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Biomedical subjects

H F Carvajal

Publications and source records attributed to H F Carvajal.

At least 19 recordsLinked to original sources
PubMed1994

Fluid resuscitation of pediatric burn victims: a critical appraisal.

The objectives of fluid therapy in the burned child can be simply stated and defined, and they should represent the basis for the resuscitation process. During the first 24 h after the burn, the ultimate goal is restoration of the patient's volume and electrolyte homeostasis. All efforts should be directed at monitoring or restoring organ function while simultaneously minimizing edema formation. Only the minimum amount of fluids and other nutrients needed to restore cell function should be provided. Electrolyte deficits and lactic acidosis must be promptly corrected and every attempt should be made to prevent further derangement in body homeostasis by replacing concurrent losses and anticipating maintenance fluid and electrolyte requirements. Restoration and maintenance of perfusion pressures should lead to maximal oxygenation of injured and noninjured tissues, which promotes spontaneous healing, minimizes wound conversion, decreases bacterial colonization and prepares the injured areas for early excision and grafting. It must be emphasized, however, that restoration of fluid and electrolyte balance and organ function does not necessarily imply a return to normal of all physiological variables. The cardiac output, for example, may not return to preburn levels for 24-48 h post injury, even when the intravascular volume has been completely replenished. Likewise, oliguria may persist for 48-72 h, or even longer, after the burn, as a result of excessive secretion of antidiuretic hormone stimulated by the stress of the injury rather than its effect on fluid balance. Thus, while the objectives can be easily enumerated and defined, they are difficult to meet.

Adolescent↗
PubMed1994

Pediatric trauma care is cost effective: a comparison of pediatric and adult trauma care reimbursement.

Trauma causes staggering losses: in 1987, Hermann Hospital lost $8 million to uncompensated trauma care. To demonstrate the survivability of pediatric trauma care delivery we examined reimbursement profiles for adult and pediatric trauma patients. We retrospectively reviewed the records of 3445 patients with serious trauma from October 1987 through March 1992. The group was divided into adult (> or = 17 years) and pediatric patients (< 17 years). We compared reimbursement profiles based on hospital costs generated, reimbursement, financial class, demographics, discharge diagnostic codes, and outcome. Significance was assessed by t test and Chi-square. We found a decreased length of stay (LOS) and a lower association with under-reimbursement or zero reimbursement in pediatric patients. A significantly lower percentage of pediatric patients paid none of their bill (17.1%) compared with the adults (23.2%). Pediatric reimbursement exceeded hospital costs (110.0%) compared with adult reimbursement (90.3%). This suggests that pediatric trauma care can survive in an atmosphere of shrinking resources.

Adult↗
PubMed1988

Optimal composition of burn resuscitation fluids.

The hemodynamic, renal, and hematologic responses to fluid resuscitation with four different hydrating solutions (lactated Ringer's and hypertonic salt solutions, with and without albumin) administered in equal quantities were compared in an ovine burn model. Forty-five animals, including a sham group, were studied. The burn (40%, flame) was inflicted under anesthesia, but the animals were then studied while in the awakened state. Fluid resuscitation was begun one hour after the burn. While all animals survived the burn and disclosed reasonable hemodynamic stability throughout the experiment, those that received lactated Ringer's with albumin (LRA) restored their cardiac output to preburn values, by 24 h postinjury demonstrated higher serum albumin and colloid osmotic pressure levels, experienced no electrolyte or acid-base imbalances, and maintained serum osmolality within normal limits. In contrast to the other solutions, LRA did not induce edema in unburned tissues, and seemed optimal for burn resuscitation.

Albumins↗
PubMed1988

The relationship of lactic dehydrogenase to epithelial cells in the urine of normal neonates.

Urinary lactic dehydrogenase (LDH) isoenzyme assays in 20 female and 15 male normal newborn infants during the first 3 days of life revealed higher levels than in older populations and a tendency toward a "slow zone pattern" (predominance of isoenzymes 4 and 5). Total LDH and LDH-5 activities were higher in the female (33.2 +/- 5.2 and 12.4 +/- 2.8 mU/mL, respectively), than in the male population (9.7 +/- 2.2 and 1.0 +/- 0.3 mU/mL, respectively). The amount of LDH correlated with the presence of epithelial cells in the urine that also were prominent in female patients and were apparently derived from the vagina. Separation of epithelial cells by centrifugation and filtration decreased total LDH and isoenzyme activities in the remaining sample, while sonification of the resuspended cells increased TLDH and LDH-5 activities by 6- and 12-fold respectively. Saline washings of the perineum and vagina revealed large numbers of epithelial cells and similar LDH isoenzyme patterns suggesting that contamination of the urine with these cells is a frequent occurrence during collection of voided and/or bag urine samples, and that these cells are responsible for much of the LDH activity found in the urine. We conclude that epithelial cells can increase both total LDH and isoenzyme activity in voided urine samples from otherwise normal female neonates. In this age group, urine collected by other methods (catheterization or suprapubic aspiration) must be studied to minimize the possibility of contamination of the sample with epithelial cells from the vagina or the perineum or both.

Epithelial Cells↗
PubMed1987

Initial fluid therapy for children with meningitis with consideration of the syndrome of inappropriate anti-diuretic hormone.

A review of 85 children with meningitis admitted to the University Children's Hospital at Hermann Hospital revealed that only six patients (7%) had sufficient clinical and laboratory evidence to be compatible with the diagnosis of inappropriate secretion of antidiuretic hormone (SIADH). This is in contrast with various communications in the pediatric literature that have reported an association between the two conditions of as high as 85%. Hyponatremia (serum sodium 135 mEq/L) was observed in 27 (32%), but neither the initial laboratory data nor the subsequent follow-up data supported the diagnosis of SIADH. Moderate to severe dehydration was documented in 16 patients (19%) and suspected in more than 50% of the cases (serial weight determinations indicating an increase in weight from admission to discharge). Although the incidence of neurologic sequelae in this series was not influenced significantly by the presence or absence of hyponatremia, SIADH, or fluid restriction, the numbers are still small. Based on these data, routine fluid restriction cannot be recommended unless there is confirmatory evidence of SIADH.

Child↗
PubMed1981

An objective method for early diagnosis of gram-negative septicemia in burned children.

The present investigation was undertaken to standardize the early diagnosis of Gram-negative septicemia in burned children. Data were collected by means of a matrix which encompassed eight clinical variables routinely monitored by nursing personnel. These variables were evaluated according to their severity using a numerical scale of 0 to 3. A sepsis score was thus calculated for each of 243 burned patients, three times a day throughout their entire hospitalization. Eighty patients with suspiciously high scores (controls) were subjected to a battery of ten laboratory tests aimed at confirming the presence or absence of septicemia. During the 26 months of the study 16 patients (22 episodes) had clinical and laboratory evidence of Gram-negative septicemia. Multiple regression and discriminant analysis techniques were then used to develop statistical models for early diagnosis of septicemia. The two most practical and reliable of these are reported herein. Model I and II would have predicted the diagnosis of sepsis, 83% and 86% of the time, respectively, 1 day before the diagnosis was made using conventional methods. The false positive rates of Models I and II were 7% and 3%, respectively. On the basis of this information it seems possible and rewarding to utilize decision-making charts for monitoring and diagnosis of septicemia.

Adolescent↗
PubMed1980

A physiologic approach to fluid therapy in severely burned children.

Fluid balance data in 30 severely burned children hydrated according to a fluid resuscitation program were reviewed. The formula to estimate fluid requirements is based upon body surface area and surface area burned rather than weight. It uses two independent figures to estimate maintenance fluid needs and fluid requirements as a result of the burn. A standard isotonic solution containing 12.5 grams of human serum albumin is used for hydration. The state of hydration is monitored using several clinical and laboratory guides. The use of hourly urine volume for this purpose has been de-emphasized. Although no complications directly related to fluid therapy were encountered, five of the 30 children died as a result of septicemia five, ten, 12, 23 and 37 days postburn, respectively. A maximal weight increase following resuscitation averaged 4 kilograms per square meter of body surface burned. The volumes of urine that can be expected from patients similarly resuscitated have been defined. This program is safe, accurate and effective for a wide range of burn sizes and age groups.

Adolescent↗
PubMed1979

Effect of inhibiting prostaglandin synthesis on edema formation and albumin leakage during thermal trauma in the rat.

Prostaglandins (PGs) participate in the inflammatory response, but the contribution of endogenously synthesized PGs to edema formation and increased vascular permeability is not known. Using a 10% scald burn in the rat, we measured water content (as percent, wet minus dry/wet weight) and 131I-RISA leakage (counts/g dry tissue) in scalded and normal skin at 30 minutes and 3 hr post injury. Four groups (10 rats/group) in each time period studied: control; scald; scald, 5 mg/kg indomethacin; scald, 10 mg/kg indomethacin. Indomethacin was administered intravenously 30 minutes before the scald; RISA was injected intravenously 30 min before termination of the study. In all indomethacin-treated groups immunoreactive plasma PGA was significantly lower (p less than 0.05) than in scalded, untreated groups. All scalded groups showed significantly higher RISA counts and water content than did the control group (p less than 0.01). At 30 min post-injury the indomethacin -treated groups did not differ from the untreated scald group (p greater than 0.20). In the 3 hour study all scalded groups had significantly higher content and RISA counts than control (p less than 0.01). Thus PGs produced during thermal trauma do not greatly contribute to the edema formation and increase in vascular permeability.

Albumins↗
PubMed1979

Relationship of burn size to vascular permeability changes in rats.

Studies to determine the relationship between increased vascular permeability, water content and protein leakage, and burn size were performed on rats. Partial thickness scald burn covering 10, 20, 30 and 40 per cent of the rats' body surface area were induced in four groups of rats. A fifth group of rats served as the controls. Following the burn, all rats received intravenously fluid resuscitation. Burn edema was maximal at three hours postburn for the 30 and 40 per cent groups. The edema persisted throughout the 24 hour study period. No significant change in water content of unburned skin was demonstrated. Albumin leakage into injuried tissues was maximal at 30 minutes and disappeared by 12 hours postinjury. The size of the burn had no effect on 131Risa leakage into injuried tissues. Albumin leakage into noninjured tissues occurred only in the 30 and 40 per cent burn groups was mild compared with that in burned tissues and also disappeared by 12 hours postburn. Extravasation of albumin in lung, liver, spleen, kidney and muscle was mild and seen only in the 30 and 40 per cent burn groups. Except for a mild increase in water content of lung tissue in the 30 and 40 per cent groups only, no consistent increase in the water content of other organs was observed. While the size of the burn appears to have some influence on capillary permeability, burns up to 40 per cent of the body surface have only a mild and transient effect upon capillaries distant to the site of injury. This observation supports the concept of a humoral mediator for capillary permeability and suggests that more pronounced changes can occur with larger burns. Nonetheless, extravasation of albumin appears to be short-lived.

Animals↗
PubMed1978

Effect of nicotinic acid on vascular permeability after thermal trauma in the rat.

Nicotinic acid has been suggested to decrease plasma volume loss after thermal injury. However, conflicting data have recently appeared, in reports of laboratory measurements of major derangements in cardiovascular function after large third-degree thermal injury. We investigated the microvascular effect of nicotinic acid on water and albumin leakage after a small second-degree thermal burn in the rat. No effect of nicotinic acid on albumin leakage was observed at 1/2 hour, 3 hours, or 6 hours; a minimal but significant (p less than 0.05) decrease in water content of burned tissue was observed 1/2 hour postinjury. Our studies confirm in rats previous work with sheep and dogs demonstrating that nicotinic acid has slight, if any, effect on fluid and protein loss after thermal injury.

Albumins↗
PubMed1977

Management of burns.

An overview of the management of the acutely burned patient has been described. Adherence to the sound principles of early resuscitation, appropriate nutrition, wound management, and rehabilitation can provide hope for many of the victims of this tragic injury. Complications encountered throughout the burn illness present unique and perplexing problems for the physician, who must utilize all the clinical wisdom and facility available in the management of such complex problems.

Anesthesia↗