T. Lund

Alpha-trinositol inhibits edema generation and albumin extravasation in thermally injured skin

Pharmacologic attempts to reduce edema generation and albumin extravasation into thermally injured skin have until recently been disappointing unless the drugs (usually antiphlogistic or anti-inflammatory drugs) were given before injury. We have studied the effect of alpha-trinositol (PP56, i.e., 1D-myo-inositol-1,2,6-trisphosphate) given after the injury in an experimental full-thickness 10% TBSA scald burn in anesthetized rats. Total tissue water content (TTW) and albumin extravasation (Ealb) were determined in injured and noninjured skin (series I, n = 12). Interstitial fluid hydrostatic pressure (Pif) was measured in injured skin (series II, n = 14). alpha-Trinositol was administered (alpha-trinositol groups) as an i.v. bolus (40 mg/kg) at 5 minutes after injury followed by an i.v. infusion (1.3 mg/kg/min). In both series a placebo group received burn injury and normal saline in equal volumes instead of alpha-trinositol. Compared with placebo, alpha-trinositol reduced TTW and Ealb as well as the increased negatively of Pif in injured tissue significantly. The effect on Ealb was most prominent, with a reduction from 153.9 +/- 35.6 (SEM) microL/g in the NaCl group to 23.1 +/- 6.3 after alpha-trinositol (p < 0.005). Total tissue water was reduced from 2.51 +/- 0.13 to 2.17 +/- 0.06 mL/g (p < 0.05) and Pif (measured between 21 and 40 minutes postinjury) from -24.7 +/- 4.1 to -3.2 +/- 1.1 mm Hg (p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Burn depth affects dermal interstitial fluid pressure, free radical production, and serum histamine levels in rats.

BACKGROUND We measured the amount of edema and the free radical production in burn-injured skin and the serum histamine levels, as well as changes in dermal interstitial fluid pressure. METHODS Thirty-six Wistar rats with 20% total body surface area burns of different depth were resuscitated by lactated Ringers solution intravenously. The rats were divided into a deep burn (DB) group (n = 12), a superficial dermal burn (SDB) group (n = 12), and a sham burn (Sham) group (n = 12). Dermal interstitial fluid hydrostatic pressure (Pif), total skin water and xanthine oxidase activity, and serum histamine levels were measured until 60 minutes postburn. RESULTS In the DB group, dermal Pif significantly fell to -35.9 +/- 11.0 and -40.9 +/- 7.0 mm Hg at 10 and 15 minutes postburn, respectively (p < 0.05); it returned to preburn values at 50 minutes postburn. In the SDB group, dermal Pif was slightly negative but did not markedly change. Total skin water was significantly higher than that of the DB and the Sham groups; however, in the SDB group, serum histamine and dermal xanthine oxidase were significantly higher than in the DB group at 15, 30, and 45 minutes postburn (p < 0.05). CONCLUSION The fluid-resuscitated DB produced a more negative dermal Pif than the SDB, but less dermal edema. In contrast, the SDB appeared to mainly generate dermal edema formation by wound free radical production and serum histamine release. The dermal Pif is one of the factors associated with edema formation immediately after deep burns. However, an increase in vascular permeability associated with oxygen radical production plays a more important role in dermal edema formation than does dermal Pif.

Transplacental passage of diazepam during labor: Influence of uterine contractions

The rate of transplacental passage of diazepam (DZ) has been studied in 33 cases of cephalic presentation where operative forceps delivery was indicated by intrauterine hypoxia or by prolonged second stage of labor. The drug (30 mg) was injected intravenously immediately before delivery either during uterine contractions (Group I) or in the relaxation period (Group II) according to a randomized protocol. As judged by the concentration in the newborn and the child/mother concentration ratio at 2 hr after delivery, and the concentration on the second day, the fetal exposure to the drug was probably less when the injection was timed to coincide with uterine contractions. In the group of patients given the drug in the relaxation period, the injection‐delivery (I‐D) interval was up to 305 sec, and the 2‐hr child/mother concentration ratio was close to unity in some cases. It therefore appears that the transplacental passage of DZ is rapid when the high initial concentrations in the maternal circulation coincide with favorable conditions for transfer in the relaxation period. Although sleep was induced by the injection of DZ in all of the mothers, the amounts of drug transferred during the short I‐D intervals in the present study did not exert deleterious effects on the newborn infants.

Transcapillary colloid osmotic pressures in injured and non-injured skin of seriously burned patients

Thermal skin injury is accompanied by rapid and excessive oedema formation implicating a dramatic increase in the transcapillary fluid transport. In order to clarify the pressure changes occurring across the microvasculature after a thermal skin injury we have measured colloid osmotic pressures (COP) in interstitial fluid (COPi) of injured and non-injured skin as well as in plasma (COPp) from patients suffering major cutaneous burns. Interstitial fluid was collected with a wick-technique and analysed for COP. Measurements were performed as early as 6 h and continued until 56 h after injury. A severe hypoproteinaemia occurred in all patients with a marked reduction in COPp down to about 10 mmHg. Up to 12h post-burn we found a higher COPi in injured skin than in plasma. The first measurement of COPp averaged 9.8 mmHg as compared to an average COPi of 11.1 and 9.3 mmHg in injured and non-injured skin respectively. Measurements performed later than 12h showed a return of the transcapillary COP gradient towards the normal direction (COPp greater than COPi). The gradient was considerably less than in a normal situation. Based on the present observations of transcapillary COP it is suggested that colloids should be withheld until the transcapillary COP gradient returns to the normal direction.

Fluid resuscitation following a burn injury: implications of a mathematical model of microvascular exchange

A validated mathematical model of microvascular exchange in thermally injured humans has been used to predict the consequences of different forms of resuscitation and potential modes of action of pharmaceuticals on the distribution and transport of fluid and macromolecules in the body. Specially, for 10 and/or 50 per cent burn surface area injuries, predictions are presented for no resuscitation, resuscitation with the Parkland formula (a high fluid and low protein formulation) and resuscitation with the Evans formula (a low fluid and high protein formulation). As expected, Parkland formula resuscitation leads to interstitial accumulation of excess fluid, while use of the Evans formula leads to interstitial accumulation of excessive amounts of proteins. The hypothetical effects of pharmaceuticals on the transport barrier properties of the microvascular barrier and on the highly negative tissue pressure generated postburn in the injured tissue were also investigated. Simulations predict a relatively greater amelioration of the acute postburn edema through modulation of the postburn tissue pressure effects.

A model of fluid resuscitation following burn injury: formulation and parameter estimation

A dynamic compartmental model is developed to describe the redistribution of fluid and albumin between the circulation and the intact and injured interstitia following burn injury in humans. Transcapillary fluid and albumin exchange is described by a coupled Starling mechanism, while the effect of the burn is represented by time-dependent perturbations to all three compartments. The unknown model parameters are determined for two groups of patients, having less than and greater than 25% total body surface area burns, by statistical fitting of model predictions to patient data from two sources. The parameters include the perturbations to the fluid filtration coefficients in uninjured and injured tissue, GkF,Tl and GkF,BT, respectively, the relaxation coefficient, r, which describes the exponential decay of the perturbations, and the exudation factor, EXFAC, which relates the protein concentration in the exudate to that in the injured tissue. Perturbations to other parameters, including the membrane permeability-surface area product and the albumin reflection coefficient in the injured and uninjured tissues, are determined based on interrelationships with GkF,Tl and GkF,BT. The values of GkF,BT, when corrected for tissue destruction and decreased post-injury perfusion, are in reasonable agreement with the limited experimental data available from the literature. The model and its parameters are further validated by comparing the simulated patient responses to the clinical data used in the parameter estimation as well as to data available from two additional sources.

Intensive care treatment of burn patients

Treatment of patients suffering extensive cutaneous burns continues to challenge all involved. Although this review begins with basic pathophysiology, it deals mainly with resuscitation and intensive care of burn patients. After the initial phase, infection control and pulmonary problems secondary to inhalation injury and/or systemic infection are main determinants of morbidity and mortality. The principles of early excision and autografting are presented together with anaesthetic considerations and guidelines for metabolic support.

Interstitial Fluid Pressure in Control of Interstitial Fluid Volume During Normal Conditions, Injury and Inflammation

The interstitial space is the intercellular and extravascular compartment which is present in all tissues and which comprise from a few percent of the total tissue weight in brain to forty percent of the tissue weight in skin (Aukland & Nicolaysen 1981). The fluid contained in this compartment is an ultrafiltrate of plasma and contains proteins and electrolytes.

Acute postburn edema: Role of strongly negative interstitial fluid pressure

Interstitial fluid hydrostatic pressure (Pif) was measured with micropipettes during the acute edema generation that followed thermal skin injury in rats. Intradermal Pif was reduced from normal level of -1 mmHg to very negative values after thermal injury. The strongly negative Pif reflects a tissue imbibition pressure created by the thermal injury. The magnitude and duration of this pressure was dependent on the extent of the injury and the availability of fluid. After in vivo injury to 10 and 40% of the total body surface area (TBSA), mean intradermal Pif was temporarily reduced to -20 and -31 mmHg, respectively. Intravenous fluid infusion resulted in a rapid return of Pif to slightly positive values. Fluid available for transfer from the circulation was reduced by inducing the injury after killing the animal (postmortem injury) and even more by the subcutaneous insertion of a plastic barrier: this led to more pronounced reductions in Pif to average minimum values of -95 and -135 mmHg, respectively. Our data show that increased tissue imbibition pressure and increased net filtration pressure (tissue mechanisms) are responsible for a major part of the acute fluid shifts into thermally injured skin. Vascular mechanisms (permeability changes and intravascular pressure) are involved in the postburn edema development but are clearly less important than hitherto believed.