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PubMed2004

Capillary leakage in cardiac surgery with cardiopulmonary bypass.

Cardiopulmonary bypass causes a systemic inflammatory response, which can lead to capillary leak syndrome. In 15 adults undergoing elective cardiac surgery with cardiopulmonary bypass, we determined the volume and peak time of capillary leakage from the measurements of extracellular fluid volume and circulating blood volume taken preoperatively, at various intervals up to 24 hours after surgery, and on the 7th postoperative day. Extracellular fluid volume rose from 15.5 +/- 2.7 L preoperatively to a peak 4 hours after surgery of 18.3 +/- 3.2 L and remained elevated at 24 hours. Circulating blood volume fell from 4.10 +/- 0.68 L preoperatively to 3.20 +/- 0.58 L at the end of surgery. Fluid administered intraoperatively did not raise the circulating blood volume. Intraoperative fluid balance was positive at 2.62 +/- 0.72 L but negative at all time points postoperatively. There was significant postoperative capillary leakage, increasing from 4.7% +/- 2.3% of body weight at the end of surgery to a peak 4 hours later of 5.4% +/- 2.0% and falling to 2.8% +/- 3.3% at 24 hours. This knowledge of the pattern of change in capillary leakage after cardiac surgery with cardiopulmonary bypass might serve as a valuable guide for postoperative management.

Adult↗
PubMed2006

The hyponatramia of multiple myeloma is true and not pseudohyponatramia.

The hyponatremia found in multiple myeloma and which is associated with a reduced anion gap (ag) is considered to be pseudohyponatremia due to the displacement of water by the high globulin content in the blood. Serum proteins participate in acid-base balance. Stewart and other authors in their approach to acid-base interpretation acknowledge electrical neutrality as a fundamental characteristic of body fluids. Furthermore, they have shown that both the strong ion difference (SID) and protein, specifically, negatively-charged albumin affect hydrogen ion concentration (H(+)) in the body--i.e., for example an increase in SID leads to a decrease in H(+) and a decrease in albumin leads to a similar effect. The M proteins of multiple myeloma are positively charged. As a result they cause a decrease in sodium levels and the anion gap and thus a true hyponatremia.

Acid-Base Equilibrium↗
PubMed2006

Supportive care in acute respiratory distress syndrome.

Although the central focus of acute respiratory distress syndrome (ARDS) is the pathology within the lung, ARDS is very much a systemic disease. As such, the whole body needs care and support while the disease process within the lung runs its course. The issues of pain management, sedation, fluid balance, nutrition, metabolic and hormonal processes, infection control, and patient positioning are important for any patient in a critical care setting. For patients with ARDS, the required ventilatory support and ARDS-associated systemic inflammation mandate the above supportive measures.

Procedural Sedation↗
PubMed1996

Cardiovascular adaptation to spaceflight.

This article reviews recent flight and ground-based studies of cardiovascular adaptation to spaceflight. Prominent features of microgravity exposure include loss of gravitational pressures, relatively low venous pressures, headward fluid shifts, plasma volume loss, and postflight orthostatic intolerance and reduced exercise capacity. Many of these short-term responses to microgravity extend themselves during long-duration microgravity exposure and may be explained by altered pressures (blood and tissue) and fluid balance in local tissues nourished by the cardiovascular system. In this regard, it is particularly noteworthy that tissues of the lower body (e.g., foot) are well adapted to local hypertension on Earth, whereas tissues of the upper body (e.g., head) are not as well adapted to increase in local blood pressure. For these and other reasons, countermeasures for long-duration flight should include reestablishment of higher, Earth-like blood pressures in the lower body.

Adaptation, Physiological↗
PubMed2000

Syndrome of inappropriate antidiuretic hormone secretion: recognition and management.

Older persons are at greater risk for developing hyponatremia. Renal system changes which occur with aging cause alterations in the functional balance of fluid and electrolytes, and sodium regulation is not as effective. In one form of hyponatremia seen among the elderly, total body sodium content is normal, but water is retained because of increased antidiuretic hormone (ADH) secretion. This condition, called the syndrome of inappropriate antidiuretic hormone secretion (SIADH), has many causes including chronic illnesses and various medications. The physiology behind SIADH, its causes, diagnostics, and various treatment modalities are explored.

Age Factors↗
PubMed1983

Modern quantitative acid-base chemistry.

Quantitative analysis of ionic solutions in terms of physical and chemical principles has been effectively prohibited in the past by the overwhelming amount of calculation it required, but computers have suddenly eliminated that prohibition. The result is an approach to acid-base which revolutionizes our ability to understand, predict, and control what happens to hydrogen ions in living systems. This review outlines that approach and suggests some of its most useful implications. Quantitative understanding requires distinctions between independent variables (in body fluids: pCO2, net strong ion charge, and total weak acid, usually protein), and dependent variables [( HCO-3], [HA], [A-], [CO(2-)3], [OH-], and [H+] (or pH]. Dependent variables are determined by independent variables, and can be calculated from the defining equations for the specific system. Hydrogen ion movements between solutions can not affect hydrogen ion concentration; only changes in independent variables can. Many current models for ion movements through membranes will require modification on the basis of this quantitative analysis. Whole body acid-base balance can be understood quantitatively in terms of the three independent variables and their physiological regulation by the lungs, kidneys, gut, and liver. Quantitative analysis also shows that body fluids interact mainly by strong ion movements through the membranes separating them.

Acid-Base Equilibrium↗
PubMed2007

Nitrogen balance, protein loss, and the open abdomen.

OBJECTIVE: Goal-directed nutritional support is essential to improving morbidity and mortality. Open abdominal decompression is similarly crucial to the successful treatment of intra-abdominal hypertension and abdominal compartment syndrome. The open abdomen, however, places the patient at risk for potentially significant fluid, electrolyte, and presumably protein losses from the exposed viscera. Although nutritional protein assessments are frequently utilized to measure urinary nitrogen, these calculations do not consider the loss of protein from the open abdomen. We hypothesize that accurate assessment of nitrogen balance in the patient requiring an open abdomen must include either a measurement or estimation of abdominal fluid nitrogen loss. DESIGN: Prospective, observational cohort study. SETTING: Adult surgical/trauma intensive care unit of a level I trauma center. PATIENTS: Surgical/trauma patients requiring laparotomy. INTERVENTIONS: Serial 24-hr collections of urine and abdominal fluid protein were performed to characterize abdominal fluid protein loss and evaluate the clinical effect of accounting for abdominal fluid nitrogen as part of nitrogen balance calculations. MEASUREMENTS AND MAIN RESULTS: Nitrogen intake correlates with urinary nitrogen loss but not with abdominal fluid nitrogen loss. Abdominal fluid nitrogen loss is significant and remains relatively stable in the early postoperative period. Nutritional calculations that fail to account for abdominal fluid nitrogen loss significantly overestimate actual nitrogen balance by an average of 3.5 g/24 hrs. CONCLUSIONS: The open abdomen represents a significant source of protein/nitrogen loss in the critically ill. Failure to account for this loss in nutritional calculations may lead to underfeeding and inadequate nutritional support with a direct effect on patient outcome. Although direct measurement of abdominal fluid protein loss may be optimal, an estimate of 2 g of nitrogen per liter of abdominal fluid output should be included in the nitrogen balance calculations of any patient with an open abdomen.

Abdominal Cavity↗
PubMed1976

Metabolic consequences of glucose-insulin-potassium infusion in treatment of acute myocardial infarction.

Eighteen patients treated with glucose-insulin-potassium infusion for anaerobic support of acutely ischemic myocardial tissue were studied to ascertain the metabolic consequences of this therapy, for acute myocardial infarction. Twelve patients with acute myocardial infarction were treated in a conventional manner and served as control subjects. The glucose-insulin-potassium solution was composed of 300 g of glucose, 50 units of regular insulin and 80 mEq of potassium ion per liter, and was infused at a rate of 1.5 ml/kg per hour through the right atrial port of an indwelling Swan-Ganz thermodilution catheter. Serial measurements of serum electrolytes, cardiac and hepatic enzymes, glucose and osmolality were obtained every 4 to 6 hours for 4 days. Twenty-four urinary volume and potassium levels were measured daily. Pulmonary arterial end-diastolic pressure was measured hourly and the cardiac index daily for the duration of the study. Serum potassium increased to 5 mEq/liter during the infusion and to more than 6 mEq/liter after infusion in 28 percent of patients. No recognizable complications or arrhythmias accompanied this transient hyperkalemia. Potassium balance studies revealed a net total body potassium ion gain of 120 MEq during the study. The second most frequent finding was an elevation of serum glucose (mean 175 mg/100 ml); in all instances this was controlled with supplemental administration of insulin. The serum osmolality and fluid balance remained normal in all patients during the study. Serum glutamic oxaloacetic transaminase (SGOT) and fraction 5 of lactic dehydrogenase (LDH) were increased in 34 percent of the patients during the last 12 to 18 hours of the glucose-insulin-potassium infusion. Characterization of these enzymes suggested a hepatic origin for these changes. This study suggests that glucose-insulin-potassium infusion is a relatively safe procedure in which postinfusion hyperkalemia is the most serious potential complication.

Aspartate Aminotransferases↗
PubMed1996

Behavioural, autonomic and endocrine responses associated with C-fos expression in the forebrain and brainstem after intracerebroventricular infusions of endothelins.

Endothelins are a range of peptides (endothelin-1, endothelin-2, and endothelin-3) well known to act peripherally as powerful cardiovascular-regulating agents. Recently, they have been shown to be localized in CSN, where they may act as central neurotransmitters. A variety of putative roles has been ascribed to them in the CNS. To identify those regions of the brain capable of responding to these peptides, the expression of c-fos (an immediate-early gene), has been used to map patterns of activation following intracerebroventricular (i.c.v.) infusions of endothelins in Lister-hooded rats. This has been correlated with changes in heart rate, core temperature and plasma corticosterone levels. Endothelin-3 i.c.v. (50 pmol) decreased both heart rate and core temperature (both recorded by telemetry). This effect lasted for about 30-45 min. Endothelin-1 (10 pmol) or endothelin-3 (50 pmol) i.c.v. induced c-fos expression in the specific regions in the forebrain and brainstem. Strong expression was found in the septum, bed nucleus of the stria terminalis, parvicellular paraventricular nucleus, the central nucleus of the amygdala, dorsal motor nucleus of the vagus and solitary nucleus. There was less marked c-fos expression in other areas of the basal forebrain, such as the organum vasculosum of the lamina terminals, median preoptic nucleus, supraoptic nucleus and the magnocellular. There are two classes of endothelin receptor (A and B). An endothelin-A receptor antagonist, BQ-123, abolished c-fos expression in all structures in the forebrain and brainstem following endothelin-1 infusions. However, an endothelin-B agonist (TetraAla endothelin-1) did not induce discernible c-fos expression in the forebrain or brainstem. These results suggest that the endothelin-A receptor is responsible for endothelin-dependent c-fos induction in the brain. Interactions between endothelins and angiotensin II were also studied. The pattern of c-fos induced by endothelin-3 and angiotensin II was different (particularly in the anteroventral region of the third ventricle). Furthermore, prior infusions of endothelin-3 interfered with the expression of c-fos induced by subsequent angiotensin II, and also suppressed the latter's dipsogenic effect. These results show that endothelin-3 and angiotensin II interact at both behavioural and cellular levels, and that endothelins may play significant roles in the central control of fluid balance and autonomic activity.

Angiotensin II↗
PubMed1992

A target weight procedure for disordered water balance in long-term care facilities.

1. Water intoxication is a severe complication of disordered water balance. Hyponatremia precedes water intoxication and can be identified through abnormal diurnal weight variation. 2. The St. Louis Target Weight Procedure (STWP) is a nonintrusive method that includes a client's baseline weight, frequent weights throughout the day, a target weight of 5% above the baseline weight, and restricted fluids if the target weight is exceeded. 3. The STWP was positively related to an increase in urine concentration; thus it is successful in restoring normal fluid balance.

Adult↗
PubMed2002

Body composition in patients with an ileostomy and inflammatory bowel disease: validation of bio-electric impedance spectroscopy (BIS).

OBJECTIVE: To validate bio-electric impedance spectroscopy (BIS) by comparison with other methods for determination of body water compartments in stable subjects with an ileostomy and no or minor small bowel resection for inflammatory bowel disease (IBD). SUBJECTS: Twenty-one subjects were included, age range 36-65 y (female/male=12/9), Crohn's disease (CD), n=14, ulcerative colitis (UC), n=6 and indeterminate colitis (IDC), n=1. METHODS: Fluid compartments were assessed by the use of three independent methods: BIS, dual-energy X-ray absorptiometry (DXA) and dilution techniques (DIL); tritiated water (total body water, TBW); and bromide (extracellular water, ECW), respectively. Intra-cellular water (ICW) was calculated as TBW-ECW. For comparison TBW was also predicted according to an empirical formula. Differences were analysed using Bland-Altman plots. RESULTS: The mean TBW values obtained from the impedance measurement differed in the order of -2.21 (DIL) to 1.41 (DXA) in women and -2.01 (DIL) to 2.61 (DXA) in men, from the measured and derived values of total body water. Prediction of TBW gave values that were close to BIS, with a mean difference of -0.31 in male subjects and +0.51 in female subjects. Assessment of ECW revealed that the mean difference between dilution and impedance was less in women than in men (P<0.01). CONCLUSION: The differences between all methods to assess fluid compartments are pronounced. To further investigate the use of the method in clinical practice for dynamic monitoring of rehydration in ileostomates with acute diarrhoea, repeated measurements together with comparison with weight fluid-balance charts are suggested. SPONSORSHIP: The study was supported by grants from the Swedish Medical Research Council (17X-03117), Göteborgs Läkarsällskap and IB and A Lundbergs forskningsstiftelse.

Absorptiometry, Photon↗
PubMed2000

Defective fluid and HCO(3)(-) absorption in proximal tubule of neuronal nitric oxide synthase-knockout mice.

Using renal clearance techniques and in situ microperfusion of proximal tubules, we examined the effects of N(G)-monomethyl-L-arginine methyl ester (L-NAME) on fluid and HCO(3)(-) transport in wild-type mice and also investigated proximal tubule transport in neuronal nitric oxide synthase (nNOS)-knockout mice. In wild-type mice, administration of L-NAME (3 mg/kg bolus iv) significantly increased mean blood pressure, urine volume, and urinary Na(+) excretion. L-NAME, given by intravenous bolus and added to the luminal perfusion solution, decreased absorption of fluid (60%) and HCO(3)(-) (49%) in the proximal tubule. In nNOS-knockout mice, the urinary excretion of HCO(3)(-) was significantly higher than in the wild-type mice (3.12 +/- 0.52 vs. 1. 40 +/- 0.33 mM) and the rates of HCO(3)(-) and fluid absorption were 62 and 72% lower, respectively. Both arterial blood HCO(3)(-) concentration (20.7 vs. 25.7 mM) and blood pH (7.27 vs. 7.34) were lower, indicating a significant metabolic acidosis in nNOS-knockout mice. Blood pressure was lower in nNOS-knockout mice (76.2 +/- 4.6 mmHg) than in wild-type control animals (102.9 +/- 8.4 mmHg); however, it increased in response to L-NAME (125.5 +/- 5.07 mmHg). Plasma Na(+) and K(+) were not significantly different from control values. Our data show that a large component of HCO(3)(-) and fluid absorption in the proximal tubule is controlled by nNOS. Mice without this isozyme are defective in absorption of fluid and HCO(3)(-) in the proximal tubule and develop metabolic acidosis, suggesting that nNOS plays an important role in the regulation of acid-base balance.

Acid-Base Equilibrium↗
PubMed1983

Effects of sequential periods of intracranial hypertension on lung fluid balance.

Pulmonary hemodynamics and fluid and protein exchange were examined in dogs subjected to three successive periods of intracranial hypertension. Results indicate that the alteration in lung fluid balance is due to increased microvascular surface area following capillary recruitment. The relationship to the mechanism of neurogenic pulmonary edema is discussed.

Animals↗
PubMed2006

Cytokine signalling in rat pulp interstitial fluid and transcapillary fluid exchange during lipopolysaccharide-induced acute inflammation.

The dental pulp consists of loose connective tissue encased in rigid dentinal walls. Because of its topography the tissue has low interstitial compliance and limited capacity to expand during fluid volume changes. Due to limitations regarding access to interstitial fluid, basic knowledge on transcapillary fluid transport parameters is lacking for this organ. The scope of this project was dual: first we aimed at establishing a method for isolation of pulp interstitial fluid (IF), and second we applied the method in rats subjected to lipopolysaccharide (LPS)-induced endotoxaemia. The aim was to measure colloid osmotic pressure (COP) and pro-inflammatory cytokines in the pulp IF during acute inflammation. Fluid volumes and pulpal blood flow (PBF) were measured to obtain more information about microcirculatory changes that take place in this pulpitis model. By centrifugation of incisor pulp at 239 g we were able to extract fluid representative for IF. Pulp IF had a relative high control COP (approximately 83% of plasma COP) and was similar to plasma COP 3 h after LPS challenge. The pulp exhibited a high content of IF (0.60 +/- 0.03 ml (g wet weight)(-1)) and a vascular volume of 0.03 +/- 0.01 ml (g w.w.)(-1) No differences were observed in the distribution of fluid volumes after 1.5 and 3 h LPS exposure. PBF and systemic blood pressure dropped significantly after LPS administration. PBF remained low whereas systemic blood pressure was re-established during the 3-h period, implying organ dysfunction. There was a differential pattern of cytokine expression in pulp IF and serum with cytokines such as IL-1alpha, IL-1beta and TNF-alpha locally produced, whereas others such as IFN-gamma and IL-6 were produced systemically and probably spilled over to the pulp IF after LPS exposure. Our findings show that pulp IF can be isolated by centrifugation and that this method is useful when studying fluid balance and extracellular signalling mechanisms in the dental pulp in normal and pathological conditions.

Acute Disease↗