-2999(95)00420-p] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The effects of pretreatment with the nitric oxide (NO)-releasing substances 3-morpholino-sydnoninime (SIN-1) and nitroglycerin were investigated on relaxations induced by non-adrenergic non-cholinergic (NANC) nerve stimulation, authentic NO and vasoactive intestinal polypeptide (VIP) in the rat gastric fundus. Short periods of electrical stimulation (0.5-16 Hz, 1 ms, pulse trains of 10 s) induced frequency-dependent transient relaxations, previously shown to be mainly mediated by NO. Both SIN-1 (10-100 microM) and nitroglycerin (0.5 mM) pretreatment significantly reduced these electrically induced responses to a similar extent as the inhibitor of the NO biosynthesis L-nitroarginine (30-300 microM). Prolonged periods of electrical stimulation (16 Hz, 1 ms, pulse trains of 180 s) induced a sustained relaxation, previously shown to be mediated by NO and VIP. L-Nitroarginine (30-300 microM) or pretreatment with SIN-1 (100 microM) or nitroglycerin (0.5 mM) did not affect the amplitude of this relaxation but slowed down its onset. Authentic NO (0.01-10 microM) and VIP (0.01-10 nM) induced respectively transient and sustained concentration-dependent relaxations. SIN-1 or nitroglycerin pretreatment had no effect on the concentration-response curves to NO and VIP. These results indicate that prolonged exposure to NO donors inhibits electrically induced nerve-mediated NANC relaxations without affecting the postjunctional response to NO and VIP. As similar results are obtained with NO biosynthesis inhibitors, our results illustrate a prejunctional inhibitory effect of NO on the NANC nerves of the rat gastric fundus and suggest the presence of an autoregulatory mechanism for the nitrergic innervation.
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Affiliation(s)
- J G De Man
- Division of Gastroenterology, University of Antwerp, Faculty of Medicine, Antwerp, Belgium
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Frostell CG, Zapol WM. Inhaled nitric oxide, clinical rationale and applications. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 1995; 34:439-56. [PMID: 8562450 DOI: 10.1016/s1054-3589(08)61102-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- C G Frostell
- Department of Anaesthesia and Intensive Care, Karolinska Institute at the Danderyd Hospital, Sweden
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