Acute kidney injury is common, parallels organ dysfunction or failure, and carries appreciable mortality in patients with major burns: a prospective exploratory cohort study.

INTRODUCTION: The purpose of this study was to determine the incidence, time course, and outcome of acute kidney injury after major burns and to evaluate the impact of possible predisposing factors (age, gender, and depth and extent of injury) and the relation to other dysfunctioning organs and sepsis. METHOD: We performed an explorative cohort study on patients with a TBSA% (percentage burned of total body surface area) of 20% or more who were admitted to a national burn centre. Acute kidney injury was classified according to the international consensus classification of RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease). Prospectively collected clinical and laboratory data were used for assessing organ dysfunction, systemic inflammatory response, and sepsis. RESULTS: The incidence of acute kidney injury among major burns was 0.11 per 100,000 people per year. Of 127 patients, 31 (24%) developed acute kidney injury (12% Risk, 8% Injury, and 5% Failure). Mean age was 40.6 years (95% confidence interval [CI] 36.7 to 44.5), TBSA% was 38.6% (95% CI 35.5% to 41.6%), and 25% were women. Mortality was 14% and increased with increasing RIFLE class (7% normal, 13% Risk, 40% Injury, and 83% Failure). Renal dysfunction occurred within 7 days in 55% of the patients and recovered among all survivors. Age, TBSA%, and extent of full thickness burns were higher among the patients who developed acute kidney injury. Pulmonary dysfunction and systemic inflammatory response syndrome were present in all of the patients with acute kidney injury and developed before the acute kidney injury. Sepsis was a possible aggravating factor in acute kidney injury in 48%. Extensive deep burns (25% or more full thickness burn) increased the risk for developing acute kidney injury early (risk ratio 2.25). CONCLUSIONS: Acute kidney injury is common, develops soon after the burn, and parallels other dysfunctioning organs. Although acute kidney injury recovered in all survivors, in higher acute kidney injury groups, together with cardiovascular dysfunction, it correlated with mortality.

Cardiac dysfunction after burns.

OBJECTIVES: Using transoesophageal echocardiography (TEE) we investigated the occurrence, and the association of possible abnormalities of motion of the regional wall of the heart (WMA) or diastolic dysfunction with raised troponin concentrations, or both during fluid resuscitation in patients with severe burns. PATIENTS AND METHODS: Ten consecutive adults (aged 36-89 years, two women) with burns exceeding 20% total burned body surface area who needed mechanical ventilation were studied. Their mean Baux index was 92.7, and they were resuscitated according to the Parkland formula. Thirty series of TEE examinations and simultaneous laboratory tests for myocyte damage were done 12, 24, and 36h after the burn. RESULTS: Half (n=5) the patients had varying grades of leakage of the marker that correlated with changeable WMA at 12, 24 and 36h after the burn (p< or =0.001, 0.044 and 0.02, respectively). No patient had WMA and normal concentrations of biomarkers or vice versa. The mitral deceleration time was short, but left ventricular filling velocity increased together with stroke volume. CONCLUSION: Acute myocardial damage recorded by both echocardiography and leakage of troponin was common, and there was a close correlation between them. This is true also when global systolic function is not deteriorated. The mitral flow Doppler pattern suggested restrictive left ventricular diastolic function.

Human cardiovascular dose-response to supplemental oxygen.

AIM: The aim of the study was to examine the central and peripheral cardiovascular adaptation and its coupling during increasing levels of hyperoxaemia. We hypothesized a dose-related effect of hyperoxaemia on left ventricular performance and the vascular properties of the arterial tree. METHODS: Oscillometrically calibrated arterial subclavian pulse trace data were combined with echocardiographic recordings to obtain non-invasive estimates of left ventricular volumes, aortic root pressure and flow data. For complementary vascular parameters and control purposes whole-body impedance cardiography was applied. In nine (seven males) supine, resting healthy volunteers, aged 23-48 years, data was collected after 15 min of air breathing and at increasing transcutaneous oxygen tensions (20, 40 and 60 kPa), accomplished by a two group, random order and blinded hyperoxemic protocol. RESULTS: Left ventricular stroke volume [86 +/- 13 to 75 +/- 9 mL (mean +/- SD)] and end-diastolic area (19.3 +/- 4.4 to 16.8 +/- 4.3 cm(2)) declined (P < 0.05), and showed a linear, negative dose-response relationship to increasing arterial oxygen levels in a regression model. Peripheral resistance and characteristic impedance increased in a similar manner. Heart rate, left ventricular fractional area change, end-systolic area, mean arterial pressure, arterial compliance or carbon dioxide levels did not change. CONCLUSION: There is a linear dose-response relationship between arterial oxygen and cardiovascular parameters when the systemic oxygen tension increases above normal. A direct effect of supplemental oxygen on the vessels may therefore not be excluded. Proximal aortic and peripheral resistance increases from hyperoxaemia, but a decrease of venous return implies extra cardiac blood-pooling and compensatory relaxation of the capacitance vessels.

Inhalation injury assessed by score does not contribute to the development of acute respiratory distress syndrome in burn victims.

OBJECTIVE: To establish the incidence, mortality, and time of onset of acute respiratory distress syndrome (ARDS) in relation to extent of burn and inhalation injury in patients who required mechanical ventilation. DESIGN: Data about burn and inhalation injury were recorded prospectively whereas ARDS and multiple organ dysfunction were assessed by review of patient charts. SETTING: National burn intensive care unit at Linkoping University Hospital, Sweden (a tertiary referral hospital). PATIENTS: Between 1993 and 1999, we studied all patients with thermal injury (n=553) who required mechanical ventilation for more than two days (n=91). MEASUREMENTS AND RESULTS: Out of the thirty-six burn victims who developed ARDS (40%), 25 (70%) did so early post burn (in less than 6 days). Patients with ARDS had higher multiple organ dysfunction scores (mean 10.5) than those who did not develop ARDS (mean 5.6) (p<0.01). The probable presence of inhalation injury as assessed by an inhalation lung injury score (ILIS) did not contribute to the development of ARDS. Mortality tended to be higher in patients who developed ARDS (14%) compared to those who did not (6%, p=0.2). CONCLUSIONS: In our burn patients the incidence of ARDS was high whereas mortality was low. We found no association between inhalation injury as assessed using the ILIS and development of ARDS. Our data support a multi-factorial origin of ARDS in burn victims as a part of a multiple organ failure event.

Acute hyperoxaemia-induced effects on regional blood flow, oxygen consumption and central circulation in man.

AIM: Despite numerous in vitro and animal studies, circulatory effects and mechanisms responsible for the vasoconstriction seen during hyperoxaemia are yet to be ascertained. The present study set out to: (i) set up a non-invasive human model for the study of hyperoxia-induced cardiovascular effects, (ii) describe the dynamics of this effect and (iii) determine whether hyperoxaemia also, by vasoconstriction alters oxygen consumption (O(2)). METHODS: The study comprised four experiments (A, B, C and D) on healthy volunteers examined before, during and after 100% oxygen breathing. A: Blood flow (mL min(-1).100 mL(-1) tissue), venous occlusion plethysmography was assessed (n = 12). B: Blood flow was recorded with increasing transcutaneous oxygen tension (P(tc)O(2)) levels (dose-response) (n = 8). C: Heart rate (HR), stroke volume, cardiac output (CO) and systemic vascular resistance (SVR) was assessed using echocardiography (n = 8). D: O(2) was measured using an open circuit technique when breathing an air-O(2) mix (fraction of inhaled oxygen: F(i)O(2) = 0.58) (n = 8). RESULTS: Calf blood flow decreased 30% during O(2) breathing. The decrease in calf blood flow was found to be oxygen dose dependent. A similar magnitude, as for the peripheral circulation, of the effect on central parameters (HR/CO and SVR) and in the time relationship was noted. Hyperoxia did not change O(2). An average of 207 (93) mL O(2) per subject was washed in during the experiments. CONCLUSION: This model appears suitable for the investigation of O(2)-related effects on the central and peripheral circulation in man. Our findings, based on a more comprehensive (central/peripheral circulation examination) evaluation than earlier made, suggest significant circulatory effects of hyperoxia. Further studies are warranted to elucidate the underlying mechanisms.

Computed tomography--a possible aid in the diagnosis of smoke inhalation injury?

Inhalation injury is an important contributor to morbidity and mortality in burn victims and can trigger acute lung injury and acute respiratory distress syndrome (ARDS) (1-3). Early diagnosis and treatment of inhalation injury are important, but a major problem in planning treatment and evaluating the prognosis has been the lack of consensus about diagnostic criteria (4). Chest radiographs on admission are often non-specific (5, 6), but indicators include indoor fires, facial burns, bronchoscopic findings of soot in the airways, and detection of carbon monoxide or cyanide in the blood (7). Changes in the lungs may be detected by bronchoscopy with biopsy, xenon imaging, or measurement of pulmonary extracellular fluid (4, 5, 8). These methods have, however, been associated with low sensitivity and specificity, as exemplified by the 50% predictive value in the study of Masanes et al. (8). Computed tomographs (CTs) are better than normal chest radiographs in the detection of other pulmonary lesions such as pulmonary contusion (9, 10). The importance of CT scans in patients with ARDS has been reviewed recently (9), but unfortunately there has been no experience of CT in patients with smoke inhalation injury. To our knowledge, there are only two animal studies reporting that smoke inhalation injury can be detected by CT (4, 11); specific changes in human CT scans have not yet been described. Therefore, confronted with a patient with severe respiratory failure after a burn who from the history and physical examination showed the classic risk factors for inhalation injury, we decided to request a CT.

Transesophageal echocardiographic hemodynamic monitoring during preoperative acute normovolemic hemodilution.

BACKGROUND: Preoperative acute normovolemic hemodilution may compromise oxygen transport. The aims of our study were to describe the hemodynamic effects of normovolemic hemodilution and to determine its effect on systolic and diastolic cardiac function by multiplane transesophageal echocardiography. METHODS: In eight anesthetized patients (aged 13-51 yr) without heart disease, hemoglobin was reduced in steps from 123 +/- 8 (mean +/- SD) to 98 +/- 3 and to 79 +/- 5 g/l. Hemodynamic measurements (intravascular pressures, thermodilution cardiac output, and echocardiographic recordings) were obtained during a stabilization period and at each level of hemodilution. Left ventricular wall motion was monitored continuously, and Doppler variables, annular motion, and changes in ejection fractional area were analyzed off-line. RESULTS: During hemodilution, cardiac output by thermodilution increased by 16 +/- 7% and 26 +/- 10%, corresponding well to the increase in cardiac output as measured by Doppler (difference, 0.32 +/- 1.2 l/min). Systemic vascular resistance fell 16 +/- 14% and 23 +/- 9% and pulmonary capillary wedge pressure increased slightly (2 +/- 2 mmHg), whereas other pressures, heart rate, wall motion, and diastolic Doppler variables remained unchanged. Ejection fractional area change increased from 44 +/- 7% to 54 +/- 10% and 60 +/- 9% as a result of reduced end-systolic and increased end-diastolic left ventricular areas. CONCLUSIONS: A reduction in hemoglobin to 80 g/l during acute normovolemic hemodilution does not normally compromise systolic or diastolic myocardial function as determined by transesophageal echocardiography. Preload, left ventricular ejection fraction, and cardiac output increase with a concomitant fall in systemic vascular resistance.

Cerebral venous drainage via the ophthalmic veins in the Sturge-Weber syndrome.

We describe a 23-year-old girl with an extremely uncommon form of cerebral venous drainage and cerebellar leptomeningeal angiomatosis as a possible variant of the Sturge-Weber syndrome. Extensive congenital port-wine stains all over the body, hypoplastic left renal and subclavian and iliac veins, cardiomegaly and ptosis and hypoplasia of the left kidney had been recognised in early childhood. She rapidly developed signs of intracranial hypertension. CT and MRI showed a right medial temporal lesion. Angiography revealed cerebellar pial angiomatosis with enlarged medullary veins and no functioning sigmoid sinuses or jugular veins. Cerebral venous drainage was via enlarged ophthalmic veins. Although the intracranial venous abnormalities were characteristic of the Sturge-Weber syndrome anomalies beyond the encephalofacial territory suggested a more complex developmental abnormality.

[The effect of cadmium poisoning on glucose transformation in skeletal muscles]. / Der Einfluss der Cadmiumintoxikation auf den Glucoseumsatz in Skelettmuskeln.

Long-time effects of Cd on carbohydrate metabolism were investigated in male Wistar rats. A dose of 0.3 mg/kg body weight of Cd in acetate form was subcutaneously injected to the experimental animals twice a week through 3 months. Selected enzyme activities of glycolysis as well as concentrations of glycogen, glucose, pyruvate, lactate, triglycerides, and free fatty acids (FFA) were determined in blood serum, muscles, liver, and fatty tissues. The experimental animals differed from the control group, in that Cd intoxication was followed by decline in the blood serum only of pyruvate kinase and lactate dehydrogenase activities. In the liver, however, all enzyme activities were reduced. Glycogen glucose and FFA levels were increased. Intramuscular alterations were found to depend on the fibre type. The severest disturbance of glycolysis was recordable from red long fibres, whereas rapid white fibres were more resistant. The change in FFA concentration may be interpreted as some compensation for the impairment of carbohydrate metabolism in the energy balance.

[Early and late results after Colonna arthroplasties of the hip-joint (author's transl)]. / Früh- und Spätergebnisse von Operationen nach Colonna

In 10 years the authors have carried out 107 Colonna arthroplasties of the hip-joint. Results could be followed up in 98 patients, of whom 56 were - at the time of operation-less than 5-year-old, 42 holder. Among the early operations results were good and satisfactory in 60 per cent, in the late operations 50 per cent. They found that the quality of the result depended largely on the age of the patient, pre-operative traction and additional osteotomy. They recommend this operation for patients with neglected CDH or for those in whom closed reduction did not succeed and operations after Pemberton or Salter cannot be carried out any more.