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While the mechanism remains unclear, a growing body of experimental and clinical evidence suggests that aggressive crystalloid resuscitation in near fatal uncontrolled hemorrhage is associated with poor outcome. Limited attempts to restore blood pressure improve cardiac output, tissue perfusion, and survival while attempts to restore normal tension with crystalloid result in increased hemorrhage volume and higher mortality. The current standard of therapy for treatment of hemorrhagic shock includes initial aggressive crystalloid resuscitation. This mini-review summarizes some of the experimental and clinical data suggesting that this approach may not be desirable in the presence of uncontrolled hemorrhage following injury.

The efficacy of interferon gamma therapy in reducing infection and improving outcome from infection in patients sustaining major injury was examined.Randomized double-blind placebo control trialNine level one university affiliated trauma centers in the United States.Four hundred sixteen patients with injury severity score (ISS)or = 25 or ISSor = 20 with evidence of wound contamination.Recombinant human interferon gamma 100 ug or placebo was given subcutaneously daily for up to 21 days in addition to standard antibiotic therapy.Comparable rates of major and minor infections were observed. Among the patients treated with interferon gamma there were fewer deaths related to major infection regardless of type [7-(3%) vs 18-(9%)]. The results, however, were dominated by one center which had the highest enrollment, infection and death rates.Further studies are warranted to investigate the role of interferon gamma therapy in improving outcome with major infection.

The role of isolated blood transfusion as a means toward improving oxygen transport was evaluated in 19 critically ill patients having sepsis syndrome as defined by standard criteria. ICU therapies were unchanged during transfusion and hemodynamic profiles with serum lactate levels were obtained before and after packed red blood cells were given. Blood transfusions in these patients did not cause a change in hemodynamic status. Arterial lactate determination was normal before and after transfusion was administered. Oxygen uptake failed to increase with transfusion, corresponding to increased arterial and mixed venous oxygen content. In the presence of sepsis, patients having oxygen delivery and uptake above normal without evidence of ischemia (normal lactate) will not increase oxygen consumption by raising the hemoglobin.

Thermal injury is one trigger for pulmonary neutrophil recruitment. This article describes the time course of neutrophil recruitment after scald injury. Mice aged 8 to 10 weeks were anesthetized and subjected to 15% topical scald injury. Animals were put to death at 6 hours, 24 hours, 3 days, and 7 days after injury, and the pulmonary tissue harvested for staining with hematoxylin and eosin and neutrophil esterase. Cell counts for neutrophil accumulation were obtained. Control animals were handled in a comparable manner apart from the scald injury. Animals killed at 6 hours demonstrated significant neutrophil recruitment relative to the control. This difference had resolved at 24 hours. Animals killed at 3 and 7 days again demonstrated neutrophil accumulation despite normal behavior and absence of weight change from the control. Quantitative cultures of burn wounds failed to disclose infection. Scald injury was associated with significant pulmonary neutrophil recruitment that resolved at 24 hours. The presence of an untreated wound was associated with neutrophil recruitment beyond 24 hours despite outward normal behavior.

The objective of this study was to demonstrate that bedside burn intensive care unit tracheostomy is a safe and cost-effective procedure and has advantages over operating room tracheostomy. The charts of all patients who underwent tracheostomies in the burn unit between January 1990 and September 1993 were reviewed retrospectively. All tracheostomies were performed by residents in their second to fourth postgraduate years. The identical operating room technique was used for all bedside procedures including complete instrument tray, electrocautery, and adequate lighting. Standard tracheostomies were routinely performed at the bedside instead of the operating room in an attempt to deal with an increasing number of critically ill patients with burns requiring operating room surgical procedures. No patient-specific criteria were used to determine whether bedside or operating room tracheostomy would be performed. Charges for bedside intensive care unit and operating room tracheostomy were compared. Group t test and chi-square analysis were used with significance set at p < 0.05. Forty-three tracheostomies were performed in the 45-month period reviewed. Twenty-five tracheostomies performed in the operating room were compared with the 18 tracheostomies performed at the bedside in the burn intensive care unit. No statistical difference existed in age, sex, mean total body surface area percent burned, mean inspired oxygen, mean positive end expiratory pressure, mean pretracheostomy intubated days, presence of inhalation injury, or complication rate between groups. The average combined cost for operating room and anesthesia was $1740 per tracheostomy performed in the operating room. No charge was given to the patient for a bedside tracheostomy apart from the surgeon's fee and tracheostomy tube. This charge was the same for both groups. Bedside burn intensive care unit tracheostomy has the same complication rate as operating room tracheostomy and can be performed for a substantially lower charge. Thus bedside tracheostomy is safe and cost-efficient.

Objective: To assess the efficacy of interferon gamma in reducing infection and death in patients sustaining severe injury. Design: Multicenter, randomized, double-blind, placebo-controlled trial with observation for 60 days and until discharge for patients with major infection on day 60. Setting: Nine university-affiliated level 1 trauma centers. Patients: Four hundred sixteen patients with severe injuries, assessed by Injury Severity Score and degree of contamination. Intervention: Recombinant human interferon gamma, 100 μg, was administered subcutaneously once daily for 21 days (or until patient discharge if prior to 21 days) as an adjunct to standard antibiotic and supportive therapy. Main Outcome Measures: Incidence of major infection, death related to infection, and death. Results: Infection rates were similar in both treatment groups; however, patients treated with interferon gamma experienced fewer deaths related to infection (seven [3%] vs 18 [9%]; P =.008) and fewer overall deaths (21 [10%] vs 30 [14%]; P =.17). While 12 early deaths (days 1 through 7) occurred in each treatment group, late death occurred in 18 placebo-treated patients and nine in interferon gamma—treated patients. The results were dominated by findings at one center, which had the highest enrollment and higher infection and death rates. Statistical analysis did not eliminate the possibility of an unidentified imbalance between arms as an explanation for the results. Conclusion: Further evaluation is required to determine the validity of the observed reduction in infection-related deaths in patients treated with interferon gamma. (Arch Surg. 1994;129:1031-1041)

Interferon-gamma (IFN-gamma) has been demonstrated to improve outcome following localized infection and hemorrhagic shock in experimental studies. We sought to determine the effects of IFN-gamma in a clinically relevant murine model of intra-abdominal polymicrobial sepsis. Fifty male BDF1 mice, each weighing 23-28 g, underwent cecal ligation and puncture (CLP) followed by administration of subcutaneous injections of IFN-gamma 100-22,500 U or vehicle control immediately post-CLP and then daily. In a second set of experiments, 60 mice underwent daily injections of vehicle control or 100 U IFN-gamma 24, 48, or 72 hours prior to CLP. Interferon-gamma administered following CLP led to increased mortality and earlier deaths in a dose-dependent fashion (p < 0.05). Interferon-gamma given 24, 48, or 72 hours prior to CLP resulted in no demonstrable benefit when compared with animals that did not receive IFN-gamma (p = 0.14, p = 0.94, and p = 0.97, respectively). While IFN-gamma has been reported to be of value in selected clinical situations by improving resistance to infection, it may not be capable of conferring protection following surgery or trauma with intra-abdominal sepsis, and in fact may be detrimental.

Interferon-gamma (IFN-gamma), a cytokine that has been shown to upregulate macrophage function, has recently been demonstrated to improve outcome when exogenously administered in several animal models of injury. Because the macrophage is also important in the events that govern wound healing, we evaluated the effects of IFN-gamma upon wound healing in a murine model. IFN-gamma was administered in doses of 937.5-22,500 u synchronous with the creation of a left paraspinous wound and then daily. At Day 10, wounds were harvested, evaluated for wound disruption strength (WDS), and subjected to morphometric analysis. Wounds were also subjected to 36-hr formalin fixation to maximally cross-link collagen fibrils and retested for WDS. We found that IFN-gamma impaired wound healing at all doses relative to control, and WDS was impaired in a dose-dependent fashion. Our highest dose of IFN-gamma (22,500 u) produced a WDS only 65% of the control. Morphometric studies demonstrated less collagen deposition and a lower degree of neovascularity in IFN-gamma-treated animals. In addition, formalin fixation studies suggested that IFN-gamma may impair collagen cross-linking. The potential benefits of IFN-gamma in the multiply injured patient must be weighed against the possibility that IFN-gamma might deleteriously effect events fundamental to wound healing.

The lung injury in adult respiratory distress syndrome (ARDS) has been associated with increased expiratory hydrogen peroxide (H2O2) concentrations. Furthermore, patients with sepsis and ARDS are reported to have greater serum scavenging of H2O2 than patients with ARDS only. We hypothesized that the systemic presence of H2O2 would be detectable in the urine of these two groups of patients and that, in the case of ARDS sepsis, the relative contribution of each disease to the production this analyte would be discernible. Accordingly, we used an in vitro radioisotope assay to follow the weekly course of urine H2O2 levels in ARDS patients with and without sepsis, and in samples from control non-ARDS patients with sepsis with indwelling urinary catheters and in samples provided by healthy volunteers.Thirty patients with ARDS were included in the study: 23 had sepsis and 7 were sepsis free. An indwelling catheter was used to collect urine from each patient over a 24-h period, first within 48 h of ICU admission and then every seventh day over the course of their illness. Urine H2O2 was measured by competitive decarboxylation of 1-14C-alpha-ketoglutaric acid by H2O2. Urine samples were provided by 20 healthy volunteers while, in 10 non-ARDS patients with sepsis, urine was collected over one 24-h period following a 5-day minimum with an indwelling urinary catheter.Urine H2O2 concentration in healthy control subjects (88 +/- 4 mumol/L) and non-ARDS patients with urinary catheters (96 +/- 5 mumol/L) was not significantly different. During the first 48 h in the ICU, urine H2O2 in patients with ARDS only (295 +/- 29 mumol/L) was significantly lower (p0.05) than patients with ARDS and sepsis (380 +/- 13 mumol/L); however, the lung injury scores of these two groups did not differ. Furthermore, within the first 48 h, the urine H2O2 of the patients with ARDS and sepsis who did not survive (427 +/- 19 mumol/L; n = 7) was significantly higher than that in patients who survived sepsis (352 +/- 14 mumol/L; n = 15). Thereafter, the lung injury scores and urine H2O2 levels of the nonsurvivor ARDS-sepsis group remained significantly higher compared with the other two groups. At lung injury scores of 3 and 2, regardless of days in ICU, the patients with ARDS only had significantly lower urine H2O2 (266 +/- 30 mumol/L and 167 +/- 24 mumol/L, respectively) compared with the survivor ARDS-sepsis group (376 +/- 19 mumol/L and 250 +/- mumol/L). When the patients with ARDS (both ARDS only and with sepsis) recovered, their urine H2O2 concentration did not differ from the control groups (healthy donors and patients without ARDS).Lung injury scores did not differentiate patients with ARDS and sepsis from patients with ARDS only during the first 10 days in the ICU; however, urine H2O2 levels were significantly greater in the patients with ARDS and sepsis. Moreover, despite no initial difference in lung injury, patients who did not survive ARDS and sepsis had consistently greater urine H2O2 concentration than patients who survived sepsis. The urine H2O2 level in the ARDS-only group was about 70 percent of the level in the survivor ARDS and sepsis group, suggesting that ARDS alone is the major contributor to the H2O2 oxidant processes during combined ARDS and sepsis. Furthermore, these studies demonstrate that urine H2O2 may be a useful analyte to differentiate the severity of oxidant processes in patients with ARDS and sepsis albeit the prognosis appears to be survival or nonsurvival.

Abstract 3376 Background: Hemorrhagic shock accounts for a significant number of deaths in patients with acute injury. Early administration of multicomponent blood product transfusion in high plasma to red cell ratios have been associated with decreased mortality. Significant bleeding may occur in many settings outside of injury, including abdominal aortic aneurysm (AAA) rupture and postpartum or gastrointestinal hemorrhage. At a Level I Adult and Pediatric Trauma Center, activation of a Massive Transfusion Protocol (MTP) provides immediate release of sets of blood products with high component ratios (i.e. 1 unit plasma for every 1 unit PRBC) for patients with severe injury. The protocol has also been utilized in patients with major bleeding from non-trauma etiologies. To our knowledge, there are no systematic studies of the effectiveness of blood transfusion with high component ratios in non-traumatic hemorrhage; therefore, we performed a retrospective case review of patients transfused via the MTP for non-traumatic indications and outcomes at our institution. Methods: Clinical data for 58 patients with non-traumatic activation of the MTP between October 2009 and May 2011 was reviewed. Medications, laboratory parameters prior to transfusion, medical conditions affecting bleeding, and amount of blood products administered were evaluated. Outcomes including 24 hour and in-hospital mortality and incidence of transfusion reactions including Transfusion Related Acute Lung Injury (TRALI) were assessed. Associations between medications or medical problems and transfused blood products, as well as component ratio on mortality were assessed using logistic regression. Fisher's exact test was used to examine the impact of transfusion reactions including TRALI on mortality. Results: Forty-nine of 58 patients studied (84%) received blood products after activation of the MTP. Patients ranged in age between 19 and 82 years-old (median 61 years) and 69% were male. Thirty eight percent of patients had the MTP activated for vascular catastrophies (AAA), 24% for GI bleeding, 16% for open heart surgery, and 10% for obstetrical complications. Patients on average received 9 units of red blood cells (range 0–39 units), 6.6 units of plasma (range 0–34 units), and 1.5 apheresis units of platelets (range 0–5). Twelve patients (24%) received cryoprecipitate. Administered adjunctive medications included activated factor VII for 11 patients (22%), aminocaproic acid in 14 patients (28%), vitamin K in 15 patients (30%), and desmopressin in 6 patients (12%). The odds of a patient receiving activated Factor VII increased significantly as the units of PRBCs increased (OR = 3.925; 95% CI = 1.15 – 13.38). Concurrent medications most likely to affect bleeding included heparin in 26 patients (53%), aspirin in 18 patients (37%), and warfarin in 4 patients (8%). Active liver failure was seen in 11 patients (22%), renal failure in 16 patients (32%), and one patient with either a hematologic or solid malignancy. Patient's medications or these medical diagnoses were not associated with the amount of blood product transfused. Twenty one patients (43%) died during the hospitalization, and six patients (12% of total) died within the first 24 hours. In hospital mortality for patients with GI hemorrhage was the highest at 66%. No patients died after receiving transfusion for obstetric complications. Influence of ratio of Plasma:PRBC transfusion on in-hospital morality was seen with mortality of 80% in the Conclusions: MTPs with infusion of blood products with high ratios of plasma to red cells compared to transfusion with low ratios have improved mortality in patients with hemorrhage due to trauma. Our data suggests the applicability of MTP as part of resuscitation in the management of acute hemorrhage in non-trauma settings. Transfusion reactions were infrequent. Therefore, physicians should strive for transfusion of high ratios of Plasma:PRBC in all instances of major hemorrhage. Disclosures: Off Label Use: Use of activated factor VII to assist with cessation of hemorrhage in patients without hemophilia.

Fluid resuscitation following burn injury must support organ perfusion with the least amount of fluid necessary and the least physiological cost. Under resuscitation may lead to organ failure and death. With adoption of weight and injury size-based formulas for resuscitation, multiple organ dysfunction and inadequate resuscitation have become uncommon. Instead, administration of fluid volumes well in excess of historic guidelines has been reported. A number of strategies including greater use of colloids and vasoactive drugs are now under investigation to optimize preservation of end organ function while avoiding complications which can include respiratory failure and compartment syndromes. Adjuncts to resuscitation, such as antioxidants, are also being investigated along with parameters beyond urine output and vital signs to identify endpoints of therapy. Here we briefly review the state-of-the-art and provide a sample of protocols now under investigation in North American burn centers.

The laparoscope offers a novel avenue for the diagnosis of intra-abdominal injury and the use of fibrin glue (FG) as a treatment for hemorrhage in trauma patients. This study was undertaken to assess the practicality and effectiveness of FG injection under laparoscopic direction to arrest hemorrhage in solid viscera. Twenty dogs were randomized into a control group (CG) and a treatment group (TG). All animals underwent laparotomy to surgically induce uniform injuries to the hepatic and splenic parenchyma. The TG animals (n = 12) were allowed to hemorrhage for 30 minutes. The injuries were then visualized and FG injected intraparenchymally under laparoscopic direction. The average duration of the procedure was 25 minutes (range, 15-50). No hemostatic interventions were performed on the CG animals (n = 8). Mortality in the CG was 63% (5 of 8); there were no deaths in TG animals prior to sacrifice. Necropsy of TG animals revealed progressively healing hepatic and splenic injuries with no gross evidence of pulmonary FG emboli, intraparenchymal microemboli, or increased adhesion formation. No other complications were noted. This study demonstrates that hemorrhage from the liver and spleen can be successfully controlled using the laparoscope to direct the intraparenchymal injection of FG. In this experimental model, the procedure can be performed expeditiously. It is associated with reduction of mortality to zero when compared with controls. No complications associated with laparoscopy or FG injection were recognized. This technique may have potential for application in the management of stable patients who manifest evidence of intraperitoneal hemorrhage as a result of solid organ injury.

This study evaluated the role and advantages of diagnostic laparoscopy (DL) compared with diagnostic peritoneal lavage (DPL) in 75 trauma patients who were prospectively studied with DL followed by DPL. Of these, 59 patients had blunt injuries and 16 stab wounds. Seventy patients (93%) had the procedures performed in the emergency department (ED); 41 (59%) of these were awake and under local anesthesia. Forty-two patients had negative DPL and DL results with no subsequent sequelae. Twenty-three patients had negative DPL results and abnormal DL results. Of these, 20 were managed nonsurgically, and three (DPL < 10,000 RBC) underwent surgery based solely on DL findings of diaphragmatic lacerations from stab wounds. These were repaired. All 23 had an uneventful course. Three patients had positive DPL and insignificant DL findings. Laparotomy and DL findings correlated. A splenectomy for iatrogenic injury unrelated to DL and two nontherapeutic laparotomies were performed. Seven patients demonstrated both positive DPL and significant DL findings, and all had therapeutic laparotomies. Management based on DL rather than DPL would potentially have improved care in 8% of cases (6 of 75). Reliance on DL improved care in 19% (3 of 16) of patients with stab wounds and possibly could have in 3% (2 of 59) of those with blunt injuries. Management using DL would have potentially improved care in 30% (3 of 10) of patients with positive DPL findings and 5% (3 of 65) with negative DPL findings. Diagnostic laparoscopy can be performed safely in stable patients under local anesthesia in the ED. It offers no advantage over DPL as a primary assessment tool in blunt trauma. It does have advantages in the management of stab wounds. Diagnostic laparoscopy has a role in redefining DPL criteria for laparotomy and, in selected patients, as an adjunct to DPL, allowing further diagnosis and potentially the treatment of injuries without laparotomy.

OBJECTIVE This study was designed to evaluate the oxygen transport adjustments and myocardial metabolic adaptation that occurs with different levels of hemodilution during normothermia after cardiopulmonary bypass. DESIGN Prospective, nonrandomized study. SETTING Operating room in a university hospital. PATIENTS Eight patients with ejection fractions (> 40%) undergoing elective coronary artery bypass grafting. METHODS Before the institution of cardiopulmonary bypass, blood was withdrawn from patients to a target hematocrit of 15%. After coronary artery bypass grafting, a catheter was inserted directly into the coronary sinus. After the patients were rewarmed to 37 degrees C, they were weaned from cardiopulmonary bypass. Hemodynamic indices were measured, as well as measurements of myocardial oxygen consumption (VO2) and myocardial metabolism (lactate extraction and coronary sinus hypoxanthine). Measurements were made at three different hematocrit values: 15%, 20%, and 25%. Hematocrit was increased by autologous blood transfusion. MEASUREMENTS AND MAIN RESULTS The three levels of hemodilution (hematocrit: 17.4 +/- 3.4%; 23.0 +/- 3.7%; 27.8 +/- 4.8%) were significantly different from baseline (hematocrit 37 +/- 2.6%; p < .05). Oxygen delivery, which increased with autologous transfusion, exceeded 350 mL/min/m2 at each level of dilution. The myocardial VO2 increased significantly after autologous transfusion compared with the most dilute condition (7.0 +/- 3.7 mL/min at hematocrit 17.4% vs. 11.2 +/- 4.8 mL/min at hematocrit 23.0% and 12.4 +/- 4.0 mL/min at hematocrit 27.8%). This transfusion-induced increase was also true of myocardial oxygen extraction. Lactate extraction and hypoxanthine release were normal and unchanged at each level of hemodilution. Systemic oxygen extraction ratio increased with hemodilution and decreased with autologous transfusion. CONCLUSIONS Hemodilution to a hematocrit of approximately 15% is tolerated in anesthetized humans after coronary artery bypass surgery. There was no evidence of myocardial ischemia, as demonstrated by absence of S-T depression on the electrocardiogram, lactate extraction, or hypoxanthine release. In selected patients, postoperative transfusion may be based on systemic physiologic end-points, such as oxygen extraction ratio, rather than set hematocrit values.

Study objective: Induction of paralysis before intubation is controversial in the aeromedical setting. We reviewed our experience using neuromuscular blockade with nurse/paramedic aeromedical teams to determine effectiveness and outcome. Materials and methods: In 670 flights during a 16-month period, 119 patients required endotracheal intubation aided by muscle relaxant administration. Age ranged from two months to 83 years, with a mean of 33 years. All patients were hyperventilated with 100% oxygen before intubation. Sedation was given if presenting systolic blood pressure was greater than 100 mm Hg. A short-acting depolarizing agent was then given in a 1-mg/kg dose. Once the airway was secure, a longer-acting, nondepolarizing agent and/or sedation was given. Results: Of the 119 patients, 115(96.6%) were orally intubated. Four (3.4%) required surgical airway intervention because of injuries and conditions prohibiting oral intubation. Of 115 oral intubations, 99(86%) were achieved on the first attempt. Eight patients (7%) were intubated on a second attempt, and another eight were intubated on a third attempt. There was no change in operator. Sixty-eight percent of patients requiring airway management were multiple trauma victims with associated head injuries. There were no laryngeal injuries, detected cardiac rhythm changes, bleeding episodes, or neurologic complications despite incomplete cervical-spine evaluation. Conclusion: Neuromuscular blockade can be used safely and effectively in the field by experienced nurse/paramedic teams. Although problematic intubation was not eliminated, the difficulties encountered were manageable and the overall risk/benefit ratio was acceptable.

Human atria through release of atrial natriuretic peptide play an important role in extracellular fluid homeostasis. This study investigates the perioperative role of atrial natriuretic peptide, renin, angiotensin, aldosterone, and vasopressin in patient response to cardiopulmonary bypass after coronary artery bypass operations. Serum levels of these hormones were measured, along with hemodynamic profiles, urine output, and urine electrolytes, before induction of anesthesia, after discontinuation of cardiopulmonary bypass, 1 hour postoperatively, and 3 hours postoperatively. Serum levels of atrial natriuretic peptide were found to be significantly elevated immediately after discontinuation of cardiopulmonary bypass. These elevations did not correspond temporally to elevated central venous pressure or tachycardia. Significant natriuresis and diuresis were observed during the first postoperative hour. This diuresis failed to correspond temporally with alterations noted in serum levels of atrial natriuretic peptide, renin, angiotensin, aldosterone, and vasopressin. The mechanism responsible for the increases in serum atrial natriuretic peptide and the postoperative natriuresis and diuresis after cardiopulmonary bypass remain unknown.

Minnesota state law requires medical facilities to report adverse events including surgical procedures on the wrong body part, wrong patient, wrong procedure and retention of foreign bodies. All hospitals in the State of Minnesota now have safety procedures in place designed to eliminate these complications. In an attempt to understand the impact of implemented safety procedures on errors in acute surgery, complications related to acute surgery are examined for hospitals in the State of Minnesota which contains three American College of Surgeons verified Level I trauma centers.

Introduction Burn injury and its subsequent multisystem effects are commonly encountered by acute care practitioners. Resuscitation is the major component of initial burn care and must be managed to restore and preserve remote organ function. Later complications of burn injury are dominated by infection. Burn centers are often called to manage soft tissue problems outside thermal injury including soft tissue infection and Toxic Epidermal Necrolysis. Methods A selected review of recent reports published by the American Burn Association is provided. Results The burn-injured patient is easily and frequently over resuscitated with complications including delayed wound healing and respiratory compromise. A feedback protocol is designed to limit the occurrence of excessive resuscitation has been proposed but no new "gold standard" for resuscitation has replaced the Parkland formula. Significant additional work has been included in recent guidelines identifying specific infectious complications and criteria for these diagnoses in the burn-injured patient. While new medical therapies have been proposed for patients sustaining inhalation injury, a new standard of medical therapy has not emerged. Renal failure as a contributor to adverse outcome in burns has been reinforced by recent data generated in Scandinavia. Of special problems addressed in burn centers, soft tissue infections and Toxic Epidermal Necrolysis have been reviewed but new treatment strategies have not been identified. The value of burn centers in management of burns and other soft tissue problems is supported in several recent reports. Conclusion Recent reports emphasize the dangers of over resuscitation in the setting of burn injury. No new medical therapy for inhalation injury exists but new standards for description of burn-related infections have been presented. The value of the burn center in care of soft tissue problems including Toxic Epidermal Necrolysis and soft tissue infections is supported in recent papers.

To examine the cardiovascular adjustments and pattern of gas exchange that occur during hemodilution. Nonrandomized prospective study. Operating room in a university hospital. Seven patients undergoing elective aortocoronary artery bypass surgery. Before initiating cardiopulmonary bypass, the patients' hematocrit levels were decreased to approximately 15%. This hemodilution was done by removing a sufficient amount of autologous blood from the aortic cannula and replacing it with a sufficient amount of crystalloid solution. After the discontinuation of cardiopulmonary bypass, measurements were made at a hematocrit of approximately 15%. Then, after autologous blood infusion, measurements were made at a hematocrit of 20%, followed by more blood infusion to approximately 25% with repeat measurements. The following measurements were made before hemodilution and then at all three levels of hemodilution: heart rate, mean arterial pressure (MAP), right atrial pressure, mean pulmonary artery pressure, pulmonary artery occlusion pressure, and cardiac output. From these measurements, the following derived variables were calculated: cardiac index, systemic vascular resistance, and pulmonary vascular resistance. From measurements of arterial oxygen content, mixed venous oxygen content, and cardiac output, intrapulmonary shunt (JOURNAL/ccme/04.02/00003246-199105000-00017/ENTITY_OV0422/v/2017-07-20T220756Z/r/image-pngsp/JOURNAL/ccme/04.02/00003246-199105000-00017/ENTITY_OV0422/v/2017-07-20T220756Z/r/image-pngt), oxygen uptake (JOURNAL/ccme/04.02/00003246-199105000-00017/ENTITY_OV0413/v/2017-07-20T220756Z/r/image-pngo2), oxygen extraction ratio, and oxygen delivery (Ḋo2) were derived. The MAP was lowest (57 ± 3 [SD] vs. 92 ± 3 mm Hg) at the lowest hematocrit. The cardiac index was highest (4.0 ± 0.3 vs. 2.3 ± 0.6 L/min-m2) at the lowest hematocrit. Ḋo2 was lowest at the lowest hematocrit but JOURNAL/ccme/04.02/00003246-199105000-00017/ENTITY_OV0413/v/2017-07-20T220756Z/r/image-pngo2 remained constant at all levels of hematocrit. The oxygen extraction ratio increased as hematocrit decreased. With progressive increases in hematocrit, Ḋo2 increased and JOURNAL/ccme/04.02/00003246-199105000-00017/ENTITY_OV0422/v/2017-07-20T220756Z/r/image-pngsp/JOURNAL/ccme/04.02/00003246-199105000-00017/ENTITY_OV0422/v/2017-07-20T220756Z/r/image-pngt decreased. The data suggest that, during hemodilution, tissue autoregulation of JOURNAL/ccme/04.02/00003246-199105000-00017/ENTITY_OV0413/v/2017-07-20T220756Z/r/image-pngo2 and utilization are not impaired, but gas exchange function (JOURNAL/ccme/04.02/00003246-199105000-00017/ENTITY_OV0422/v/2017-07-20T220756Z/r/image-pngsp/JOURNAL/ccme/04.02/00003246-199105000-00017/ENTITY_OV0422/v/2017-07-20T220756Z/r/image-pngt) is impaired. (Crit Care Med 1991; 19:700)

To compare vital sign and urine output monitoring of seriously burned patients with invasive monitoring during early resuscitation.Retrospective review.A university hospital burn unit.Fourteen seriously burned patients who had pulmonary arterial monitoring. Monitoring data were compared at baseline and after fluid challenges.There was no correlation between invasively derived physiologic variables and vital signs and urine output. Vital signs and urine output changed little after fluid challenge, while variables from invasive monitoring demonstrated significant change. In half of the patients, oxygen consumption increased after fluid challenge; vital signs and urine output did not distinguish these patients.The use of urinary output and vital signs to guide initial burn resuscitation may lead to suboptimal resuscitation. Invasive cardiorespiratory monitoring may be necessary to optimize resuscitation of seriously burned patients.