Intravenous Resuscitation Research Articles

Intravenous fluid resuscitation for the trauma patient

Although longstanding practice in trauma care has been to provide immediate, aggressive intravenous fluid resuscitation to injured patients with presumed internal hemorrhage, recent experimental and clinical data suggest a more discriminating approach that first considers concurrent head injury, hemodynamic stability, and the presence of potentially uncontrollable hemorrhage (e.g., deep truncal injury) versus a controllable source (e.g., distal extremity wound). The data suggest that rapid intravenous fluid infusions could be used for patients with isolated extremity, thermal or head injury. However, intravenous fluids should be limited in conditions with potentially uncontrollable internal hemorrhage, and particularly in patients with penetrating truncal injury being transported immediately to a trauma center. Likewise, positive pressure ventilatory support should be limited with severe hemorrhage due to the secondary reductions in venous return off-setting the effects of the fluids. For trauma patients with severe bleeding, there is growing evidence for the increased use of plasma and factor VIIa, as well as tourniquets, intra-osseus devices, and evolving monitoring techniques. Future research efforts in trauma should focus on the timing and rate of infusions as well as the concept of infusing alternative intravenous resuscitative fluids such as hemoglobin-based oxygen carriers (HBOCs) and the use of hemostatic agents and special blood products.

Effect of early enteral nutrition on morbidity and mortality in children with burns

Burns increase the metabolic demands of the body and can lead to severe weight loss and increased risk of death. Early enteral support is believed to improve gastrointestinal, immunological, nutritional and metabolic responses to critical injury; however, this premise is in need of further substantiation by definitive data. This research aimed to examine the effectiveness and safety of early enteral feeding in paediatric patients suffering from burns. Materials and methods This clinical trial was carried out with a total number of 688 children with burns hospitalised in the Burn Department across a 2-year period (September 2002–September 2004). The subjects were randomised into two groups. A total of 322 patients received only intravenous resuscitation, in accordance with current treatment protocols, in the first 48 h and were considered as the late enteral nutrition group (LEN group); 366 patients were nourished early enteral nutrition group (EEN group), such that both groups received similar amounts of fluid in the first 48 h. Initiation of enteral nutrition commenced between 3 and 6 h following the burn. The patients were kept in the unit until they were discharged. Wound management did not vary between groups. Results In our study, the mean age was 5 ± 3 years in the LEN group and 5 ± 3.5 years in the EEN group. Hot liquids were the most common cause of burns in both groups. The mean percentage of burn was reported as 20 ± 13 in the LEN group and 22 ± 15 in the EEN group. Mean duration of hospitalisation was 16.4 ± 3.7 days in the LEN group and 12.6 ± 1.3 in the EEN group for cured patients ( P < 0.05). A total of 40 patients (12%) in the LEN group and 31 patients (8.5%) in the EEN group expired ( P < 0.05). Conclusion Our research showed that EEN decreases duration of hospitalisation and mortality in children with burns.

Effects of early oral fluid resuscitation on hemodynamic and tissue perfusion during shock stage in dogs with a 50% total body surface area full-thickness burn.

To investigate the effect of early oral fluid resuscitation on hemodynamic and tissue perfusion in dogs with severe burn shock. Eighteen male Beagle dogs with intubation of carotid artery, jugular vein, stomach, jejunum and bladder for 24 h were subjected to a 50%TBSA full-thickness burn, then were equally divided into non fluid resuscitation (NR), oral resuscitation (OR) and intravenous resuscitation(IR) groups, (each n = 6). Dogs in IR and OR groups were given glucose-electrolyte solution (GES) by gastric tube or intravenous infusion according to Parkland formula within 24 h after burn, while those in NR group were not given any treatment. Dogs in each group were given intravenous fluid resuscitation from 24 h after burn. The mean arterial pressure (MAP), cardiac output (CO), systemic vascular resistance (SVR), dp/dt max of left ventricular contractility (dp/dt(max)), gastric carbon dioxide pressure (PgCO2), intestinal mucosal blood flow (IMBF), and urinary output were determined before burn (0 h) and 2, 4, 8, 24, 48 and 72 h after burn at no anaesthesia state. Mortality rate of 72 h after burn was also recorded. MAP, CO, dp/dt(max), IMBF greatly decreased, and SVR and PgCO2 obviously increased from 2 h after burn in each group (P < 0.01). The measurements except IMBF of IR group returned to pre-injury levels at 72 h after burn, while CO, SVR, PgCO2 and IMBF of OR group still worse compared with 0 h (P < 0.01). All measurements of NR group kept on worsen, and died with anuria within 24 h after burn. Parameters of hemodynamic and tissue perfusion of OR group were significantly superior to those of NR group, but it inferior to those of IR group. At 72 h after burn, 6 (6/6) survived in IR group, 3 (3/6) in OR group and 0 (0/6) in NR group. Although oral resuscitation with GES is not as efficient as intravenous resuscitation in a 50%TBSA burn injury, it still can promote hemodynamic, improve the tissue perfusion and reduce the mortality comparing to no resuscitation. Oral resuscitation might be an ideal alternative way of intravenous resuscitation, especially in wars or other site of mass casualties.

Effects of early oral fluid resuscitation on organ functions and survival during shock stage in dogs with a 50% total body surface area full-thickness burn

To investigate the effects of early oral fluid resuscitation on organ functions and survival in severe burn shock. Eighteen male Beagle dogs were surgically prepared for measurement, subjected to 50% total body surface area (TBSA) full-thickness flame injury 24 hours later, and then randomly divided into 3 equal groups: oral fluid resuscitation group (OR group) undergoing gastric infusion of glucose-electrolyte solution(GES)according to Parkland formula 0.5 hour after burn with the dose of 4 ml x kg(-1).%TBSA(-1), 1/2 being given in the first 8 h and 1/2 in the latter 16 h. Intravenous (IV) resuscitation of GES group (VR group) undergoing IV infusion of GES with the same dose as mentioned above, and no fluid resuscitation (NR) group given with GES during the first 24 h. In the second 24 hours all dogs received IV fluid resuscitation. At the end of 72-hours-period experiment, the mortality was recorded. The mean arterial pressure (MAP), plasma blood volume (PV), hematocrit (HCT), urinary output, alanine aminotransferase (ALT), creatinine (Cr), and MB isoenzyme of creatine kinase (CK-MB) were examined before injury and at 2, 4, 8, 24, 48 and 72 hours after injury. At the end of 72-hours-period experiment, all dogs died in the NR group, 3 dogs died in the OR group, and no dog died in the VR group. The MAP and PV were significantly reduced after burn compared with those before-injury in the NR group, with the lowest levels of (34 +/- 9) mm Hg and (32.7 +/- 3.5) ml/kg (both P < 0.05) 8 h after burn, and the HCT, ALT, Cr, and CK-MB levels of the NR group peaked 8 h after burn to the levels of (61.7 +/- 2.7)%, (121.1 +/- 4.8) U/L, (91.0 +/- 6.1) micromol/L, and (13 891 +/- 297) U/L respectively. Eight hours after burn 4 dogs of the NR group showed anuria, and the rest two had the urine volume of 1.2 and 2.1 ml/kg respectively. Eight hours after burn the MAP, PV, and urinary output levels of the OR group were (84.3 +/- 17.1) mm Hg, (41.7 +/- 3.6) ml/kg, and (2.6 +/- 1.8) ml/kg respectively, all significantly higher than those of the NR group (all P < 0.05), but significantly lower than those of the VR group [(113.0 +/- 10.0) mm Hg, (50.3 +/- 5.2) ml/kg, and (7.0 +/- 1.9) ml/kg respectively, all P < 0.05]. The plasma ALT level of the OR group was (81.4 +/- 10.8) U/L, significantly lower than that of the NR group (P < 0.05), but significantly higher than that of the VR group [(66.3 +/- 7.6) U/L, P < 0.05]. The levels of plasma ALT at other time points, as well as the Cr and CK-MB levels at all time points of the OR group were all significantly higher than those of the VR group (all P < 0.05). The MAP, PV, HCT and urinary output levels of the two resuscitation groups returned to the pre-injury levels 72 h after burn, but the ALT, Cr, and CK-MB levels were still significantly higher than the pre-injury levels. Although oral resuscitation with GES is not as efficient as IV resuscitation in 50%TBSA burn, it still can maintain the MAP and PV, protect the organ functions and reduce the mortality comparing to no resuscitation. Oral resuscitation may be an ideal alternative way of IV resuscitation, especially in wars or other site of mass casualties.

Normal saline resuscitation induces increased sinusoidal MIP‐2 expression in early sepsis

Fluid resuscitation is an integral part of the treatment of patients with severe sepsis. Common fluids administered within the first 6 hours of diagnosis include normal saline and Ringer's lactate, however, currently there is no clear evidence that support the use of one resuscitation fluid over another. Previous work in our lab demonstrated that normal saline increases leukocyte‐endothelial cell interactions. The objective in this study was to determine the mechanisms for saline‐induced hepatic leukocyte recruitment.Sepsis was induced by cecal ligation and perforation in C57Bl/6 mice. Septic, sham‐operated or naïve mice received an IV bolus (20mL/kg) of Ringer's lactate or normal saline (0.9% NaCl). Six hours later the hepatic microcirculation was examined by confocal intravital microscopy to visualize the neutrophil chemokine macrophage inflammatory protein‐2 (MIP‐2) expression using an Alexafluor conjugated monoclonal antibody.MIP‐2 expression, as measured by mean fluorescent intensity, was significantly higher in the hepatic sinusoids of septic mice treated with normal saline compare to septic mice given Ringer's lactate. The use of normal saline as an intravenous resuscitation fluid was associated with increased chemokine expression in the both sinusoids and post‐sinusoidal venules.These data suggest that saline treatment in early sepsis augments neutrophil recruitment by increasing endothelial cell chemokine expression.

FACTORS AFFECTING FLUID REQUIREMENT ON THE FIRST DAY AFTER SEVERE BURN TRAUMA

Parkland formula (PF) is the most often used schema for calculating intravenous resuscitation fluid requirement in burn patients. Some studies have reported that PF underestimates the fluid requirement in 45-63% of patients. The aim of this retrospective study was to analyse factors influencing first-day intravenous fluid replacement set for a targeted urinary output in severely burnt patients. Data of 47 patients with burn injury affecting equal or more than 15% of body surface area were retrieved from the archived files. The local intensive care protocol rendered the infusion rate of lactated Ringer's solution to achieve a urinary output of 0.5-1.0 mL/kg per hour in the first 24 h after burn trauma. First-day i.v. infusion volume was significantly higher than PF preferred. In the first 24 h the hourly volume of intravenous fluid resuscitation per bodyweight per burnt surface area showed significant negative correlation to the burnt body surface area and body mass index, (r = -0.553, P < 0.001; r = -0.570, P < 0.001, respectively) no correlation was found to bodyweight, height or patient age. Patients having deep-burn injury required higher intravenous fluid resuscitation rate than patients having superficial injury only (P < 0.01). Our data suggest that fluid requirement is higher than predicted by PF if the extent of burn or body mass index is low and less if the extent of burn or body mass index is high. The presence of deep burn increases fluid requirement.

Enteral resuscitation and early enteral feeding in children with major burns—Effect on McFarlane response to stress

Aim Early enteral feeding has become standard practice for burned patients. The aim of this study was to determine whether early enteral feeding could be used as an avenue for resuscitation and feeding and the effect it would have on the induction/amelioration of the hormonal stress response. Method Eighteen children with <20% TBSA were randomly assigned to either early enteral feeding and resuscitation, or intravenous resuscitation with the induction of enteral feeding delayed. The enteral fluid volume was incrementally increased every 3 h with a simultaneous equal reduction in the intravenous volume until all the calculated intravenous fluid requirements for resuscitation and maintenance could be administered enterally. In the second group, intravenous resuscitation continued for 48 h when enteral feeding was introduced. Parameters measured were the clinical responses and outcome as well as the concentrations of insulin, insulin-like growth factor 1, glucagon, cortisone and growth hormone. The estimated and calculated energy expenditure was measured calorimetrically and bowel permeability was assessed using a dual sugar absorption test. Results Three children were excluded from the study because of early death from organ failure or carbon monoxide poisoning. Early enteral resuscitation and feeding (ER/EEF) was initiated within a median of 10.7 h post-burn in nine children and late enteral feeding introduced on an average 54 h post-burn. The ER/EEF group showed an anabolic response with significantly higher insulin concentrations ( p = 0.008) and insulin: glucagon ratios ( p = 0.043). Although blood glucose concentrations were initially slightly elevated (EEF: 10.3 g/l, LEF: 8.1 g/l), they rapidly returned to within the normal range. The cortisol and IGF1 concentrations did not differ significantly between the two treatment groups. Growth hormone concentrations were significantly higher in the late enteral feeding (LEF) group ( p = 0.03). The estimated energy expenditure was not different amongst the groups. Small bowel permeability [lactulose:rhamnose (L:R) ratios] decreased significantly over time ( p = 0.02) in both study groups. No pulmonary aspiration was found. Diarrhoea in the ER/EEF settled quickly (2–4 days), whereas in the LEF group it persisted for longer than a week. The LEF group lost a median of 7.75% (acceptable range = ≤5%) of admission body weight, whereas the ER/EEF group lost a median of 3.01%. Patients in the LEF group required antibiotic treatment for a longer period ( p = 0.08) and their hospital stay was longer, though not significant. Conclusions Enteral resuscitation and early enteral feeding is a safe and effective method and particularly suited for children in developing countries. It resulted in the amelioration of the hormonal stress response and improved outcome. Enteral resuscitation should not be introduced in a patient in shock or with existing gastrointestinal disease. Complications were minimal.

Acute burn intravenous resuscitation—Are we giving too much volume to our patients?

Acute burn intravenous resuscitation—Are we giving too much volume to our patients?

Severe Plasmodium falciparum malaria in refugee children despite reported predeparture antimalarial treatment

TO THE EDITOR: Predeparture screening and treatment for Plasmodium falciparum malaria is increasingly administered to humanitarian refugees from malariaendemic areas immediately before resettlement in Australia. It is undertaken by the International Organization for Migration (IOM), under contract from the Department of Immigration and Multicultural Affairs (DIMA). Combination therapy (usually an artemisinin derivative in combination with another drug, or chloroquine) is used for both adults and children. The first dose (of what is usually a 3–5-dose treatment course) is supervised, and written documentation of the treatment should accompany the refugee to Australia. Giving predeparture antimalarial treatment has the potential benefit of reducing the incidence of malaria after arrival, as well as reducing the risk of local transmission in malaria-receptive areas of Australia. Onshore health assessments are performed in about 80% of humanitarian refugees resettled in Western Australia (A Thambiran, Medical Director, Migrant Health Unit, Perth, WA, personal communication). Between August 2005 and March 2006 — a period of increased offshore predeparture management of malaria (in line with DIMA/IOM policy in response, presumably, to the increasing burden of imported malaria in refugees coming to Australia) — 336 African refugee children were screened on arrival in WA. Thirty-two children (9.5%) with P. falciparum malaria were identified, of whom 20 (10 Burundian, eight Congolese and two Sudanese) had received predeparture antimalarial medications. Eleven children who presented in a 3-week period had all been treated at a single centre in Kenya with pyrimethamine–sulphadoxine and artesunate, according to sighted IOM documentation. Of the remaining nine children, some had transited through countries other than Kenya, but not all had complete documentation. Three children presented with malaria parasite loads ranging from 6% to 14% within 7–10 days of arrival in WA. One child had severe malaria (14% parasite load), was obtunded at presentation and required intravenous quinine therapy and resuscitation. Overall, 15 of the 20 children treated before departure required hospital admission, despite our selective non-admission policy for uncomplicated P. falciparum malaria. No child had long-term sequelae and all had parasitological cure at Day-28 follow-up. Possible explanations for these apparent failures of predeparture treatment include: (i) incorrect documentation of treatment; (ii) poor compliance; (iii) lack of supervision; and (iv) inactive or expired medication. Delays in departure must also be considered at assessment, as these allow potential re-infection — in this cohort, the time between treatment and migration was poorly documented. Subsequent clinical presentation in WA ranged from 24 to 31 days after treatment in Africa (in cases where documentation was available). As all children were not treated at a single centre offshore, these cases are likely to reflect more widespread and multifactorial issues about the effectiveness of predeparture antimalarial management. Another concern is the rise of multidrugresistant strains of P. falciparum, particularly throughout sub-Saharan Africa and SouthEast Asia. Combination therapy with artemisinin derivatives is now recommended by the World Health Organization as first-line treatment. However, many of the patients in this cohort received treatment with pyrimethamine–sulphadoxine and artesunate, despite reported high levels of parasite resistance. IOM protocols are evolving in an attempt to reflect the rapidly changing multidrug-resistance patterns in these malaria-endemic regions. A recent Ugandan study reported high Day-28 cure rates with artemether–lumefantrine (despite a relatively complex dosing schedule) because of lower drug resistance. These cases highlight the continuing need for comprehensive and timely onshore assessment (including malaria screening), irrespective of predeparture treatment. P. falciparum malaria remains a major global cause of morbidity and mortality — there were an estimated 515 million clinical infections in 2002, with 70% occurring in Africa. P. falciparum has a significant casefatality rate (up to 20% in cerebral malaria), even when managed appropriately. It results in 1–2 million deaths each year, mainly of children, and about 18% of all child deaths in sub-Saharan Africa are directly attributable to malaria. Australia resettles more humanitarian refugees per capita than any other nation and many are from malariaendemic regions. Predeparture antimalarial treatment should reduce the number of clinical episodes of malaria presenting within Australia, but the efficacy of this unproven intervention warrants prospective study. Importantly, documented predeparture antimalarial treatment should not distract health care providers from considering this potentially life-threatening infection in a febrile child recently migrated from a malaria-endemic area.

Evolution of Burn Resuscitation in Operation Iraqi Freedom

Abstract : Burns are common in all military conflicts, comprising approximately 10% of all casualties. Of these, nearly 20% are categorized as severe, or involving greater than 20% TBSA, and require significant intravenous resuscitation. A unique set of challenges have emerged during the present conflict associated with global evacuation of burned soldiers, adding a new dimension to the already complex and often-controversial topic of the burn resuscitation. Critical advances in air evacuation of the war wounded, thorough prewar planning, and sustained burn care education of deployed personnel have proven vital in the optimal care of our injured soldiers. During the Vietnam conflict, burned soldiers were evacuated to an Army Hospital in Japan (Camp Zama) and were treated for up to 6 months before they were evacuated to the United States. Since that time, the transfer of the patient to the burn center for definitive care has been expedited by the Army Burn Flight Team's ability to transport the most severely burned patients within the first several days after injury. With the emergence of the U.S. Air Force Critical Care Air Transport Team (CCATT) program in the 1990s, global air evacuation of burn patients became even more rapid, maximizing available U.S. Air Force aircraft for patient evacuation. The doctrine has shifted from aeromedical transport of the stable to aeromedical transport of the stabilized. In burn patients, evacuation presents a unique problem because it usually takes place while resuscitation in the first 24 to 48 hours after burn injury is ongoing. In addition to the innate complexity involved in global evacuation, war burn patients often exhibit multisystem traumatic injuries further complicating and augmenting resuscitation fluid needs above and beyond standard burn resuscitation formulas. The presence of smoke inhalation injury, occurring in 5% to 15% of patients with severe burns, also increases fluid requirements.

A case study: Boerhaave's Syndrome

JG was a 50-year-old man who had been having epigastric pain and shortness of breath for 2 or 3 days, which he attributed to his history of gastritis and self-treated with antacids. He had several episodes of vomiting but did not note any blood in the emesis. Four hours after awakening with continued sharp right upper quadrant pain, chest pain, worsening dizziness, difficulty breathing, and general malaise, he called 9-1-1. Emergency medical service personnel found him awake and fully oriented, with respiratory rate of 40 breaths per minute, wheezing in both lung fields, and cool, clammy skin. His heart rate was 120 beats per minute with no obtainable blood pressure or pulse oximetry waveform from a probe placed on his fingertip. Intravenous therapy with 900-mL crystalloid bolus and albuterol nebulizer treatment were completed during transport to the local emergency department (ED). On arrival at the community hospital, JG’s initial vital signs were heart rate 126 beats per minute, blood pressure 119/66 mm Hg, respiratory rate 38 breaths per minute, SpO2 92% on room air, and temperature 96.8° F. Additional large bore intravenous access was secured because the staff noted the patient’s skin to be “clammy and mottled.” ED workup included arterial blood gas analysis, chest x-ray, and continued intravenous crystalloid resuscitation. The differential diagnosis was listed as “acute surgical abdomen” by the ED attending and consulting general surgeon. Foley and nasogastric tubes were placed while waiting for the lab results to return. JG’s initial arterial blood gas was reported as pH 7.23, PCO2 24 mm Hg, PO2 72 mm Hg, HCO3 10 meq/L, and base excess (BE) -15.9 The x-ray film showed bilateral pleural effusions, with the worst being on the left. A left tube thoracostomy was performed with a 28-French chest tube. Immediately 1100 mL of a brown fluid drained into the chest drainage unit. Symptoms of shortness of breath continued, as did oxygen saturations of 89% on room air and 93% on 2 L by nasal cannula (NC). He was set up for a contrasted abdominal/chest computed tomography (CT) scan and given oral contrast mixed with methylene blue. After the CT scan, his chest drainage unit contained blue pleural fluid. His blood pressure dropped precipitously to 66/39, heart rate 124 beats per minute, and O2 saturation down to 89% on 2 L NC. While the intravenous fluids were opened wide, arrangements were made to transfer him to Virginia Commonwealth University Health System for evaluation by the cardiothoracic surgical services. The time from arrival in the ED to the transfer request totaled 6 hours. When the air medical crew arrived, JG was normotensive but remained tachycardic and tachypneic. He had received a total of 5 L crystalloid and remained on an NC at 4 L. He was anxious, mucous membranes were dry and cracked, and skin was cool and moist. Review of the 12-lead electrocardiogram revealed only sinus tachycardia with no acute changes. Abdominal assessment revealed a firm abdomen with pain rated 10 on a 10-point scale. Intravenous fluids remained wide open, so the patient was placed on nonrebreather 100% oxygen and rapidly packaged for transport. While loading into the helicopter, JG’s anxiety and work of breathing increased. Once he was secure, the flight crew per-

Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation

Objectives: To assess a protocol for treatment of sting anaphylaxis. Design: Prospective assessment of treatment with oxygen, intravenous infusion of adrenaline (epinephrine), and volume resuscitation with normal saline. Setting: Sub-study...

Incidence of vomiting in burns and implications for mass burn casualty management

When faced with large numbers of burn patients and limited resources such as in war or disaster, oral fluids may be used as an alternative to intravenous resuscitation. Vomiting during the first 48 h can limit the usefulness of this method; yet its incidence has not been documented. This study aimed to identify those patients at risk of vomiting following burn injury and who therefore might be suitable for oral resuscitation. A retrospective review of case notes from burn patients between 1990 and 2001 was undertaken. Burns requiring intravenous resuscitation (>10% total body surface area (TBSA) in children, >15% TBSA in adults) were included ( n=110). Documentation of vomiting during the first 48 h following burn injury to an extent that prevented commencement of feeding was regarded as significant. Patients that vomited were significantly older (28.3 years compared with 18.5 years, P=0.03), and had sustained significantly larger burns (29.8% compared with 22.9%, P=0.047). Administration of opiates and anti-emetics was similar in both groups and not significant. Although the number of patients in this study excludes a logistic regression analysis, it would seem reasonable to attempt oral resuscitation in patients under 25 years of age and with burns up to 25% TBSA given limited resources.

Influence of coconut water on hemostasis

Coconut water (CNW) can be used as short-term intravenous hydration and resuscitation fluid. We investigated the influence of coconut water on plasma coagulation in vitro. Either CNW or physiological saline (PS) was added to citrated plasma of 8 healthy volunteers. Coagulation capability of diluted plasma was evaluated by thrombelastography (TEG). Replacement of up to 50 % of citrated plasma by CNW or PS did not influence initiation of coagulation as indicated by split point and reaction time, respectively. Strength of fibrin clot as expressed by maximum amplitude (MA) of TEG recording dose dependently declined in both groups. Replacing 50 % of citrated plasma by CNW or PS reduced MA by 39% and 32%, respectively. The influence of coconut water on hemostasis as assessed by TEG does not differ from the effect caused by an identical volume of PS.

Hypertonic saline attenuates end-organ damage in an experimental model of acute pancreatitis.

Hypertonic saline (HTS) has been noted previously to reduce neutrophil activation. The aim of this study was to elucidate the effect of hypertonic resuscitation on the development of end-organ damage in an animal model of pancreatitis. Pancreatitis was induced in Sprague-Dawley rats by intraperitoneal injection of 20 per cent L-arginine. Animals were randomized into four groups (each n = 8): controls; pancreatitis without intervention; pancreatitis plus intravenous resuscitation with normal saline (0.9 per cent sodium chloride 2 ml/kg) at 24 and 48 h; or HTS (7.5 per cent sodium chloride 2 ml/kg) at these time points. Pulmonary endothelial leakage was assessed by measurement of lung wet : dry ratios, bronchoalveolar lavage protein and myeloperoxidase activity. Animals that received HTS showed less pancreatic damage than those resuscitated with normal saline (1.0 versus 3.0; P = 0.04). Lung injury scores were also significantly diminished in the HTS group (1.0 versus 3.5; P = 0.03). Pulmonary neutrophil sequestration (myeloperoxidase activity 1.80 units/g) and increased endothelial permeability (bronchoalveolar lavage protein content 1287 microgram/ml) were evident in animals resuscitated with normal saline compared with HTS (1.22 units/g and 277 microgram/ml respectively; P < 0.02). HTS resuscitation results in a significant attenuation of end-organ injury following a systemic inflammatory response to severe pancreatitis.

The intravenous use of coconut water

Medical resources routinely used for intravenous hydration and resuscitation of critically ill patients may be limited in remote regions of the world. When faced with these shortages, physicians have had to improvise with the available resources, or simply do without. We report the successful use of coconut water as a short-term intravenous hydration fluid for a Solomon Island patient, a laboratory analysis of the local coconuts, and a review of previously documented intravenous coconut use.

Interventions to improve cardiopulmonary hemodynamics during laparoscopy in a porcine sepsis model

Background: Laparoscopy is increasingly used in severely ill and acutely septic patients. In animals undergoing laparoscopy, the hemodynamic response to sepsis is blunted. Specific interventions to augment the hemodynamic potential may make laparoscopic intervention a safer alternative in septic patients. We compared different interventions to improve hemodynamic performance during exploratory laparoscopy in a porcine endotoxic shock model. Study Design: Domestic pigs (n = 12) received intravenous lipopolysaccharide injection and underwent surgical abdominal exploration using either laparoscopy or conventional laparotomy. For comparison, pigs exposed to endotoxin underwent laparoscopy with these interventions: intravenous infusions of prostacyclin (n = 5) or indomethacin (n = 4), intravenous crystalloid resuscitation (n = 5), pulmonary hyperventilation (n = 4), or abdominal insufflation with air (n = 5). Hemodynamic measurements and blood gas analyses were obtained using Swan-Ganz and arterial catheters. Results: Septic animals treated with prostacyclin undergoing laparoscopy had a higher cardiac index (CI, p < 0.01), stroke volume (SV; p < 0.001) and oxygen delivery (p < 0.05) than the untreated group. Likewise, treatment with indomethacin was associated with a higher CI (p < 0.001), SV (p < 0.005), and oxygen delivery (p < 0.005) compared with the untreated group. These effects may be secondary to a decreased pulmonary vascular resistance, demonstrated in the animals that received either prostacyclin (p < 0.05) or indomethacin (p < 0.05). In addition, animals given aggressive fluid resuscitation had a significantly higher CI (p < 0.05) and SV (p < 0.001) than those with normal fluid resuscitation during laparoscopy. Manipulation of arterial pH by insufflation of the abdomen with air to create the pneumoperitoneum, or by aggressively hyperventilating the animals, did not improve CI. Conclusions: Adverse effects of laparoscopy on cardiovascular hemodynamics in the septic state may be mediated by increased pulmonary vascular resistance, diminished venous return, or both. Specific interventions to reverse these variables may ameliorate hemodynamic changes seen.

Effects of long-term hemofiltration on circulating mediators and superoxide production during continuous endotoxin administration.

The purpose of this study was to test whether continuous hemofiltration eliminates cytokines and eicosanoids, or stimulates granulocyte function. Nineteen pigs were divided into a control group (n = 7), a hemofiltration group (n = 7), and an extracorporeal circuit only group (n = 5). All animals received the same amount of intravenous endotoxin and resuscitation fluid. Zero-balanced hemofiltration was started 30 minutes after initiation of endotoxemia and continued throughout the experiment. Plasma endotoxin, tumor necrosis factor-alpha, eicosanoids, superoxide production, and other physiologic parameters were measured before challenge and at scheduled intervals thereafter. Eicosanoids were filtered but plasma concentrations were not reduced. Tumor necrosis factor-alpha was not filtered or adsorbed. There were no significant differences between groups in any measured parameters. Continuous hemofiltration could not efficiently remove tumor necrosis factor-alpha or eicosanoids. Also, continuous hemofiltration did not stimulate production of the proinflammatory mediators measured, nor improve respiratory distress.

Patient Assessment and Resuscitation

The patient with acute variceal bleeding requires prompt attention and is best served by an organized approach to assessment and resuscitation. Knowledge of the differential diagnosis for acute bleeding from portal hypertension is essential. Special attention is needed during resuscitation regarding endotracheal intubation, intravenous resuscitation, and management of coagulopathy and thrombocytopenia. Carefully selected patients may be triaged into outpatient, overnight observation, routine inpatient, and intensive care settings.

Pediatric burns: A decade later

PATIENTS AND METHODS The records of 255 burn patients admitted to The Hospital for Sick Children, Toronto, Ontario from 1986 to 1988 were reviewed with respect to the following parameters: age, sex, etiology, anatomical area involved, extent of burn, days of hospitalization and need for intravenous resuscitation, escharotomy and grafting. Contributing factors, associated injuries, home remedies, complications and mortality were noted. These parameters were then compared with those of burn patients admitted in the preceding decade (1977 to 1979) (1) by using a t-test with a test for variance.