Plasma volume estimation in severely ill infants and children using a simplified Evans blue method

Blood volume reduction due to rapid plasma loss after birth in preterm piglets

BACKGROUND

Understanding changes in blood volume after preterm birth is critical to preventing cardiovascular deterioration in preterm infants. The aims were to determine if blood volume is higher in preterm than term piglets and if blood volume changes in the hours after birth.

METHODS

Paired blood volume measurements were conducted in preterm piglets (98/115d gestation, ~28wk gestation infant) at 0.5-5 h (n = 12), 0.5-9 h (n = 44) and 5-11 h (n = 7) after birth, and in a term cohort at 0.5-9 h (n = 40) while under intensive care.

RESULTS

At 30 min after birth, blood volume was significantly lower in preterm piglets compared to term piglets. By 9 h after birth, blood volume had reduced by 18% in preterm piglets and 13% in term piglets. By 5-9 h after birth, preterm piglets had significantly lower blood volumes than at term (61 ± 10 vs. 76 ± 11 mL/kg).

CONCLUSIONS

In contrast to clinical resources, preterm piglets have a lower blood volume than at term. Substantial reductions in blood volume after birth leave some preterm piglets hypovolemic. If this also occurs in preterm infants, this may have important clinical consequences. Modern studies of blood volume changes after birth are essential for improving preterm outcomes.

IMPACT

Preterm piglets do not have a higher blood volume than their term counterparts, in contrast to current clinical estimates. Rapid reduction in blood volume after birth leads to hypovolemia in some preterm piglets. There is a critical need to understand blood volume changes after birth in preterm infants in order to improve clinical management of blood volume.

A Preterm Physiologically Based Pharmacokinetic Model. Part I: Physiological Parameters and Model Building

BACKGROUND

Developmental physiology can alter pharmacotherapy in preterm populations. Because of ethical and clinical constraints in studying this vulnerable age group, physiologically based pharmacokinetic models offer a viable alternative approach to predicting drug pharmacokinetics and pharmacodynamics in this population. However, such models require comprehensive information on the changes of anatomical, physiological and biochemical variables, where such data are not available in a single source.

OBJECTIVE

The objective of this study was to integrate the relevant physiological parameters required to build a physiologically based pharmacokinetic model for the preterm population.

METHODS

Published information on developmental preterm physiology and some drug-metabolising enzymes were collated and analysed. Equations were generated to describe the changes in parameter values during growth.

RESULTS

Data on organ size show different growth patterns that were quantified as functions of bodyweight to retain physiological variability and correlation. Protein binding data were quantified as functions of age as the body weight was not reported in the original articles. Ontogeny functions were derived for cytochrome P450 1A2, 3A4 and 2C9. Tissue composition values and how they change with age are limited.

CONCLUSIONS

Despite the limitations identified in the availability of some tissue composition values, the data presented in this article provide an integrated resource of system parameters needed for building a preterm physiologically based pharmacokinetic model.

Pediatric physiology in relation to the pharmacokinetics of monoclonal antibodies

INTRODUCTION

Dose design for pediatric trials with monoclonal antibodies (mAbs) is often extrapolated from the adult dose according to weight, age, or body surface area. While these methods account for the size differences between adults and children, they do not account for the maturation of processes that may play a key role in the pharmacokinetics and/or pharmacodynamics of mAbs. With the same weight-based dose, infants and young children typically receive lower plasma exposures when compared to adults. Areas covered: The mechanistic features of mAb distribution, elimination, and absorption are explored in detail and literature-based hypotheses are generated to describe their age-dependence. This knowledge can be incorporated into a physiologically based pharmacokinetic (PBPK) modeling approach to pediatric dose determination. Expert opinion: As data from pediatric clinical trials become increasingly available, we have the opportunity to reflect on the physiologic drivers of pharmacokinetics, safety, and efficacy in children with mathematical models. A modeling approach that accounts for the age-related features of mAb disposition can be used to derive first-in-pediatric doses, design optimal sampling schemes for children in clinical trials and even explore new pharmacokinetic end-points as predictors of safety and efficacy in children.

131I-Evans blue: evaluation of necrosis targeting property and preliminary assessment of the mechanism in animal models

Necrosis is a form of cell death, which is related to various serious diseases such as cardiovascular disease, cancer, and neurodegeneration. Necrosis-avid agents (NAAs) selectively accumulated in the necrotic tissues can be used for imaging and/or therapy of related diseases. The aim of this study was to preliminarily investigate necrosis avidity of ¹³¹I-evans blue (¹³¹I-EB) and its mechanism. The biodistribution of ¹³¹I-EB at 24 h after intravenous administration showed that the radioactivity ratio of necrotic to viable tissue was 3.41 in the liver and 11.82 in the muscle as determined by γ counting in model rats. Autoradiography and histological staining displayed preferential uptake of ¹³¹I-EB in necrotic tissues. In vitro nuclear extracts from necrotic cells exhibited 82.3% of the uptake in nuclei at 15 min, as well as 79.2% of the uptake at 2 h after ¹³¹I-EB incubation. The DNA binding study demonstrated that evans blue (EB) has strong binding affinity with calf-thymus DNA (CT-DNA) (K_sv=5.08×10⁵ L/(mol/L)). Furthermore, the accumulation of ¹³¹I-EB in necrotic muscle was efficiently blocked by an excess amount of unlabeled EB. In conclusion, ¹³¹I-EB can not only detect necrosis by binding the DNA released from necrotic cells, but also image necrotic tissues generated from the disease clinically.

Infrared fluorescence for vascular barrier breach in vivo--a novel method for quantitation of albumin efflux

Vascular hyperpermeability contributes to morbidity in inflammation. Current methodologies for in vivo assessment of permeability based on extravasation of Evans Blue (EB)-bound albumin are cumbersome and often lack sensitivity. We developed a novel infrared fluorescence (IRF) methodology for measurement of EB-albumin extravasation to quantify vascular permeability in murine models. Vascular permeability induced by endotoxaemia was examined for all solid organs, brain, skin and peritoneum by IRF and the traditional absorbance-based measurement of EB in tissue extracts. Organ IRF increased linearly with increasing concentrations of intravenous EB (2.5-25 mg/kg). Tissue IRF was more sensitive for EB accumulation compared to the absorbance-based method. Accordingly, differences in vascular permeability and organ EB accumulation between lipopolysaccharide-treated and saline-treated mice were often significant when analysed by IRF-based detection but not by absorbance-based detection. EB was detected in all 353 organs analysed with IRF but only in 67% (239/353) of organs analysed by absorbance-based methodology, demonstrating improved sensitivity of EB detection in organs with IRF. In contrast, EB in plasma after EB administration was readily measured by both methods with high correlation between the two methods (n=116, r2=0.86). Quantitation of organ-specific EB-IRF differences due to endotoxin was optimal when IRF was compared between mice matched for weight, gender, and age, and with appropriate corrections for organ weight and EB plasma concentrations. Notably, EB-IRF methodology leaves organs intact for subsequent histopathology. In summary, EB-IRF is a novel, highly sensitive, rapid, and convenient method for the relative quantification of EB in intact organs of treatment versus control mice.

Circulating blood volumes: a review of measurement techniques and a meta-analysis in children

The accurate determination of circulating blood volume (CBV) in children has many clinical applications. The purposes of this article were to review currently available CBV measurement techniques and perform a meta-analysis using values from many small-scale studies that calculated CBV values for normal healthy children. A literature review demonstrated numerous methods by which to determine CBV. However, these methods necessitate repetitive blood sampling, require the introduction of foreign substances into the bloodstream, or address the uncertainty of substance distribution and clearance. Many small-scale studies have calculated CBV values for normal healthy children, and we performed a meta-analysis using these values. Age groups were defined, and within each group, means +/- 1 and 2 standard deviations were compared. A pooled estimate of mean blood volume and a 95% confidence interval was calculated after Q-statistics calculations indicated that the groups were homogeneous. Mean values showed agreement with typically accepted normal values. A large-scale study should be repeated when a gold standard for CBV measurements is developed.

Re-evaluation of Evans Blue dye as a marker of albumin clearance in murine models of acute lung injury

Quantifying the amount of albumin conjugated to Evans Blue dye (EBA) fluxing across organ-specific vascular barriers is a popular technique to measure endothelial monolayer integrity in rodent and murine models of human diseases. We have re-evaluated this technique with a specific focus of assessing the commonly used turbidity correction factors. These factors, originally developed and required in a spectrophotometric assay to quantify Evans Blue (EB) in human infant or dog serum, produced negative numbers when applied to murine models of acute lung injury. We next sought to determine tissue-specific correction factors for murine tissues and experimentally derived such factors, which allow estimation of the amount of EB in formamide extracts of murine tissues as positive numbers. Utilization of a best fit correction factor in a lipopolysaccharide (LPS)-induced murine model of acute lung injury resulted in significantly increased sensitivity and repeatability of the EB dye tissue extravasation assay. This factor may be of significant utility in animal models of inflammatory injury.

Extravasation of albumin after cardiopulmonary bypass in newborns

OBJECTIVE

The systemic inflammatory response to cardiopulmonary bypass (CPB) possibly increases microvascular permeability to plasma proteins, leading to capillary leak syndrome. The study was conducted to elucidate any protein leakage in newborns using Evans blue dye as tracer.

DESIGN

Prospective controlled study.

SETTING

University-affiliated heart center.

PARTICIPANTS

Eleven neonates with transposition of the great arteries.

INTERVENTIONS

Plasma interleukin-6 (IL-6), IL-10, fractional escape rate (FER) of an intravenous bolus of Evans blue, and colloid osmotic pressure (COP) were assessed before and after surgery (statistics: median and 25th-75th percentile, Friedman's 2-way analysis of variance, and Wilcoxon matched-pairs signed-rank test [before and after surgery]).

MEASUREMENTS AND MAIN RESULTS

All patients had an uneventful intraoperative course. The demographic and operative data were age 11 (10-13) days, body weight 3.2 (3.0-3.3) kg, CPB time 132 (123-144) minutes, and aortic cross-clamp time 66 (64-78) minutes. The proinflammatory IL-6 increased 60-fold and the anti-inflammatory IL-10 only 3-fold after CPB. FER, however, was not changed, whereas COP was significantly reduced after CPB.

CONCLUSIONS

In contrast to the expectation, the escape rate of Evans blue, reflecting the extravasation of albumin, was not increased after CPB. However, reduced COP, hypothermia, and also a reduced lymphatic drainage may contribute to edema formation. The present data do not support the hypothesis of a capillary leak after CPB in newborns.

Ventilation-induced neutrophil infiltration and apoptosis depend on apoptosis signal-regulated kinase 1 pathway*

OBJECTIVE

Positive pressure ventilation with large tidal volumes has been shown to cause release of cytokines, including macrophage inflammatory protein (MIP)-2, a functional equivalent of human interleukin-8, neutrophil infiltration, and apoptosis. The mechanisms regulating ventilation-induced cytokine production and lung cell death are unclear. Based on our previous in vitro and in vivo models of lung cell stretch, we hypothesized that high tidal volume ventilation-induced MIP-2 production, neutrophil infiltration, and apoptosis are dependent on the activation of apoptosis signal-regulated kinase 1 (ASK1), the upstream activator of c-Jun N-terminal kinase (JNK).

DESIGN

: Prospective, controlled animal experiment.

SETTING

University research laboratory.

SUBJECTS

Male C57BL/6 mice, weighting 20-25 g.

INTERVENTIONS

C57BL/6 mice were exposed to high tidal volume (30 mL/kg) or low tidal volume (6 mL/kg) mechanical ventilation for 15 mins to 5 hrs.

MEASUREMENTS AND MAIN RESULTS

High tidal volume ventilation induced MIP-2 messenger RNA expression, MIP-2 protein production, neutrophil migration into the lung, airway epithelial cell apoptosis, and activation of ASK1, JNK, and activator protein (AP)-1 DNA binding in a dose-dependent and time-dependent manner. ASK1 inhibition with thioredoxin attenuated high tidal volume ventilation-induced MIP-2 messenger RNA expression, MIP-2 protein production, neutrophil migration into the lung, airway epithelial cell apoptosis, activation of JNK, and AP-1 DNA binding.

CONCLUSIONS

Our data showed that high tidal volume ventilation-induced MIP-2 production, neutrophil sequestration, and apoptotic cell death were dependent, in part, on activation of the ASK1/JNK/AP-1 pathway.

Capillary leak syndrome in children with C4A-deficiency undergoing cardiac surgery with cardiopulmonary bypass: a double-blind, randomised controlled study

BACKGROUND

Capillary leak syndrome is a life-threatening complication after cardiopulmonary bypass (CPB), with an incidence of about 4-37% in children worldwide. On the basis of previous results, we undertook a randomised controlled study to investigate the priming with plasma rich in the C4A isotype of complement component 4 on the incidence of capillary leak syndrome in children with C4A deficiency.

METHODS

In a hospital in Wuhan, China, we randomly assigned 116 neonates, infants, and children lacking complement component C4A to receive C4A-free or C4A-rich plasma priming (n=58 each, 20 mL/kg). The primary outcome was capillary leak syndrome, identified as an increased transvascular escape rate of Evans blue dye from plasma. Concentrations of activated complement components C4 and C3, inflammatory mediators interleukin 6, interleukin 8, tumour necrosis factor (TNF) alpha, plasma protein, and PaO2/F(I)O2 ratios (ratio of the partial arterial pressure of oxygen to the fractional concentration of oxygen in inspired air) were measured before and 4 h after CPB. Analysis was by intention to treat.

FINDINGS

Three (5%) patients given C4A-rich plasma priming had capillary leak syndrome compared with 56 (97%) given C4A-free plasma (p<0.0001). At 4 h after CPB, activated C4, interleukin 6, interleukin 8, and TNFalpha concentrations were higher, whereas PaO2/F(I)O2 ratios and plasma protein concentrations were significantly lower in the C4A-free group than changes in the C4A-rich group. Activated C3 rose equally in both groups. Activated C4 significantly correlated with interleukin 6, interleukin 8, and TNFalpha concentrations; PaO2/F(I)O2 ratios; and the escape rate of Evans blue dye at 4 h after CPB. Two patients in the C4A-free group died of respiratory and renal failure on day 3 after CPB.

INTERPRETATION

In paediatric patients with C4A deficiency, C4A-rich plasma priming reduces the incidence of CPB-related capillary leak syndrome by blocking the activated C4 increase and attenuating the systemic inflammatory response after CPB.

Estimation of circulating blood volume in infants using the pulse dye densitometry method

BACKGROUND

Estimation of hemodynamics is important for critically ill infants. Pulse dye densitometry (PDD) using indocyanine green (ICG), which enables measurements of circulating blood volume at the bedside, has recently been developed for adults.

METHODS

We conducted a basic investigation to determine whether this method can be applied to infants and measured circulating blood volume in 25 infants whose gestational ages ranged from 24 to 40 weeks (median, 32 weeks). At first, to validate the accuracy of measurements, arterial ICG concentrations determined by blood sample measurements were compared using a spectrophotometer ([ICG blood]) and by noninvasive measurement using PDD ([ICG pdd]) in seven infants. Next, blood volumes in 25 infants were estimated by the PDD method.

RESULTS

There was a positive relationships between [ICG blood] and [ICG pdd] (r = 0.913, P < 0.0001). Using Bland Altman analysis, the bias between the two methods was 0.24 +/- 0.30 mg.l(-1) (95% confidence interval: 0.39-0.09 mg.l(-1)) and the limits of agreement (2 sd) were -0.36 and 0.84 mg.l(-1), respectively. Mean (sd) blood volume was 94.9 ml.kg(-1) (24.3). The values obtained by this study are almost the same as previously reported values obtained by using other methods.

CONCLUSIONS

PDD using ICG can be used to monitor of hemodynamics in infants.

Hydrogen peroxide derived from intestine through the mesenteric lymph induces lung edema after surgical stress

Compelling evidence indicates that the small intestine is the primary source of factors inducing lung injury after major surgery and that the lymphatic system is the major route by which these gut-derived factors reach the pulmonary circulation. This study investigated the mechanism of lung edema induced by surgical stress. After subjecting male, fasted, pathogen-free Sprague-Dawley rats to surgical stress (laparotomy and intestinal handling for 5 min), followed by ventilation for 5 h, we measured H2O2 production in the mucosa of small intestine and in the lung using 2',7'-dichlorofluorescein and intravital fluorescence microscopy. In addition, H2O2 in mesenteric lymph was measured using a quantitative assay; lung permeability was assessed as a function of extravasation of Evans blue dye; neutrophil accumulation was visualized by intravital fluorescence microscopy and assessed as a function of myeloperoxidase activity; and TNF-alpha levels were measured using a specific ELISA. The intensity of 2',7'-dichlorofluorescein fluorescence in the mucosa of small intestine, H2O2 levels of mesenteric lymph, and lung permeability were all significantly higher in rats subjected to surgical stress than in control animals. Moreover, all of these effects were blocked by pretreatment with a specific xanthine oxidase inhibitor. Surgical stress did not increase neutrophil accumulation or TNF-alpha production in the lung. In conclusion, surgical stress induces xanthine oxidase-dependent H2O2 production in the small intestine. The H2O2 then enters the mesenteric lymph and travels to the lung, where it increases capillary permeability and thus induces edema.

Increased matrix metalloproteinase expression and activation following experimental acute pancreatitis

BACKGROUND

The observation that matrix metalloproteinases (MMPs) are central to tissue remodeling and may contribute to organ failure prompted us to investigate the role of MMPs in acute pancreatitis. We hypothesize that increased expression and activation of MMP-2 and MMP-9 will correlate with organ injury following acute pancreatitis.

METHODS

Acute pancreatitis was induced in five male rats by retrograde infusion of 5% sodium taurocholate into the pancreatic duct. Sham laparotomy was performed on five rats serving as a control. Pancreatitis was confirmed by histology and serum amylase levels. MMP-2 and MMP-9 activity and expression were assayed by gelatin zymography in the lungs and ascitic fluid of each animal. Lung permeability was assayed by Evans blue dye extravasation. Lung activity of MMP-2 and MMP-9 was confirmed by a specific fluorogenic MMP substrate assay.

RESULTS

Lung permeability increased twofold in the animals with severe pancreatitis compared with sham. Analysis of the zymograms from lung homogenate revealed a threefold increase in active MMP-2 in severe pancreatitis compared with sham and no change in MMP-9 activity. Gelatin zymograms of peritoneal fluid from severe pancreatitis animals demonstrated increased levels of active MMP-2 and MMP-9 compared with the sham group. Increases in MMP activity were confirmed by MMP activity assay using a fluorogenic substrate.

CONCLUSIONS

This study demonstrates a correlation between severity of acute pancreatitis and active MMP-2 and MMP-9 levels in the peritoneal fluid and MMP-2 activity in lung homogenate. The MMP-mediated degradation of the basement membrane offers a potential pharmacologic and therapeutic target for halting the final biologic outcome of severe pancreatitis.

The role of cytokine-induced neutrophil chemoattractant-1 in neutrophil-mediated remote lung injury after intestinal ischaemia/reperfusion in rats

OBJECTIVE

Remote lung injury is induced by ischaemia/reperfusion (I/R) of the gastrointestinal tract and the liver following hypovolaemic shock. In the present study, the role of cytokine-induced neutrophil chemoattractant (CINC), a member of the interleukin (IL)-8 family, in neutrophil-mediated remote lung injury following intestinal I/R was investigated in anaesthetized rats.

METHODOLOGY

The I/R group was subjected to 60 min of occlusion of the superior mesenteric artery with laparotomy, followed by 240 min of intestinal reperfusion. The sham-operated (sham) group was subjected to the same procedures with the exception of intestinal I/R.

RESULTS

In the I/R group, the permeability index of the lung, the neutrophil count in pulmonary vascular lavage fluid and bronchoalveolar lavage fluid (BALF), lung myeloperoxidase activity and neutrophil oxidative production were all significantly greater than those in the sham group. Cytokine-induced neutrophil chemoattractant-1 levels in blood and BALF were significantly increased at 240 min after intestinal reperfusion. There was a significant relationship between neutrophils in BALF and CINC-1 level in BALE CONCLUSION: These findings suggest that intestinal reperfusion was associated with activation and accumulation of neutrophils in the lung and resulted in remote lung injury with increased microvascular permeability. Thus, CINC-1 in BALF may induce neutrophil migration from the pulmonary vessels to the interstitium and alveolar spaces in remote lung injury after intestinal I/R.

Aquaporin channels may modulate ventilator-induced lung injury

Adult Respiratory Distress Syndrome is a disease with functional lung heterogeneity and thus a ventilator-delivered breath may over-distend non-involved areas. In rats we examined ventilator-delivered tidal volume (TV) breaths of 7 and 20 ml/kg on lung water as evidence of lung injury. We examined the role of aquaporins on ventilator-induced lung injury (VILI) by infusing HgCl(2) which inhibits aquaporins by binding cysteine. Wet to dry lung weight ratio (W/D) as evidence of lung water was 4.47+/-0.1 SEM in controls, 4.6+/-0.1 and 5.5+/-0.2 (P<0.05) in rats ventilated at 7 and 20 ml/kg, respectively. Pulmonary artery pressure (PAP) rose from 23+/-1 to 26+/-1 mmHg (P<0.05, n=7) and cardiac output fell from 104+/-2 to 67+/-3 ml/min (P<0.05) in rats ventilated at 20 ml/kg. Left ventricular end diastolic pressure (n=3) was unchanged. Evans Blue dye, an albumin marker, increased from a control 37+/-11 to 97+/-41 mg/g wet lung in TV 20 rats (P<0.05). HgCl(2) infused slowly by tail vein did not significantly raise PAP, but did increase W/D to 6+/-0.2 (P<0.05) in rats ventilated at 20 ml/kg but not at 7 ml/kg. Equimolar cysteine infusions prevented the HgCl(2) from increasing the W/D above that seen with TV 20 ml/kg. Thus ventilation with TV of 20 ml/kg produced a protein-rich lung edema. Aquaporin channels may have a protective effect in VILI.

Topical hepatic hypothermia attenuates pulmonary injury after hepatic ischemia and reperfusion

BACKGROUND

Prolonged periods of hepatic ischemia are associated with hepatocellular injury and distant organ dysfunction in experimental models. Neutrophils (PMN) and tumor necrosis factor (TNF)-alpha have been implicated, mostly because of their local deleterious effects on the hepatocyte after hepatic ischemia and reperfusion (I/R) injury. We hypothesize that topical hepatic hypothermia (THH) reduces ischemia and reperfusion-induced hepatic necrosis, PMN infiltration, TNF-alpha release, and consequent acute pulmonary injury.

STUDY DESIGN

Sprague-Dawley rats (250 to 300g) were evenly divided into three groups: 90 minutes of normothermic (37 degrees C) partial hepatic ischemia (normothermic I/R), 90 minutes of hypothermic (25 degrees C) partial hepatic ischemia (hypothermic I/R), and sham laparotomy (without ischemia). There were six animals in each experimental group per time point unless otherwise specified. Hepatic necrosis and PMN infiltration were evaluated and scored on hematoxylin and eosin-stained liver specimens 12 hours after reperfusion. Serum TNF-alpha levels were determined by ELISA at 0 minutes, 15 minutes, 30 minutes, 1 hour, and 12 hours postreperfusion. Pulmonary PMN infiltration and vascular permeability were measured by myeloperoxidase activity and Evans blue dye extravasation, respectively, to quantitate pulmonary injury 12 hours after reperfusion.

RESULTS

Normothermic I/R results in a significant increase in TNF-alpha at 15 and 30 minutes (p < 0.005), PMN infiltration (p < 0.001), and hepatic necrosis (p < 0.001), compared with sham. Institution of THH reduced peak serum TNF-alpha levels by 54% at 15 minutes (p < 0.005) and by 73% at 30 minutes (p < 0.001) postreperfusion compared with normothermic I/R. Similarly, hepatic PMN infiltration and necrosis at 12 hours were reduced by 60% (p < 0.05) and 47% (p < 0.05), respectively. Myeloperoxidase activity and Evans blue extravasation (measures of acute lung injury) were reduced by 42% and 39%, respectively, with institution of THH compared with animals undergoing normothermic I/R (p < 0.001).

CONCLUSIONS

These results demonstrate that THH protects the liver from ischemia and reperfusion-induced necrosis and PMN infiltration. In addition, THH reduces the serum levels of TNF-alpha and associated pulmonary injury. These data suggest that the ischemic liver is a potential source of inflammatory mediators associated with hepatic ischemia and reperfusion-induced pulmonary injury.

The ratio of ELR+ to ELR- CXC chemokines affects the lung and liver injury following hepatic ischemia/ reperfusion in the rat

Hepatic ischemia/reperfusion (I/R) results in a neutrophil-dependent lung and liver injury. The process of neutrophil recruitment and activation in this injury is at least partially dependent on the presence of the ELR+ CXC chemokines. Other investigations have shown that ELR- CXC chemokines can block ELR+ CXC chemokine neutrophil recruitment and activation in vitro. To begin to investigate the role of the balance between these 2 types of molecules in vivo in neutrophil recruitment and activation following hepatic I/R, we used our rat model of lobar hepatic I/R and pretreated animals with pharmacologic doses of gamma-interferon (gamma-IFN). gamma-IFN is known to upregulate some of the ELR- CXC chemokines, including gamma-IFN-inducible protein (IP-10) and monokine-induced by gamma-IFN (MIG), as well as down-regulate ELR+ CXC chemokine production. Following hepatic I/R or sham laparotomy, hepatic and pulmonary levels of the ELR- chemokines, IP-10 and MIG, and the ELR+ chemokines, rat cytokine-induced neutrophil chemoattractant (KC), macrophage inflammatory protein-2 (MIP-2), and epithelial neutrophil activating protein (ENA-78) were determined by ELISA, and lung and liver injury were assessed. In response to gamma-IFN, hepatic and pulmonary levels of the ELR- chemokines were increased and the levels of the ELR+ chemokines were decreased. Immunohistochemical staining confirmed the hepatocyte as the source of these molecules, as well as the changes in chemokine levels in response to gamma-IFN. There was an associated significant decrease in liver and lung injury, although there was no significant decrease in neutrophil influx in either tissue. This suggests that the alteration in the balance of ELR+ to ELR- CXC chemokines results in a decrease in tissue injury through a mechanism other than through an alteration in tissue neutrophil levels.

Amniotic fluid composition in the fetal lamb with intrauterine growth restriction

OBJECTIVE

Our aim was to examine changes from normal in the composition of amniotic fluid in fetal lambs with mild and severe hypoxemia and intrauterine growth restriction.

STUDY DESIGN

Pregnant sheep underwent maternal catheterization at 88 to 93 days' gestation and fetal catheterization at 105-112 days' gestation. Twelve pregnancies (group 1) provided control data (fetal PaO 2 18-22 mm Hg), in 12 fetuses (group 2) mild hypoxemia (PaO 2 16-19 mm Hg) was induced by prevention of the normal expansion of maternal blood volume, and in 7 fetuses (group 3) chronic hypoxemia (PaO 2 12-18 mm Hg) developed spontaneously.

RESULTS

In group 2 amniotic fluid osmolality and sodium concentrations were lower (approximately 30 mOsm/kg and 10 mEq/L, P <.05) and urea nitrogen level was higher (10 mg/dL, P <.05) than in group 1. In group 3 osmolality and sodium concentrations at approximately 120 days' gestation were similar to those in group 1. Whereas these values decreased with gestation in groups 1 and 2 (P <.05), they remained unchanged or increased in all fetuses in group 3. Mortality rates in groups 1, 2, and 3 were 1 of 12, 4 of 12 (difference not significant), and 5 of 7 (P <.05), respectively.

CONCLUSION

Absence of normal decrease in amniotic fluid osmolality with gestation, in association with a high perinatal mortality rate, was found in severely but not in mildly hypoxemic fetuses with intrauterine growth restriction.

Low-dose low-molecular-weight heparin is anti-inflammatory during venous thrombosis

PURPOSE

Venous thrombosis results in a vein wall inflammatory response initiated by thrombus. Although anticoagulation with standard heparin (SH) and low-molecular-weight heparin (LMWH) is known to limit further thrombosis, their anti-inflammatory properties are poorly defined. The anti-inflammatory properties of these heparins were studied.

METHODS

Sprague-Dawley rats were divided into groups and underwent inferior vena caval (IVC) ligation just below the renal level producing IVC thrombosis. One hour before ligation, animals received subcutaneous SH or LMWH at either high or low dose; normal saline (NS) was used as control. Six hours after ligation, animals were killed, and the IVCs were analyzed for clot presence, vein wall morphometrics, and vein wall permeability (VP) to define injury.

RESULTS

Animals in both low-dose groups had no measurable anticoagulation, whereas those in both high-dose groups were adequately anticoagulated. There were statistically less IVC neutrophils for all groups compared with the control group, with low-dose LMWH showing the least cells (low-dose LMWH, 16 +/- 3; high-dose LMWH, 37 +/- 10; low-dose SH, 37 +/- 6; high-dose SH, 32 +/- 9; NS control, 63 +/- 2). Similar results were noted for total inflammatory cells. The lowest VP was noted for low-dose LMWH.

CONCLUSION

Although both SH and LMWH inhibited vein wall neutrophils and total inflammatory cells, low-dose LMWH was most effective limiting neutrophil extravasation and was the only intervention to decrease VP below control levels. This occurred without preventing thrombus formation or causing a state of anticoagulation. Low-dose LMWH possesses anti-inflammatory properties distinct from its anticoagulant properties.

Platelet-activating factor mediates intercellular adhesion molecule-1-dependent radical production in the nonhypoxic ischemia rat lung

It has been reported that reperfusion is the most important factor in ischemia-reperfusion (I/R) injury. However, causes of I/R injury in the lung are controversial, because oxygen is always supplied if ventilation continues. Therefore, we hypothesized that nonhypoxic ischemia without reperfusion is sufficient for lung injury. To test our hypothesis, we measured both hydrogen peroxide (H2O2) production in the pulmonary circulation, by digital imaging fluorescent dichlorofluorescein, and microvascular permeability (MVP), by the Evans blue extravasation technique in the nonhypoxic ischemia rat lung. We made a nonhypoxic ischemia rat lung by clamping the left pulmonary artery. Both H2O2 production and MVP increased in the nonhypoxic ischemia rat lung. We also determined the effect of oxygen removal by clamping the bronchus in advance of pulmonary artery occlusion, intercellular adhesion molecule-1 (ICAM-1) neutralization with monoclonal antibody 1A29, and platelet-activating factor (PAF) receptor antagonist CV6209 on H2O2 production and MVP. These treatments inhibited both H2O2 production and MVP increase. At high-power viewing of the fluorescent dichlorofluorescein image, H2O2 was detected in the leukocytes within pulmonary capillaries. These data indicate that the nonhypoxic ischemia without reperfusion alone causes radical production and increases MVP. Furthermore, PAF and ICAM-1 contribute to these reactions.

Comparison of total blood volume in normal, preeclamptic, and nonproteinuric gestational hypertensive pregnancy by simultaneous measurement of red blood cell and plasma volumes

OBJECTIVE

Our purpose was to demonstrate reduced blood volume in preeclampsia compared with nonproteinuric gestational hypertension and normal pregnancy by use of independent measures of red blood cell and plasma volumes.

STUDY DESIGN

Red blood cells labeled with a nonradioactive stable isotope of chromium and Evans' blue were infused in subjects with preeclampsia or gestational hypertension and normotensive pregnant controls. Blood was sampled eight times over 60 minutes for dye concentration and at 30 minutes for chromium analysis.

RESULTS

Total blood and plasma volumes are decreased in preeclampsia (2660 +/- 382 mL/m2 and 1790 +/- 332 mL/m2, respectively) compared with normotensive subjects (3217 +/- 391 mL/m2, P < 0.001 and 2279 +/- 325 mL/m2, P < .001) and gestational hypertension (3139 +/- 272 mL/m2, P < .001 and 2132 +/- 265 mL/m2, P = .003). Total body/peripheral hematocrit ratio is increased in preeclampsia.

CONCLUSIONS

Blood volume, by measurement of red blood cell and plasma volumes, is reduced and has altered distribution in preeclampsia but is normal in gestational hypertension.

Delayed treatment with desulfato-hirudin prevents fibrin formation in lipopolysaccharide-induced shock

Previous work has shown that pre-treatment with the thrombin inhibitor recombinant desulfato-hirudin prevented fibrin formation and respiratory dysfunction in porcine lipopolysaccharide shock. We examined the effects of delayed administration of recombinant desulfato-hirudin in bacterial lipopolysaccharide shock. Miniature pigs were studied under anaesthesia and ventilation, and received a bacterial lipopolysaccharide infusion (2 microg/kg/h) for 7 h; recombinant desulfato-hirudin was started 1 h after bacterial lipopolysaccharide in 10 animals (bolus 12.9 nmol/kg; continuous infusion 6.5 nmol/ kg/h); 10 randomised control animals received saline instead of recombinant desulfato-hirudin. Fibrin and thrombin-antithrombin complex levels in plasma were significantly lower in bacterial lipopolysaccharide+recombinant desulfato-hirudin animals than in controls. Both groups displayed a similar rise in pulmonary vascular resistance and other parameters of lung dysfunction; only lung tissue wet/dry ratio was lower in recombinant desulfato-hirudin-treated than in control animals. Both groups had similar circulatory alterations. Recombinant desulfato-hirudin interrupted coagulation activation during ongoing bacterial lipopolysaccharide-induced shock in pigs even when administered with a delay of one hour after start of the bacterial lipopolysaccharide infusion. A protective effect of delayed recombinant desulfato-hirudin administration on bacterial lipopolysaccharide-induced acute lung injury and alterations in the systemic circulation could not be demonstrated in this experiment.

Chemokine expression during hepatic ischemia/reperfusion-induced lung injury in the rat. The role of epithelial neutrophil activating protein

The liver is highly susceptible to a number of pathological insults, including ischemia/reperfusion injury. One of the striking consequences of liver injury is the associated pulmonary dysfunction that may be related to the release of hepatic-derived cytokines. We have previously employed an animal model of hepatic ischemia/reperfusion injury, and demonstrated that this injury causes the production and release of hepatic-derived TNF, which mediates a neutrophil-dependent pulmonary microvascular injury. In this study, we have extended these previous observations to assess whether an interrelationship between TNF and the neutrophil chemoattractant/activating factor, epithelial neutrophil activating protein-78 (ENA-78), exists that may be accountable for the pathology of lung injury found in this model. In the context of hepatic ischemia/reperfusion injury, we demonstrated the following alterations in lung pathophysiology: (a) an increase in pulmonary microvascular permeability, lung neutrophil sequestration, and production of pulmonary-derived ENA-78; (b) passive immunization with neutralizing TNF antiserum resulted in a significant suppression of pulmonary-derived ENA-78; and (c) passive immunization with neutralizing ENA-78 antiserum resulted in a significant attenuation of pulmonary neutrophil sequestration and microvascular permeability similar to our previous studies with anti-TNF. These findings support the notion that pulmonary ENA-78 produced in response to hepatic-derived TNF is an important mediator of lung injury.

Randomized controlled trial of Ringer solution versus serum for partial exchange transfusion in neonatal polycythaemia

We tested whether crystalliod solutions could be used instead of colloid solutions for partial exchange transfusions (PET) in polycythaemic neonates because crystalloid solutions are cheap, carry no risk of anaphylactic reactions and can be sterilized. We randomly assigned 20 term neonates with venous haematocrit (Hct) > 0.65 l/l to PET with either a serum preparation (BISEKO) or Ringer solution. Plasma volume (PV) was measured with Evans blue dilution. Blood volume (BV) and red cell mass were calculated from PV and venous Hct. Before PET both serum and Ringer groups had the same Hct (0.69 (0.66-0.76) vs 0.69 (0.66-0.71) l/l; median (range)) and BV (108 (81-116) versus 96 (68-121) ml/kg. During PET an equivalent amount of blood was withdrawn stepwise (19 (14-26) versus 17 (13-25) ml/kg and replaced by either serum or Ringer solution. More of the Ringer solution (median 77%) than of the serum (median 36%) given left the intravascular space within 4 h after PET (P = 0.016); but there was no significant difference in Hct after Ringer-PET compared to serum-PET (median 0.58 vs 0.56 l/l). No infant required repeat PET. Ringer-PET reduced BV from high to normal values (from median 96 to 83 ml/kg; P = 0.005), whereas after serum-PET BV remained high (from median 108 to 98 ml/kg; not significant).

CONCLUSION

PET with Ringer solution resulted in a haemodilution comparable to PET with serum and a correction of hypervolaemia.

Short-term effects of blood transfusion on blood volume and resting peripheral blood flow in preterm infants

The effects of blood transfusion on cardiac output and blood pressure are variable, but resting peripheral blood flow (RPBF) may be a sensitive indicator of changes in blood volume. The purpose of this investigation was to study the effects of red cell transfusion on blood volume (Evans blue), blood pressure, RPBF in the leg (strain-gauge plethysmography) and blood viscosity (cone-plate viscometer) in preterm infants during the first week after birth. Fourteen infants with mean +/- SD birth weight of 1658 +/- 429 g, gestational age 33 +/- 3 weeks and postnatal age 64 +/- 40 h received 18 +/- 4 ml/kg of packed red cells (red cells 11 +/- 2 ml/kg, plasma 7 +/- 1 ml/kg) because their hematocrit was less than 0.45 l/1. Mean blood volume before transfusion was 88 +/- 15 ml/kg. The increase in blood volume (9 +/- 4 ml/kg) measured 4 to 6 h after transfusion was smaller than the transfused volume (18 +/- 4 ml/kg), due to a shift of plasma to the extravascular space. The plasma shift increased with increasing pretransfusion blood volume (r = 0.70; p = 0.007). Red cell transfusion caused an increase in RPBF by 25% (p < 0.01), whereas systolic blood pressure (BP) increased by only 12%. Peripheral resistance (R = BP/RPBF) decreased by 9% (p < 0.01). Blood viscosity (eta) increased by 21% (p < 0.001) and vascular hindrance (R/eta) decreased by 24% (p < 0.001), indicating vasodilatation of limb arteries. The increase in RPBF and the decrease in hindrance were particularly pronounced in infants with high pretransfusion blood volume.(ABSTRACT TRUNCATED AT 250 WORDS)

Systolic blood pressure and blood volume in preterm infants

Blood volume and systolic blood pressure (SBP) were measured in 43 preterm infants. Mean (SD) blood volume was 83 (19) ml/kg (range 48-119) and SBP 50 (9) mm Hg (range 34-69), showing a significant overall relationship. Blood volume in infants with SBP > 60 mm Hg (110 (6) ml/kg) was significantly higher than in infants with SBP 40-60 mm Hg (78 (16) ml/kg) and in infants with SBP < 40 mm Hg (75 (10) ml/kg). In conclusion, SBP is of limited value in detecting hypovolaemia in very low birthweight infants.

Precision of a new bedside method for estimation of the circulating blood volume

The present study is a theoretical and experimental evaluation of a modification of the carbon monoxide method for estimation of the circulating blood volume (CBV) with respect to the precision of the method. The CBV was determined from measurements of the CO-saturation of hemoglobin before and after ventilation with a gas mixture containing 20-50 ml of CO for a period of 10-15 min. A special Water's to and fro system was designed in order to avoid any leakage when measuring during intermittent positive pressure ventilation (IPPV). Blood samples were taken before and immediately after ventilation with the CO gas mixture. The amount of CO administered during each determination of CBV resulted in an increase in the CO saturation of hemoglobin of 2.1%-3.9%. A theoretical noise propagation analysis was performed by means of the Monte Carlo method. The analysis showed that a CO dose corresponding to an increase of less than 2% will result in an unacceptable coefficient of variation of repeated estimates. In the experimental study the coefficient of variation of repeated estimates of CBV was determined from duplicate measurements of CBV in nine healthy subjects and in nine intensive care patients. The coefficients of variation were 6.2% and 4.7% in healthy and diseased subjects, respectively. Furthermore, the day-to-day variation of the method with respect to the total amount of circulating hemoglobin (nHb) and CBV was determined from duplicate estimates separated by 24-48 h. In conclusion, determination of CBV can be performed with an amount of CO that gives rise to a harmless increase in the carboxyhemoglobin concentration.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of plasma volume in neonates

There is no reliable and safe method for measuring plasma volume in ill newborn infants. We describe an adaptation of the dye dilution technique using indocyanine green as the plasma label, which can be used in the sickest and smallest of infants with the minimum of disturbance. To avoid the need to take large volumes of blood from the infant, samples were diluted 1:1 with distilled water and pooled adult sera was used to construct the dye dilution standard curves. Eighteen preterm and fullterm infants were studied on 30 occasions. The measured plasma volume ranged between 21.4 and 106 ml/kg. Paired measurements were performed within 30-90 minutes of each other in seven infants. In five infants estimations of plasma volume were made shortly before and 30 minutes after the infusion of a known quantity of plasma. In eight out of 12 infants who had two measurements made there was close agreement between the second measured volume and the first measured volume, taking into account how much plasma had been given to or taken from the infant between the two measurements. The error ranged from 0.2 to 5.2 ml and the plasma recovery error ranged from -2.9% to +4.7%. In the remaining four infants the errors ranged from 2.1 to 9.5 ml and -14.2% to +8.8%. Errors in the measurement of plasma volume may arise as the result of sampling too early before full mixing of the dye has occurred, and there is a potential error in the measurement due to the distribution of albumin in the extracellular space in sick infants resulting in an overestimation of the plasma volume. Proposals for reducing sources of errors are discussed.

Heart-lung transplantation for cystic fibrosis. 1: Assessment

Forty five patients with cystic fibrosis (age 5-15 years) were assessed for heart-lung transplantation between September 1987 and March 1990. The two main conditions for acceptance were (i) life expectancy less than 2 years and (ii) a severely impaired quality of life. Patients were accepted onto an active waiting list (n = 26), a provisional waiting list (n = 15), or not accepted (n = 4). Selection was made on clinical grounds with objective measurements used as an aid in assessment. As expected, the mean values for objective measures were significantly different between patients on the active waiting list compared with the provisional waiting list/not accepted group for resting heart rate (118/minute v 101/minute), percentage of ideal weight (83.2% v 93.1%), forced expiratory volume at one second as percent of predicted normal (27.3% v 47.6%), Shwachman-Kulczycki score (33.6 v 52.5), Chrispin-Norman x ray score (25.8 v 22.1), 12 minute walk (540 m v 854 m), and minimal oxygen saturation (81.5% v 92%). Psychological evaluation demonstrated a 55% incidence of individual and a 50% incidence of family morbidity. Of the 26 patients accepted onto the active waiting list, 11 have been transplanted (mean waiting time 3.3 months), 10 have died within a mean of 3.7 months of acceptance, and five remain on the active list (mean 5.6 months).

Body composition, nutrition, and fluid balance during the first two weeks of life in preterm neonates weighing less than 1500 grams

To determine whether body weight during the first 2 weeks of life in preterm infants weighing less than 1500 gm reflects nutritional status or fluid balance, we studied total body water (TBW) (deuterium oxide dilution), extracellular volume (sucrose dilution), and plasma volume (Evans blue dilution), together with intake-output studies of nitrogen, fluid, and sodium on day 1 (median age 0.3 day), at a weight loss of 7.8% of birth weight (median age 3.4 days), and after birth weight was regained (median age 8.9 days) in eight clinically stable preterm infants (birth weight 810 to 1310 gm, gestational age 26 to 30 weeks) receiving ventilatory support. During the initial weight loss we found no evidence of catabolism. Body solids (weight--TBW) remained unchanged, there was nitrogen retention, and energy intake was sufficient to meet energy expenditure by day 2. However, we found evidence of fluid loss: TBW (mean +/- SD, -95 +/- 99 ml), extracellular volume (-98 +/- 63 ml), and interstitial volume (-102 +/- 75 ml) decreased significantly, indicating negative fluid and sodium balances. Blood volume and plasma volume remained unchanged. With the regaining of birth weight there was no increase in body solids despite a high degree of nitrogen retention, but there was a positive fluid balance although no significant increase in any body fluid compartment was found. We conclude that the observed postnatal weight changes reflect changes in interstitial volume.

Repeated plasma volume determination with the Evans Blue dye dilution technique: the method and a computer program

This paper describes a reliable multiple sample Evans Blue dye dilution technique and a Pascal program which computes plasma and blood volume on the basis of this technique. The program performs needed corrections and dye disappearance curve fitting. It provides menu-driven facilities for data correction, graphic display of the dye disappearance curve, and print-out of all the involved data. Means +/- S.E.M. for three plasma volume determinations in each of six resting subjects were: 3239 +/- 96 ml, 3189 +/- 81 ml, and 3187 +/- 102 ml. The differences were not statistically significant.

Thoracic duct lymph and PEEP studies in anaesthetized dogs. I. Lymph formation and the effect of a thoracic duct fistula on lymph flow

The effect of positive end-expiratory pressure ventilation (PEEP, 11-12 mmHg, 60-90 min without, 19 h with circulatory support) on fractional escape rate of plasma proteins (FER), and on thoracic duct lymph flow draining against jugular venous (LFJVP) or atmospheric pressure (LFAP) was studied in anaesthetized dogs. FER was 10.8%/h, 15.3%/h, and 8.5%/h before, during, and after PEEP, respectively, indicating augmented lymph formation probably due to the increase in venous pressure from 4.8 to 10.8 mmHg during PEEP. LFJVP was 39 microliter/min per kg before PEEP, decreased transiently during PEEP but the steady state value (up to 19 h) was not different from control, and increased transiently after PEEP. LFAP was 37, 80, and 38 microliter/min per kg before, during, and after PEEP, respectively. Long-term PEEP increased LFAP fourfold. Changing the drainage mode during PEEP yielded an immediate increase from LFJVP = 34 to LFAP = 79 microliter/min per kg and an instantaneous reduction from LFAP = 95 to LFJVP = 35 microliter/min per kg. Lymph protein concentration and protein lymph/plasma ratio increased concomitantly with LFAP during PEEP suggesting augmented hepatic contribution to LFAP, augmented intestinal contribution was revealed by labelling intestinal lymph using olive oil orally, muscular lymph flow was not increased as shown by i.m. Evans blue. In conclusion, the augmentation of venous pressure by PEEP promotes capillary filtration but obstructs lymph drainage from the thoracic duct into the jugular vein. PEEP imbalances formation and return of lymph and affects the development and removal of oedema.

Relationship between amniotic fluid volume and maternal plasma volume expansion

Amniotic fluid and maternal plasma volumes were estimated in high-risk obstetric patients suspected of being hypovolemic. Excluding cases of intrinsic maternal or fetal disease, there were good (P less than 0.001) correlations between maternal plasma volume expansion and amniotic fluid volume. In the presence of oligohydramnios, there is usually maternal hypovolemia, and vice versa. Oligohydramnios may often be corrected by vigorous maternal plasma volume expansion, which is sometimes indicated in the treatment of cases of fetal distress. It is presumed that only when maternal plasma volume expansion is normal, is uterine perfusion sufficient to provide amniotic fluid formation in normal amounts. The varying amounts of amniotic fluid seen in normal pregnancies at term probably reflect the varying fetal activities of swallowing and voiding.

Clinical signs of normal plasma volume expansion during pregnancy

A majority of cases of pregnancy complications are associated with a relative maternal hypovolemia. The records of 200 pregnant women who had had plasma volume determinations were reviewed in hopes of finding indicators of relative maternal hypovolemia other than the pregnancy complication itself. The signs of relative hypovolemia in pregnant women include those of decreased uterine growth, absence of a maternal systolic flow murmur, and absence of significant dependent ankle edema. Laboratory tests indicative of maternal hypovolemia include failure to develop a decline in maternal hematocrit, serum blood urea nitrogen/creatinine ratio greater than 15, a decreased creatinine clearance, abnormal platelet function, elevated serum glutamic oxaloacetic transaminase, ultrasonic evidence of oligohydramnios and/or decreased maternal heart size, and absence of hypervolemia on chest x-ray film. These findings and tests are only relative indicators of maternal hypovolemia, and it is suggested that, for an accurate defining of pregnant women who are at risk, the actual plasma volume determination has to be performed frequently in the pregnant population.

Hypovolemic pregnant women and their risk determinants

Among hypovolemic pregnant women there is a high risk of premature labor, fetal growth retardation, and/or hypertension. Arterial wave velocity was determined and Evan's blue disappearance rates measured in hypovolemic gravidas with complications. It appeared that those hypovolemic gravidas without increased cardiac performance are more likely to give birth prematurely, while those with increased cardiac performance and delayed in vivo mixing of Evan's blue dye develop hypertension.

Association of neonatal respiratory distress with birth asphyxia and deficiency of red cell mass in premature infants

Red cell mass (RCM) was estimated using 125I-labelled human serum albumin in 128 premature infants born after 26 to 36 weeks gestation. Infants of three different gestational periods (26--29, 30--32, and 33--36 weeks) with respiratory distress (RD) averaged lower one-minute Apgar scores and lower RCM than infants without RD (P less than 0.05). The incidence of RD was significantly (P less than 0.05) higher in infants with Apgar scores below 6 and in infants with RCM of less than 35 ml/kg than in the infants with greater values. The highest incidence of RD and the highest mortality rate were found in the infants with low Apgar scores and low RCM values. Prematures with similar Apgar scores showed a higher incidence of RD when RCM was low, and infants with similar RCM showed a higher incidence of RD when Apgar scores were low. Our results suggest that both birth asphyxia and deficiency of red cell mass interfere with postnatal cardio-respiratory adaptation. In high-risk premature infants, erythrocytes should be transfused when the venous haematocrit is below 0.459

Peripheral circulation in the newborn: interaction of peripheral blood flow, blood pressure, blood volume, and blood viscosity

Peripheral blood flow and systolic blood pressure (strain-gauge plethysmograph), blood volume (Evans blue) and whole blood viscosity (cone-plate viscometer) have been measured in 66 premature and full-term infants 6 to 144h of age. Blood flow and blood volume were moderately decreased in the infants with respiratory distress. Highly significant (P less than 0.001) correlations were found between blood flow and blood volume (r = 0.77), blood pressure and blood volume (r = 0.50), peripheral resistance and blood volume (r = -0.44), blood flow and blood pressure (r = 0.50), blood flow and peripheral resistance (r = -0.67), peripheral resistance and blood viscosity (r = 0.45), and blood viscosity and haematocrit (r = 0.86). There was no correlation between peripheral blood flow and blood viscosity. However, at given blood volume, peripheral blood flow decreased with increasing blood viscosity. These results indicate that in newborn infants peripheral blood flow, blood pressure and peripheral resistance are influenced by blood volume, but also depend on blood viscosity.

Blood volume of children with leukemia

Blood volume was measured using 125iodinated human serum albumin in 27 children with acute lymphoblastic leukemia, and in 7 children with various types of leukemia. Total blood volume was normal in patients without marked enlargement of spleen and liver, and increased progressively as spleen and liver size increased. The hypervolemia was entirely due to expansion of plasma volume. In the children with marked hepatosplenomegaly, only hematocrit (but not red cell mass) was below the normal range in most cases. Both hematocrit and red cell mass were subnormal in the majority of patients without considerably enlarged spleen and liver. Therefore, anemia in children with marked hepatosplenomegaly may be partly caused by hemodilution of red blood cells in expanded plasma volume.

Capillary-venous hematocrit differences in newborn infants. I. Relationship to blood volume, peripheral blood flow, and acid base parameters

Venous and capillary hematocrit, acid base values, and circulatory parameters were measured simultaneously in 92 newborn infants within six hours of birth. Gestational age ranged from 26 to 41 weeks. The capillary/venous hematocrit ratio (Hctc/Hctv) was greater than 1.00 in 89 infants. We found significant inverse correlations between Hctc/Hctv and several parameters, such as pH (r = -0.82), standard bicarbonate (r = -0.73), systolic blood pressure (r = -0.51), and peripheral blood flow (r = -0.70). Most of the infants with a Hctc/Hctv of 1.20 and above had red cell mass values of less than 35 ml/kg. However, blood volume apparently did not influence the Hctc/Hctv. Gestational age appeared to affect Hctc/Hctv only before 30 weeks, when compared with the Hctc/Hctv of term infants. Our results indicate that disturbed circulation, and in particular, disturbed microcirculation is involved in the development of high Hctc/Hctv ratios. We strongly advise that hematocrits obtained by skin prick from a sick newborn infant should not be relied on as they may give misleading information on oxygen carrying capacity to vital organs.

Estimation and prediction of blood volume in infants and children

Blood volume was studied in 160 infants and children aged from one hour to 14 years. From these data linear and logarithmic regression equations relating blood volume to weight, height and surface area were calculated. Equations utilizing combined weight and logarithmic weight values were found to be the most accurate for predicting blood volume. Therefore, nomograms were constructed for reading blood volume directly from height and weight.