Guidelines for the treatment of acidaemia with THAM.

THAM (trometamol; tris-hydroxymethyl aminomethane) is a biologically inert amino alcohol of low toxicity, which buffers carbon dioxide and acids in vitro and in vivo. At 37 degrees C, the pK (the pH at which the weak conjugate acid or base in the solution is 50% ionised) of THAM is 7.8, making it a more effective buffer than bicarbonate in the physiological range of blood pH. THAM is a proton acceptor with a stoichiometric equivalence of titrating 1 proton per molecule. In vivo, THAM supplements the buffering capacity of the blood bicarbonate system, accepting a proton, generating bicarbonate and decreasing the partial pressure of carbon dioxide in arterial blood (paCO2). It rapidly distributes through the extracellular space and slowly penetrates the intracellular space, except for erythrocytes and hepatocytes, and it is excreted by the kidney in its protonated form at a rate that slightly exceeds creatinine clearance. Unlike bicarbonate, which requires an open system for carbon dioxide elimination in order to exert its buffering effect, THAM is effective in a closed or semiclosed system, and maintains its buffering power in the presence of hypothermia. THAM rapidly restores pH and acid-base regulation in acidaemia caused by carbon dioxide retention or metabolic acid accumulation, which have the potential to impair organ function. Tissue irritation and venous thrombosis at the site of administration occurs with THAM base (pH 10.4) administered through a peripheral or umbilical vein: THAM acetate 0.3 mol/L (pH 8.6) is well tolerated, does not cause tissue or venous irritation and is the only formulation available in the US. In large doses, THAM may induce respiratory depression and hypoglycaemia, which will require ventilatory assistance and glucose administration. The initial loading dose of THAM acetate 0.3 mol/L in the treatment of acidaemia may be estimated as follows: THAM (ml of 0.3 mol/L solution) = lean body-weight (kg) x base deficit (mmol/L). The maximum daily dose is 15 mmol/kg for an adult (3.5L of a 0.3 mol/L solution in a 70kg patient). When disturbances result in severe hypercapnic or metabolic acidaemia, which overwhelms the capacity of normal pH homeostatic mechanisms (pH < or = 7.20), the use of THAM within a 'therapeutic window' is an effective therapy. It may restore the pH of the internal milieu, thus permitting the homeostatic mechanisms of acid-base regulation to assume their normal function. In the treatment of respiratory failure, THAM has been used in conjunction with hypothermia and controlled hypercapnia. Other indications are diabetic or renal acidosis, salicylate or barbiturate intoxication, and increased intracranial pressure associated with cerebral trauma. THAM is also used in cardioplegic solutions, during liver transplantation and for chemolysis of renal calculi. THAM administration must follow established guidelines, along with concurrent monitoring of acid-base status (blood gas analysis), ventilation, and plasma electrolytes and glucose.

Basic fibroblast growth factor reduces lactic acid-induced neuronal injury in rat hippocampal neurons.

OBJECTIVE: To evaluate the long-term effects of lactic acidosis and to examine a potential neuroprotective role of basic fibroblast growth factor (bFGF) on hippocampal neurons. DESIGN: Long-term observation in a cell-culture study. SETTING: University research laboratory. SUBJECTS: Adult, differentiated, primary rat hippocampal neurons. INTERVENTIONS: Neurons were exposed to medium acidified with 20 mM lactic acid, pH 6.2, for a 10-min period, and maintained untreated or in the presence of bFGF (500 pg/mL, 1 ng/mL, 10 ng/mL, 20 ng/mL) applied after exposure. MEASUREMENTS AND MAIN RESULTS: Viability was analyzed by a dye inclusion/enzyme activity test and morphology by phase contrast and immunofluorescence microscopy. [3H]Arachidonic acid (AA) release was measured by liquid scintillation spectrometry. All cultures appeared to be unchanged during the first days after exposure to lactic acidosis. Neurodegeneration became apparent within 3 days. Seven days after exposure, cell survival decreased to 60% in lactic acidosis-injured, untreated cultures. Morphologic damage appeared as a 50% reduction in axonal and 25% reduction in dendritic arborizations. AA release increased to four-fold enhanced levels relative to control values. bFGF (1, 20, and 10 ng/ mL) enhanced neuronal viability (p < .05), and 10 ng/mL bFGF induced a maximal increase in live cells to 80% of controls. Axonal arborizations increased to 50% and dendritic arborizations to 75% of controls after 10 ng/mL bFGF (p< .05). bFGF in a dose of 20 ng/ mL enhanced axonal branching to 40% and dendrites in number and branching to 50% of controls (p< .05). bFGF (500 pg/mL, and 1 and 10 ng/mL) decreased enhanced AA (p < .05), and 10 ng/mL bFGF maximally reduced increased AA to two-fold enhanced values relative to controls. CONCLUSIONS: In vulnerable neurons, exposure to moderate lactic acidosis induces a process of cell injury with long latency. bFGF applied postinjury reduces the delayed neurodegeneration and may have neuroprotective efficacy in new therapeutic strategies to ischemia-induced cerebral injury.

Effects of basic fibroblast growth factor on hippocampal neurons after axonal injury.

OBJECTIVE: Axons of adult central nervous system neurons fail to regenerate after diffuse axonal injury in head trauma. Basic fibroblast growth factor (bFGF) has been reported to enhance neuritic extensions after neuronal injury in immature nerve cells. To investigate the effects of bFGF on adult neurons and axonal reoutgrowth, differentiated nerve cells were axonally transected and bFGF was applied. DESIGN: Cell culture study with primary rat hippocampal neurons. MATERIALS AND METHODS: After axotomy, hippocampal cultures were maintained untreated or in the presence of 0.5, 1, 10, or 20 ng/mL bFGF and evaluated over a 7-day period after injury. MEASUREMENTS AND MAIN RESULTS: Seven days after injury, axotomy decreased cell survival to 65%, increased [3H]arachidonic acid release 1.8-fold from prelabeled cells, and showed negligible effects on neuronal dendrites. bFGF reduced this neurodegeneration at all doses applied. bFGF at 10 ng/mL most efficiently increased live cells to 85% and decreased [3H]arachidonic acid release from prelabeled cells to control values (p < 0.01, vs. damaged cells). Furthermore, 10 ng/mL bFGF induced axonal branching and the longest axonal re-extensions from 60 +/- 8 to 377 +/- 10 microns 7 days after injury (p < 0.01, vs. damaged cells). CONCLUSIONS: bFGF increased cell survival and supported axonal re-elongations in adult hippocampal neurons in vitro when applied after axotomy. bFGF may play a role in new therapeutic concepts for the management of axonal injury after head trauma.

Cerebrospinal and plasma amino acid concentrations after administration of i.v. glycyl-glutamine and glycyl-tyrosine containing amino acid solutions in humans.

BACKGROUND: Glycyl-glutamine and glycyl-tyrosine may supply adequate glutamine and tyrosine in amino acid solutions for parenteral nutrition. However, plasma peptides may be transported into the cerebrospinal fluid, exerting effects on the neuronal tissue. Cerebrospinal fluid (CSF) and plasma amino acid concentrations after administration of a glycyl-glutamine/glycyltyrosine supplemented amino acid solution were therefore evaluated in a randomized controlled comparison with a conventional amino acid infusion. METHODS: Dipeptide/amino acid solutions (0.60 mL/h/kg; 82.2 mg total dipeptides/amino acids/h/kg) or conventional amino acid solutions (0.73 mL/h/kg; 83.2 mg total amino acids/h/kg) were infused in 15 patients per group scheduled to undergo spinal anesthesia for urologic surgery over a 12-hour period preoperatively. Plasma amino acids were measured before the infusion was started. CSF and venous concentrations were analyzed simultaneously before the infusion was stopped. CSF samples were drawn through the spinal needle for anesthesia. RESULTS: The dipeptide-containing solution did not increase either dipeptide to detectable levels in the CSF (detection limit < 5.0 nmol/mL). Venous glycyl-glutamine increased from below detection limits up to 308 +/- 111 nmol/mL (p < .05), whereas glycyl-tyrosine could not be found. In the dipeptide group, venous glutamine and tyrosine were higher (p < .05) but only tyrosine appeared in small amounts (p < .05) in the cerebrospinal fluid. CONCLUSIONS: This study provides no evidence to support a CSF entry of IV glycyl-tyrosine and glycyl-glutamine under conditions of a normal blood-brain barrier in the adult (detection limit 5 nmol/mL). The data suggest that amino acid solutions containing these dipeptides may be used in parenteral solutions for nutrition support.