Running on (Too Many) Fumes? Gaseous Mediators in Septic Shock

We eagerly read the results by Patel et al1 in this issue of CHEST regarding the vasopressor-sparing effects of a single high dose (5 g IV) of vitamin B12 (hydroxocobalamin [B12]) in patients with early septic shock. The endogenous gaseous transmitters nitric oxide (NO) and hydrogen sulfide (H2S) have been targets of clinical investigation with regards to their vasoactive and immune effects for years. Unfortunately, the isolated pharmacologic modulation of NO in vasodilatory shock that is associated with sepsis at times yielded sobering results, especially in one large multicenter randomized controlled trial (RCT).