Use of power Doppler ultrasound to monitor renal perfusion during burn shock

Xuebijing injection treatment inhibits vasopermeability and reduces fluid requirements in a canine burn model

OBJECTIVE

High vasopermeability and excessive inflammation following severe burns may result in tissue edema, organ dysfunction and the loss of circulatory plasma volume, which can influence the doctor to do the prognosis to the patients. The study aims to examine whether Xuebijing injection (XBJ), an extracts of a traditional Chinese medicine used to treat sepsis in clinic, can reduces fluid requirements by inhibiting vasopermeability and tissue edema in a canine model after burn injury.

METHODS

Twenty-four beagle dogs were subjected to 50% TBSA burns, and then were randomly allocated to the following three groups: lactated Ringer's resuscitation (LR) group (n = 8), immediate LR containing Xuebijing injection (LR/XBJ) group (n = 8), and operation control group (n = 8). Hemodynamic variables and net fluid accumulation were measured. Blood samples were collected for measurement of hematocrit and circulatory plasma volume (PV). At 24 h after burn injury, heart, lung, small intestine and kidney were harvested for evaluation of the activities of myeloperoxidase (MPO) and neutrophil elastase (NE), vasopermeability, tissue water content and the amount of neutrophil infiltration.

RESULTS

XBJ treatment significantly reduced net fluid accumulation, and pulmonary vascular permeability index (PVPI), extravascular lung water index (ELWI), and water content of heart, small intestine, kidney and lung compared with LR group. Furthermore, XBJ infusion significantly reduced tissue activities of MPO and NE compared with LR group. The amount of neutrophil infiltration in LR/XBJ group was lower than that in LR group.

CONCLUSIONS

These results indicate that XBJ injection can reduce fluid requirements by inhibition of neutrophil protease-induced high vasopermeability and tissue edema.

Progress of clinical practice on the management of burn-associated pain: Lessons from animal models

Opioid-based analgesics provide the mainstay for attenuating burn pain, but they have a myriad of side effects including respiratory depression, nausea, impaired gastrointestinal motility, sedation, dependence, physiologic tolerance, and opioid-induced hyperalgesia. To test and develop novel analgesics, validated burn-relevant animal models of pain are indispensable. Herein we review such animal models, which are mostly limited to rodent models of burn-induced, inflammatory, and neuropathic pain. The latter two are pain syndromes that provide insight into the pain caused by systemic pro-inflammatory cytokines and direct injury to nerves (e.g., after severe burn), respectively. To date, no single animal model optimally mimics the complex pathophysiology and pain that a human burn patient experiences. No currently available burn-pain model examines effects of pharmacological intervention on wound healing. As cornerstones of pain and wound healing, pro-inflammatory mediators may be utilized for insight into both processes. Moreover, common clinical concerns such as systemic inflammatory response syndrome and multiple organ dysfunction remain unaddressed. For development of analgesics, these aberrations can significantly alter the potential efficacy and/or adverse effects of a prescribed analgesic following burn trauma. We therefore suggest that a multi-model strategy would be the most clinically relevant when evaluating novel analgesics for use in burn patients.

Donation after cardiac death in non-survivable burns

Major burns have previously been considered a contraindication to solid organ donation. We present two cases of successful organ donation and transplantation, after Maastricht category III cardiac death in adult patients with non-survivable burns injury. The implications of the outcome of these cases are that major burns should not be considered a contraindication to organ donation, and that cardiac death provides opportunity for patients with non-survivable burns to contribute to the pool of potential organ donors.

A preclinical study to explore vasculature differences between primary and recurrent tumors using ultrasound Doppler imaging

The purpose of this preclinical study was to perform a longitudinal investigation of the function and morphology of the vasculatures of primary and recurrent tumors, because recurrent tumors have lower curability. Thus, elucidating differences in the features of the vasculatures of primary and recurrent tumors could help to improve tumor therapies. The transgenic adenocarcinoma of the mouse prostate tumors were transplanted in nonirradiated and with 25 Gy of preirradiation normal tissues to produce the primary and recurrent tumor models, respectively. The perfusion and branching index of tumor vasculatures were characterized to reveal the function and morphology information, respectively. The blood vessels were more dilated and continuous in recurrent tumors than in primary tumors. During tumor progression, the perfusion increased in primary tumors but did not change significantly in recurrent tumors. The tumor perfusion was lower in recurrent tumors than in primary tumors, whereas branching index in 2-D ultrasound images did not differ between the two tumor models. Furthermore, the introducing 3-D volumetric power Doppler image may have the potential for accurately revealing the morphologic features within tumors. The results of this study suggest that power Doppler imaging is an easily applied and rapid method for noninvasively assessing the vascular features of primary and recurrent tumors and for exploring differences between their vasculature pathways.

Ulinastatin suppresses burn-induced lipid peroxidation and reduces fluid requirements in a Swine model

Objective. Lipid peroxidation plays a critical role in burn-induced plasma leakage, and ulinastatin has been reported to reduce lipid peroxidation in various models. This study aims to examine whether ulinastatin reduces fluid requirements through inhibition of lipid peroxidation in a swine burn model. Methods. Forty miniature swine were subjected to 40% TBSA burns and were randomly allocated to the following four groups: immediate lactated Ringer's resuscitation (ILR), immediate LR containing ulinastatin (ILR/ULI), delayed LR resuscitation (DLR), and delayed LR containing ulinastatin (DLR/ULI). Hemodynamic variables, net fluid accumulation, and plasma thiobarbituric acid reactive substances (TBARS) concentrations were measured. Heart, liver, lung, skeletal muscle, and ileum were harvested at 48 hours after burn for evaluation of TBARS concentrations, activities of antioxidant enzymes, and tissue water content. Results. Ulinastatin significantly reduced pulmonary vascular permeability index (PVPI) and extravascular lung water index (ELWI), net fluid accumulation, and water content of heart, lung, and ileum in both immediate or delayed resuscitation groups. Furthermore, ulinastatin infusion significantly reduced plasma and tissue concentrations of TBARS in both immediate or delayed resuscitation groups. Conclusions. These results indicate that ulinastatin can reduce fluid requirements through inhibition of lipid peroxidation.

Effects of fluid resuscitation methods on the pro- and anti-inflammatory cytokines and expression of adhesion molecules after burn injury

Fluid resuscitation management can influence inflammatory response after burn injury. The aim of this study was to analyze the effects of two fluid resuscitation methods on the cytokine production and on the expression of the leukocyte surface markers. Thirty patients were included in this prospective randomized study with burn injury affecting more than 20% of the body surface area. Fluid resuscitation was guided by hourly urine output (HUO, n = 15) or by intrathoracic blood volume index (ITBVI, n = 15). Blood samples were taken on admission and on the next five consecutive mornings. Concentrations of interleukin (IL)-1beta, IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor-alpha were measured in phorbol myristate acetate-stimulated and -nonstimulated samples. Leukocyte surface marker expressions (CD11a, CD11b, CD14, CD18, CD49d, and CD97) were also determined. In the ITBVI group, IL-6 levels on days 2 to 3 and IL-6/IL-10 ratios on days 2 to 3, and the IL-8/IL-10 ratios on days 3 to 5 were significantly higher than those in HUO group (P < .05). In the HUO group, IL-10 levels were significantly higher (P < .05) on days 4 and 5. Granulocyte CD11a levels on day 2, CD11b levels on days 4 to 6, lymphocyte CD11a on days 5 to 6, CD11b on days 3 to 6, CD49d on days 2 to 6, CD97 on day 6, monocyte CD11a, CD11b, CD18 levels on days 4 to 6, and CD14 levels on days 3 to 5 were significantly higher in the HUO group (P < .05). Our study suggests that ITBVI-guided fluid resuscitation of burned patients suppresses the shift toward anti-inflammatory imbalance and the expression of leukocyte surface markers more than HUO-guided resuscitation.

Fluid Resuscitation in Burns: An Update

Fluid resuscitation has been a mainstay in the treatment of major burns for over 50 years. Fluids must be commenced as soon as possible prior to transfer to a specialist unit in order to minimise burn wound conversion and reduce the incidences of burn shock, post-burn renal failure, life-threatening electrolyte disturbances and mortality. Due to the lack of robust evidence, uncertainty exists regarding the type of fluid, the rate of fluid administration and method of monitoring fluid resuscitation in these patients. The advances in our understanding of burn pathology and technology may have rendered fluid resuscitation formulae, such as the Parkland, obsolete. This review aims to provide an up-to-date summary on the controversies and advances in burns fluid resuscitation to aid the emergency practitioner to make informed decisions.

Burn resuscitation

Current guidelines outlining the resuscitation of severely burned patients, in the United States, were developed over 30 years ago. Unfortunately, clinical burn resuscitation has not advanced significantly since that time despite ongoing research efforts. Many formulas exist and have been developed with the intention of providing appropriate, more precise fluid resuscitation with decreased morbidity as compared to the current standards, such as the Parkland and modified Brooke formulas. The aim of this review was to outline the evolution of burn resuscitation, while closely analyzing current worldwide guidelines, adjuncts to resuscitation, as well as addressing future goals.

Advances in burn care

PURPOSE OF REVIEW

This article reviews and critiques new developments in the critical care of burn patients.

RECENT FINDINGS

The practice of restrictive transfusion is slowly gaining traction. Abdominal compartment syndrome is associated with resuscitation volumes of 300 ml/kg per 24 h, and percutaneous decompression may be a treatment option. Adrenal insufficiency is common, but whom and when to treat are unclear. Imaging or noninvasive monitoring may confirm renal perfusion before urine output, and the concept of permissive hypovolemia should be explored. There is progress in the laboratory in smoke inhalation and myocardial depression, but no human translation. Antibiotic pharmacokinetics in large burns are unpredictable, and so aminoglycosides (measurable concentrations) are not obsolete. Selective digestive decontamination remains controversial. Nutritional predictions by formula are inaccurate. Oxandrolone is safe and effective in promoting anabolism in large burns. Deep venous thrombosis prophylaxis remains guided only by expert opinion. Females fare worse than male patients after burns.

SUMMARY

The application of the scientific method to burn care is improving slowly. Randomized controlled trials are becoming more common. There is a need for translation of excellent animal work to the human arena.