Decreased fluid volume to reduce organ damage: a new approach to burn shock resuscitation? A preliminary study.

OBJECTIVE: To evaluate the impact of decreased fluid resuscitation on multiple-organ dysfunction after severe burns. This approach was referred to as "permissive hypovolaemia". METHODS: Two cohorts of patients with burns>20% BSA without associated injuries and admitted to ICU within 6 h from the thermal injury were compared. Patients were matched for both age and burn severity. The multiple-organ dysfunction score (MODS) by Marshall was calculated for 10 days after ICU admission. Permissive hypovolaemia was administered by a haemodynamic-oriented approach throughout the first 24-h period. Haemodynamic variables, arterial blood lactates and net fluid balance were obtained throughout the first 48 h. RESULTS: Twenty-four patients were enrolled: twelve of them received the Parkland Formula while twelve were resuscitated according to the permissive hypovolaemic approach. Permissive hypovolaemia allowed for less volume infusion (3.2+/-0.7 ml/kg/% burn versus 4.6+/-0.3 ml/kg/% burn; P<0.001), a reduced positive fluid balance (+7.5+/-5.4 l/day versus +12+/-4.7 l/day; P<0.05) and significantly lesser MODS Score values (P=0.003) than the Parkland Formula. Both haemodynamic variables and arterial blood lactate levels were comparable between the patient cohorts throughout the resuscitation period. CONCLUSIONS: Permissive hypovolaemia seems safe and well tolerated by burn patients. Moreover, it seems effective in reducing multiple-organ dysfunction as induced by oedema fluid accumulation and inadequate O2 tissue utilization.

Comparison of left ventricular function and volumes during transesophageal atrial pacing combined with two-dimensional echocardiography in patients with syndrome X, atherosclerotic coronary artery disease, and normal subjects.

Nine patients with syndrome X were compared with 2 groups of patients known to have coronary artery disease (CAD) (8 patients who developed regional wall motion abnormalities [group ECHO+] and 6 patients who showed only ST depression at echo-pacing [group ECG+]) and with 6 healthy volunteer control subjects. Left ventricular function at rest was normal in all patients. End-diastolic and end-systolic volumes (ml/m2) and ejection fraction were calculated at baseline and at peak of echo-pacing using a Simpson's biplane method. No regional wall motion abnormalities were observed during the echo-pacing in patients with syndrome X or in the volunteers. End-diastolic volume decreased in patients with syndrome X, in the volunteers (from 47 +/- 11 to 30 +/- 12 and from 72 +/- 7 to 38 +/- 6, respectively, p <0.01 for both), and in ECG+ patients (from 48 +/- 10 to 33 +/- 6, p <0.05), whereas it did not change in ECHO+ patients. End-systolic volume decreased in patients with syndrome X and in the volunteers (from 17 +/- 5 to 11 +/- 4 and from 28 +/- 6 to 16 +/- 4, respectively, p <0.01 for both), whereas it did not change or else slightly increased in patients with CAD (from 18 +/- 10 to 16 +/- 5 for ECG+ patients and from 19 +/- 5 to 24 +/- 9 for ECHO+ patients, p = NS for both), regardless of whether regional wall motion abnormalities appeared. Ejection fraction decreased in ECG+ and ECHO+ patients (from 64 +/- 12 to 52 +/- 11 and from 62 +/- 9 to 44 +/- 13, respectively, p <0.01 for both), whereas it did not change in patients with syndrome X and in the volunteers (from 64 +/- 8 to 61 +/- 8 and from 61 +/- 7 to 58 +/- 7, respectively, p = NS for both). During echo-pacing in syndrome X patients no regional wall motion was detected. Left ventricular volumes and ejection fraction showed the same patterns of variation in these patients as they did in the healthy control subjects, in contrast with those patients with CAD, whether or not regional wall motion abnormalities appeared in the latter.

[Global and regional function in microvascular angina]. / Funzione globale e regionale nell'angina microvascolare.

Because of the existing relation between myocardial blood flow and systolic function, various noninvasive techniques, capable of assessing regional and global left ventricular function, especially two-dimensional echocardiography, have been used in patients with chest pain, ECG evidence of myocardial ischemia and/or reduced coronary flow reserve and angiographically detected normal coronary vessels. The results, however, have been contradictory, while only few of them have reported stress-induced regional or global left ventricular dysfunction combined with ST-segment depression and/or angina. The reason for such discrepancy could be due to a diffuse but patchy distribution of myocardial ischemia, or to a non-ischemic origin of the clinical and instrumental features of this syndrome, relying on the effect of algogenic mediators, as suggested from recent metabolic studies. Even if the most recent theories agree on the functional involvement of the small coronary vessels, many points on microvascular angina remain confused. An agreement on the nosological classification of this syndrome would be welcome, given the high technological cost required for the study of coronary microcirculation.

[The determination of myocardial necrosis in unstable angina by the immunoradiometric measurement of circulating myosin]. / Individuazione della necrosi miocardica nell'angina instabile mediante dosaggio immunoradiometrico della miosina circolante.

Ventricular myosin heavy chains serum levels are a new marker of myocardial necrosis. We have studied plasma levels of myosin in 30 patients with unstable angina, 30 patients with acute myocardial infarction and 25 healthy subjects. The myosin peak level was 317 +/- 101 microU/L in angina patients, 2510 +/- 433 microU/L in infarcted patients and 62.3 +/- 17 microU/L in the controls. In both groups, the increase in serum myosin was more marked in those with larger infarction and in those with more severe angina. These data suggest that the measurement of serum myosin can identify the presence of micronecrosis in patients with unstable angina, according to what has been found using other markers of myocellular necrosis.

[Effect, on renal function, of a product rich in polyunsaturated fatty acids: results obtained in subjects with chronic renal failure caused by nephroangiosclerosis]. / Effetti sulla funzionalita' renale di un prodotto ricco di acidi grassi polinsaturi: risultati ottenuti in soggetti con insufficienza renale cronica da nefroangiosclersoi.

Subjects with renal chronic failure were studied. Four patients were treated with 2,5 mg/Kg of phosphatidylcholine, a drug with an high content of polyunsatured fatty acids. The drug's effects, studied during three successive 30 min. Clearance periods, were the same as in healthy subjects, i.e.: a statistically significant increase of: urine flow, renal blood flow, glomerular filtration rate and sodium excretion. In other 6 patients, administration of i.v. lysine acetylsalicylate (10,5 mg/Kg) caused a decrease of the parameters under study, that were increasing for a previous dose of phosphatidylcholine and made ineffective another administration of this drug. If the thesis is assumed that in normal subjects phenomena may be referred to the local synthesis of PG, then the authors believe that the potential synthesis capacity of these substances is not compromised in chronic renal failure.

[Effect, on renal function, of a product rich in polyunsaturated fatty acids: results obtained in healthy subjects]. / Effetti sulla funzionalita renale di un prodotto ricco di acidi grassi polinsaturi: risultati ottenuti in soggetti sani.

In 7 healthy subjects a 2,5 mg/Kg dose of i.v. phosphatidylcholine a drug with an high content of polyunsaturated fatty acids, caused variations in renal functionality as follows: a statistically significant increase of: urine flow, renal blood flow, glomerular filtration rate and sodium excretion. The above phenomena which resulted in a hypertonic poliuria, were detected during three 30 mins clearance periods. In other 5 subjects, a dose of lysine acetylsalicylate (10,5 mg/Kg) either suppressed the phenomena induced by the previous administration of phosphatidylcholine or prevented them to appear when the drug was given successively. Authors suggest that the data obtained may be ascribed to stimulation of local PG synthesis.

[Endoscopic treatment of obstructive cholangitis]. / La terapia endoscopica della colangite ostruttiva.

A long catheter can be positioned in the bile ducts by means of a fibre glass gastroduodenoscope, thus making it possible to drain bile and inject medicaments locally. This technique gives excellent results and is particularly indicated in cases of choledocic lithiasis complicated by cholangitis in order to clear up the infection and send the patient in for surgery in ideal condition.