Nitric oxide and septic shock. From bench to bedside

Refractory hypotension with end-organ hypoperfusion is an ominous feature of inflammatory shock. In the past fifteen years, nitric oxide (a diffusible, short-lived product of arginine metabolism) has been found to be an important regulatory molecule in several areas of metabolism, including vascular tone control. Vascular endothelial cells constitutively produce low levels of nitric oxide that regulate blood pressure by mediating adjacent smooth-muscle relaxation. In an inflammatory shock state, cytokines, like interleukin-1 and tumor necrosis factor-alpha, induce a separate, high-output form of the enzyme that synthesizes nitric oxide in both endothelial and smooth-muscle cells. The ensuing high rates of nitric oxide formation result in extensive smooth-muscle relaxation, pressor refractory vasodilation, and--ultimately--shock. The concept of the pathogenesis of inflammatory shock explains many limitations of current therapies and may foster the development of new interventions to mitigate the effects of nitric oxide overproduction in this syndrome.