Urinary output a key parameter guiding fluid resuscitation in burn trauma is an inadequate measure of renal function In this study the clearance of iohexol (CL) was used to follow the glomerular filtration rate during the first week after burn Nineteen adults with major burns received an intravenous bolus injection of iohexol every other day Plasma concentration of iohexol was measured over 4 h and CL was calculated by a one compartment kinetic model The results were compared to the CL as obtained by a two compartment model and also to the CL measured in 10 healthy controls The results show that CL values for burn patients were high The first day after burn median CL was 155 mL/min/1 73 m(2) (range 46-237) which exceeded that for the controls (mean 117 mL/min/1 73 m(2) P less than 0 01) However on day 7 the CL approached the expected baseline (mean 122 mL/min/1 73 m(2)) CL was 10% lower when calculated from two compartment kinetics and a correction factor of 0 9 was applied to all results obtained by the one compartment calculations to give results comparable to those from the two compartment kinetics In conclusion CL is increased early after burn The mechanism is unclear but it parallels the period of vascular dysfunction and increased cardiac output

Background: Pain management after surgery has been used as a sales argument for the use of COX-2 inhibitors, but their potential positive and negative effects have not been fully investigated. We thus conducted a controlled evaluation of the effect of celecoxib on perioperative blood loss, pain relief and consumption of analgesics, range of motion, and subjective outcome in conjunction with total knee replacement (TKR).

Method: 50 patients were randomized to either placebo or celecoxib (200 mg) preoperatively and then twice daily. Total blood loss was calculated by the Hb balance method, taking the patient's pre- and postoperative hemoglobin and blood volume into account. Pain scores (VAS), range of motion, and subjective outcome (KOOS) were monitored postoperatively and during the first year after surgery.

Results: No differences in total, hidden, or drainage blood loss were found between the groups. There were 30% lower pain scores during the first 4 weeks after surgery and lower morphine consumption after surgery in the celecoxib group, while no effect was seen on pain, range of motion, and subjective outcome at the 1 year follow-up.

Interpretation: Celecoxib does not increase perioperative blood loss but reduces pain during the postoperative period after TKR. It is not necessary to discontinue celecoxib before surgery. The postoperative use of celecoxib did not increase range of motion or subjective outcome 1 year after TKR.

Aims: To investigate the effect of an amino acid mixture given intravenously (i.v.) on the rate of ethanol elimination from blood compared with equicaloric glucose and Ringer's acetate as control treatments.

Methods: In a randomized cross-over study, six healthy men (mean age 23 years) fasted overnight before receiving either Ringer's acetate, glucose or the amino acid mixture (Vamin 18 g N/l^®) by constant rate i.v. infusion over 4.5 h. Ethanol (0.4 g/kg) was given by an i.v. infusion lasting 60 min during the time each of the treatments was administered. At various times post-infusion, blood samples were taken for determination of ethanol by headspace gas chromatography. Blood glucose and heart rate were monitored at regular intervals. Concentration–time profiles of ethanol were plotted for each subject and the rate of ethanol disappearance from blood as well as other pharmacokinetic parameters were compared by repeated measures analysis of variance.

Results: The rate of ethanol elimination from blood was increased significantly (P < 0.001) after treatment with amino acids (mean ± SD, 0.174 ± 0.011 g/l/h) compared with equicaloric glucose (0.121 ± 0.016 g/l/h) or Ringer's acetate (0.110 ± 0.013 g/l/h). Heart rate was also slightly higher during infusion of the amino acid mixture (P < 0.05).

Conclusions: When the rate of ethanol elimination from blood is relatively slow, such as after an overnight fast, it can be increased by ∼60% after treatment with i.v. amino acids. The efficacy of amino acid treatment was not related to the supply of calories because glucose was no more effective than Ringer's acetate. We suggest that amino acids might increase hepatic oxygen consumption, resulting in a more effective conversion of NADH to NAD⁺ in mitochondria. An important feature of the experimental design was ensuring hepatic availability of amino acids during much of the time that ethanol was being metabolized.

A randomized, controlled study compared the effects of wound compression with drainage after primary total hip arthroplasty. In 51 patients, an inflatable cuff was placed over the wound underneath a girdle (System Calmed, Calmed AB, Askim, Sweden). Control patients had wound drainage (n = 54). Preoperative and intraoperative variables did not differ between groups. Total blood loss was calculated using hemoglobin balance, with compression it was 1510 ± 656 mL (mean ± SD) and in controls 1695 ± 712 mL (P = .13). However, less blood was transfused in the compression group (P = .05). Wound infection was seen in 2 patients with compression and in 3 controls. Deep venous thrombosis occurred in 3 controls. Wound discharge was more frequent in controls (19/54 vs 8/51, P = .04). Thus, wound compression had no obvious negative effects and reduced wound discharge and need for transfusion. It may replace drainage after total hip arthroplasty. © 2005 Elsevier Inc. All rights reserved.

There is a need to find methods to assess the size of the extracellular fluid (ECF) volume without involving radioactive tracers. For this purpose, we applied 3 methods for measuring the ECF volume in 10 male volunteers (mean age, 34 yr). Steady-state plasma bromide concentration (control) was compared to the results of kinetic analysis of plasma iohexol and to kinetic analysis of the dilution of serum sodium after IV infusion of 1 L of isotonic mannitol. The volume of distribution of these tracers was used to indicate the ECF volume. The results disclosed statistically significant correlations between the results of all 3 methods, although the average sodium dilution showed 0.7 L lower values than iohexol and 1.4 L lower than bromide. All three methods correlated significantly with body weight. The percentage of the body weight indicated by the methods was 18.3% (3.1%) for sodium, 19.6% (1.0%) for iohexol, and 20.5% (1.1%) for bromide. We conclude that sodium dilution may be performed at bedside but iohexol and bromide showed less intersubject variability. Iohexol simultaneously measures the glomerular filtration rate and should be a viable clinical option if the hospital performs routine assessments of kidney function using this tracer. ©2005 by the International Anesthesia Research Society.

Background: Nitric oxide (NO) formed from inducible NO synthase (iNOS) is assumed to promote vascular permeability in sepsis and endotoxemia.

Methods: Thirty-seven anesthetized rats were examined for the effects of endotoxin. After randomization, 17 animals had lipopolysaccharide (LPS) administered and 20 rats served as controls and were given the corresponding volume of saline. The observation period was 5 hours after administration of endotoxin. Mean arterial blood pressure, heart rate, and hematocrit were recorded in all animals, and transcapillary exchange of albumin, tissue water content, immunohistochemistry for nitric oxide synthase, and blood gases were investigated in subsets of animals.

Results: When anesthetized rats were studied for 5 hours after endotoxin (LPS), the sequestration of albumin decreased in the intestine (double-isotope method) and there was no increased water content (freeze-drying technique) when the elevated tissue plasma volume of the LPS-treated rats was corrected for. Immunohistochemical methods showed a similar distribution and intensity of staining for endothelial NOS and neuronal NOS in LPS and control groups. In the lung of the LPS-treated rats, there was a significantly larger number of infiltrating, inflammatory cells staining for iNOS. There was no iNOS demonstrated in vascular structures or heart.

Conclusion: At 5 hours after LPS, there was no increased loss of water or albumin from the circulation. This challenges the notion that NO causes vascular damage in endotoxemia and extravasation as an obligatory sequela to endotoxemia.

Background: A blood transfusion is a costly transplantation of tissue that may endanger the health for the recipient. Blood transfusions are common after total hip arthroplasty. The total saving potential is substantial if the blood loss could be reduced. Studies on the use of tranexamic acid have shown interesting results, but its benefits in total hip arthroplasty have not yet been resolved. Patients and methods: 100 patients receiving a total hip arthroplasty (THA) got a single injection of tranexamic acid (15 mg/kg) or placebo intravenously before the start of the operation. The study was double-blind and randomized. Total blood loss was calculated from the hemoglobin (Hb) balance. Volume and Hb concentration of the drainage was measured 24 h after the operation. Intraoperative blood loss was estimated volumetrically and visually. Results: The patients who received tranexamic acid (TA) bled less. The total blood loss was on average 0.97 L in the TA group and 1.3 L in the placebo group (p < 0.001). 8/47 (0.2) in the TA group were given blood transfusion versus 23/53 (0.4) in the placebo group (p = 0.009). Drainage volume and drainage Hb concentration were less in the TA group (p < 0.001 and p = 0.001). No thromboembolic complications occurred. Interpretation: Considering the cost of blood and tranexamic acid only, use of the drug would save EUR 47 Euro per patient. We recommend a preoperative single dose of tranexamic acid for standard use in THA. Copyright © Taylor & Francis 2005.

"This book is not another attempt to create a ""cook book"" on volume replacement of fluid substitution. This book, in contrast, summarizes the up-to-date-knowledge of this topic presented by experts from a wide range of disciplines. Everybody caring for the critically ill will profit from the different chapters at different levels - nurses, students, residents, consultants, and even experts on volume therapy

Background. Total knee arthroplasty (TKA) is often carried out using a tourniquet and shed blood is collected in drains. Tranexamic acid decreases the external blood loss. Some blood loss may be concealed, and the overall effect of tranexamic acid on the haemoglobin (Hb) balance is not known. Methods. Patients with osteoarthrosis had unilateral cemented TKA using spinal anaesthesia. In a double-blind fashion, they received either placebo (n=24) or tranexamic acid 10 mg kg-1 (n=27) i.v. just before tourniquet release and 3 h later. The decrease in circulating Hb on the fifth day after surgery, after correction for Hb transfused, was used to calculate the loss of Hb in grams. This value was then expressed as ml of blood loss. Results. The groups had similar characteristics. The median volume of drainage fluid after placebo was 845 (interquartile range 523-990) ml and after tranexamic acid was 385 (331-586) ml (P<0.001). Placebo patients received 2 (0-2) units and tranexamic acid patients 0 (0-0) units of packed red cells (P<0.001). The estimated blood loss was 1426 (1135-1977) ml and 1045 (792-1292) ml, respectively (P<0.001). The hidden loss of blood (calculated as loss minus drainage volume) was 618 (330-1347) ml and 524 (330-9620) ml, respectively (P=0.41). Two patients in each group developed deep vein thrombosis. Conclusions. Tranexamic acid decreased total blood loss by nearly 30%, drainage volume by ~50% and drastically reduced transfusion. However, concealed loss was only marginally influenced by tranexamic acid and was at least as large as the drainage volume.