Therapeutic Approaches in Modulating the Inflammatory and Immunological Response in Patients With Sepsis, Acute Respiratory Distress Syndrome, and Pancreatitis: An Expert Opinion Review

Abstract

Immunomodulation has long been an adjunct approach in treating critically ill patients with sepsis, acute respiratory distress syndrome (ARDS), and acute pancreatitis (AP). Hyperactive immune response with immunopathogenesis leads to organ dysfunction and alters the clinical outcomes in critically ill. Though the immune response in the critically ill might have been overlooked, it has gathered greater attention during this novel coronavirus disease 2019 (COVID-19) pandemic. Modulating hyperactive immune response, the cytokine storm, especially with steroids, has shown to improve the outcomes in COVID-19 patients. In this review, we find that immune response pathogenesis in critically ill patients with sepsis, ARDS, and AP is nearly similar. The use of immunomodulators such as steroids, broad-spectrum serine protease inhibitors such as ulinastatin, thymosin alpha, intravenous immunoglobulins, and therapies such as CytoSorb and therapeutic plasma exchange may help in improving the clinical outcomes in these conditions. As the experience of the majority of physicians in using such therapeutics may be limited, we provide our expert comments regarding immunomodulation to optimize outcomes in patients with sepsis/septic shock, ARDS, and AP.

Keywords: ards; covid-19; immunomodulators; sepsis; steroid; ulinastatin.

Figure 1. A pictorial representation of the similarities and differences in mechanism, circumstances, and patient base between the three major types of pathogenic sepsis. The best-known mechanisms for each sepsis type are represented, although these molecules and mechanisms are not universal.

CNS: central nervous system; IFN: interferon; IL: interleukin; ICU: intensive care unit; MAP: mitogen-activated protein; ROS: reactive oxygen species; TLR: toll-like receptor; TNF: tumor necrosis factor Dolin HH, Papadimos TJ, Chen X, Pan ZK: Characterization of pathogenic sepsis etiologies and patient profiles: a novel approach to triage and treatment. Microbiol Insights. 2019, 12:1178636118825081. [19] (Reprinted with permission from SAGE publications).