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Toki T, Mizunoya K, Itabashi M, Nishikawa N, Hoshino K, Saito H, Morimoto Y. Acute decompensated right heart failure potentially triggered by multiple factors including pulmonary vasodilator removal during plasma exchange: a case report. JA Clin Rep 2025; 11:5. [PMID: 39869255 PMCID: PMC11772900 DOI: 10.1186/s40981-025-00765-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2024] [Revised: 12/28/2024] [Accepted: 01/07/2025] [Indexed: 01/28/2025] Open
Abstract
BACKGROUND Plasma exchange (PE) removes high-molecular-weight substances and is sometimes used for antineutrophil cytoplasmic antibody-associated vasculitis (AAV) with alveolar hemorrhage. Hypotension during PE is rare, except in allergic cases. We report a case of shock likely caused by increased pulmonary vascular resistance (PVR) during PE. CASE PRESENTATION A 66-year-old man with pulmonary hypertension (PH) and glomerulonephritis was admitted with dyspnea. He had discontinued sildenafil prior to admission. Alveolar hemorrhage associated with AAV was suspected, and PE was performed. Soon after, he developed circulatory failure and hyperlactatemia. Echocardiography revealed right ventricular dilation, suggesting increased PVR. Inhaled nitric oxide (iNO) was administered, rapidly improving hyperlactatemia and oxygenation. The shock observed during PE was attributed to multiple factors, including the potential removal of sildenafil, which may have led to an increase in PVR. CONCLUSIONS The shock was attributable to acute right heart failure caused by an exacerbation of PH, possibly due to sildenafil removal via PE, although other contributing factors could not be excluded.
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Affiliation(s)
- Takayuki Toki
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan.
| | - Kazuyuki Mizunoya
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Misa Itabashi
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Naoki Nishikawa
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Koji Hoshino
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Hitoshi Saito
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Hospital, N14W5, Kita-ku, Sapporo, 060-8648, Japan
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Liu QK, Xiang GH, Liu WL, Dong JY, Wen YQ, Hao H. Efficacy and safety of several common drugs in the treatment of acute respiratory distress syndrome: A systematic review and network meta-analysis. Medicine (Baltimore) 2024; 103:e40472. [PMID: 39809198 PMCID: PMC11596352 DOI: 10.1097/md.0000000000040472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 10/24/2024] [Indexed: 01/16/2025] Open
Abstract
BACKGROUND This study aimed to compare the effectiveness and safety of neuromuscular blockers, mesenchymal stem cells (MSC), and inhaled pulmonary vasodilators (IV) for acute respiratory distress syndrome through a network meta-analysis of randomized controlled trials (RCTs). METHODS We searched Chinese and English databases, including China National Knowledge Infrastructure, The Cochrane Library, PubMed, and EMbase, with no time restrictions. We conducted a network meta-analysis and reported the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We included 27 clinical RCTs, all of which were two-arm trials, totaling 3492 patients. We selected 28-day mortality as the primary outcome measure, whereas 90-day mortality, ventilator-free days, and oxygenation served as secondary outcome measures for analysis and comparison. RESULTS We selected 3 treatment modalities and evaluated their clinical trials in comparison with the standard control group. For the 28-day in-hospital mortality, we included 21 RCTs, involving 2789 patients. Compared to standard treatment, neuromuscular blockers were associated with reduced 28-day hospital mortality (odds ratios [OR] 0.52, 95% confidence intervals [CI] (0.31, 0.88)), while IV and MSC were not associated with reduced hospital mortality (OR 0.89, 95% CI (0.50, 1.55); OR 0.90, 95% CI (0.49, 1.66)). In terms of 90-day mortality, days free of mechanical ventilation, and improvement in oxygenation, there were no significant differences compared to standard treatment with neuromuscular blockers, MSC, and IV. CONCLUSION Neuromuscular blockers significantly reduced the 28-day mortality rate in acute respiratory distress syndrome patients. However, in terms of 90-day mortality, ventilator-free days, oxygenation improvement, IV, MSC, and neuromuscular blockers did not significantly improve.
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Affiliation(s)
- Qing-Kuo Liu
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Guo-Han Xiang
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Wen-Li Liu
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Jin-Yan Dong
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Yu-Qi Wen
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Hao Hao
- Intensive Care Unit, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
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Isha S, Balasubramanian P, Hanson AJ, Jonna S, Raavi L, Khadka S, Vasudhar A, Sinclair De Frias J, Jenkins A, Balavenkataraman A, Tekin A, Bansal V, Reddy S, Caples SM, Khan SA, Jain NK, LaNou AT, Kashyap R, Cartin-Ceba R, Milian RD, Venegas CP, Shapiro AB, Bhattacharyya A, Chaudhary S, Kiley SP, Quinones QJ, Patel NM, Guru PK, Moreno Franco P, Sanghavi DK. Impact of low dose inhaled nitric oxide treatment in spontaneously breathing and intubated COVID-19 patients: a retrospective propensity-matched study. Crit Care 2024; 28:344. [PMID: 39456071 PMCID: PMC11515277 DOI: 10.1186/s13054-024-05093-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 09/09/2024] [Indexed: 10/28/2024] Open
Abstract
BACKGROUND The benefit of Inhaled nitric oxide (iNO) therapy in the setting of COVID-19-related ARDS is obscure. We performed a multicenter retrospective study to evaluate the impact of iNO on patients with COVID-19 who require respiratory support. METHODS This retrospective multicenter study included COVID-19 patients enrolled in the SCCM VIRUS COVID-19 registry who were admitted to different Mayo Clinic sites between March 2020 and June 2022 and required high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), or invasive mechanical ventilation (IMV). Patients were included in the 'spontaneously breathing' group if they remained non-intubated or were initiated on an HFNC (± NIV) before intubation. Patients who got intubated without prior use of an HFNC (± NIV) were included in the 'intubated group.' They were further divided into categories based on their iNO usage. Propensity score matching (PSM) and inverse propensity of treatment weighting (IPTW) were performed to examine outcomes. RESULTS Among 2767 patients included in our analysis, 1879 belonged to spontaneously breathing (153 received iNO), and 888 belonged to the intubated group (193 received iNO). There was a consistent improvement in FiO2 requirement, P/F ratio, and respiratory rate within 48 h of iNO use among both spontaneously breathing and intubated groups. However, there was no significant difference in intubation risk with iNO use among spontaneously breathing patients (PSM OR 1.08, CI 0.71-1.65; IPTW OR 1.10, CI 0.90-1.33). In a time-to-event analysis using Cox proportional hazard model, spontaneously breathing patients initiated on iNO had a lower hazard ratio of in-hospital mortality (PSM HR 0.49, CI 0.32-0.75, IPTW HR 0.40, 95% CI 0.26-0.62) but intubated patients did not (PSM HR: 0.90; CI 0.66-1.24, IPTW HR 0.98, 95% CI 0.73-1.31). iNO use was associated with longer in-hospital stays, ICU stays, ventilation duration, and a higher incidence of creatinine rise. CONCLUSIONS This retrospective propensity-score matched study showed that spontaneously breathing COVID-19 patients on HFNC/ NIV support had a decreased in-hospital mortality risk with iNO use in a time-to-event analysis. Both intubated and spontaneously breathing patients had improvement in oxygenation parameters with iNO therapy but were associated with longer in-hospital stays, ICU stays, ventilation duration, and higher incidence of creatinine rise.
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Affiliation(s)
- Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | | | - Abby J Hanson
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Sadhana Jonna
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Lekhya Raavi
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Subekshya Khadka
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Ananya Vasudhar
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Jorge Sinclair De Frias
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Anna Jenkins
- Mayo Clinic Alix School of Medicine, Jacksonville, FL, USA
| | | | - Aysun Tekin
- Department of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Swetha Reddy
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Sean M Caples
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Syed Anjum Khan
- Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN, USA
| | - Nitesh K Jain
- Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN, USA
| | - Abigail T LaNou
- Emergency Medicine and Critical Care, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Rahul Kashyap
- Department of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Ricardo Diaz Milian
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Carla P Venegas
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Anna B Shapiro
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Anirban Bhattacharyya
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Sean P Kiley
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Quintin J Quinones
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Neal M Patel
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Devang K Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
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Carmona CA, Miller Ferguson N. Taking a Breather From Pulmonary Aspiration and a Multidrug Ingestion. Clin Pediatr (Phila) 2024; 63:1467-1472. [PMID: 38158825 DOI: 10.1177/00099228231221341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Carlos A Carmona
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Nikki Miller Ferguson
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, USA
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Radman M, McGuire J, Sharek P, Baden H, Koth A, DiGeronimo R, Migita D, Barry D, Johnson JB, Rutman L, Vora S. Changes in Inhaled Nitric Oxide Use Across ICUs After Implementation of a Standard Pathway. Pediatr Crit Care Med 2024; 25:e347-e357. [PMID: 38786980 DOI: 10.1097/pcc.0000000000003544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator. It is expensive, frequently used, and not without risk. There is limited evidence supporting a standard approach to initiation and weaning. Our objective was to optimize the use of iNO in the cardiac ICU (CICU), PICU, and neonatal ICU (NICU) by establishing a standard approach to iNO utilization. DESIGN A quality improvement study using a prospective cohort design with historical controls. SETTING Four hundred seven-bed free standing quaternary care academic children's hospital. PATIENTS All patients on iNO in the CICU, PICU, and NICU from January 1, 2017 to December 31, 2022. INTERVENTIONS Unit-specific standard approaches to iNO initiation and weaning. MEASUREMENTS AND MAIN RESULTS Sixteen thousand eighty-seven patients were admitted to the CICU, PICU, and NICU with 9343 in the pre-iNO pathway era (January 1, 2017 to June 30, 2020) and 6744 in the postpathway era (July 1, 2020 to December 31, 2022). We found a decrease in the percentage of CICU patients initiated on iNO from 17.8% to 11.8% after implementation of the iNO utilization pathway. We did not observe a change in iNO utilization between the pre- and post-iNO pathway eras in either the PICU or NICU. Based on these data, we estimate 564 total days of iNO (-24%) were saved over 24 months in association with the standard pathway in the CICU, with associated cost savings. CONCLUSIONS Implementation of a standard pathway for iNO use was associated with a statistically discernible reduction in total iNO usage in the CICU, but no change in iNO use in the NICU and PICU. These differential results likely occurred because of multiple contextual factors in each care setting.
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Affiliation(s)
- Monique Radman
- Division of Cardiac Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - John McGuire
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Paul Sharek
- Center for Quality and Patient Safety, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Harris Baden
- Division of Cardiac Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Andy Koth
- Division of Cardiac Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Robert DiGeronimo
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Darren Migita
- Center for Quality and Patient Safety, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Dwight Barry
- Clinical Analytics, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - James B Johnson
- Clinical Analytics, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Lori Rutman
- Center for Quality and Patient Safety, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Surabhi Vora
- Center for Quality and Patient Safety, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
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Oláh A, Barta BA, Ruppert M, Sayour AA, Nagy D, Bálint T, Nagy GV, Puskás I, Szente L, Szőcs L, Sohajda T, Zima E, Merkely B, Radovits T. A Comparative Investigation of the Pulmonary Vasodilating Effects of Inhaled NO Gas Therapy and Inhalation of a New Drug Formulation Containing a NO Donor Metabolite (SIN-1A). Int J Mol Sci 2024; 25:7981. [PMID: 39063223 PMCID: PMC11277253 DOI: 10.3390/ijms25147981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Numerous research projects focused on the management of acute pulmonary hypertension as Coronavirus Disease 2019 (COVID-19) might lead to hypoxia-induced pulmonary vasoconstriction related to acute respiratory distress syndrome. For that reason, inhalative therapeutic options have been the subject of several clinical trials. In this experimental study, we aimed to examine the hemodynamic impact of the inhalation of the SIN-1A formulation (N-nitroso-N-morpholino-amino-acetonitrile, the unstable active metabolite of molsidomine, stabilized by a cyclodextrin derivative) in a porcine model of acute pulmonary hypertension. Landrace pigs were divided into the following experimental groups: iNO (inhaled nitric oxide, n = 3), SIN-1A-5 (5 mg, n = 3), and SIN-1A-10 (10 mg, n = 3). Parallel insertion of a PiCCO system and a pulmonary artery catheter (Swan-Ganz) was performed for continuous hemodynamic monitoring. The impact of iNO (15 min) and SIN-1A inhalation (30 min) was investigated under physiologic conditions and U46619-induced acute pulmonary hypertension. Mean pulmonary arterial pressure (PAP) was reduced transiently by both substances. SIN-1A-10 had a comparable impact compared to iNO after U46619-induced pulmonary hypertension. PAP and PVR decreased significantly (changes in PAP: -30.1% iNO, -22.1% SIN-1A-5, -31.2% SIN-1A-10). While iNO therapy did not alter the mean arterial pressure (MAP) and systemic vascular resistance (SVR), SIN-1A administration resulted in decreased MAP and SVR values. Consequently, the PVR/SVR ratio was markedly reduced in the iNO group, while SIN-1A did not alter this parameter. The pulmonary vasodilatory impact of inhaled SIN-1A was shown to be dose-dependent. A larger dose of SIN-1A (10 mg) resulted in decreased PAP and PVR in a similar manner to the gold standard iNO therapy. Inhalation of the nebulized solution of the new SIN-1A formulation (stabilized by a cyclodextrin derivative) might be a valuable, effective option where iNO therapy is not available due to dosing difficulties or availability.
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Affiliation(s)
- Attila Oláh
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Bálint András Barta
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Mihály Ruppert
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Alex Ali Sayour
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Dávid Nagy
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Tímea Bálint
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Georgina Viktória Nagy
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | | | | | | | | | - Endre Zima
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Tamás Radovits
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
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Kaplish D, Vagha JD, Meshram RJ, Lohiya S. A Comprehensive Review of Inhaled Nitric Oxide Therapy: Current Trends, Challenges, and Future Directions. Cureus 2024; 16:e53558. [PMID: 38445143 PMCID: PMC10913844 DOI: 10.7759/cureus.53558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/04/2024] [Indexed: 03/07/2024] Open
Abstract
This comprehensive review explores the multifaceted landscape of inhaled nitric oxide (iNO) therapy, tracing its historical evolution, mechanisms of action, clinical applications, challenges, and future directions. The nitric oxide signaling pathway, characterized by vasodilatory effects and anti-inflammatory properties, forms the foundation of iNO's therapeutic efficacy. Clinical applications are found in neonatal respiratory distress syndrome, pulmonary hypertension, and acute respiratory distress syndrome, showcasing its versatility. However, challenges, including cost considerations, technical intricacies, safety concerns, and resistance, highlight the nuanced landscape surrounding iNO therapy. Implications for clinical practice underscore the need for a tailored and evidence-based approach, considering individual patient characteristics and indications. Recommendations for future research emphasize ongoing exploration, novel indications, and the development of targeted therapies. In conclusion, this review positions iNO as a dynamic and adaptable intervention, poised to reshape therapeutic strategies and enhance patient outcomes in critical care.
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Affiliation(s)
- Divyanshi Kaplish
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Jayant D Vagha
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Revat J Meshram
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sham Lohiya
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Fawley JA, Tignanelli CJ, Werner NL, Kasotakis G, Mandell SP, Glass NE, Dries DJ, Costantini TW, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for management of acute respiratory distress syndrome and severe hypoxemia. J Trauma Acute Care Surg 2023; 95:592-602. [PMID: 37314843 PMCID: PMC10545067 DOI: 10.1097/ta.0000000000004046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023]
Abstract
LEVEL OF EVIDENCE Therapeutic/Care Management: Level V.
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9
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Abdulla HM, Gangwar P, Sajith PK, Ramachandran CN. Probing the Interaction of NO with C 60: Comparison between Endohedral and Exohedral Complexes. J Phys Chem A 2023; 127:3598-3607. [PMID: 37051864 DOI: 10.1021/acs.jpca.3c00381] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Recent advances in synthetic methodologies have opened new strategies for synthesizing stable metal-free electron spin systems based on fullerenes. Introducing nitric oxide (NO) inside a fullerene cage is one of the methods to attain this goal. In the present study, dispersion corrected density functional theory (B3LYP-D3) has been used to evaluate the structure, stability, and electronic properties of NO encapsulated fullerene NO@C60 and compared those with its exohedral fullerene NO.C60 analog. The calculated stabilization energy for NO@C60 is appreciably higher than NO.C60, and this difference is comprehended via the Quantum theory of atoms in molecules (QTAIM) and noncovalent interaction (NCI) topological analyses. The delocalization of electron density of NO and the C60 cage in NO@C60 is discussed using electrostatic potential analysis. In addition, an attempt has been made to understand the different locations and orientations involving the interaction of two NO radicals and the fullerene C60. It is shown that the encapsulation of the NO dimer inside the C60 cage is an energetically unfavorable process. On the other hand, stable structures are obtained upon the physisorption of other NO on the surface of NO@C60 and NO.C60. The present work provides an in-depth understanding of the interaction of NO and C60 fullerene, its preferable position, and its orientation in both endohedral and exohedral complexes.
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Affiliation(s)
| | - Peaush Gangwar
- Department of Chemistry, Indian Institute of Technology Roorkee, Roorkee, Uttarakhand 247667, India
| | - Pookkottu K Sajith
- Department of Chemistry, Farook College, Kozhikode, Kerala 673632, India
| | - C N Ramachandran
- Department of Chemistry, Indian Institute of Technology Roorkee, Roorkee, Uttarakhand 247667, India
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10
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Pulmonary Specific Ancillary Treatment for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S99-S111. [PMID: 36661439 DOI: 10.1097/pcc.0000000000003162] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We conducted an updated review of the literature on pulmonary-specific ancillary therapies for pediatric acute respiratory distress syndrome (PARDS) to provide an update to the Pediatric Acute Lung Injury Consensus Conference recommendations and statements about clinical practice and research. DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION Searches were limited to children, PARDS or hypoxic respiratory failure and overlap with pulmonary-specific ancillary therapies. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-six studies were identified for full-text extraction. Four clinical recommendations were generated, related to use of inhaled nitric oxide, surfactant, prone positioning, and corticosteroids. Two good practice statements were generated on the use of routine endotracheal suctioning and installation of isotonic saline prior to endotracheal suctioning. Three research statements were generated related to: the use of open versus closed suctioning, specific methods of airway clearance, and various other ancillary therapies. CONCLUSIONS The evidence to support or refute any of the specific ancillary therapies in children with PARDS remains low. Further investigation, including a focus on specific subpopulations, is needed to better understand the role, if any, of these various ancillary therapies in PARDS.
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Al Sulaiman K, Korayem GB, Altebainawi AF, Al Harbi S, Alissa A, Alharthi A, Kensara R, Alfahed A, Vishwakarma R, Al Haji H, Almohaimid N, Al Zumai O, Alrubayan F, Asiri A, Alkahtani N, Alolayan A, Alsohimi S, Melibari N, Almagthali A, Aljahdali S, Alenazi AA, Alsaeedi AS, Al Ghamdi G, Al Faris O, Alqahtani J, Al Qahtani J, Alshammari KA, Alshammari KI, Aljuhani O. Evaluation of inhaled nitric oxide (iNO) treatment for moderate-to-severe ARDS in critically ill patients with COVID-19: a multicenter cohort study. Crit Care 2022; 26:304. [PMID: 36192801 PMCID: PMC9527729 DOI: 10.1186/s13054-022-04158-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/04/2022] [Indexed: 11/07/2022] Open
Abstract
Background Inhaled nitric oxide (iNO) is used as rescue therapy in patients with refractory hypoxemia due to severe COVID-19 acute respiratory distress syndrome (ARDS) despite the recommendation against the use of this treatment. To date, the effect of iNO on the clinical outcomes of critically ill COVID-19 patients with moderate-to-severe ARDS remains arguable. Therefore, this study aimed to evaluate the use of iNO in critically ill COVID-19 patients with moderate-to-severe ARDS. Methods This multicenter, retrospective cohort study included critically ill adult patients with confirmed COVID-19 treated from March 01, 2020, until July 31, 2021. Eligible patients with moderate-to-severe ARDS were subsequently categorized into two groups based on inhaled nitric oxide (iNO) use throughout their ICU stay. The primary endpoint was the improvement in oxygenation parameters 24 h after iNO use. Other outcomes were considered secondary. Propensity score matching (1:2) was used based on the predefined criteria. Results A total of 1598 patients were screened, and 815 were included based on the eligibility criteria. Among them, 210 patients were matched based on predefined criteria. Oxygenation parameters (PaO2, FiO2 requirement, P/F ratio, oxygenation index) were significantly improved 24 h after iNO administration within a median of six days of ICU admission. However, the risk of 30-day and in-hospital mortality were found to be similar between the two groups (HR: 1.18; 95% CI: 0.77, 1.82; p = 0.45 and HR: 1.40; 95% CI: 0.94, 2.11; p= 0.10, respectively). On the other hand, ventilator-free days (VFDs) were significantly fewer, and ICU and hospital LOS were significantly longer in the iNO group. In addition, patients who received iNO had higher odds of acute kidney injury (AKI) (OR (95% CI): 2.35 (1.30, 4.26), p value = 0.005) and hospital/ventilator-acquired pneumonia (OR (95% CI): 3.2 (1.76, 5.83), p value = 0.001). Conclusion In critically ill COVID-19 patients with moderate-to-severe ARDS, iNO rescue therapy is associated with improved oxygenation parameters but no mortality benefits. Moreover, iNO use is associated with higher odds of AKI, pneumonia, longer LOS, and fewer VFDs. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04158-y.
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Affiliation(s)
- Khalid Al Sulaiman
- grid.415254.30000 0004 1790 7311Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.449346.80000 0004 0501 7602Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O.Box 84428, Riyadh, 11671 Saudi Arabia ,Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
| | - Ghazwa B. Korayem
- grid.449346.80000 0004 0501 7602Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O.Box 84428, Riyadh, 11671 Saudi Arabia
| | - Ali F. Altebainawi
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Hail, Saudi Arabia
| | - Shmeylan Al Harbi
- grid.415254.30000 0004 1790 7311Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman Alissa
- Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Abdullah Alharthi
- grid.415254.30000 0004 1790 7311Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Raed Kensara
- grid.415254.30000 0004 1790 7311Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Amjaad Alfahed
- grid.449346.80000 0004 0501 7602Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O.Box 84428, Riyadh, 11671 Saudi Arabia
| | - Ramesh Vishwakarma
- grid.418936.10000 0004 0610 0854Statistics Department, European Organization for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Hussain Al Haji
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Naif Almohaimid
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Omar Al Zumai
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Fahad Alrubayan
- grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.415254.30000 0004 1790 7311Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulmajid Asiri
- grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.415254.30000 0004 1790 7311Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nasser Alkahtani
- grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulaziz Alolayan
- grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Samiah Alsohimi
- grid.412126.20000 0004 0607 9688Pharmaceutical Services Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia ,grid.415271.40000 0004 0573 8987Phamacy Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Nawal Melibari
- grid.412125.10000 0001 0619 1117Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Alaa Almagthali
- grid.412126.20000 0004 0607 9688Pharmaceutical Services Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Seba Aljahdali
- grid.412125.10000 0001 0619 1117Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abeer A. Alenazi
- grid.415989.80000 0000 9759 8141Pharmaceutical Care Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Alawi S. Alsaeedi
- grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.415254.30000 0004 1790 7311Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ghassan Al Ghamdi
- grid.416641.00000 0004 0607 2419King Abdullah International Medical Research Center, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia ,grid.415254.30000 0004 1790 7311Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia ,grid.412149.b0000 0004 0608 0662College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Omar Al Faris
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Joud Alqahtani
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Jalal Al Qahtani
- grid.415254.30000 0004 1790 7311Respiratory Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Khalid A. Alshammari
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Hail, Saudi Arabia
| | - Khalil I. Alshammari
- grid.440750.20000 0001 2243 1790Department of Internal Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- grid.412125.10000 0001 0619 1117Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
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12
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Yu JJ, Non AL, Heinrich EC, Gu W, Alcock J, Moya EA, Lawrence ES, Tift MS, O'Brien KA, Storz JF, Signore AV, Khudyakov JI, Milsom WK, Wilson SM, Beall CM, Villafuerte FC, Stobdan T, Julian CG, Moore LG, Fuster MM, Stokes JA, Milner R, West JB, Zhang J, Shyy JY, Childebayeva A, Vázquez-Medina JP, Pham LV, Mesarwi OA, Hall JE, Cheviron ZA, Sieker J, Blood AB, Yuan JX, Scott GR, Rana BK, Ponganis PJ, Malhotra A, Powell FL, Simonson TS. Time Domains of Hypoxia Responses and -Omics Insights. Front Physiol 2022; 13:885295. [PMID: 36035495 PMCID: PMC9400701 DOI: 10.3389/fphys.2022.885295] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/24/2022] [Indexed: 02/04/2023] Open
Abstract
The ability to respond rapidly to changes in oxygen tension is critical for many forms of life. Challenges to oxygen homeostasis, specifically in the contexts of evolutionary biology and biomedicine, provide important insights into mechanisms of hypoxia adaptation and tolerance. Here we synthesize findings across varying time domains of hypoxia in terms of oxygen delivery, ranging from early animal to modern human evolution and examine the potential impacts of environmental and clinical challenges through emerging multi-omics approaches. We discuss how diverse animal species have adapted to hypoxic environments, how humans vary in their responses to hypoxia (i.e., in the context of high-altitude exposure, cardiopulmonary disease, and sleep apnea), and how findings from each of these fields inform the other and lead to promising new directions in basic and clinical hypoxia research.
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Affiliation(s)
- James J. Yu
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Amy L. Non
- Department of Anthropology, Division of Social Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Erica C. Heinrich
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA, United States
| | - Wanjun Gu
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
- Herbert Wertheim School of Public Health and Longevity Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Joe Alcock
- Department of Emergency Medicine, University of New Mexico, Albuquerque, MX, United States
| | - Esteban A. Moya
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Elijah S. Lawrence
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Michael S. Tift
- Department of Biology and Marine Biology, College of Arts and Sciences, University of North Carolina Wilmington, Wilmington, NC, United States
| | - Katie A. O'Brien
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
- Department of Physiology, Development and Neuroscience, Faculty of Biology, School of Biological Sciences, University of Cambridge, Cambridge, ENG, United Kingdom
| | - Jay F. Storz
- School of Biological Sciences, College of Arts and Sciences, University of Nebraska-Lincoln, Lincoln, IL, United States
| | - Anthony V. Signore
- School of Biological Sciences, College of Arts and Sciences, University of Nebraska-Lincoln, Lincoln, IL, United States
| | - Jane I. Khudyakov
- Department of Biological Sciences, University of the Pacific, Stockton, CA, United States
| | | | - Sean M. Wilson
- Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda, CA, United States
| | | | | | | | - Colleen G. Julian
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lorna G. Moore
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, Aurora, CO, United States
| | - Mark M. Fuster
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Jennifer A. Stokes
- Department of Kinesiology, Southwestern University, Georgetown, TX, United States
| | - Richard Milner
- San Diego Biomedical Research Institute, San Diego, CA, United States
| | - John B. West
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Jiao Zhang
- Department of Medicine, UC San Diego School of Medicine, San Diego, CA, United States
| | - John Y. Shyy
- Department of Medicine, UC San Diego School of Medicine, San Diego, CA, United States
| | - Ainash Childebayeva
- Department of Archaeogenetics, Max Planck Institute for Evolutionary Anthropology, Leipzig, Germany
| | - José Pablo Vázquez-Medina
- Department of Integrative Biology, College of Letters and Science, University of California, Berkeley, Berkeley, CA, United States
| | - Luu V. Pham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Omar A. Mesarwi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - James E. Hall
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Zachary A. Cheviron
- Division of Biological Sciences, College of Humanities and Sciences, University of Montana, Missoula, MT, United States
| | - Jeremy Sieker
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Arlin B. Blood
- Department of Pediatrics Division of Neonatology, School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Jason X. Yuan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Graham R. Scott
- Department of Pediatrics Division of Neonatology, School of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Brinda K. Rana
- Moores Cancer Center, UC San Diego, La Jolla, CA, United States
- Department of Psychiatry, UC San Diego, La Jolla, CA, United States
| | - Paul J. Ponganis
- Center for Marine Biotechnology and Biomedicine, La Jolla, CA, United States
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Frank L. Powell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Tatum S. Simonson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA, United States
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13
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Abstract
Acute respiratory distress syndrome (ARDS) occurs in up to 10% of patients with respiratory failure admitted through the emergency department. Use of noninvasive respiratory support has proliferated in recent years; clinicians must understand the relative merits and risks of these technologies and know how to recognize signs of failure. The cornerstone of ARDS care of the mechanically ventilated patient is low-tidal volume ventilation based on ideal body weight. Adjunctive therapies, such as prone positioning and neuromuscular blockade, may have a role in the emergency department management of ARDS depending on patient and department characteristics.
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Affiliation(s)
- Alin Gragossian
- Department of Critical Care Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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14
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Smith LM, Glauser JM. Managing Severe Hypoxic Respiratory Failure in COVID-19. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022; 10:31-35. [PMID: 35572208 PMCID: PMC9091541 DOI: 10.1007/s40138-022-00245-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 12/11/2022]
Abstract
Purpose of Review Adult respiratory distress syndrome is a life-threatening complication from severe COVID-19 infection resulting in severe hypoxic respiratory failure. Strategies at improving oxygenation have evolved over the course of the pandemic. Recent Findings Although non-invasive respiratory support reduces the need for intubation, a significant number of patients with COVID-19 progress to invasive mechanical ventilation. Once intubated, a lung protective ventilation strategy should be employed that limits tidal volumes to 6 ml/kg of predicted body weight and employs sufficient positive end-expiratory pressure to maximize oxygen delivery while minimizing the fraction of inspired oxygen. Intermittent prone positioning is effective at improving survival, and there is a growing body of evidence that it can be safely performed in spontaneously breathing patients to reduce the need for invasive mechanical ventilation. Inhaled pulmonary vasodilators have not been shown to improve survival or cost-effectiveness in COVID-19 and should be used selectively. Summary Finally, the best outcomes are likely achieved at centers with experience at severe ARDS management and protocols for escalation of care.
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Affiliation(s)
- Lane M. Smith
- Division of Critical Care Medicine, Department of Anesthesiology, University of Michigan Health System, 4172 Cardiovascular Center, 1500 East Medical Center Dr., SPC 5861, Ann Arbor, MI 48109-5861 USA
| | - Jonathan M. Glauser
- Department of Emergency Medicine, MetroHealth System and Case Western Reserve University, Cleveland, OH 44109 USA
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15
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Sodano F, Gazzano E, Fruttero R, Lazzarato L. NO in Viral Infections: Role and Development of Antiviral Therapies. Molecules 2022; 27:2337. [PMID: 35408735 PMCID: PMC9000700 DOI: 10.3390/molecules27072337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 11/16/2022] Open
Abstract
Nitric oxide is a ubiquitous signaling radical that influences critical body functions. Its importance in the cardiovascular system and the innate immune response to bacterial and viral infections has been extensively investigated. The overproduction of NO is an early component of viral infections, including those affecting the respiratory tract. The production of high levels of NO is due to the overexpression of NO biosynthesis by inducible NO synthase (iNOS), which is involved in viral clearance. The development of NO-based antiviral therapies, particularly gaseous NO inhalation and NO-donors, has proven to be an excellent antiviral therapeutic strategy. The aim of this review is to systematically examine the multiple research studies that have been carried out to elucidate the role of NO in viral infections and to comprehensively describe the NO-based antiviral strategies that have been developed thus far. Particular attention has been paid to the potential mechanisms of NO and its clinical use in the prevention and therapy of COVID-19.
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Affiliation(s)
- Federica Sodano
- Department of Drug Science and Technology, University of Torino, 10125 Torino, Italy; (R.F.); (L.L.)
- Department of Pharmacy, “Federico II” University of Naples, 80131 Naples, Italy
| | - Elena Gazzano
- Department of Life Sciences and Systems Biology, University of Torino, 10123 Torino, Italy
| | - Roberta Fruttero
- Department of Drug Science and Technology, University of Torino, 10125 Torino, Italy; (R.F.); (L.L.)
| | - Loretta Lazzarato
- Department of Drug Science and Technology, University of Torino, 10125 Torino, Italy; (R.F.); (L.L.)
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16
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Schlömmer C, Schittek GA, Meier J, Hasibeder W, Valentin A, Dünser MW. The Austrian ICU survey : A questionnaire-based evaluation of intensive care medicine in Austria. Wien Klin Wochenschr 2022; 134:351-360. [PMID: 35084589 PMCID: PMC8792524 DOI: 10.1007/s00508-021-02002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 12/27/2021] [Indexed: 11/28/2022]
Abstract
Background While structures of intensive care medicine in Austria are well defined, data on organisational and medical practice in intensive care units (ICUs) have not been systematically evaluated. Methods In this explorative survey, organisational and medical details of ICUs in Austria were collected using an online questionnaire consisting of 147 questions. Results Out of 249 registered ICUs 73 (29.3%) responded, 60 were adult, 10 pediatric/neonatal ICUs and 19, 25 and 16 ICUs were located in level I, II and III hospitals, respectively. Of the respondents 89% reported that the ICU director was board-certified in intensive care medicine. Consultants were constantly present in 78% of ICUs during routine working hours and in 45% during nights and weekends. The nurse:bed ratio varied between 1:1 and 1:2 in 74% during day shifts and 60% during night shifts. Routine physiotherapist rounds were reported to take place daily except weekends in 67% of ICUs. Common monitoring techniques were reported to be in routine or occasional use in 85% and 83% of ICUs, respectively. The majority of ICUs provided daily visiting hours ranging between 2–12 h. Waiting rooms for relatives were available in 66% and an electronic documentation system in 66% of ICUs. Written protocols were available in 70% of ICUs. Conclusion The Austrian ICU survey suggests that ICUs in Austria are clearly structured, well-organized and well-equipped and have a high nurse:bed ratio. In view of the relatively low return rate we cannot exclude that a selection bias has led to overestimation of the survey findings. Supplementary Information The online version of this article (10.1007/s00508-021-02002-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christine Schlömmer
- Department of Anesthesia, Critical Care and Pain Medicine, Medical University Vienna, Vienna, Austria
| | - Gregor A Schittek
- Department of Anesthesiology and Intensive, Medical University Graz, Graz, Austria
| | - Jens Meier
- Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Krankenhausstraße 9, 4020, Linz, Austria
| | - Walter Hasibeder
- Department of Anaesthesiology and Critical Care Medicine, Hospital Zams, Zams, Austria
| | - Andreas Valentin
- Department of Internal and Critical Care Medicine, Hospital Schwarzach, Schwarzach, Austria
| | - Martin W Dünser
- Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Krankenhausstraße 9, 4020, Linz, Austria.
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17
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Adams CE, McAuley DF. Acute Respiratory Distress Syndrome. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8106506 DOI: 10.1016/b978-0-08-102723-3.00233-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a prevalent and important cause of respiratory failure. Underlying causes include pulmonary and non-pulmonary aetiologies. ARDS is acute hypoxaemic respiratory failure associated with non-cardiogenic pulmonary oedema, reduced pulmonary compliance, and can lead to lung fibrosis. In addition to treating the underlying cause, often the mainstay of the management of ARDS is invasive mechanical ventilation. This can perpetuate lung injury—ventilator-associated lung injury (VALI). Despite recent advances in our understanding of this, ARDS-associated morbidity and mortality remains high. This chapter discusses the pathophysiology of ARDS and its management, including mechanical ventilation, adjunctive therapies, and some recently trialed pharmacotherapies.
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18
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Sarangi MK, Padhi S, Dheeman S, Karn SK, Patel LD, Yi DK, Nanda SS. Diagnosis, prevention, and treatment of coronavirus disease: a review. Expert Rev Anti Infect Ther 2021; 20:243-266. [PMID: 34151679 DOI: 10.1080/14787210.2021.1944103] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Introduction: Coronavirus disease (COVID-19) was first reported in Wuhan, China, in late December 2019 and subsequently, declared a pandemic. As of 3 June 2021, 172,493,290 individuals have acquired COVID-19 and 3,708,334 patients have died worldwide, according to the World Health Organization.Areas covered: This review explores epidemiology; virology; pathogenesis; genomic variations; mode of transmission; clinical occurrence; diagnosis; and treatment with antiviral agents, antibiotics, and supportive therapies. It covers a nanotechnology-based treatment approach and emphasizes the importance of herbal and marine antiviral drugs. The review attempts to explain current advances in research, prevention, and control of COVID-19 spread through artificial intelligence and vaccine development status under cosmopolitan consideration.Expert opinion: While COVID-19 research is advancing at full capacity, the discovery of drugs or vaccines that can fight the pandemic is necessary. Human survival in such a critical situation will be possible only with the development of strong immunity by opting for exercise, yoga, and consumption of hygienic food and beverages. Therefore, education about COVID-19 lethality and its impact on livelihood is important. The pandemic has also shown positive effects on the environment, such as a significant reduction in environmental pollution and global warming and improvement in river water quality.
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Affiliation(s)
- Manoj Kumar Sarangi
- Department of Pharmaceutics, School of Pharmaceutical Sciences & Technology, Sardar Bhagwan Singh University, Balawala, Dehradun, Uttarakhand, India
| | - Sasmita Padhi
- Department of Pharmaceutics, School of Pharmaceutical Sciences & Technology, Sardar Bhagwan Singh University, Balawala, Dehradun, Uttarakhand, India
| | - Shrivardhan Dheeman
- Department of Microbiology, School of Life Sciences, Sardar Bhagwan Singh University, Balawala, Dehradun, Uttarakhand, India
| | - Santosh Kumar Karn
- Department of Biotechnology and Biochemistry, School of Life Sciences, Sardar Bhagwan Singh University, Balawala, Dehradun, Uttarakhand, India
| | - L D Patel
- Department of Pharmacy, Sharda School of Pharmacy, Ahmedabad, Gujarat, India
| | - Dong Kee Yi
- Department of Chemistry, Myongji University, Yongin, South Korea
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19
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Park SK, Lim T, Cho H, Yoon HK, Lee HJ, Lee JH, Yoo S, Kim JT, Kim WH. Comparative effectiveness of pharmacological interventions to prevent postoperative delirium: a network meta-analysis. Sci Rep 2021; 11:11922. [PMID: 34099790 PMCID: PMC8184858 DOI: 10.1038/s41598-021-91314-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 05/24/2021] [Indexed: 12/30/2022] Open
Abstract
Many pharmacologic agents were investigated for the effect to prevent delirium. We aimed to comprehensively compare the effect of the pharmacological interventions to prevent postoperative delirium. A Bayesian network meta-analysis of randomized trials was performed using random effects model. PubMed, the Cochrane Central Register of Controlled Trials, and Embase were searched on 20 January 2021. Randomized trials comparing the effect of a drug to prevent postoperative delirium with another drug or placebo in adult patients undergoing any kind of surgery were included. Primary outcome was the postoperative incidence of delirium. Eighty-six trials with 26,992 participants were included. Dexmedetomidine, haloperidol, and atypical antipsychotics significantly decreased the incidence of delirium than placebo [dexmedetomidine: odds ratio 0.51, 95% credible interval (CrI) 0.40-0.66, moderate quality of evidence (QOE); haloperidol: odds ratio 0.59, 95% CrI 0.37-0.95, moderate QOE; atypical antipsychotics: odds ratio 0.27, 95% CrI 0.14-0.51, moderate QOE]. Dexmedetomidine and atypical antipsychotics had the highest-ranking probabilities to be the best. However, significant heterogeneity regarding diagnostic time window as well as small study effects precludes firm conclusion.
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Affiliation(s)
- Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Taeyoon Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyeyeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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20
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Kramer A, Mortensen CS, Schultz JG, Lyhne MD, Andersen A, Nielsen-Kudsk JE. Inhaled nitric oxide has pulmonary vasodilator efficacy both in the immediate and prolonged phase of acute pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:265–272. [PMID: 32662283 DOI: 10.1177/2048872620918713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/24/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) effectively reduces right ventricular afterload when administered in the immediate phase of acute pulmonary embolism (PE) in preclinical animal models. In a porcine model of intermediate-risk PE, we aimed to investigate whether iNO has pulmonary vasodilator efficacy both in the immediate and prolonged phase of acute PE. METHODS Anesthetized pigs (n = 18) were randomized into three subgroups. An acute PE iNO-group (n = 6) received iNO at 40 ppm at one, three, six, nine and 12 hours after onset of PE. Vehicle animals (n = 6) received PE, but no active treatment. A third group of sham animals (n = 6) received neither PE nor treatment. Animals were evaluated using intravascular pressures, respiratory parameters, biochemistry and intracardiac pressure-volume measurements. RESULTS The administration of PE increased mean pulmonary artery pressure (mPAP) (vehicle vs sham; 33.3 vs 17.7 mmHg, p < 0.0001), pulmonary vascular resistance (vehicle vs sham; 847.5 vs 82.0 dynes, p < 0.0001) and right ventricular arterial elastance (vehicle vs sham; 1.2 vs 0.2 mmHg/ml, p < 0.0001). Significant mPAP reduction by iNO was preserved at 12 hours after the onset of acute PE (vehicle vs iNO; 0.5 vs -3.5 mmHg, p < 0.0001). However, this response was attenuated over time (p = 0.0313). iNO did not affect the systemic circulation. CONCLUSIONS iNO is a safe and effective pulmonary vasodilator both in the immediate and prolonged phase of acute PE in an in-vivo porcine model of intermediate-risk PE.
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Affiliation(s)
- Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Christian Schmidt Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Jacob Gammelgaard Schultz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Mads Dam Lyhne
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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21
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Tsonas AM, Botta M, Serpa Neto A, Horn J, Paulus F, Schultz MJ. Ventilation management in acute respiratory failure related to COVID-19 versus ARDS from another origin - a descriptive narrative review. Expert Rev Respir Med 2021; 15:1013-1023. [PMID: 33847219 PMCID: PMC8054495 DOI: 10.1080/17476348.2021.1913060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Introduction It is uncertain whether ventilation in patients with acute respiratory failure related to coronavirus disease 2019 (COVID-19) differs from that in patients with acute respiratory distress syndrome (ARDS) from another origin. Areas covered We undertook two literature searches in PubMed to identify observational studies reporting on ventilation management––one in patients with acute respiratory failure related to COVID-19, and one in patients with ARDS from another origin. The searches identified 14 studies in patients with acute respiratory failure related to COVID-19, and 8 studies in patients with ARDS from another origin. Expert opinion In patients with acute respiratory failure related to COVID-19, ventilation management seems to be similar to that of patients with ARDS from another origin. The future lies in studies focused on personalized treatment of ARDS of all origins, including COVID-19.
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Affiliation(s)
- Anissa M Tsonas
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Australian and New Zealand Intensive Care Research Center (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Australia.,Melbourne Medical School, Department of Critical Care, Austin Hospital and University of Melbourne, Melbourne, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Amsterdam Neuroscience, Amsterdam UMC Research Institute, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,, ACHIEVE, Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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22
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Garren MR, Ashcraft M, Qian Y, Douglass M, Brisbois EJ, Handa H. Nitric oxide and viral infection: Recent developments in antiviral therapies and platforms. APPLIED MATERIALS TODAY 2021; 22:100887. [PMID: 38620577 PMCID: PMC7718584 DOI: 10.1016/j.apmt.2020.100887] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/11/2020] [Accepted: 11/14/2020] [Indexed: 05/09/2023]
Abstract
Nitric oxide (NO) is a gasotransmitter of great significance to developing the innate immune response to many bacterial and viral infections, while also modulating vascular physiology. The generation of NO from the upregulation of endogenous nitric oxide synthases serves as an efficacious method for inhibiting viral replication in host defense and warrants investigation for the development of antiviral therapeutics. With increased incidence of global pandemics concerning several respiratory-based viral infections, it is necessary to develop broad therapeutic platforms for inhibiting viral replication and enabling more efficient host clearance, as well as to fabricate new materials for deterring viral transmission from medical devices. Recent developments in creating stabilized NO donor compounds and their incorporation into macromolecular scaffolds and polymeric substrates has created a new paradigm for developing NO-based therapeutics for long-term NO release in applications for bactericidal and blood-contacting surfaces. Despite this abundance of research, there has been little consideration of NO-releasing scaffolds and substrates for reducing passive transmission of viral infections or for treating several respiratory viral infections. The aim of this review is to highlight the recent advances in developing gaseous NO, NO prodrugs, and NO donor compounds for antiviral therapies; discuss the limitations of NO as an antiviral agent; and outline future prospects for guiding materials design of a next generation of NO-releasing antiviral platforms.
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Key Words
- ACE, angiotensin converting enzyme
- AP1, activator protein 1
- COVID-19
- COVID-19, coronavirus disease 2019
- ECMO, extracorporeal membrane oxygenation, FDA, United States Food and Drug Administration
- GNSO, S-nitrosoglutathione
- H1N1, influenza A virus subtype H1N1
- HI, Host Immunology
- HIV, human immunodeficiency virus
- HPV, human papillomavirus
- HSV, herpes simplex virus
- I/R, pulmonary ischemia-reperfusion
- IC50, inhibitory concentration 50
- IFN, interferon
- IFNγ, interferon gamma
- IKK, inhibitor of nuclear factor kappa B kinase
- IRF-1, interferon regulatory factor 1
- Inhalation therapy
- Medical Terminology: ARDS, acute respiratory distress syndrome
- NF-κB, nuclear factor kappa-light-chain enhancer of activated B cells
- NO, nitric oxide
- NOS, nitric oxide synthase
- Nitric Oxide and Related Compounds: eNOS/NOS 3, endothelial nitric oxide synthase
- Nitric oxide
- Other: DNA, deoxyribonucleic acid
- P38-MAPK, P38 mitogen-activated protein kinases
- PAMP, pathogen-associated molecular pattern
- PCV2, porcine circovirus type 2
- PHT, pulmonary hypertension
- PKR, protein kinase R
- RNA, ribonucleic acid
- RNI, reactive nitrogen intermediate
- RSNO, S-nitrosothiol
- SARS, severe acute respiratory syndrome
- SARS-CoV-2, severe acute respiratory syndrome coronavirus 2
- SNAP, S-nitroso-N-acetyl-penicillamine
- STAT-1, signal transducer and activator of transcription 1
- Severe acute respiratory distress
- TAK1, transforming growth factor β-activated kinases-1
- TLR, toll-like receptor
- VAP, ventilator associated pneumonia
- Viral infection
- Viruses: CVB3, coxsackievirus
- dsRNA, double stranded (viral) ribonucleic acid
- gNO, gaseous nitric oxide
- iNOS/NOS 2, inducible nitric oxide synthase
- mtALDH, mitochondrial aldehyde dehydrogenase
- nNOS/NOS 1, neuronal nitric oxide synthase
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Affiliation(s)
- Mark R Garren
- School of Chemical, Materials, and Biochemical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Morgan Ashcraft
- School of Chemical, Materials, and Biochemical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
- Department of Pharmaceutical and Biomedical Sciences, College of Pharmacy, University of Georgia, Athens, GA, USA
| | - Yun Qian
- School of Chemical, Materials, and Biochemical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Megan Douglass
- School of Chemical, Materials, and Biochemical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Elizabeth J Brisbois
- School of Chemical, Materials, and Biochemical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Hitesh Handa
- School of Chemical, Materials, and Biochemical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
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23
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Ferrari M, Santini A, Protti A, Andreis DT, Iapichino G, Castellani G, Rendiniello V, Costantini E, Cecconi M. Inhaled nitric oxide in mechanically ventilated patients with COVID-19. J Crit Care 2020; 60:159-160. [PMID: 32814271 PMCID: PMC7417286 DOI: 10.1016/j.jcrc.2020.08.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Michele Ferrari
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Alessandro Santini
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Alessandro Protti
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
| | - Davide T Andreis
- Intensive Care Unit, Ospedale Civile di Legnano, ASST Ovest Milanese, Legnano, Milan, Italy
| | - Giacomo Iapichino
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Gianluca Castellani
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Valerio Rendiniello
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Elena Costantini
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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24
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25
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Stene Hurtsén A, Zorikhin Nilsson I, Dogan EM, Nilsson KF. A Comparative Study of Inhaled Nitric Oxide and an Intravenously Administered Nitric Oxide Donor in Acute Pulmonary Hypertension. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:635-645. [PMID: 32109989 PMCID: PMC7034972 DOI: 10.2147/dddt.s237477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/21/2020] [Indexed: 12/20/2022]
Abstract
Purpose Inhaled nitric oxide (iNO) selectively vasodilates the pulmonary circulation but the effects are sometimes insufficient. Available intravenous (iv) substances are non-selective and cause systemic side effects. The pulmonary and systemic effects of iNO and an iv mono-organic nitrite (PDNO) were compared in porcine models of acute pulmonary hypertension. Methods In anesthetized piglets, dose–response experiments of iv PDNO at normal pulmonary arterial pressure (n=10) were executed. Dose–response experiments of iv PDNO (n=6) and iNO (n=7) were performed during pharmacologically induced pulmonary hypertension (U46619 iv). The effects of iv PDNO and iNO were also explored in 5 mins of hypoxia-induced increase in pulmonary pressure (n=2-4). Results PDNO (15, 30, 45 and 60 nmol NO kg−1 min−1 iv) and iNO (5, 10, 20 and 40 ppm which corresponded to 56, 112, 227, 449 nmol NO kg−1 min−1, respectively) significantly decreased the U46619-increased mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance (PVR) to a similar degree without significant decreases in mean arterial pressure (MAP) or systemic vascular resistance (SVR). iNO caused increased levels of methemoglobin. At an equivalent delivered NO quantity (iNO 5 ppm and PDNO 45 nmol kg−1 min−1 iv), PDNO decreased PVR and SVR significantly more than iNO. Both drugs counteracted hypoxia-induced pulmonary vasoconstriction and they decreased the ratio of PVR and SVR in both settings. Conclusion Intravenous PDNO was a more potent pulmonary vasodilator than iNO in pulmonary hypertension, with no severe side effects. Hence, this study supports the potential of iv PDNO in the treatment of acute pulmonary hypertension.
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Affiliation(s)
- Anna Stene Hurtsén
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Centre for Clinical Research and Education, Karlstad Central Hospital, Karlstad, Sweden
| | - Ilya Zorikhin Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Emanuel M Dogan
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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26
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46:10-67. [PMID: 32030529 PMCID: PMC7095013 DOI: 10.1007/s00134-019-05878-6] [Citation(s) in RCA: 330] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, UK
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, UK
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | | | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, Singapore
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Nunnally
- New York University Langone Medical Center, New York, NY, USA
| | | | - Raina M Paul
- Advocate Children's Hospital, Park Ridge, IL, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-Sur-Yvette, France
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27
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020; 21:e52-e106. [PMID: 32032273 DOI: 10.1097/pcc.0000000000002198] [Citation(s) in RCA: 575] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | - Akash Deep
- King's College Hospital, London, United Kingdom
| | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, and Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | - Adrienne G Randolph
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Lyvonne N Tume
- University of the West of England, Bristol, United Kingdom
| | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,College of Nursing, University of Iowa, Iowa City, IA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-sur-Yvette, France
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28
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Allareddy V, Cheifetz IM. Clinical trials and future directions in pediatric acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:514. [PMID: 31728367 PMCID: PMC6828784 DOI: 10.21037/atm.2019.09.14] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/30/2019] [Indexed: 01/08/2023]
Abstract
The pediatric acute respiratory distress syndrome (PARDS), a description specific for children with acute respiratory distress syndrome (ARDS), was proposed in the recent Pediatric Acute Lung Injury Consensus Conference (PALICC, 2015). This recent standardization of PARDS diagnosis is expected to aid in uniform earlier recognition of the entity, enable use of consistent management strategies and potentially increase the ease of enrollment in future PARDS clinical trials-all of which are expected to optimize outcomes in PARDS. Clinical trials in PARDS are few but ongoing studies are expected to lay the foundation for future clinical studies. The Randomized Evaluation of Sedation Titration for Respiratory Failure trial (RESTORE) trial has revealed that a goal directed sedation protocol does not reduce the duration of invasive ventilation in critically ill children. PROSpect trial is a large multi-institute clinical trial that is expected to reveal optimal ventilation strategies and patient positioning (supine vs. prone) in patients with severe PARDS. The PARDS neuromuscular blockade (NMB) study is expected to yield important information about the impact of active NMB on PARDS outcomes. Information from these studies could be used to design future clinical trials in PARDS and to lessen the anecdotal or extrapolated experiences from adult clinical studies that often guide clinical practices in PARDS management. Finally, it is expected that these definitions and management strategies will be revised periodically as our understanding of PARDS evolves. Emerging data on PARDS subtypes suggest that patient heterogeneity is an important factor in designing these clinical trials.
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Affiliation(s)
- Veerajalandhar Allareddy
- Section Chief Pediatric Cardiac ICU, Duke Children's Hospital, Duke University Medical Center, Durham, NC, USA
| | - Ira M Cheifetz
- Section Chief Pediatric Cardiac ICU, Duke Children's Hospital, Duke University Medical Center, Durham, NC, USA
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29
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Jelting Y, Weibel S, Afshari A, Pace NL, Jokinen J, Artmann T, Eberhart LHJ, Kranke P. Patient-controlled analgesia with remifentanil vs. alternative parenteral methods for pain management in labour: a Cochrane systematic review. Anaesthesia 2019; 72:1016-1028. [PMID: 28695584 DOI: 10.1111/anae.13971] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2017] [Indexed: 01/10/2023]
Abstract
We aimed to assess the effectiveness of remifentanil used as intravenous patient-controlled analgesia for the pain of labour. We performed a systematic literature search in December 2015 (updated in December 2016). We included randomised, controlled and cluster-randomised trials of women in labour with planned vaginal delivery receiving patient-controlled remifentanil compared principally with other parenteral and patient-controlled opioids, epidural analgesia and continuous remifentanil infusion or placebo. The primary outcomes were patient satisfaction with pain relief and the occurrence of adverse events for mothers and newborns. We assessed risk of bias for each included study and applied the GRADE approach for the quality of evidence. We included total zero event trials, using a constant continuity correction of 0.01 and a random-effect meta-analysis. Twenty studies were included in the qualitative analysis; within these, 3713 participants were randomised and 3569 analysed. Most of our pre-specified outcomes were not studied in the included trials. However, we found evidence that women using patient-controlled remifentanil were more satisfied with pain relief than women receiving parenteral opioids (four trials, 216 patients, very low quality evidence) with a standardised mean difference ([SMD] 95%CI) of 2.11 (0.72-3.49), but were less satisfied than women receiving epidural analgesia (seven trials, 2135 patients, very low quality evidence), -0.22 (-0.40 to -0.04). Data on adverse events were sparse. However, the relative risk (95%CI) for maternal respiratory depression for patient-controlled remifentanil compared with epidural analgesia (three trials, 687 patients, low-quality evidence) was 0.91 (0.51-1.62). Compared with continuous intravenous infusion of remifentanil (two trials, 135 patients, low-quality evidence) no conclusion could be reached as all study arms showed zero events. The relative risk (95%CI) of Apgar scores less than 7 at 5 min after birth compared with epidural analgesia (five trials, 1322 participants, low-quality evidence) was 1.26 (0.62-2.57).
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Affiliation(s)
- Y Jelting
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - S Weibel
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - A Afshari
- Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark
| | - N L Pace
- Department of Anaesthesiology, University of Utah, Salt Lake City, USA
| | - J Jokinen
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - T Artmann
- Department of Anaesthesia and Intensive Care Medicine, Cnopf Children's Hospital, Nürnberg, Germany
| | - L H J Eberhart
- Department of Anaesthesiology and Intensive Care Medicine, Philipps-University Marburg, Marburg, Germany
| | - P Kranke
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
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30
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Erdem Ö, Ince C, Tibboel D, Kuiper JW. Assessing the Microcirculation With Handheld Vital Microscopy in Critically Ill Neonates and Children: Evolution of the Technique and Its Potential for Critical Care. Front Pediatr 2019; 7:273. [PMID: 31338353 PMCID: PMC6629784 DOI: 10.3389/fped.2019.00273] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022] Open
Abstract
Assuring adequate tissue oxygenation in the critically ill, but still developing child is challenging. Conventional hemodynamic monitoring techniques fall short in assessing tissue oxygenation as these are directed at the macrocirculation and indirect surrogates of tissue oxygenation. The introduction of handheld vital microscopy (HVM) has allowed for the direct visualization of the microcirculation and with this has offered insight into tissue oxygenation on a microcirculatory level. Since its introduction, technical improvements have been made to HVM, to both hardware and software, and guidelines have been developed through expert consensus on image assessment and analysis. Using HVM, the microcirculation of the skin, the buccal mucosa, and the sublingual mucosa of healthy and (critically) ill neonates and children have been visualized and investigated. Yet, integration of HVM in hemodynamic monitoring has been limited due to technical shortcomings. Only superficial microcirculatory beds can be visualized, inter-observer and intra-observer variabilities are not accounted for and image analysis happens offline and is semi-automated and time-consuming. More importantly, patients need to be cooperative or fully sedated to prevent pressure and movement artifacts, which is often not the case in children. Despite these shortcomings, observational research with HVM in neonates and children has revealed the following: (1) age-related developmental changes in the microcirculation, (2) loss of hemodynamic coherence, i.e., microcirculatory disturbances in the presence of a normal macrocirculation and, (3) microcirculatory disturbances which were independently associated with increased mortality risk. Although these observations underline the importance of microcirculatory monitoring, several steps have to be taken before integration in the decision process during critical care can happen. These steps include technological innovations to ease the use of HVM in the pediatric age group, measuring additional functional parameters of microvascular blood flow and integrated automated analysis software. As a next step, reference values for microcirculatory parameters need to be established, while also accounting for developmental changes. Finally, studies on microcirculatory guided therapies are necessary to assess whether the integration of microcirculatory monitoring will actually improve patient outcome. Nevertheless, HVM remains a promising, non-invasive tool to help physicians assure tissue oxygenation in the critically ill child.
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Affiliation(s)
- Özge Erdem
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Translational Physiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jan Willem Kuiper
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
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31
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Kuriyama A, Maeda H, Sun R, Aga M. Topical application of corticosteroids to tracheal tubes to prevent postoperative sore throat in adults undergoing tracheal intubation: a systematic review and meta-analysis. Anaesthesia 2018; 73:1546-1556. [PMID: 29574683 DOI: 10.1111/anae.14273] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2018] [Indexed: 12/17/2022]
Abstract
Postoperative sore throat negatively affects patient satisfaction and recovery. Numerous randomised trials have tested the efficacy of corticosteroids applied to tracheal tubes to prevent postoperative sore throat. We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Wanfang Database, and the China Academic Journal Network Publishing Database from inception to 7 December 2017. We included randomised controlled trials that assessed the efficacy and safety of corticosteroids applied to tracheal tubes, compared either with non-analgesic controls and analgesic agents, in adults undergoing elective surgery under general anaesthesia. We pooled the data using a random-effects model and assessed the risk of random error by applying trial sequential analysis. Our primary outcomes were postoperative sore throat 24 h after surgery/extubation, and adverse events. The evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. We included 20 randomised controlled trials involving 2200 patients. Compared with non-analgesic controls, corticosteroids applied to tracheal tubes were associated with a reduced incidence of postoperative sore throat, risk ratio (95%CI) 0.39 (0.32-0.49) (18 trials, 1506 patients). Two randomised trials reported no adverse events. Compared with lidocaine, corticosteroids applied to tracheal tubes were associated with reduced incidence of postoperative sore throat, risk ratio (95%CI) 0.42 (0.35-0.51) (nine trials, 706 patients). Trial sequential analyses suggested the presence of firm evidence that corticosteroids applied to tracheal tubes were superior both to non-analgesic controls and lidocaine, in preventing postoperative sore throat. Evidence for postoperative sore throat for both comparisons was assessed as high quality. Only two trials sought adverse events; none were recorded.
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Affiliation(s)
- A Kuriyama
- Emergency and Critical Care Centre, Kurashiki Central Hospital, Kurashiki, Japan
| | - H Maeda
- Department of Emergency Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - R Sun
- Department of Anaesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei, China
| | - M Aga
- Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki, Japan
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32
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Chen Y, Lu GP. [Advances in the diagnosis and treatment of pediatric acute respiratory distress syndrome]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:717-723. [PMID: 30210022 PMCID: PMC7389174 DOI: 10.7499/j.issn.1008-8830.2018.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/06/2018] [Indexed: 06/08/2023]
Abstract
Pediatric acute respiratory distress syndrome (ARDS) is an important cause of deaths in critically ill children admitted to the pediatric intensive care unit. Although lung-protective ventilation improves the prognosis of pediatric ARDS, the mortality rate of children with moderate or severe ARDS is still high. Given that the epidemiology, treatment, and prognosis of pediatric ARDS are different from those of adult ARDS, pediatric ARDS was first defined in the 2015 Pediatric Acute Lung Injury Consensus Conference. Early diagnosis and appropriate clinical management of ARDS are still great challenges for pediatric critical care medicine. This paper focuses on the definition, epidemiology, and management of pediatric ARDS.
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Affiliation(s)
- Yang Chen
- Department of Pediatric Emergency and Critical Care Medicine, Children's Hospital of Fudan University, Shanghai 201102, China.
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33
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Thomas CA, Valentine K. Utility of routine methemoglobin laboratory assays in critically ill pediatric subjects receiving inhaled nitric oxide. J Crit Care 2018; 48:63-65. [PMID: 30172035 DOI: 10.1016/j.jcrc.2018.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/15/2018] [Accepted: 08/16/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE Inhaled nitric oxide (iNO) has been associated with safety risks including reports of methemoglobinemia. While standard of care recommends routine monitoring of methemoglobin in subjects on iNO therapy, the utility of this practice remains unknown. MATERIALS AND METHODS This retrospective chart review aimed to determine the frequency of methemoglobinemia in pediatric patients receiving iNO. Included subjects were under 18 years of age receiving iNO therapy with at least one methemoglobin concentration measured from 10/18/2014 to 11/18/2016. RESULTS In total, 1809 methemoglobin concentrations were collected in 247 subjects during the study period. Median age was 0.33 (0.04-0.83) years. The mean methemoglobin concentration was 1.33% (±0.42) while receiving a mean iNO dose of 11.71 ppm (±7.97). Twenty-nine subjects had a total of 131 methemoglobin concentrations analyzed while receiving iNO doses above 20 ppm which were similar to the entire cohort at 1.33% (±0.42); (p = .95). CONCLUSIONS Pediatric patients receiving iNO at doses below 40 ppm have minimal risk of developing clinically significant methemoglobinemia. Routine, ongoing monitoring of metHb levels in all pediatric subjects receiving iNO therapy at doses <40 ppm without the presence of risk factors predisposing the subject to increased risk of methemoglobinemia is unnecessary and should be avoided.
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Affiliation(s)
- Christopher A Thomas
- Department of Pharmacy Services, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, AZ, USA.
| | - Kevin Valentine
- Section of Pediatric Cardiac Intensive Care, Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Indianapolis, IN, USA; Department of Pediatrics, Indiana University School of Medicine, 340 W. 10th St. #6200, Indianapolis, IN, USA
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34
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Kim WH, Hur M, Park SK, Jung DE, Kang P, Yoo S, Bahk JH. Pharmacological interventions for protecting renal function after cardiac surgery: a Bayesian network meta-analysis of comparative effectiveness. Anaesthesia 2018; 73:1019-1031. [PMID: 29682727 DOI: 10.1111/anae.14227] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2018] [Indexed: 12/25/2022]
Abstract
Many drugs have been investigated as potentially protective of renal function after cardiac surgery. However, their comparative effectiveness has not been established. We performed an arm-based hierarchical Bayesian network meta-analysis including 95 randomised controlled trials with 28,833 participants, which allowed us to compare some agents not previously compared directly. Renal outcomes, including: the incidence of postoperative renal dysfunction and haemodialysis; serum creatinine level at 24 hours postoperatively; all-cause mortality; and length of hospital and ICU stay, were compared. Exploratory meta-regression was conducted for potential effect modifiers. A random effects model was selected according to the evaluation of model fit by deviance information criteria. Atrial natriuretic peptide (odds ratio (95%CrI) 0.28 (0.17-0.48); moderate-quality evidence), B-type natriuretic peptide, dexmedetomidine, levosimendan and N-acetyl cysteine significantly decreased the rate of postoperative renal dysfunction compared with placebo. Atrial natriuretic peptide (OR (95%CrI) 0.24 (0.10-0.58); low-quality evidence), B-type natriuretic peptide, and dexamethasone significantly decreased the need for haemodialysis. Levosimendan significantly decreased mortality, OR (95%CrI) 0.49 (0.27-0.91); low-quality evidence). The benefit of atrial natriuretic peptide was still apparent when baseline renal function was normal. None of the potential effect modifiers were significantly correlated with our renal outcomes. Atrial natriuretic peptide was ranked best regarding renal dysfunction, haemodialysis and length of hospital stay. Levosimendan was ranked best regarding mortality and ICU stay. However, our results should be interpreted cautiously given the assumptions made about transitivity and consistency.
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Affiliation(s)
- W H Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - M Hur
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - S-K Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - D E Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - P Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - S Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - J-H Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
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35
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Nokes B, Yeneneh B, Maddux J, Van Woerkom RC, Lowell A, Callisen H, Patel B, Shamoun F, Fortuin FD, DeValeria P, Sen A. Inhaled nitric oxide mitigates need for extracorporeal membrane oxygenation in a patient with refractory acute hypoxemic respiratory failure due to cardiac and pulmonary shunts. Respir Med Case Rep 2018; 24:98-102. [PMID: 29977772 PMCID: PMC6010619 DOI: 10.1016/j.rmcr.2018.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/25/2018] [Indexed: 11/23/2022] Open
Abstract
We present a case of refractory acute hypoxemic respiratory failure due to influenza B pneumonia with concomitant large intra-atrial shunt (IAS) and severe pulmonary regurgitation in a patient with Saethre-Chotzen syndrome with prior pulmonary homograft placement. Our patient's hypoxemia improved with inhaled nitric oxide as an adjunct to mechanical ventilation without requiring extracorporeal membrane oxygenation, and eventually a percutaneous closure with a 30 mm CardioSeal patent foramen ovale closure device was accomplished. However, his peri-procedural hospital course was complicated by occluder device migration, which was retrieved with eventual surgical closure of the PFO. Nitric oxide has not demonstrated any statistically significant effect on mortality and only reported to transiently improved oxygenation in patients with hypoxemic respiratory failure. Our case demonstrates that inhaled nitric oxide may have a role in acute hypoxemic respiratory failure in a case with significant cardiac and pulmonary shunts.
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Affiliation(s)
- Brandon Nokes
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Jake Maddux
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Amelia Lowell
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Bhavesh Patel
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Fadi Shamoun
- Division of Cardiology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
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36
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Kuriyama A, Aga M, Maeda H. Topical benzydamine hydrochloride for prevention of postoperative sore throat in adults undergoing tracheal intubation for elective surgery: a systematic review and meta-analysis. Anaesthesia 2018; 73:889-900. [DOI: 10.1111/anae.14224] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 12/19/2022]
Affiliation(s)
- A. Kuriyama
- Emergency and Critical Care Centre; Kurashiki Central Hospital; Okayama Japan
| | - M. Aga
- Department of Respiratory Medicine; Kurashiki Central Hospital; Okayama Japan
| | - H. Maeda
- Department of Emergency Medicine; Sugita Genpaku Memorial Obama Municipal Hospital; Fukui Japan
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37
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Elmi-Sarabi M, Denault AY. In Response. Anesth Analg 2018; 125:2167-2168. [PMID: 28953495 DOI: 10.1213/ane.0000000000002520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Mahsa Elmi-Sarabi
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada, Department of Medicine, Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada,
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38
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Hristovska AM, Duch P, Allingstrup M, Afshari A. The comparative efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. A Cochrane systematic review with meta-analysis and trial sequential analysis. Anaesthesia 2017; 73:631-641. [DOI: 10.1111/anae.14160] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2017] [Indexed: 12/14/2022]
Affiliation(s)
- A.-M. Hristovska
- Department of Pediatric and Obstetric Anaesthesia; Juliane Marie Centre; Copenhagen University Hospital; Copenhagen Denmark
| | - P. Duch
- Department of Neuroanaesthesia; Juliane Marie Centre; Copenhagen University Hospital; Copenhagen Denmark
| | - M. Allingstrup
- Department of Pediatric and Obstetric Anaesthesia; Juliane Marie Centre; Copenhagen University Hospital; Copenhagen Denmark
| | - A. Afshari
- Department of Pediatric and Obstetric Anaesthesia; Juliane Marie Centre; Copenhagen University Hospital; Copenhagen Denmark
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39
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Della Torre V, Badenes R, Corradi F, Racca F, Lavinio A, Matta B, Bilotta F, Robba C. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis 2017; 9:5368-5381. [PMID: 29312748 PMCID: PMC5756968 DOI: 10.21037/jtd.2017.11.03] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise.
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Affiliation(s)
- Valentina Della Torre
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Rafael Badenes
- Department of Anesthesiology and Surgical Trauma Intensive Care, Hospital Clinic Universitari Valencia, University of Valencia, Valencia, Spain
| | | | - Fabrizio Racca
- Department of Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Lavinio
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Federico Bilotta
- Department of Anaesthesia and Intensive Care, La Sapienza University, Rome, Italy
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Neuroscience, University of Genova, Italy
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40
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Association of Response to Inhaled Nitric Oxide and Duration of Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2017; 18:1019-1026. [PMID: 29099443 PMCID: PMC5679068 DOI: 10.1097/pcc.0000000000001305] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Literature regarding appropriate use of inhaled nitric oxide for pediatric acute respiratory distress syndrome is sparse. This study aims to determine if positive response to inhaled nitric oxide is associated with decreased mortality and duration of mechanical ventilation in pediatric acute respiratory distress syndrome. DESIGN Retrospective cohort study. SETTING Large pediatric academic medical center. PATIENTS OR SUBJECTS One hundred sixty-one children with pediatric acute respiratory distress syndrome and inhaled nitric oxide exposure for greater than or equal to 1 hour within 3 days of pediatric acute respiratory distress syndrome onset. INTERVENTIONS Patients with greater than or equal to 20% improvement in oxygenation index or oxygen saturation index by 6 hours after inhaled nitric oxide initiation were classified as "responders." MEASUREMENTS AND MAIN RESULTS Oxygenation index, oxygen saturation index, and ventilator settings were evaluated prior to inhaled nitric oxide initiation and 1, 6, 12, and 24 hours following inhaled nitric oxide initiation. Primary outcomes were mortality and duration of mechanical ventilation. Baseline characteristics, including severity of illness, were similar between responders and nonresponders. Univariate analysis showed no difference in mortality between responders and nonresponders (21% vs 21%; p = 0.999). Ventilator days were significantly lower in responders (10 vs 16; p < 0.001). Competing risk regression (competing risk of death) confirmed association between inhaled nitric oxide response and successful extubation (subdistribution hazard ratio = 2.11; 95% CI, 1.41-3.17; p < 0.001). Response to inhaled nitric oxide was associated with decreased utilization of high-frequency oscillatory ventilation and extracorporeal membrane oxygenation and lower hospital charges (difference in medians of $424,000). CONCLUSIONS Positive response to inhaled nitric oxide was associated with fewer ventilator days, without change in mortality, potentially via reduced use of high-frequency oscillatory ventilation and extracorporeal membrane oxygenation. Future studies of inhaled nitric oxide for pediatric acute respiratory distress syndrome should stratify based on oxygenation response, given the association with favorable outcomes.
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Gebistorf F, Karam O, Wetterslev J, Afshari A, Cochrane Emergency and Critical Care Group. Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults. Cochrane Database Syst Rev 2016; 2016:CD002787. [PMID: 27347773 PMCID: PMC6464789 DOI: 10.1002/14651858.cd002787.pub3] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Acute hypoxaemic respiratory failure (AHRF) and mostly acute respiratory distress syndrome (ARDS) are critical conditions. AHRF results from several systemic conditions and is associated with high mortality and morbidity in individuals of all ages. Inhaled nitric oxide (INO) has been used to improve oxygenation, but its role remains controversial. This Cochrane review was originally published in 2003, and has been updated in 2010 and 2016. OBJECTIVES The primary objective was to examine the effects of administration of inhaled nitric oxide on mortality in adults and children with ARDS. Secondary objectives were to examine secondary outcomes such as pulmonary bleeding events, duration of mechanical ventilation, length of stay, etc. We conducted subgroup and sensitivity analyses, examined the role of bias and applied trial sequential analyses (TSAs) to examine the level of evidence. SEARCH METHODS In this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015 Issue 11); MEDLINE (Ovid SP, to 18 November 2015), EMBASE (Ovid SP, to 18 November 2015), CAB, BIOSIS and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We handsearched the reference lists of the newest reviews and cross-checked them with our search of MEDLINE. We contacted the main authors of included studies to request any missed, unreported or ongoing studies. The search was run from inception until 18 November 2015. SELECTION CRITERIA We included all randomized controlled trials (RCTs), irrespective of publication status, date of publication, blinding status, outcomes published or language. We contacted trial investigators and study authors to retrieve relevant and missing data. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and resolved disagreements by discussion. Our primary outcome measure was all-cause mortality. We performed several subgroup and sensitivity analyses to assess the effects of INO in adults and children and on various clinical and physiological outcomes. We presented pooled estimates of the effects of interventions as risk ratios (RRs) with 95% confidence intervals (CIs). We assessed risk of bias through assessment of trial methodological components and risk of random error through trial sequential analysis. MAIN RESULTS Our primary objective was to assess effects of INO on mortality. We found no statistically significant effects of INO on longest follow-up mortality: 250/654 deaths (38.2%) in the INO group compared with 221/589 deaths (37.5%) in the control group (RR 1.04, 95% CI 0.9 to 1.19; I² statistic = 0%; moderate quality of evidence). We found no statistically significant effects of INO on mortality at 28 days: 202/587 deaths (34.4%) in the INO group compared with 166/518 deaths (32.0%) in the control group (RR 1.08, 95% CI 0.92 to 1.27; I² statistic = 0%; moderate quality of evidence). In children, there was no statistically significant effects of INO on mortality: 25/89 deaths (28.1%) in the INO group compared with 34/96 deaths (35.4%) in the control group (RR 0.78, 95% CI 0.51 to 1.18; I² statistic = 22%; moderate quality of evidence).Our secondary objective was to assess the benefits and harms of INO. For partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2), we found significant improvement at 24 hours (mean difference (MD) 15.91, 95% CI 8.25 to 23.56; I² statistic = 25%; 11 trials, 614 participants; moderate quality of evidence). For the oxygenation index, we noted significant improvement at 24 hours (MD -2.31, 95% CI -2.73 to -1.89; I² statistic = 0%; five trials, 368 participants; moderate quality of evidence). For ventilator-free days, the difference was not statistically significant (MD -0.57, 95% CI -1.82 to 0.69; I² statistic = 0%; five trials, 804 participants; high quality of evidence). There was a statistically significant increase in renal failure in the INO groups (RR 1.59, 95% CI 1.17 to 2.16; I² statistic = 0%; high quality of evidence). AUTHORS' CONCLUSIONS Evidence is insufficient to support INO in any category of critically ill patients with AHRF. Inhaled nitric oxide results in a transient improvement in oxygenation but does not reduce mortality and may be harmful, as it seems to increase renal impairment.
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Affiliation(s)
- Fabienne Gebistorf
- Geneva University HospitalPediatric Intensive Care Unit6 rue Willy DonzéGenevaSwitzerland1205
| | - Oliver Karam
- Children's Hospital of Richmond at VCUDivision of Pediatric Critical Care1250 East Marshall StRichmondVAUSA23298
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
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