Henning Onarheim

Effectiveness of hypertonic saline-dextran 70 for initial fluid resuscitation of major burns

Small-volume resuscitation (4 ml/kg) with hypertonic saline-dextran (HSD) has been shown effective in hemorrhagic shock. In the present study the effectiveness of an initial 4 ml/kg bolus infusion of HSD on cardiovascular function and fluid resuscitation requirements after a major burn injury was evaluated in anesthetized sheep following a 40% BSA scald burn. One hour after injury resuscitation was initiated by a rapid intravenous bolus infusion (4 ml/kg) of either hypertonic saline-dextran (7.5% NaCl in 6% dextran 70) (HSD) or the same volume of normal (isotonic) saline (NS). Lactated Ringers was later infused as needed to maintain cardiac output at 90% of baseline. HSD rapidly and effectively restored cardiac output and mean arterial pressure significantly better than the same volume of NS. Hemodynamic improvement by HSD was short lived, and need for further fluid therapy was only marginally delayed (HSD 38 +/- 8 min, NS 20 +/- 3 min; p = 0.06) (mean +/- SEM). The total requirements for fluid therapy during the first 6 hr postburn were not reduced by the initial HSD bolus (HSD 3,145 +/- 605 ml, NS 2,905 +/- 495 ml; n.s.), nor was skin edema formation reduced. We conclude that in anesthetized sheep HSD resuscitation was only transiently effective in treating burn shock. This may be attributed to the sustained increase in vascular permeability and continued plasma leak following thermal injury.

The epidemiology of patients with burn injuries admitted to Norwegian hospitals in 2007.

OBJECTIVES To study the incidence and outcome of burns in Norway in 2007, and to establish estimates for effective length of stay, mortality and economical costs. METHODS Data from the Norwegian Patient Registry on all patients discharged from all somatic hospitals in Norway in 2007 with main or subsidiary diagnosis of burn injury (ICD-10: T20-31) were collected. RESULTS Seven hundred and twenty-six patients (65.0% male) with acute burns were admitted to Norwegian hospitals in 2007, requiring 8157 in-hospital days and resulting in a mean length of hospitalization per burn case of 11.3 days (S.D. 15.2). The mean age of the patients was 26.9 years (S.D. 25.5), and the mortality was 2.1%. For children below 5 years of age the incidence of burns admitted to hospital was 82.5/100,000/year. The annual total cost for in-hospital burn care exceeded 10.5 million euros (2,200,000 euros/million inhabitants) CONCLUSION Compared to similar data from Norway (1992) the rate of admission for burns in 2007 (15.5/100,000/year) appeared as high as in 1992, whereas the mean length of stay was reduced by 26%. Children under the age of 5 had a seven times higher incidence compared the rest of the population.

Thermal skin injury : effect of fluid therapy on the transcapillary colloid osmotic gradient

The effects of fluid therapy on interstitial colloid osmotic and hydrostatic pressures in thermally injured skin were investigated in anesthetized rats subjected to full-thickness scald burns to 40% of the body surface area and resuscitation for 3 hr by either lactated Ringers or plasma. Interstitial fluid hydrostatic pressure (Pif) was reduced from -2 mm Hg to -20 to -40 mm Hg after injury, which will profoundly increase transcapillary filtration. Following the onset of fluid therapy, Pif increased to slightly positive values. In control, colloid osmotic pressure in plasma (COPp) was 20.6 +/- 0.4 mm Hg and in interstitial fluid (COPif) 13.7 +/- 0.3 mm Hg (means +/- SEM). The transcapillary oncotic pressure gradient (COPgrad = COPp-COPif) was 6.9 +/- 0.4 mm Hg. Following nonresuscitated thermal injury, COPp declined to 18-19 mm Hg (P less than 0.05) and COPif was reduced to 10.4 +/- 0.5 mm Hg (P less than 0.05). Fluid therapy by lactated Ringers markedly reduced COPp (12.3 +/- 0.3 mm Hg; P less than 0.05), and COPgrad was almost abolished (2.6 +/- 0.7 mm Hg; P less than 0.05). In contrast, plasma infusion maintained COPp, whereas COPgrad increased significantly (11.1 +/- 1.2 mm Hg; P less than 0.05). Noncolloid saline solutions have been preferred for the initial fluid therapy for burns. The present study provides evidence that this will reduce both COPp and COPgrad, a situation in which edema formation will be favored.

Increased hyaluronan flux from skin following burn injury

Hyaluronan (formerly hyaluronic acid) is an important constituent of the interstitial matrix in skin. Following major burn injury in animal models, plasma hyaluronan can increase to levels 10-fold greater than normal. The present experiments were designed to determine whether this is a result of the increased lymph flow (QL) accompanying the injury or of an increased release of hyaluronan from the burned skin and subcutaneous tissue. The lateral saphenous vein and a prenodal lymphatic were cannulated in the hindpaw of five anesthetized canines. Hindpaw venous pressure was elevated until the total protein concentration in lymph declined to steady-state levels, and QL and hyaluronan flux (QL X [hyaluronan]) was measured. A minor burn was inflicted by immersion of the paw into 100 degrees C water for five sec, and measurements were repeated at regular intervals for a minimum of 4 hr. Burn injury resulted in significant and persistent increases in QL (154 +/- 61 microliters/min versus 562 +/- 105 microliters/min 4 hr postburn) and lymph total protein concentration (1.34 +/- 0.04 g/dl versus 4.08 +/- 0.18 g/dl 4 hr postburn), while lymph hyaluronan concentration fell (3.01 +/- 0.20 micrograms/ml versus 2.1 +/- 0.16 micrograms/ml 4 hr postburn). The resultant increase in hyaluronan flux (0.42 +/- 0.13 microgram/min versus 1.17 +/- 0.22 microgram/min 4 hr postburn) appears to be a function of lymph flow rather than burn-induced release of skin hyaluronan. Hence, the increased plasma concentration of hyaluronan following major burns is likely a consequence of increased lymph flow from the site of injury.

Fluid shift is moderate and short‐lived during acute crystalloid hemodilution and normothermic cardiopulmonary bypass in piglets

Background:  Crystalloids are commonly used as priming solutions during cardiopulmonary bypass (CPB). Consequently, hemodilution is a regular occurrence at the start of a CPB. This study describes the time‐course variations of hemodynamic parameters, plasma volume (PV) and fluid exchange following crystalloid hemodilution at start of normothermic CPB.

Porcine surfactant (Curosurf) for acute respiratory failure after near-drowning in 12 year old.

This case report describes rapid and persistent improvement after one single dose of porcine surfactant (Curosurf®) 0.5 ml/kg−1 (40 mg/kg) intratracheally for adult respiratory distress syndrome (ARDS) with severe oxygenation failure 8 h after freshwater near‐drowning in a 12‐year‐old girl.

Elevated hyaluronan blood concentrations in severely burned patients

Hyaluronan (HYA) is a polysaccharide found in the interstitial matrix in most tissues. HYA is removed by lymphatic drainage and degraded in local lymph nodes and in the liver. Its normal concentration in human plasma is very low (10-100 micrograms l-1). Following major burn injury in sheep plasma HYA can increase to levels tenfold greater than normal. In the present study, serum HYA concentrations were determined in 10 severely burned patients (burn size: 28 +/- 5% of body surface area (mean +/- SEM)). Serum HYA concentration was 206 +/- 71 micrograms l-1 at 24 h post-injury, twice the upper normal HYA concentration, and remained moderately elevated for the first week post-injury. It appears that mobilization and transport of HYA from the tissues is increased after thermal injury. Increased systemic concentrations of an interstitial matrix component have not previously been reported in burn patients. Possibly, plasma concentrations of connective tissue components might serve as indicators of the severity and extent of burn injuries.

Retention and distribution of polygeline (Haemaccel) in the rat.

The plasma substitute polygeline (Haemaccel®) contains a large fraction of molecules sufficiently small to cross the capillary and glomerular membranes. Plasma volume expansion, tissue extravasation and renal elimination of this artificial colloid were quantified using 125l‐labelled polygeline molecules. In pentobarbital anaesthetized rats, either 10 ml 3.5% polygeline (n=8) or 10 ml 0.9% saline (n=8) was infused intravenously over 60 min. The plasma volume was assessed by the 3 min distribution volume for 131l‐albumin and the plasma volume changes over time were calculated from erythrocyte volume fractions. The plasma volume increased by 4.6 (2.0) ml (mean (SD)) at the end of the Haemaccel infusion compared with 2.1 (1.8) ml after the saline infusion (P=0.02). One hour later the increase was 2.4 (1.5) and 1.6 (1.0) ml respectively, not significantly different (P=0.20). Extravasation of labelled polygeline was greatest in the kidney, possibly due to cellular uptake. Skin and skeletal muscle contained 4–5 times more polygeline than could be attributed to intravascular radioactivity, but still uptake in these tissues did not reach one percent of the amount injected. Following a 60 min infusion and a 60 min interval, 23 (4)% of the polygeline was recovered intravascularly, 43 (9)% had been excreted in urine, leaving 33% to other compartments. Thus, more polygeline was distributed to the interstitium than remained in the circulation. This calls for further investigations into the handling and effect of polygeline in this extravascular compartment.

Markedly increased lymphatic removal of hyaluronan from skin after major thermal injury.

Hyaluronam (HYA) (formerly hyaluronic acid) is an important constituent of the interstitial matrix in skin. Following major burn injury plasma HYA is known to increase markedly. The present study investigated to what extent the lymphatic removal of HYA from skin is affected following major burn injuries. Under ketamine anaesthesia a 30 per cent full thickness scald injury was inflicted on sheep previously provided with a chronic prefemoral lymph fistula. Animals were resuscitated for 24 h using lactated Ringers infusion as needed to restore and maintain cardiac output within +/- 10 per cent of baseline. Following burn injury, lymph flow from thermally injured tissue gradually increased to 10-25 times above baseline. The baseline HYA concentration in lymph was 4.3 +/- 1.1 micrograms/ml; the HYA concentration in lymph was not significantly altered postinjury. The lymphatic HYA flux (flow x concentration) increased postinjury to 5-30 times control. The HYA concentration in plasma was 162 +/- 12 ng/ml at baseline; postinjury plasma HYA peaked at two to three times baseline at 4-8 h after the injury. At 24 h postinjury plasma HYA was reduced compared to baseline. In conclusion, after major burn injury the lymphatic transport of HYA from the injured area into the systemic circulation increased markedly, leading to elevated plasma concentrations of this high molecular weight connective tissue component.

A patient with sepsis following a burn injury in Pakistan.

During her stay in Pakistan, a Norwegian female patient, in her forties, suffered burns to 30 – 35 % of her body surface following ignition with inflammable liquid. She was admitted to a local hospital the same day. On the third day she was transferred to the Burn Care Centre at the Pakistan Institute of Medical Sciences in Islamabad. She was found to have deep burns on her face, neck, back, upper arms and hands.