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Kharrat A, Jain A. Hemodynamic dysfunction in neonatal sepsis. Pediatr Res 2022; 91:413-424. [PMID: 34819654 DOI: 10.1038/s41390-021-01855-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/20/2021] [Accepted: 10/31/2021] [Indexed: 11/09/2022]
Abstract
Cardiovascular disturbances are a frequent occurrence in neonatal sepsis. Preterm and term infants are particularly vulnerable due to the unique features of their cardiovascular function and reserve, compared to older children and adults. The clinical manifestations of neonatal sepsis are a product of the variable inflammatory pathways involved (warm vs. cold shock physiology), developmental state of the cardiovascular system, and hormonal responses. Targeted neonatal echocardiography has played an important role in advancing our knowledge, may help delineate specific hemodynamic phenotypes in real-time, and supports an individualized physiology-based management of sepsis-associated cardiovascular dysfunction. IMPACT: Cardiovascular dysfunction is a common sequela of sepsis. This review aims to highlight the pathophysiological mechanisms involved in hemodynamic disturbance in neonatal sepsis, provide insights from targeted neonatal echocardiography-based clinical studies, and suggest its potential incorporation in day-to-day management.
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Affiliation(s)
- Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada. .,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
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Greene MA, Klotz JL, Goodman JP, May JB, Harlow BE, Baldwin WS, Strickland JR, Britt JL, Schrick FN, Duckett SK. Evaluation of oral citrulline administration as a mitigation strategy for fescue toxicosis in sheep. Transl Anim Sci 2020; 4:txaa197. [PMID: 33269340 PMCID: PMC7684870 DOI: 10.1093/tas/txaa197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/23/2020] [Indexed: 01/13/2023] Open
Abstract
Gestating ewes consuming ergot alkaloids, from endophyte-infected (E+) tall fescue seed, suffer from intrauterine growth restriction and produce smaller lambs. Arginine (Arg) supplementation has been shown to increase birth weight and oral citrulline (Cit) administration is reported to increase arginine concentrations. Two experiments were conducted to: 1) evaluate if oral supplementation with Cit or water, to ewes consuming E+ fescue seed, increases lamb birth weight and 2) determine the effectiveness of Cit and citrulline:malate as an oral drench and elevating circulating levels of Cit to determine levels and dose frequency. In experiment 1, gestating Suffolk ewes (n = 10) were assigned to one of two treatments [oral drench of citrulline-malate 2:1 (CITM; 81 mg/kg/d of citrulline) or water (TOX)] to start on d 86 of gestation and continued until parturition. Ewes on CITM treatment had decreased (P < 0.05) plasma Arg and Cit concentrations during gestation. At birth, lambs from CITM ewes had reduced (P < 0.05) crude fat and total fat but did not differ (P > 0.05) in birth weight from lambs born to TOX ewes. In experiment 2, nonpregnant Suffolk ewes (n = 3) were assigned to either oral citrulline (CIT; 81 mg/kg/d), citrulline-malate 2:1 (CITM; 81 mg/kg/d of citrulline), or water (CON) drench in a Latin Square design for a treatment period of 4 d with a washout period of 3 d. On d 4, blood samples were collected at 0, 0.5, 1, 2, 3, 4, 6, 8, 10, 12, and 18 h post drench. Oral drenching of CIT and CITM increased (P < 0.0001) Cit concentrations within 2 h and levels remained elevated for 6 h. Apparent half-life of elimination for CIT and CITM were 8.484 and 10.392 h, respectively. Our results show that lamb birth weight was not altered with a single oral drench of citrulline-malate; however, lamb body composition was altered. The level and frequency of citrulline dosing may need to be greater in order to observe consistent elevation of Cit/Arg concentrations to determine its effectiveness in mitigating fescue toxicosis.
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Affiliation(s)
- Maslyn A Greene
- Department of Animal and Veterinary Sciences, Clemson University, Clemson, SC
| | - James L Klotz
- USDA-ARS, Forage Production Research Unit, Lexington, KY
| | - Jack P Goodman
- Department of Plant and Soil Sciences, University of Kentucky, Lexington, KY
| | - John B May
- Department of Plant and Soil Sciences, University of Kentucky, Lexington, KY
| | | | | | - James R Strickland
- Department of Animal and Veterinary Sciences, Clemson University, Clemson, SC
| | - Jessica L Britt
- Department of Animal and Veterinary Sciences, Clemson University, Clemson, SC
| | - F Neal Schrick
- Department of Animal Science, University of Tennessee, Knoxville, TN
| | - Susan K Duckett
- Department of Animal and Veterinary Sciences, Clemson University, Clemson, SC
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Renal Blood Flow, Glomerular Filtration Rate, and Renal Oxygenation in Early Clinical Septic Shock*. Crit Care Med 2018. [DOI: 10.1097/ccm.0000000000003088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Johansson MJ, Kvitting JPE, Flatebø T, Nicolaysen A, Nicolaysen G, Walther SM. Inhibition of Constitutive Nitric Oxide Synthase Does Not Influence Ventilation-Perfusion Matching in Normal Prone Adult Sheep With Mechanical Ventilation. Anesth Analg 2016; 123:1492-1499. [PMID: 27622722 DOI: 10.1213/ane.0000000000001556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Local formation of nitric oxide in the lung induces vasodilation in proportion to ventilation and is a putative mechanism behind ventilation-perfusion matching. We hypothesized that regional ventilation-perfusion matching occurs in part due to local constitutive nitric oxide formation. METHODS Ventilation and perfusion were analyzed in lung regions (≈1.5 cm) before and after inhibition of constitutive nitric oxide synthase with N-nitro-L-arginine methyl ester (L-NAME) (25 mg/kg) in 7 prone sheep ventilated with 10 cm H2O positive end-expiratory pressure. Ventilation and perfusion were measured by the use of aerosolized fluorescent and infused radiolabeled microspheres, respectively. The animals were exsanguinated while deeply anesthetized; then, lungs were excised, dried at total lung capacity, and divided into cube units. The spatial location for each cube was tracked and fluorescence and radioactivity per unit weight determined. RESULTS After administration of L-NAME, pulmonary artery pressure increased from a mean of 16.6-23.6 mm Hg, P = .007 but PaO2, PaCO2, and SD log(V/Q) did not change. Distribution of ventilation was not influenced by L-NAME, but a small redistribution of perfusion from ventral to dorsal lung regions was observed. Perfusion to regions with the highest ventilation (fifth quintile of the ventilation distribution) remained unchanged after L-NAME. CONCLUSIONS We found minimal or no influence of constitutive nitric oxide synthase inhibition by L-NAME on the distributions of ventilation and perfusion, and ventilation-perfusion in prone, anesthetized, ventilated, and healthy adult sheep with normal gas exchange.
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Affiliation(s)
- Mats J Johansson
- From the *Department of Cardiothoracic Anesthesia and Intensive Care; †Division of Cardiovascular Medicine, Department of Medical and Health Sciences; ‡Department of Cardiothoracic Surgery, Linköping University Hospital, Linköping, Sweden; and §Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
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Sand CA, Hobbs AJ. The nuances of NO synthase regulation in sepsis: Could targeting BH4 be the answer? Vascul Pharmacol 2016; 77:35-7. [PMID: 26556765 DOI: 10.1016/j.vph.2015.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Claire A Sand
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, United Kingdom
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, United Kingdom
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Ghebremariam YT, Erlanson DA, Cooke JP. A novel and potent inhibitor of dimethylarginine dimethylaminohydrolase: a modulator of cardiovascular nitric oxide. J Pharmacol Exp Ther 2013; 348:69-76. [PMID: 24135074 DOI: 10.1124/jpet.113.206847] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PD 404182 [6H-6-imino-(2,3,4,5-tetrahydropyrimido)[1,2-c]-[1,3]benzothiazine], a heterocyclic iminobenzothiazine derivative, is a member of the Library of Pharmacologically Active Compounds (LOPAC) that is reported to possess antimicrobial and anti-inflammatory properties. In this study, we used biochemical assays to screen LOPAC against human dimethylarginine dimethylaminohydrolase isoform 1 (DDAH1), an enzyme that physiologically metabolizes asymmetric dimethylarginine (ADMA), an endogenous and competitive inhibitor of nitric oxide (NO) synthase. We discovered that PD 404182 directly and dose-dependently inhibits DDAH. Moreover, PD 404182 significantly increased intracellular levels of ADMA in cultured primary human vascular endothelial cells (ECs) and reduced lipopolysaccharide-induced NO production in these cells, suggesting its therapeutic potential in septic shock-induced vascular collapse. In addition, PD 404182 abrogated the formation of tube-like structures by ECs in an in vitro angiogenesis assay, indicating its antiangiogenic potential in diseases characterized by pathologically excessive angiogenesis. Furthermore, we investigated the potential mechanism of inhibition of DDAH by this small molecule and found that PD 404182, which has striking structural similarity to ADMA, could be competed by a DDAH substrate, suggesting that it is a competitive inhibitor. Finally, our enzyme kinetics assay showed time-dependent inhibition, and our inhibitor dilution assay showed that the enzymatic activity of DDAH did not recover significantly after dilution, suggesting that PD 404182 might be a tightly bound, covalent, or an irreversible inhibitor of human DDAH1. This proposal is supported by mass spectrometry studies with PD 404182 and glutathione.
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Affiliation(s)
- Yohannes T Ghebremariam
- Department of Cardiovascular Sciences, Houston Methodist Research Institute, Houston, Texas (Y.T.G., J.P.C.); and SPARK Translational Research Program, Stanford University, School of Medicine, Stanford, California (D.A.E.)
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Nandi M, Kelly P, Torondel B, Wang Z, Starr A, Ma Y, Cunningham P, Stidwill R, Leiper J. Genetic and pharmacological inhibition of dimethylarginine dimethylaminohydrolase 1 is protective in endotoxic shock. Arterioscler Thromb Vasc Biol 2012; 32:2589-97. [PMID: 22995517 DOI: 10.1161/atvbaha.112.300232] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The overproduction of vascular NO contributes toward the circulatory collapse observed in patients with septic shock. Dimethylarginine dimethylaminohydrolase (DDAH), which has 2 isoforms, metabolizes asymmetrically methylated arginines (asymmetric mono- or di-methylarginine), endogenously produced NO synthase inhibitors. We wished to investigate whether reducing DDAH1 activity, using genetic and pharmacological approaches, is protective during lipopolysaccharide-induced endotoxic shock. METHODS AND RESULTS Experiments were conducted in DDAH1 heterozygous knockout mice (DDAH1(+/-)) or naive rats treated with a synthetic pharmacological DDAH inhibitor (L-257). We demonstrate for the first time that L-257 is DDAH1 selective using recombinant human DDAH proteins. DDAH1 mRNA was expressed in aortic but not macrophage cDNA, and consistent with this expression profile, L-257 selectively inhibited NO production from lipopolysaccharide-treated aorta but not macrophages, in culture. Conscious and anesthetized cardiovascular hemodynamics were monitored using implanted radiotelemetry devices or invasive catheters, respectively. Lipopolysaccharide was administered intravenously to model endotoxemia, and all animals presented with circulatory shock. DDAH1(+/-) mice or L-257-treated rats displayed attenuation in the rate of developed hypotension compared with wild-type littermates or vehicle control animals, respectively. CONCLUSIONS Pharmacological and genetic reduction of DDAH1 activity is protective against the vascular changes observed during endotoxic shock.
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Affiliation(s)
- Manasi Nandi
- Pharmacology and Therapeutics Group, Institute of Pharmaceutical Science, School of Biomedical Sciences, King's College London, Franklin-Wilkins Bldg, 150 Stamford St, London SE1 9NH, UK.
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LEVOSIMENDAN INCREASES PORTAL BLOOD FLOW AND ATTENUATES INTESTINAL INTRAMUCOSAL ACIDOSIS IN EXPERIMENTAL SEPTIC SHOCK. Shock 2010; 34:275-80. [DOI: 10.1097/shk.0b013e3181cd8c5b] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Paciullo CA, McMahon Horner D, Hatton KW, Flynn JD. Methylene blue for the treatment of septic shock. Pharmacotherapy 2010; 30:702-15. [PMID: 20575634 DOI: 10.1592/phco.30.7.702] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Septic shock is a major cause of morbidity and mortality in the intensive care unit, and effective therapies are limited. Methylene blue is a selective inhibitor of guanylate cyclase, a second messenger involved in nitric oxide-mediated vasodilation. The use of methylene blue in the treatment of septic shock has been repeatedly evaluated over the past 20 years, but data remain scarce. To evaluate the safety and efficacy of methylene blue for the treatment of septic shock, we conducted a literature search of the EMBASE (1974-June 2009), MEDLINE (1966-June 2009), and International Pharmaceutical Abstracts (1970-June 2009) databases. All available studies published in English were reviewed. Observational studies with methylene blue have demonstrated beneficial effects on hemodynamic parameters and oxygen delivery, but use of methylene blue may be limited by adverse pulmonary effects. Methylene blue administration is associated with increases in mean arterial pressure while reducing catecholamine requirements in patients experiencing septic shock; however, its effects on morbidity and mortality remain unknown. Well-designed, prospective evaluations are needed to define the role of methylene blue as treatment of septic shock.
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Affiliation(s)
- Christopher A Paciullo
- Department of Pharmaceutical Services, Emory University Hospital, Atlanta, Georgia 30322, USA.
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El-Awady MSH, Smirnov SV, Watson ML. Voltage-independent calcium channels mediate lipopolysaccharide-induced hyporeactivity to endothelin-1 in the rat aorta. Am J Physiol Heart Circ Physiol 2009; 296:H1408-15. [PMID: 19286939 DOI: 10.1152/ajpheart.01305.2008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The roles of intracellular calcium concentration ([Ca(2+)](i)) and Ca(2+) sensitization in lipopolysaccharide (LPS)-induced vascular smooth muscle (VSM) hyporesponsiveness are incompletely understood. To investigate these roles, contraction responses to endothelin-1 (ET-1) and 80 mM KCl; relaxation responses to nifedipine; the expression levels of mRNAs of ET-1 and its receptors (ET(A) or ET(B)); the expression levels of protein kinase C (PKC) and phosphorylation of Rho kinase (ROKalpha), CPI-17, and myosin phosphatase target subunit-1 (MYPT1); and changes in aortic VSM cell [Ca(2+)](i) were measured in LPS-treated aortic rings from male Wistar rats (250-300 g). LPS (10 mug/ml, 20 h) decreased contraction induced by ET-1 (0.3-100 nM) or 80 mM KCl. LPS-induced hypocontractility was not observed in the absence of external Ca(2+), but LPS-treated aorta remained hypocontractile on subsequent stepwise restoration of extracellular Ca(2+) (0.01-10 mM). Vascular relaxation to nifedipine; mRNA expression levels of ET-1, ET(A), or ET(B); protein expression levels of PKC; and phosphorylation levels of ROKalpha, CPI-17, and MYPT1 were not affected by LPS. In isolated aortic VSM cells, ET-1 caused a transient initial increase in [Ca(2+)](i), followed by a maintained tonic increase in [Ca(2+)](i), which was decreased by LPS pretreatment and was dependent on external Ca(2+). Subsequent restoration of extracellular Ca(2+) increased [Ca(2+)](i), but this increase was lower in the LPS-treated group. This difference in response to extracellular Ca(2+) addition was not affected by diltiazem, but was abolished by SKF-96365. Therefore, LPS induces hyporeactivity to ET-1 in rat aorta that depends on external Ca(2+) influx through non-voltage-operated Ca(2+) channels, but not on ET-1 receptor expression or Ca(2+) sensitization.
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Desensitization of the soluble guanylyl cyclase/cGMP pathway by lipopolysaccharide in rat isolated pulmonary artery but not aorta. Br J Pharmacol 2008; 155:1164-73. [PMID: 18806822 DOI: 10.1038/bjp.2008.358] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND AND PURPOSE To investigate the function of soluble guanylyl cyclase (sGC)/3',5'-cyclic guanosine monophosphate (cGMP) pathway in lipopolysaccharide (LPS)-induced changes in vascular reactivity of rat isolated pulmonary artery and aorta. EXPERIMENTAL APPROACH Nitric oxide (NO) production, contraction responses to endothelin-1 (ET-1), relaxation responses to sodium nitroprusside (SNP), 8-pCPT-cGMP, BAY412272 and T-0156, SNP-induced cGMP production and expression of sGC(alpha1), sGC(beta1) and 3',5'-cyclic nucleotide phosphodiesterase-5 (PDE5) proteins were measured in LPS-treated pulmonary and aortic rings from male Wistar rats. KEY RESULTS In both vessels, LPS (10 microg mL(-1), 20 h) increased NO production, which was inhibited by the selective inducible NOS (iNOS) inhibitor 1400W (1 microM). In the aorta, LPS decreased ET-1-induced contractility and this decrease was inhibited by the selective sGC inhibitor ODQ (10 microM) but not by removal of endothelium, or inhibitors of cyclooxygenase (indomethacin, 10 microM) or iNOS (1400W, 1 microM). Furthermore, aortic relaxation responses to the direct sGC activator BAY412272 were enhanced. In the pulmonary artery, SNP (1 nM to 30 microM)-induced relaxation and cGMP production, BAY412272-induced relaxation and sGC(beta1) protein expression were decreased, whereas relaxation responses to the PDE5-specific inhibitor T-0156 (0.1-100 nM) were enhanced. Relaxation responses to the phosphodiesterase-resistant cGMP analogue, 8-pCPT-cGMP, and protein expression levels of sGC(alpha1) and PDE5 were not altered in either vessel. CONCLUSION AND IMPLICATIONS LPS caused a selective hypocontractility of rat aorta to ET-1 mediated mainly through NO-independent sGC activation, whereas in the pulmonary artery, the effect of sGC activation was reduced by a decreased protein expression of sGC(beta1) together with increased PDE5 activity.
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Vissers YLJ, Debats IBJG, Luiking YC, Jalan R, van der Hulst RRWJ, Dejong CHC, Deutz NEP. Pros and cons of L-arginine supplementation in disease. Nutr Res Rev 2007; 17:193-210. [DOI: 10.1079/nrr200490] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The amino acid arginine and one of its metabolites NO have gathered broad attention in the last decade. Although arginine is regarded as a conditionally essential amino acid in disease, L-arginine supplementation in severe illness has not found its way into clinical practice. This might be due to the invalid interpretation of results from studies with immune-enhancing diets containing L-arginine amongst other pharmaconutrients. However, not much attention is given to research using L-arginine as a monotherapy and the possibility of the alternative hypothesis: that L-arginine supplementation is beneficial in disease. The present review will discuss data from studies in healthy and diseased animals and patients with monotherapy of L-arginine to come to an objective overview of positive and negative aspects of L-arginine supplementation in disease with special emphasis on sepsis, cancer, liver failure and wound healing.
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Skarda DE, Mulier KE, Myers DE, Taylor JH, Beilman GJ. DYNAMIC NEAR-INFRARED SPECTROSCOPY MEASUREMENTS IN PATIENTS WITH SEVERE SEPSIS. Shock 2007; 27:348-53. [PMID: 17414414 DOI: 10.1097/01.shk.0000239779.25775.e4] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study evaluated near-infrared spectroscopy (NIRS)-derived measurements in hemodynamically stable patients with severe sepsis, as compared with similar measurements in healthy age-matched volunteers. Prospective, preliminary, observational study in a surgical intensive care unit and clinical research center at a university health center. We enrolled 10 patients with severe sepsis and 9 healthy age-matched volunteers. For patients with severe sepsis, we obtained pulmonary artery catheter and laboratory values three times daily for 3 days and oxygen consumption values via metabolic cart once daily for 3 days. For healthy volunteers, we obtained all noninvasive measurements during a single session. We found lower values in patients with severe sepsis (versus healthy volunteers), in tissue oxygen saturation (StO2), in the StO2 recovery slope, in the tissue hemoglobin index, and in the total tissue hemoglobin increase on venous occlusion. Patients with severe sepsis had longer StO2 recovery times and lower NIRS-derived local oxygen consumption values versus healthy volunteers. In our preliminary study, NIRS provides a noninvasive continuous method to evaluate peripheral tissue oxygen metabolism in hemodynamically stable patients with severe sepsis. Further research is needed to demonstrate whether these values apply to broader populations of patients with systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock.
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Affiliation(s)
- David E Skarda
- Department of Surgery, University of Minnesota, Minneapolis, USA
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Brueckmann M, Huhle G, Max M. [Mechanisms of action of recombinant human activated Protein C]. Anaesthesist 2006; 55 Suppl 1:5-15. [PMID: 16520928 DOI: 10.1007/s00101-006-1001-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Human activated protein C (APC) is a serineprotease and one of the most important physiological inhibitors of the coagulation system. Apart from anticoagulative effects, profibrinolytic and anti-inflammatory modes of action have been reported for APC. The administration of recombinant human activated protein C (rhAPC), drotrecogin alfa (activated), Xigris, to patients with severe sepsis and sepsis-induced multi-organ failure reduced mortality in large clinical trials. Anti-apoptotic and immunomodulatory effects of rhAPC have been examined in in vitro experiments and in experimental animal studies. Moreover, a reduction of endothelial cell permeability, enhanced endothelial cell survival as well as improvements of microcirculatory disorders have been proposed for rhAPC. The manifold mechanisms of action of APC may give reasons for its application in diseases other than sepsis, which are characterized by endothelial and microcirculatory dysfunction, e.g. acute pulmonary or renal failure, ischemic stroke, ischemia-reperfusion injury and acute pancreatitis. A better understanding of the anti-inflammatory, anti-apoptotic and immunomodulatory modes of action of APC could be relevant for dosing and mode of application and may lead to a broadening of the indication field for rhAPC.
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Affiliation(s)
- M Brueckmann
- I Medizinische Klinik, Fakultät für Klinische Medizin, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim.
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Yamaguchi N, Jesmin S, Zaedi S, Shimojo N, Maeda S, Gando S, Koyama A, Miyauchi T. Time-dependent expression of renal vaso-regulatory molecules in LPS-induced endotoxemia in rat. Peptides 2006; 27:2258-70. [PMID: 16725227 DOI: 10.1016/j.peptides.2006.03.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Revised: 03/20/2006] [Accepted: 03/22/2006] [Indexed: 10/24/2022]
Abstract
To elucidate roles of microvascular factors in the pathogenesis of renal complications during endotoxemia, that is characterized by renal vasoconstriction and systemic hypotension/generalized non-renal vasodilation, we profile the expression pattern and time-course of three key vaso-regulators, namely endothelin (ET)-1, nitric oxide (NO), and angiotensin II (Ang II). We hypothesize that disruption of the overall balance between vasodilatation and vasoconstriction in the kidney, during the early phase of sepsis, contribute to its (kidney) predisposition to acute renal failure. Adult male Wistar rats were rendered endotoxemic at different time points (1, 3, 6 and 10 h) by a single i.p. injection of lipopolysaccharide (LPS) (15 mg/kg) dissolved in saline. Control group was injected vehicle only (saline). Both systolic and diastolic blood pressures significantly decreased at different time points after LPS administration. Surprisingly, renal histopathological evaluation showed no remarkable changes in LPS-induced endotoxemia. However, overall, levels of the vaso-regulators and, where applicable, their respective receptors were upregulated: (1) plasma ET-1 increased 25-fold and peaked, as renal ET-1 mRNA, at 3 h; renal ET-1 protein and its receptors, ET type A (ET(A)) receptor (vasoconstrictive) and ET type B (ET(B)) receptor (vasodilatatory) increased in a time-dependent fashion, (2) Ang II increased by 53% compared to control, peaking at 6 h. However, while levels of Ang II type 1 (AT1) receptor increased over time after LPS injection, those of Ang II type 2 (AT2) receptor were downregulated, (3) data of NO system (NO-NOS), the key vasodilator, were the most intriguing. Whereas levels of renal NO increased time-dependently following LPS administration, with a 2240-fold increase in renal iNOS expression, levels of eNOS, were almost unchanged. In conclusion, the present study overall reveals intriguing and complex dynamics between levels of vasoconstrictors and vasodilators during the early phase of LPS-induced endotoxemia. These shifts in molecular expressions are likely triggered by compensatory mechanisms aimed at counteracting the undesirable and dominant effects of one group of vaso-regulatory moiety over the other.
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Affiliation(s)
- Naoto Yamaguchi
- Center for Medical Sciences, Ibaraki Prefectural University of Health Sciences, Ibaraki 300-0394, Japan
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Kumar A, Kumar A. Nitric oxide and inflammatory cytokines in the heart: the presence of positive feedback loops. Crit Care Med 2006; 33:2851-2. [PMID: 16352974 DOI: 10.1097/01.ccm.0000186886.00988.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Ryan M Levy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Chu SJ, Perng WC, Hung CM, Chang DM, Lin SH, Huang KL. Effects of Various Body Temperatures After Lipopolysaccharide-Induced Lung Injury in Rats. Chest 2005. [DOI: 10.1016/s0012-3692(15)37965-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Park BK, Shim TS, Lim CM, Lee SD, Kim WS, Kim DS, Kim WD, Koh Y. The effects of methylene blue on hemodynamic parameters and cytokine levels in refractory septic shock. Korean J Intern Med 2005; 20:123-8. [PMID: 16134766 PMCID: PMC3891380 DOI: 10.3904/kjim.2005.20.2.123] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Endogenous nitric oxide (NO) induces the peripheral vasodilation via the activation of guanylate cyclase in patients with septic shock. The purpose of this study was to assess the acute effects of methylene blue (MB), which is an inhibitor of guanylate cyclase, on the hemodynamics and on the production of pro-inflammatory cytokines and nitric oxide (NO) in patients with refractory septic shock. METHODS Twenty consecutive patients with refractory septic shock, which was defined as shock refractory to a dopamine infusion of more than 20 microg/kg/min with the appropriate use of antibiotics and adequate volume replacement, received MB infusion of 1 mg/kg intravenously. The hemodynamic and respiratory variables were measured at baseline, 30, 60 and 120 min after an infusion of MB (1 mg/kg). The blood levels of NO, IL-1, IL-10 and TNF-alpha were measured at baseline, 30 and 120 min after MB infusion. RESULTS The administration of MB induced an increase in the systemic vascular resistance (SVR) that resulted in an increase of the mean arterial pressure (MAP) in patients with refractory septic shock, and this was without a decrease in cardiac output. The administered MB induced an increase in pulmonary vascular resistance (PVR) that resulted in an increase of pulmonary arterial pressure (PAP), without any deterioration of gas exchange. However, the increases in SVR and PVR were not associated with the alteration of endogenous production of NO, IL-1, IL-10 and TNF- alpha. CONCLUSION MB transiently elevated the MAP by increasing the SVR without altering the endogenous productions of NO, IL-1, IL-10 and TNF- alpha during the study period in patients with refractory septic shock.
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Affiliation(s)
- Byung-Kyu Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Sun Shim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Do Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Sung Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Soon Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Dong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Galli GLJ, Skovgaard N, Abe AS, Taylor EW, Wang T. The role of nitric oxide in the regulation of the systemic and pulmonary vasculature of the rattlesnake, Crotalus durissus terrificus. J Comp Physiol B 2005; 175:201-8. [PMID: 15726384 DOI: 10.1007/s00360-005-0476-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2004] [Revised: 12/27/2004] [Accepted: 01/21/2005] [Indexed: 11/30/2022]
Abstract
The functional role of nitric oxide (NO) was investigated in the systemic and pulmonary circulations of the South American rattlesnake, Crotalus durissus terrificus. Bolus, intra-arterial injections of the NO donor, sodium nitroprusside (SNP) caused a significant systemic vasodilatation resulting in a reduction in systemic resistance (Rsys). This response was accompanied by a significant decrease in systemic pressure and a rise in systemic blood flow. Pulmonary resistance (Rpul) remained constant while pulmonary pressure (Ppul) and pulmonary blood flow (Qpul) decreased. Injection of L-Arginine (L-Arg) produced a similar response to SNP in the systemic circulation, inducing an immediate systemic vasodilatation, while Rpul was unaffected. Blockade of NO synthesis via the nitric oxide synthase inhibitor, L-NAME, did not affect haemodynamic variables in the systemic circulation, indicating a small contribution of NO to the basal regulation of systemic vascular resistance. Similarly, Rpul and Qpul remained unchanged, although there was a significant rise in Ppul. Via injection of SNP, this study clearly demonstrates that NO causes a systemic vasodilatation in the rattlesnake, indicating that NO may contribute in the regulation of systemic vascular resistance. In contrast, the pulmonary vasculature seems far less responsive to NO.
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Affiliation(s)
- Gina L J Galli
- Departamento de Zoologia, Centro de Aquicultura, UNESP, Caixa Postal, 199, 13506-907 Rio Claro, Brazil
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Abstract
OBJECTIVE Sepsis is a major health problem considering its significant morbidity and mortality rate. The amino acid L-arginine has recently received substantial attention in relation to human sepsis. However, knowledge of arginine metabolism during sepsis is limited. Therefore, we reviewed the current knowledge about arginine metabolism in sepsis. DATA SOURCE This review summarizes the literature on arginine metabolism both in general and in relation to sepsis. Moreover, arginine-related therapies are reviewed and discussed, which includes therapies of both nitric oxide (NO) and arginine administration and therapies directed toward inhibition of NO. DATA In sepsis, protein breakdown is increased, which is a key process to maintain arginine delivery, because both endogenous de novo production from citrulline and food intake are reduced. Arginine catabolism, on the other hand, is markedly increased by enhanced use of arginine in the arginase and NO pathways. As a result, lowered plasma arginine levels are usually found. Clinical symptoms of sepsis that are related to changes in arginine metabolism are mainly related to hemodynamic alterations and diminished microcirculation. NO administration and arginine supplementation as a monotherapy demonstrated beneficial effects, whereas nonselective NO synthase inhibition seemed not to be beneficial, and selective NO synthase 2 inhibition was not beneficial overall. CONCLUSIONS Because sepsis has all the characteristics of an arginine-deficiency state, we hypothesise that arginine supplementation is a logical option in the treatment of sepsis. This is supported by substantial experimental and clinical data on NO donors and NO inhibitors. However, further evidence is required to prove our hypothesis.
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Affiliation(s)
- Yvette C Luiking
- Maastricht University/Hospital, Department of Surgery, Nutrition and Toxicology Research Institute, Maastricht, The Netherlands
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24
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Stechmiller JK, Childress B, Porter T. Arginine Immunonutrition in Critically Ill Patients: A Clinical Dilemma. Am J Crit Care 2004. [DOI: 10.4037/ajcc2004.13.1.17] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Commercial enteral nutritional formulas for enhancement of the immune system are widely used in critical care. Immunonutrition with arginine can enhance inflammatory and immunologic responses in animal models and in humans. Although clinical improvements in surgical patients have been reported, benefits in critically ill patients with systemic inflammatory response syndrome, sepsis, or organ failure are less clear. Recent meta-analyses on the use of immunonutrition with arginine in critically ill and surgical patients revealed methodological weaknesses in most published studies. Specifically, a meta-analysis indicated that critically ill patients with preexisting severe sepsis may have an increased mortality rate when fed an immunonutritional enteral formula that contains arginine. These findings brought about confusion and controversy over the use of immunonutritional formulas in subsets of critically ill patients. A review of the literature on the function of arginine, its effect on the immune system, its roles in immunonutrition and in the clinical outcomes of critically ill patients, and the implications for nursing practice indicated that the benefits of immunonutrition with arginine in critically ill patients are unproven and warrant further study. Until more information is available, nutritional support should focus primarily on preventing nutritional deficiencies rather than on immunomodulation.
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Affiliation(s)
- Joyce K. Stechmiller
- Adult and Elderly Department, University of Florida College of Nursing, Gainesville, Fla
| | - Beverly Childress
- Adult and Elderly Department, University of Florida College of Nursing, Gainesville, Fla
| | - Tricia Porter
- Adult and Elderly Department, University of Florida College of Nursing, Gainesville, Fla
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25
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Watson D, Grover R, Anzueto A, Lorente J, Smithies M, Bellomo R, Guntupalli K, Grossman S, Donaldson J, Le Gall JR. Cardiovascular effects of the nitric oxide synthase inhibitor NG-methyl-l-arginine hydrochloride (546C88) in patients with septic shock: Results of a randomized, double-blind, placebo-controlled multicenter study (study no. 144-002)*. Crit Care Med 2004; 32:13-20. [PMID: 14707555 DOI: 10.1097/01.ccm.0000104209.07273.fc] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the hemodynamic effects of the nitric oxide synthase inhibitor 546C88 in patients with septic shock, although this was not a stated aim of the protocol. The predefined primary efficacy objective of the protocol was resolution of shock determined at the end of a 72-hr treatment period. DESIGN Multicentered, randomized, placebo-controlled, safety and efficacy study. SETTING Forty-eight intensive care units in Europe, North America, and Australia. PATIENTS A total of 312 patients with septic shock diagnosed within 24 hr before randomization. INTERVENTIONS Patients were randomly allocated to receive either 546C88 or placebo (5% dextrose) by intravenous infusion for up to 72 hrs. Conventional vasoactive therapy was restricted to norepinephrine, dopamine, and dobutamine. Study drug was initiated at 0.1 mL/kg/hr (5 mg/kg/hr 546C88) and titrated according to response up to a maximum rate of 0.4 mL/kg/hr with the objective to maintain mean arterial pressure at 70 mm Hg while attempting to withdraw any concurrent vasopressor(s). MEASUREMENTS AND MAIN RESULTS Requirement for vasopressors, systemic and pulmonary hemodynamics, indices of oxygen transport, and plasma concentrations of arginine and nitrate were assessed over time. The median mean arterial pressure for both groups was maintained > or =70 mm Hg. There was an early increase in systemic and pulmonary vascular tone and oxygen extraction, whereas both cardiac index and oxygen delivery decreased for patients in the 546C88 cohort. Although these parameters subsequently returned toward baseline values, the observed differences between the treatment groups, except for pulmonary vascular resistance and oxygen extraction, persisted throughout the treatment period, despite a reduced requirement for vasopressors in the 546C88 cohort. These changes were associated with a reduction in plasma nitrate concentrations, which were elevated in both groups before the start of therapy. CONCLUSIONS The nitric oxide synthase inhibitor 546C88 can reduce the elevated plasma nitrate concentrations observed in patients with septic shock. In this study, treatment with 546C88 for up to 72 hrs was associated with an increase in vascular tone and a reduction in both cardiac index and oxygen delivery. The successful maintenance of a target mean arterial blood pressure > or =70 mm Hg was achieved with a reduction in the requirement for, or withdrawal of, conventional inotropic vasoconstrictor agents (i.e., dopamine and norepinephrine). There were no substantive untoward consequences accompanying these hemodynamic effects. An international, randomized, double-blind, placebo-controlled phase III study has since been conducted in patients with septic shock. Recruitment into the study was discontinued due to the emergence of increased mortality in the 546C88-treated group.
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Affiliation(s)
- David Watson
- Department of Intensive Care, Homerton Hospital, London, UK
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26
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Danilov AI, Andersson M, Bavand N, Wiklund NP, Olsson T, Brundin L. Nitric oxide metabolite determinations reveal continuous inflammation in multiple sclerosis. J Neuroimmunol 2003; 136:112-8. [PMID: 12620649 DOI: 10.1016/s0165-5728(02)00464-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Nitric oxide (NO) is formed as a consequence of induction of the iNOS enzyme during inflammatory disorders. To investigate NO production in multiple sclerosis (MS), we determined the concentrations of its oxidation products (NOx) in the cerebrospinal fluid (CSF) and plasma of 61 MS patients. The patients were divided into three groups on the basis of their clinical disease activity. The total levels of NOx in CSF were significantly increased in all MS groups as compared to healthy controls and tension headache patients. CSF nitrite correlated with clinical disease activity. At exacerbation, the CSF nitrite levels exceed the plasma level. This suggests that clinical disease activity is due to a CNS inflammatory response, which is more intense and qualitatively different from that during clinical stable phases. This study supports NO involvement in the pathogenesis of MS and determination of nitrite levels may be useful a surrogate marker for disease activity.
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Affiliation(s)
- Alexandre I Danilov
- Department of Clinical Neuroscience, Karolinska Institutet, Karolinska Hospital, S-17176 Stockholm, Sweden
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27
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Supplementing Arginine during Sepsis: from Theory to Clinical Practice. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Tejedor C, Lorente JA, Delgado MA, Fernández-Segoviano P, De Paula M, Tobalina R, Alonso M, Moscoso A, Soto F, Blázquez J, Esteban A. Interaction between hemoglobin and glutathione in the regulation of blood flow in normal and septic pigs. Crit Care Med 2002; 30:2493-500. [PMID: 12441760 DOI: 10.1097/00003246-200211000-00015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemoglobin (Hb) induces vasoconstriction by heme group binding nitric oxide in an irreversible fashion. Recent in vitro studies indicate that the thiol groups in Hb reversibly bind nitric oxide and participate in trans-nitrosylation reactions with other thiols. Sepsis is a pathophysiologic state characterized by vasodilation mediated, at least in part, by an excessive release of nitric oxide. The role of nitrosothiols (RSNOs) in these changes is unknown. OBJECTIVES We tested the following in a porcine model of sepsis: (i) whether glutathione (GSH) reverses the hemodynamic effects of Hb; (ii) whether GSH induces an increase in blood flow in sepsis; (iii) whether RSNO plasma concentration increases in sepsis and is related to hypotension. DESIGN Nonrandomized animal controlled study. SETTING Animal research facility in a university hospital. SUBJECTS Anesthetized pigs were monitored with a pulmonary artery catheter and ultrasonic blood flow probes in the mesenteric artery and the portal vein for measurement of systemic, mesenteric, and portal blood flows (Q(TOT), Q(MES), and Q(POR), respectively). Four groups of pigs were studied: nonseptic, septic, nonseptic treated with Hb (stroma-free purified porcine hemoglobin), and septic treated with Hb (n = 6 in each group). INTERVENTIONS Sepsis was induced at 0 min by the administration of live Escherichia coli. Hb (400 mg/kg/hr) was administered at 240 mins, followed by glutathione (1 g iv). MEASUREMENTS AND MAIN RESULTS Hb induced a pressor response and a decrease in Q(TOT), Q(MES), and Q(POR). Glutathione reversed the effects of Hb on Q(MES) and Q(POR). In septic pigs not treated with Hb, GSH induced an increase in Q(POR). RSNO plasma concentration increased after the induction of sepsis and correlated significantly with blood pressure. CONCLUSIONS These results indicate the reversibility of the effects of Hb by GSH, probably by interactions between nitric oxide and the reduced sulfhydryl groups in Hb, and suggest a role of RSNOs in the cardiovascular changes of sepsis.
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Affiliation(s)
- Carmen Tejedor
- Servicio de Cuidados Intensivios, Hospital Universitario de Getafe, Madrid, Spain
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29
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Suchner U, Heyland DK, Peter K. Immune-modulatory actions of arginine in the critically ill. Br J Nutr 2002; 87 Suppl 1:S121-32. [PMID: 11895148 DOI: 10.1079/bjn2001465] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Current trials of immune-enhancing diets suggest several beneficial clinical effects. These products are associated with a reduction in infectious risk, ventilator days, ICU and hospital stay. However, methodological weaknesses limit the inferences we can make from these studies. Furthermore, improvements in outcomes were largely seen in surgical patients and in patients who tolerated critical amounts of formula. We propose that the beneficial findings cannot easily be extrapolated to other patient populations since there is suggestion from clinical trials that the sickest patients, especially those with severest appearances of sepsis, shock and organ failure may not benefit or may even be harmed. In these conditions we hypothesize that systemic inflammation might be undesirably intensified by immune-enhancing nutrients like arginine in critically ill patients. In this paper, we review the purported effects of arginine on the immune system and organ function to understand the scientific rationale for its inclusion into enteral feeding products. We conclude that patients with the most severe appearances of the systemic inflammatory response syndrome should not receive immune-enhancing substrates which may aggravate systemic inflammation and worsen clinical outcomes.
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Affiliation(s)
- U Suchner
- Clinic of Anaesthesiology, Grosshadern University Hospital, Ludwig Maximilian's University, Munich, Germany.
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30
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Feihl F, Waeber B, Liaudet L. Is nitric oxide overproduction the target of choice for the management of septic shock? Pharmacol Ther 2001; 91:179-213. [PMID: 11744067 DOI: 10.1016/s0163-7258(01)00155-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Sepsis is a heterogeneous class of syndromes caused by a systemic inflammatory response to infection. Septic shock, a severe form of sepsis, is associated with the development of progressive damage in multiple organs, and is a leading cause of patient mortality in intensive care units. Despite important advances in understanding its pathophysiology, therapy remains largely symptomatic and supportive. A decade ago, the overproduction of nitric oxide (NO) had been discovered as a potentially important event in this condition. As a result, great hopes arose that the pharmacological inhibition of NO synthesis could be developed into an efficient, mechanism-based therapeutic approach. Since then, an extraordinary effort by the scientific community has brought a deeper insight regarding the feasibility of this goal. Here we present in summary form the present state of knowledge of the biological chemistry and physiology of NO. We then proceed to a systematic review of experimental and clinical data, indicating an up-regulation of NO production in septic shock; information on the role of NO in septic shock, as provided by experiments in transgenic mice that lack the ability to up-regulate NO production; effects of pharmacological inhibitors of NO production in various experimental models of septic shock; and relevant clinical experience. The accrued evidence suggests that the contribution of NO to the pathophysiology of septic shock is highly heterogeneous and, therefore, difficult to target therapeutically without appropriate monitoring tools, which do not exist at present.
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Affiliation(s)
- F Feihl
- Division of Pathophysiology and Medical Teaching, Department of Internal Medicine, University Hospital, PPA, BH19-317, CHUV, CH 1011 Lausanne, Switzerland.
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31
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Kumar A, Krieger A, Symeoneides S, Kumar A, Parrillo JE. Myocardial dysfunction in septic shock: Part II. Role of cytokines and nitric oxide. J Cardiothorac Vasc Anesth 2001; 15:485-511. [PMID: 11505357 DOI: 10.1053/jcan.2001.25003] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- A Kumar
- Division of Cardiovascular Diseases and Critical Care Medicine, Department of Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612, USA
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32
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Albaugh G, Kann B, Strande L, Vemulapalli P, Hewitt C, Alexander JB. Nicotine induces endothelial TNF-alpha expression, which mediates growth retardation in vitro. J Surg Res 2001; 99:381-4. [PMID: 11469915 DOI: 10.1006/jsre.2001.6215] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Atherosclerosis is understood as the common pathologic manifestation of arterial injury caused by a variety of etiologies. One well-established etiologic agent is nicotine. We hypothesized that cytokines of endothelial origin are involved with the pathologic changes found in atherosclerosis associated with smoking. We chose to assay for TNF-alpha due to its many biologic actions that are similar to those found in peripheral vascular disease. METHODS Human umbilical vein endothelial cells (HUVEC) were plated in endothelial growth medium (EGM-2) on plastic coverslips until 75% confluent. Free base nicotine (FBN) was diluted in EGM-2 to a concentration of 10(-8) M and added to experimental cells. At 1, 3, and 24 h, coverslips were removed and fixed. Immunohistochemical staining was performed using anti-TNF-alpha. Digital image analysis (DIA) was performed to quantify expression of TNF-alpha. An intensity stain index measuring area and intensity of stain/total cellular area was determined for each time point (n = 5). Additional HUVEC were plated in 12-well plates in EGM-2 at 2 x 10(3) cells/cm(2) on T(-2) day. FBN was diluted in medium to 10(-9) M and added to wells with and without 0.9 microg/ml anti-TNF-alpha on T(0) day. Cell counts were performed in triplicate on days T(2-5) utilizing hemocytometry. Data was analyzed using Student's t test and ANOVA, with a 95% confidence interval. RESULTS Dose response determinations showed that the minimal concentration required to show statistically significant cell retardation is 10 (-9) M. Accordingly, this concentration was used for subsequent proliferation studies. DIA showed a threefold increase in TNF-alpha activity at 1 h and a twofold increase at 3 h. Activity returned to baseline by 24 h. Cell growth was significantly decreased in cells exposed to nicotine when compared to controls on days T(2)-T(5) (P < 0.05). In cells exposed to anti-TNF-alpha and nicotine there was inhibition of the growth retardation seen in the cells containing nicotine alone. Differences between the control group and the anti-TNF-alpha group were not statistically significant. CONCLUSION These data demonstrate the ability of endothelial cells to secrete TNF-alpha in response to nicotine at levels found in serum after smoking and also shows that endothelial cell growth retardation as a consequence of nicotine exposure may be TNF-alpha mediated.
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Affiliation(s)
- G Albaugh
- Department of Surgery, Cooper Hospital/University Medical Center, Camden, NJ 08103, USA
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Kim HW, Tai J, Greenburg AG. Nitric oxide scavenging modulates an experimental vasoplesia in-vitro. ARTIFICIAL CELLS, BLOOD SUBSTITUTES, AND IMMOBILIZATION BIOTECHNOLOGY 2001; 29:263-74. [PMID: 11495008 DOI: 10.1081/bio-100104229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Endogenous overproduction of nitric oxide (NO) is believed to be a primary cause of refractory hypotension in septic shock. Under this condition, effectiveness of vasopressors is diminished due to hyporeactivity of blood vessels, a condition termed as vasoplesia. Effective reduction of NO levels should alleviate the condition. In this study, we investigated whether NO scavenging could modulate the endotoxin mediated vasoplesia in-vitro. Further, we explored whether NO scavenging in combination with a moderate NO synthase (NOS) inhibition would also be effective in modulating NO mediated vasoplesia. Experimental vasoplesia was produced in-vitro by incubating isolated rat thoracic aortic rings with lipopolysaccharide (LPS). Vessel rings were then treated with N(omega)-nitro-L-arginine methyl ester (L-NAME; a NOS inhibitor), human hemoglobin (Hb; a NO scavenger), or both L-NAME and Hb. Vascular reactivity was assessed by measuring vessel ring isometric tension changes to norepinephrine (NE) doses; the median effective doses (logEC50) of NE before and after each experimental treatment were compared. Following a 6-hour LPS treatment, vascular reactivity logEC50 values for NE were significantly increased compared with control vessel rings incubated without LPS. Treatment with either L-NAME alone or Hb alone significantly improved the vessel ring reactivity to NE. When both L-NAME and Hb were used concomitantly, vascular reactivity was also significantly improved. These results indicate that NO scavenging with Hb is as effective as NO synthesis inhibition with NAME in modulating the endotoxin induced vasoplesia. In conclusion, NO scavenging, alone or in combination with a moderate NOS inhibition, may render an alternative therapeutic approach to NOS synthesis inhibition in modulating the vasoplesia in septic shock.
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Affiliation(s)
- H W Kim
- Brown University and The Miriam Hospital, Providence, RI 02906, USA
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Abstract
Chronic pulmonary hypertension is a serious complication of a number of chronic lung and heart diseases. In addition to vasoconstriction, its pathogenesis includes injury to the peripheral pulmonary arteries leading to their structural remodeling. Increased pulmonary vascular synthesis of an endogenous vasodilator, nitric oxide (NO), opposes excessive increases of intravascular pressure during acute pulmonary vasoconstriction and chronic pulmonary hypertension, although evidence for reduced NO activity in pulmonary hypertension has also been presented. NO can modulate the degree of vascular injury and subsequent fibroproduction, which both underlie the development of chronic pulmonary hypertension. On one hand, NO can interrupt vascular wall injury by oxygen radicals produced in increased amounts in pulmonary hypertension. NO can also inhibit pulmonary vascular smooth muscle and fibroblast proliferative response to the injury. On the other hand, NO may combine with oxygen radicals to yield peroxynitrite and other related, highly reactive compounds. The oxidants formed in this manner may exert cytotoxic and collagenolytic effects and, therefore, promote the process of reparative vascular remodeling. The balance between the protective and adverse effects of NO is determined by the relative amounts of NO and reactive oxygen species. We speculate that this balance may be shifted toward more severe injury especially during exacerbations of chronic diseases associated with pulmonary hypertension. Targeting these adverse effects of NO-derived radicals on vascular structure represents a potential novel therapeutic approach to pulmonary hypertension in chronic lung diseases.
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Affiliation(s)
- V Hampl
- Department of Physiology, Charles University Second Medical School, Prague, Czech Republic
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35
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Cohen RI, Shapir Y, Davis A, Loona R, Scharf SM. Comparison between selective and nonselective nitric oxide synthase inhibition and phenylephrine in normal and endotoxic swine. Crit Care Med 2000; 28:3257-67. [PMID: 11008990 DOI: 10.1097/00003246-200009000-00022] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the cardiopulmonary and peripheral circulatory effects of the nonselective nitric oxide synthase (NOS) inhibitor NG-nitro-L-arginine methyl ester (L-NAME) to the more selective inducible NOS inhibitor S-methylisothiourea (SMT) and to phenylephrine (PE) in endotoxic and normal swine. DESIGN Prospective, randomized, unblinded study. SETTING Research laboratory of academic medical center. SUBJECTS Nonanesthetized, sedated, mechanically ventilated, minimally invasive swine model. INTERVENTIONS Animals received either lipopolysaccharide (LPS, LPS groups) or equivalent volume of saline (normal groups). LPS animals were further randomized into four groups when mean arterial pressure (MAP) had dropped to <60 mm Hg: the LPS/saline group received saline only; the other groups received either L-NAME, SMT, or PE. These were titrated to elevate MAP by 20-25 mm Hg, and animals were followed for another 3 hrs. Pulmonary artery occlusion pressure was maintained at one to two times baseline with the infusion of saline. Normal groups received the same agents 1 hr after baseline measurements, and drugs were titrated to achieve similar increases in MAP. We measured gastric-arterial PCO2 gradient by tonometry as an index of gastric mucosal perfusion. Left ventricular volumes were determined echocardiographically; right ventricular volumes were determined by a pulmonary arterial catheter equipped with a rapid thermistor. Plasma nitrite/nitrate (NOx) concentrations were measured hourly. MEASUREMENTS AND MAIN RESULTS In the LPS groups, all agents elevated MAP and systemic vascular resistance similarly. By hr 4, cardiac output had decreased in all groups, but the decrease with L-NAME (35% +/- 16%) occurred earlier (at hr 3) and was larger than the decrease with SMT at hrs 3 and 5 and larger than the decrease with saline at hrs 3 to 5. L-NAME resulted in a larger increase in mean pulmonary arterial pressure (MPAP) when compared with saline (130% +/- 44% vs. 61% +/- 25%; p < .001) and SMT groups (130% vs. 97% +/- 80%; p < .007). Only L-NAME had detrimental effects on right ventricular function as indicated by an increase in right ventricular end-systolic volume (54 +/- 10 to 87 +/-6 mL; p < .05) and right ventricular end-diastolic volume (90 +/-11 to 128 +/- 18 mL; p < .05). SMT decreased both left ventricular end-systolic volume (10.4 +/- 2 to 7.7 +/- 4 mL; p < .05) and left ventricular end-diastolic volume (18.5 +/- 3 to 14.2 +/- 5 mL; p < .05), indicating improved left ventricular function, whereas L-NAME did not affect left ventricular volumes. Both SMT and PE corrected LPS-induced gastric mucosal acidosis, but L-NAME did not. We did not detect changes in plasma NOx concentrations in any of LPS groups. In the normal groups, all agents increased MAP without changes in plasma NOx concentrations. L-NAME caused a larger decrease in cardiac output, but the increase in MPAP was higher with SMT. Both NOS inhibitors led to left ventricular dilation, but PE did not. Only L-NAME caused right ventricular dilation. There were no changes in gastric-arterial PCO2 gradient. CONCLUSIONS In LPS animals, we failed to detect changes in plasma NOx concentrations. Furthermore, for similar increases in MAP, SMT improved gastric mucosal acidosis, had less adverse effects on right ventricular function and MPAP, and may have improved left ventricular function. However, apart from its bene-ficial effects on left ventricular function, SMT was not superior to PE. The results from normal animals indicate that both NOS inhibitors have adverse effects on cardiac function beyond those attributed to increased MAP.
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Affiliation(s)
- R I Cohen
- Division of Pulmonary/Critical Care Medicine, Long Island Jewish Medical Center, and Schneider's Children's Hospital, New Hyde Park, NY 11040, USA
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Wagner K, Schäfer R, Roth-Isigkeit A, Klotz KF, Friedrich HJ, Schmucker P. Norepinephrine vs nitric oxide synthase inhibition in endotoxemia. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2000; 471:469-79. [PMID: 10659180 DOI: 10.1007/978-1-4615-4717-4_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- K Wagner
- Department of Anesthesiology, Medical University Lübeck, Germany
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Pastor CM. Vascular hyporesponsiveness of the renal circulation during endotoxemia in anesthetized pigs. Crit Care Med 1999; 27:2735-40. [PMID: 10628619 DOI: 10.1097/00003246-199912000-00022] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the vascular reactivity of the renal circulation in control and septic conditions. DESIGN Prospective, randomized, controlled animal study. SETTING University research laboratory. SUBJECTS Anesthetized pigs (n = 17). INTERVENTIONS Ten pigs received a continuous intravenous infusion of endotoxin from Escherichia coli (160 ng x kg(-1) x hr(-1)) during 18 hrs, whereas seven control animals received a saline infusion. To test the vascular reactivity, norepinephrine (NE) (1 microg x kg(-1)), acetylcholine (10 microg x kg(-1)), and sodium nitroprusside (10 microg x kg(-1)) were intravenously injected for 20 secs and changes of mean arterial pressure and renal blood flow were observed during the 200 secs after the drug administration. To compare the evolution of the vascular reactivity over time, three tests were performed 5 hrs, 11 hrs, and 17 hrs after initial endotoxin or saline administration. MEASUREMENTS AND MAIN RESULTS Endotoxin infusion induced a hypotensive and hypokinetic syndrome with renal hypoperfusion. The mean arterial pressure increase after NE injection and the mean arterial pressure decrease after acetylcholine and nitroprusside were lower in endotoxin than in control pigs. In the renal circulation, the increase of resistance after NE injection and the decrease of renal resistance after acetylcholine and nitroprusside injections were lower in endotoxin than in control pigs. CONCLUSIONS This study shows a hyporesponsiveness of the renal circulation to vasoactive agents during endotoxemia. Vasoconstriction to NE, endothelium-dependent as well as endothelium-independent relaxations are altered during endotoxemia but not abolished, and despite the continuous infusion of endotoxin for 18 hrs, no recovery was observed over time.
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Affiliation(s)
- C M Pastor
- Division d'Investigations Anesthésiologiques, University of Geneva, Switzerland
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Lorente JA, Delgado MA, Tejedor C, Mon E, Hervás M, Pascual T, Fernández-Segoviano P, Rieppi G, Soler A, Ayuso D, Esteban A. Modulation of systemic hemodynamics by exogenous L-arginine in normal and bacteremic sheep. Crit Care Med 1999; 27:2474-9. [PMID: 10579267 DOI: 10.1097/00003246-199911000-00025] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate whether exogenous L-arginine, the substrate for nitric oxide synthase, modulates systemic hemodynamics in sepsis. DESIGN Prospective, controlled study in a sheep model of sepsis. SETTING Animal research facility in a university hospital. SUBJECTS Adult sheep weighing between 35 and 55 kg. INTERVENTIONS Adult sheep sedated and mechanically ventilated, were monitored with a pulmonary arterial catheter and an ileal tonometer. Four groups of sheep were studied: nonseptic, septic, nonseptic treated with L-arginine, and septic treated with L-arginine. Sepsis was induced by the intravenous administration of Escherichia coli (1.5x10(8) colony-forming units/kg for 30 mins). L-arginine was administered as an intravenous bolus (200 mg/kg for 10 mins) before the septic challenge followed by 200 mg/kg/hr for 300 mins. MEASUREMENTS AND MAIN RESULTS Sepsis induced a state of acidosis, hyperlactatemia, hypoxemia, and gastric intramucosal acidosis. During the first 30 mins after the septic challenge, there was a decrease in cardiac index and blood pressure, and an increase in systemic vascular resistance. Thereafter, blood pressure returned to baseline values, and systemic vascular resistance fell. Treatment with L-arginine in nonseptic sheep did not induce any biochemical or hemodynamic effect. In septic sheep, treatment with L-arginine was associated with a greater increase in systemic vascular resistance during the first 30 mins, and a more marked decrease in blood pressure and systemic vascular resistance after 180 mins. CONCLUSIONS Exogenous administration of L-arginine does not induce hemodynamic effects in normal animals, exacerbates the acute vasoconstriction associated with the intravenous infusion of E. coli and potentiates the sepsis-induced vasodilation. Our results suggest that a) nitric oxide production is not constitutively modulated by exogenous L-arginine, b) L-arginine probably enhances the sepsis-induced sympathetic discharge, and c) L-arginine becomes rate-limiting for the formation of nitric oxide at approximately 3 hrs after the initiation of the septic challenge.
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Affiliation(s)
- J A Lorente
- Hospital Universitario de Getafe, Madrid, Spain
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Abstract
In sepsis and septic shock, inflammatory mediators result in the production of increased concentrations of nitric oxide (NO) from the enzymatic breakdown of the amino acid L-arginine. The increased amounts of NO are responsible for changes in vasomotor tone, decreased vasopressor responsiveness, and decreased myocardial function, characteristic of septic insult. Therapeutic strategies designed to reduce the concentration of NO by inhibiting the action of the nitric oxide synthase enzyme, or by scavenging the excess NO, offer the potential to treat directly the vasomotor abnormalities and myocardial depression seen in sepsis and other inflammatory states. This article reviews the biology of NO in sepsis and discusses strategies for neutralization of the increased NO production, in the setting of severe sepsis and septic shock.
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Affiliation(s)
- S Symeonides
- Section of Critical Care Medicine, Rush Medical College and, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA
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Hayden MA, Nakayama DK. Cyclic nucleotides and inducible nitric oxide synthesis in pulmonary artery smooth muscle. J Surg Res 1999; 82:222-7. [PMID: 10090833 DOI: 10.1006/jsre.1999.5573] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Nitric oxide (NO), cGMP, and cAMP affect the synthesis, metabolism, and cellular effects each other. We wanted to study how cGMP and cAMP interact to affect the induced synthesis of NO in response to interleukin-1 beta (IL-1 beta) in rat pulmonary artery smooth muscle cells. To further dissect the relative contributions of each cyclic nucleotide, and to detect any possible "crossover" effect of one cyclic nucleotide activating the other protein kinase, we tested how pharmacological inhibition of cGMP-dependent and cAMP-dependent protein kinases (PKG and PKA, respectively) affected responses. MATERIALS AND METHODS We tested the effects of IL-1 beta, dibutyryl (db)-cAMP (1-100 micro) and 8-bromo (Br)-cGMP (1 microM-1 mM) on NO synthesis in cultured rat pulmonary artery smooth muscle cells. Positive effects were then tested in the presence of KT5720 (10(-9)-10(-5) M), the pharmacological inhibitor of PKA, and KT5823 (10(-9)-10(-5) M), the pharmacological inhibitor of PKG. NO production was measured using the Greiss reaction, and mRNA abundance of the inducible NO synthase (iNOS), using semiquantitative RT-PCR. RESULTS IL-1 beta caused nitrite levels to increase nearly 10-fold over basal levels at 24 h (P < 0.05). Nitrite levels increased with the addition of either db-cAMP (100 microM, an 8-fold increase) or 8-Br-cGMP (100 microM, a 3-fold increase) to IL-1 beta (P < 0.05). PKA inhibition with KT5720 (10(-5) M) completely inhibited NO synthesis in response to the combination of IL-1 beta and cAMP, while KT5823 had less effect at all doses tested. NO synthesis in response to IL-1 beta plus cGMP also decreased to PKA inhibition, but not PKG inhibition, indicating that cGMP responses are a crossover effect. Both cAMP and cGMP in combination with IL-1 beta increased iNOS mRNA abundance above basal levels on reverse transcription polymerase chain reaction. KT5720, but not KT5823, decreased iNOS mRNA to basal levels. CONCLUSION Both cAMP and cGMP augment cytokine induction of NO synthesis through activation of PKA: cAMP does so directly; cGMP, through a crossover stimulation of PKA.
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Affiliation(s)
- M A Hayden
- Section of Pediatric Surgery and the Department of Surgery, University of North Carolina at Chapel Hill, C.B. 7210, 3010 Old Clinics Building, Chapel Hill, North Carolina, 27599-7210, USA
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Scott WS, Nakayama DK. Escherichia coli lipopolysaccharide downregulates soluble guanylate cyclase in pulmonary artery smooth muscle. J Surg Res 1998; 80:309-14. [PMID: 9878330 DOI: 10.1006/jsre.1998.5442] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The soluble isoform of guanylate cyclase (sGC) is activated by nitric oxide (NO) to form guanosine 3':5'-cyclic monophosphate (cGMP). Cyclic GMP levels cause smooth muscle relaxation and regulate vascular tone to various vascular beds, including the lung. Under conditions of cytokine excess the inducible synthesis of NO may result in cGMP overproduction, generalized vasodilation, and septic shock. In the pulmonary bed the opposite response may occur, pulmonary hypertension. We hypothesized that sGC activity becomes downregulated in the face of Escherichia coli lipopolysaccharide (LPS). We tested the effects of LPS on alpha1-subunit sGC mRNA abundance, Western analysis, and enzyme activity in cultured rat pulmonary artery smooth muscle cells. LPS increased extracellular cGMP production by pulmonary artery smooth muscle cells, with increased levels being first detectable at 3-6 h (10 microg/ml LPS) and exceeding 140 pmol/ml by 24 h (P < 0.05). The response was inhibited by 0.05 mM l-NG-monomethyl-l-arginine (l-NMA) and, in turn, restored by 1 mM l-arginine, indicating a NO synthase-dependent response. Pretreating cells with LPS for >/= 3 h inhibited subsequent cGMP synthesis in response to 10(-4) M SNAP for 60 min. Coincubating cells with 0.05 mM l-NMA also reversed this effect. Soluble GC enzyme activity in cells exposed to basal medium alone measured 0.74 pmol cGMP/ml per minute; activity in cells exposed to 10 microg/ml LPS for 24 h decreased to 0.04 pmol cGMP/ml per minute (P < 0.05). LPS pretreatment decreased sGC mRNA abundance and protein mass, but did not totally eliminate them. It is concluded that LPS affects cGMP synthesis at the level of enzyme activity, enzyme mass, and mRNA abundance. Over the short term (<24 h) LPS causes the synthesis of large amounts of cGMP. As the duration of exposure progresses (>/=3 h), mechanisms come into play that decrease cGMP production significantly and include decreases in mRNA abundance, enzyme mass, and enzyme activity.
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Affiliation(s)
- W S Scott
- Section of Pediatric Surgery and Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, 27599-7210, USA
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Bjertnaes LJ, Koizumi T, Newman JH. Inhaled nitric oxide reduces lung fluid filtration after endotoxin in awake sheep. Am J Respir Crit Care Med 1998; 158:1416-23. [PMID: 9817688 DOI: 10.1164/ajrccm.158.5.9607020] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We studied the effect on lung fluid filtration of 37.6 ppm inhaled nitric oxide (NO) imposed for 1 h 2.5 h after endotoxin in seven awake sheep, with seven control subjects. The effects of NO on the longitudinal distribution of pulmonary vascular resistance (PVR) before and after endotoxin were specifically addressed in six sheep. Following endotoxin, sheep developed respiratory distress; PaO2, the alveolar-arterial oxygen tension difference (AaPO2) and venous admixture (Q S/Q T) changed significantly, as did the pulmonary artery pressure (Ppa), PVR, and lung lymph flow (Q L). Inhaled NO reduced Ppa and PVR by 50%; Q L decreased from 7.8 +/- 0.34 ml/15 min to 4.7 +/- 0.80 ml/15 min (mean +/- SEM), and lymph protein clearance from 4.9 +/- 0.18 ml/15 min to 3.6 +/- 0.75 ml/15 min. Lymph/plasma protein concentration ratio (L/P) increased from 0.63 +/- 0.016 to 0.72 +/- 0.006, concomitant with the decrease in Q L. The L/P - Q L relationships shifted from left, at baseline, to the right during endotoxemia, as did the permeability surface product (PS) isolines. The rightward shift was significantly less in the NO group. Inhaled NO significantly improved PaO2, AaPO2, and Q S/Q T, reduced the increase in pulmonary microwedge pressure back to baseline and decreased upstream and downstream PVR at 3.0 through 4. 0 h. We conclude that, in sheep, inhaled NO reduces lung fluid filtration by decreasing microvascular pressure and apparently also by declining the enhanced microvascular permeability during the late phase of endotoxemia.
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Affiliation(s)
- L J Bjertnaes
- Center for Lung Research, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Hellyer PW, Wright B, Mallinckrodt C, Gaynor JS, Mama KR, Wagner AE. The effects of hyperoxia on the biosynthesis of cyclooxygenase products and haemodynamic response to nitric oxide synthase inhibition with L-NAME in endotoxaemic pigs. J Vet Pharmacol Ther 1998; 21:348-57. [PMID: 9811434 DOI: 10.1046/j.1365-2885.1998.00147.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The interaction between constitutive nitric oxide and oxygen may depend on the degree of tissue oxygenation and may play a critical role in the pathophysiological response to endotoxaemia. We investigated if hyperoxia (100% O2) attenuated the systemic and pulmonary vasoconstriction and increased biosynthesis of thromboxane B2 (TXB2) and 6-keto-prostaglandin (PG) F1alpha induced by inhibition of nitric oxide synthase with NG-nitro-L-arginine-methyl-ester (L-NAME) in a porcine model of endotoxaemia. Twenty-two domestic, random source pigs, weighing 15.4 +/- 2.7 kg (mean +/- standard deviation) were the subjects of this study. Pigs were anaesthetized with isoflurane in 100% O2, orotracheally intubated and ventilated to maintain normocapnia, and then instrumented for haemodynamic monitoring. Following instrumentation, pigs were maintained at an end-tidal isoflurane concentration of 2%. Pigs were randomly assigned to treatment groups: saline + 30% O2 (Control, n = 6); Escherichia coli lipopolysaccharide (5 microg/kg/h from 1 to 2 h followed by 2 microg/kg/h from 2 to 5 h) + 30% O2 (LPS, n = 4); L-NAME (0.5 mg/kg/h, from 0 to 5 h) + LPS + 100% O2 (n = 6); and L-NAME + LPS + 30% O2 (n = 6). L-NAME and endotoxin significantly (P < 0.05) increased mean arterial pressure, mean pulmonary arterial pressure, and systemic and pulmonary vascular resistance index beginning at 90 min. When results were pooled across all time periods, mean arterial pressure and mean pulmonary arterial pressure were significantly higher in the L-NAME + LPS + 30% O2 group than all other groups, reflecting pulmonary and systemic vasoconstriction. Hyperoxia attenuated the L-NAME + LPS-induced increases in TXB2 and 6-keto-PGF1alpha concentrations at 90 and 120 min and 120 min, respectively, although the differences were not statistically significant. These results support the observation that nitric oxide synthase inhibition with L-NAME has deleterious haemodynamic effects in this model of endotoxaemia. The temporal attenuation of L-NAME-induced pulmonary and systemic vasoconstriction by hyperoxia suggested that the haemodynamic effects of acute endotoxaemia were in part influenced by the relative amounts of nitric oxide and oxygen present.
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Affiliation(s)
- P W Hellyer
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins 80523, USA
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Iba T, Kidokoro A, Yagi Y. The role of the endothelium in changes in procoagulant activity in sepsis. J Am Coll Surg 1998; 187:321-9. [PMID: 9740191 DOI: 10.1016/s1072-7515(98)00177-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- T Iba
- Department of Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
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Cohen RI, Shapir Y, Chen L, Scharf SM. Right ventricular overload causes the decrease in cardiac output after nitric oxide synthesis inhibition in endotoxemia. Crit Care Med 1998; 26:738-47. [PMID: 9559613 DOI: 10.1097/00003246-199804000-00026] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine whether the decrease in cardiac output after nitric oxide synthase inhibition in endotoxemia is due to increased left ventricular afterload or right ventricular afterload. DESIGN Prospective, randomized, unblinded study. SETTING Research laboratory at an academic, university medical center. SUBJECTS Nonanesthetized, sedated, mechanically ventilated pigs. INTERVENTIONS Pigs were infused with 250 microg/kg of endotoxin over 30 mins. Normal saline was infused to maintain pulmonary artery occlusion pressure (PAOP) at a value not exceeding 1.5 times the baseline value. Left ventricular dimensions and function were studied using echocardiography. Right ventricular volumes and ejection fraction were determined via a rapid thermistor pulmonary artery catheter. We also measured mean arterial pressure (MAP), cardiac output, pulmonary arterial pressure, and calculated pulmonary and systemic resistances. Gastric tonometry was used as an index of gastric mucosal oxygenation and peripheral oxygenation. When MAP had decreased to < or =60 mm Hg or had decreased 30 mm Hg from baseline, nine animals received NG-nitro-L-arginine methyl ester (L-NAME) at 15 mg/kg to restore MAP to baseline. A second group of animals (n = 6) continued to receive normal saline, ensuring that PAOP did not exceed 1.5 times its baseline value. A third group of pigs (n = 5) did not receive endotoxin and served as the time control. In this group, a balloon was used to occlude the descending thoracic aorta and to increase MAP by approximately the same amount as in the L-NAME group. MEASUREMENTS AND MAIN RESULTS Endotoxin caused an increase in pulmonary arterial pressure and right ventricular volumes, and a decrease in gastric mucosal pH. Cardiac output was maintained in the animals receiving the saline infusion. By 2 hrs, pulmonary arterial pressure had decreased but was still notably higher than baseline. However, by this time, MAP had decreased to < or =60 mm Hg. L-NAME administration restored MAP to its baseline value but resulted in worsening pulmonary hypertension, increased right ventricular volumes, and decreased cardiac output, compared with the saline group. Three animals that received L-NAME died of right ventricular failure. We did not observe any evidence of left ventricular dysfunction with increased left ventricular afterload. Moreover, the restoration of MAP with L-NAME infusion did not correct gastric mucosal acidosis. No changes were noted in the time-control group. Occlusion of the thoracic aorta increased MAP but did not change cardiac output. This finding demonstrates that increases in left ventricular afterload of the magnitude seen with the infusion of L-NAME do not lead to decreases in cardiac output. CONCLUSION The decrease in cardiac output after nitric oxide synthase inhibition in endotoxemia is due to increased right ventricular afterload and not to left ventricular afterload.
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Affiliation(s)
- R I Cohen
- Division of Pulmonary and Critical Care Medicine, The Long Island Jewish Medical Center, New Hyde Park, NY 11040-1433, USA
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Reah G, Bodenham AR, Mallick A, Daily EK, Przybelski RJ. Initial evaluation of diaspirin cross-linked hemoglobin (DCLHb) as a vasopressor in critically ill patients. Crit Care Med 1997; 25:1480-8. [PMID: 9295821 DOI: 10.1097/00003246-199709000-00014] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the hemodynamic effects and any toxicologic effects of diaspirin cross-linked hemoglobin (DCLHb) in critically ill patients. DESIGN A prospective, observational study. SETTING A seven-bed intensive care unit (ICU) in a University teaching hospital. PATIENTS Fourteen critically ill patients requiring vasopressor therapy to maintain adequate mean arterial pressure (MAP). All patients had secondary organ dysfunction. INTERVENTIONS Administration of 100 mL boluses of 10% diaspirin cross-linked hemoglobin, up to a maximum of 500 mL, given over 15 mins and separated by 60 to 90 mins. MEASUREMENTS AND MAIN RESULTS Hemodynamic parameters, norepinephrine and inotropic requirements, arterial and mixed venous blood gases, urine output, and biochemical and hematologic analyses were measured before diaspirin cross-linked hemoglobin administration and at multiple time points up to 72 hrs. MAP was maintained at approximately preinfusion values and the reduction in norepinephrine requirements was used as the main end point to assess the efficacy of diaspirin cross-linked hemoglobin as a vasopressor. Diaspirin cross-linked hemoglobin demonstrated a marked vasopressor action, allowing norepinephrine requirements to be reduced from 0.29 +/- 0.15 (SD) microgram/kg/min to 0.15 +/- 0.14 and 0.07 +/- 0.10 microgram/kg/min after the first (at 1.5 hrs, p < .001) and last (at 7.5 hrs, p < .0001) boluses, respectively. These reductions in norepinephrine requirements were maintained at 24, 48, and 72 hrs (p < .01 at all time points). These hemodynamic changes began within 5 mins of starting the diaspirin cross-linked hemoglobin infusion. MAP, heart rate, central venous pressure, pulmonary artery occlusion pressure, mean pulmonary arterial pressure (MPAP), systemic vascular resistance index, and urine output did not demonstrate any significant changes from preinfusion values. Pulmonary vascular resistance index increased at 7.5 hrs despite nonsignificant increases in MPAP. Cardiac index and oxygen delivery index decreased significantly at 7.5 hrs and 24 hrs. Total plasma bilirubin increased significantly from baseline at 24 and 48 hrs, before returning to baseline values within 5 days. Platelet count was significantly reduced at 6 and 24 hrs. No other biochemical or hematologic analyses were altered significantly post diaspirin cross-linked hemoglobin. CONCLUSIONS This preliminary study demonstrated that diaspirin cross-linked hemoglobin is a potent vasopressor agent in critically ill patients with septicemic shock or systemic inflammatory response syndrome. This vasopressor characteristic of diaspirin cross-linked hemoglobin may have future clinical applications.
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Affiliation(s)
- G Reah
- Anaesthetics Department, General Infirmary at Leeds, UK
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Hellyer PW, Johnson LW, Olson NC. Effect of NG-nitro-L-arginine-methyl-ester on cardiopulmonary function and biosynthesis of cyclooxygenase products during porcine endotoxemia. Crit Care Med 1997; 25:1051-8. [PMID: 9201060 DOI: 10.1097/00003246-199706000-00024] [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: 02/04/2023]
Abstract
OBJECTIVE To determine if inhibition of nitric oxide synthase with NG-nitro-L-arginine-methyl-ester (L-NAME) potentiates endotoxin-induced cardiopulmonary dysfunction and release of cyclooxygenase products in a porcine model of endotoxemia. DESIGN Prospective, multiple group, controlled experimental study. SETTING Physiologic research laboratory at a veterinary medicine college. SUBJECTS Fifty-seven domestic pigs (mean 28.7 +/- 0.8 [SEM] kg). INTERVENTIONS Pentobarbital-anesthetized pigs were intubated and mechanically ventilated to normocapnia with room air. A ther-modilution cardiac output catheter was advanced into the pulmonary artery. Additional catheters were inserted into the jugular and femoral veins and femoral artery. The pigs received the following infusions: saline (control, n = 5); L-NAME (0.1, 0.5, 2.2, or 5.5 mg/ kg/hr, from -0.5 to 2 hrs, n = 16); Escherichia coli endotoxin (5 micrograms/ kg from 0 to 1 hr followed by 2 micrograms/kg from 1 to 2 hrs, i.v., n = 14); L-NAME plus endotoxin (n = 9); indomethacin plus endotoxin (n = 6); or L-NAME indomethacin plus endotoxin (n = 7). MEASUREMENTS AND MAIN RESULTS L-NAME significantly (p < .05) worsened endotoxin-induced hypoxemia and enhanced the increases in pulmonary vascular resistance index and systemic vascular resistance index at 30 to 60 mins. Endotoxin increased (p < .05) plasma concentrations of thromboxane B2 by seven- to eight-fold at 30 to 120 mins and 6-keto-prostaglandin F1 alpha by 16- to 24-fold at 60 to 120 mins. L-NAME enhanced (additive effect) endotoxin-induced increases in plasma concentrations of thromboxane B2 (60 mins) and significantly (p < .05) potentiated the increases in 6-keto-prostaglandin F1 alpha (120 mins). At 120 mins of endotoxemia, indomethacin (cyclooxygenase inhibitor) plus L-NAME markedly increased (p < .05, synergistic effect) systemic vascular resistance index compared with endotoxemic pigs pretreated with either L-NAME or indomethacin. CONCLUSIONS During endotoxemia, inhibition of nitric oxide synthase with L-NAME may be deleterious to cardiopulmonary function, as evidence by potentiation of endotoxin-induced systemic and pulmonary vasoconstriction, impairment of gas exchange, and enhanced biosynthesis of cyclooxygenase products. Moreover, during endotoxemia, the concomitant inhibition of two important vasodilators (i.e., nitric oxide and prostacyclin) is associated with a potentiated (p < .05) increase in systemic vascular resistance index.
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Affiliation(s)
- P W Hellyer
- Department of Anatomy, Physiological Sciences, and Radiology, College of Veterinary Medicine, North Carolina State University, Raleigh 27606, USA
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Rutten AJ, Bersten AD, Whiting MJ. Endotoxin alters the systemic disposition of nitric oxide synthase inhibitors in the awake sheep. Clin Exp Pharmacol Physiol 1997; 24:391-7. [PMID: 9171941 DOI: 10.1111/j.1440-1681.1997.tb01207.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
1. We evaluated the haemodynamic effects and systemic disposition of the nitric oxide synthase (NOS) inhibitor NL-nitro-L-arginine (NOLA) after intravenous (i.v.) administration of two different doses (5 and 20 mg/kg) in awake healthy sheep and awake sheep given a continuous i.v. infusion of endotoxin (lipopolysaccharide, 12 ng/kg per h, i.v., for 18 h). In addition, we determined the systemic disposition of another NOS inhibitor, NL-nitro-L-arginine methylester (L-NAME; 20 mg/kg, i.v.) in awake healthy sheep only. 2. NL-Nitro-L-arginine produced a dose-dependent decrease in heart rate (HR) and cardiac output (CO) together with a dose-dependent increase in mean arterial pressure (MAP) and peripheral vascular resistance (PVR) when compared to baseline. In endotoxic sheep NOLA produced a greater increase in MAP and mean pulmonary arterial pressure (MPAP). 3. In healthy sheep there was a dose-related increase in total body clearance (Cl) of NOLA. The Cl increased from 0.028 L/min after the lower dose to 0.032 L/min after the higher dose. The infusion of endotoxin caused an increase in Cl of NOLA to 0.040 and 0.047 L/min, respectively, and a decrease in plasma slow half-life (t1/2) from 825 to 546 min and from 780 to 453 min, respectively. 4. NL-Nitro-L-arginine methylester was rapidly cleared from the plasma with a slow half-life of approximately 7.5 min and there was a simultaneous appearance of NOLA in the plasma. 5. These results support the view that nitric oxide has a significant role in regulating vascular tone in healthy and endotoxic sheep and indicate that the increases in Cl of NOLA with an increase in its dose and the presence of endotoxin will be important in influencing appropriate dosage regimens in clinical studies.
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Affiliation(s)
- A J Rutten
- Department of Critical Care Medicine, Flinders University of South Australia, Bedford Park, Australia. a.rutten@.flinders.edu.au
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Effects ofl-arginine andN-nitro-l-arginine treatment on hemodynamics, DO2, VO2, and extravascular lung water in a dog endotoxin shock model. J Anesth 1997; 11:130-5. [DOI: 10.1007/bf02480075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/1996] [Accepted: 11/22/1996] [Indexed: 10/24/2022]
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