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Volume: 1 Issue: 2 June 2021

FULL TEXT

ARTICLE
Infusion Therapy During the Period of Toxemia of Burn Disease

ABSTRACT

OBJECTIVES:In this study, our objective was to study the features of infusion therapy during the period of toxemia of burn disease in adults.

MATERIALS AND METHODS: Results of moni­toring of the daily volume of injected fluid, infusion therapy, and renal excretory activity of 25 patients were studied. All patients had been admitted to the Department of Combustiology in the Republican Research Center of Emergency Medicine (Tashkent, Uzbekistan) because of burn injury. After recovery from shock, all patients received the following treatments: anti-inflammatory agents, antibacterial therapy, correction of protein and water-electrolyte balance disorders, early surgery, delayed necrectomy, addi-tional parenteral nutrition, and syndrome- and symptom-specific therapy. All para­meters were compared and studied among 3 age groups: group 1 consisted of 12 patients from 20 to 40 years old (average 27.3 ± 5.6 years), group 2 consisted of 7 patients from 41 to 60 years old (average 50.7 ± 7.1 years), and group 3 consisted of 6 patients from 61 to 78 years old (average 71.3 ± 7.0 years).

RESULTS: The average daily volume of infusion therapy in group 1 (Frank index 119.4 ± 38.4 U) was 76 ± 7 mL/kg/day; in group 2 (Frank index 92.5 ± 20.8 U), daily administration was 64 ± 9 mL/kg/day; and in group 3 (Frank index 86.7 ± 12.8 U), daily administration was 48 ± 11 mL/kg/day.

CONCLUSIONS: In the fluctuating nature of changes in intravenous infusion, which may occur over 4 to 5 days, there are a number of factors that determine the need to increase or decrease infusion therapy. During the period of toxemia, the hourly renal excretory activity was most evident in patients in group 1, corresponding to a greater volume of water load and severity of burn injury. In group 2, which had average infusion therapy of 64 ± 9 mL/kg/day, preclinical signs of overload in pulmonary circulation were shown.


KEY WORDS: Coagulation, Combustiology, Frank index, Thermal damage, Toxemia

INTRODUCTION

Thermal damage primarily causes coagulation necrosis and cell death, with vascular thrombosis occurring in areas of the deepest lesion. The surrounding tissue is usually less affected, and zones of stasis and hyperemia cannot be clearly distinguished. If an appropriate infusion therapy is not started quickly in patients with these injuries, burn shock can develop, and damaged but viable tissues in the burn wound can undergo necrosis, increasing the area of deep lesions. In damaged tissues, vascular and capillary permeability increases, leading to edema. The formation and development of edema can also be affected by hypoproteinemia and an increase in osmotic pressure in damaged tissues. As a result of direct thermal action on erythrocytes, hemolysis can develop. Biologically active substances can reduce the osmotic resistance of erythrocytes and maintain hemolysis for several days.1-3

There remains a lack of information on methods to differentiate the severity of the condition; how infusion therapy affects hemodynamics, respiration, and other homeostasis systems; and whether therapy can be dependent on patient characteristics at different age periods. For this reason, our objective was to monitor data on the components of infusion therapy during the period of toxemia of burn disease in adults, to determine whether there was a relationship between therapy and the systemic inflammatory response, with an aim to increase the effectiveness of treatment, thus optimizing patient prognosis.

MATERIALS AND METHODS

We collected results of monitored activity of daily volume of injected fluid, infusion therapy, and renal excretory levels from 25 patients. All 25 patients had been admitted to the Department of Combustiology of Republican Research Center of Emergency Medicine because of burn injury. After recovery from shock, all patients received the following procedures: anti-inflammatory agents, antibacterial therapy, correction of protein and water-electrolyte balance disorders, early surgery, delayed necrectomy, additional parenteral nutrition, and syndrome- and symptom-specific therapy. All parameters were compared and studied among 3 age groups: group 1 consisted of 12 patients from 20 to 40 years old, group 2 consisted of 7 patients from 41 to 60 years old, and group 3 consisted of 6 patients from 61 to 78 years old. Group divisions were dictated by the well-known inherent features among age groups, as previously described in the literature.4

All protocols used in this study were approved by the ethics committee of the Republican Research Center of Emergency Medicine before the study began. All protocols conformed to the ethical guidelines of the 1975 Helsinki Declaration. Written informed consent for use of medical records was obtained from patients or their guardians.

As shown in Table 1, group 1 had an average age of 27.3 ± 5.6 years, group 2 had an average age of 50.7 ± 7.1 years, and group 3 had an average age of 71.3 ± 7.0 years. Total burn area and area of deep burn damage to the skin were similar among the groups. The highest Frank index (FI; used to determine the severity of a burn injury) was identified in group 1. Group 1 also had the longest duration of intensive therapy in the intensive care unit and the most evident burns in terms of area and depth.

RESULTS AND DISCUSSION

The fluid balance levels among the age groups are presented in Table 2 and Table 3. All age groups had similar volumes of injected intravenous and oral fluids.

In group 2, rate of parenteral administration during the first 10 days of treatment ranged from 43% on day 1 to 70% on day 6. On day 1 of treatment, 32% of group 1 received intravenous injections, with an increase to the maximum value on day 10 of 60% (Figure 1). Injected volume slightly fluctuated throughout the observation period. In group 3, 23% received intravenous administration on day 1; in addition, group 3 showed a wave-like increase of intravenous administration, with a maximum of 80% receiving treatment on day 21, followed by a gradual decrease to 60%. This finding demonstrated the feasibility and effectiveness of parenteral infusion during a later course of treatment, which amounted to at least 60% of the total daily fluid load.

As shown in Table 3, the volume of diuresis in group 1 over the first 5 days was not different from physiological values. A moderate polyuria was observed in the following days, due to the need for detoxification therapy. An increase in hourly discharge was observed in group 2 on days 3 and 4. In group 3, hourly diuresis was within normal limits. However, group 1 showed great differences after 10 days of intensive therapy on days 10, 13, 17, and 26. This fact was associated with drug stimulation according to indications (Figure 2). During the period of toxemia, hourly renal excretory activity was most evident in group 1, which corresponded to a greater volume of water load and the severity of burn injury.

As shown in Figure 3, the total fluid volume during the period of toxemia was comparatively smaller in group 3 versus group 1. As shown in Figure 4, for patients in group 1, there were no correlations between water load and hemodynamic parameters. Patients in group 2 showed a direct correlation between daily volume of fluid and excretory activity of the kidneys (0.66), with replacement carried out mainly by the enteral method (0.8) and the parenteral method (0.73). Daily fluid volume had a direct effect on mean blood pressure (0.71), diastolic blood pressure (0.6), and total peripheral vascular resistance (0.62). A negative correlation was found between daily fluid administration and oxygen saturation index (-0.6), which is an early preclinical sign of the risk of overload in the pulmonary circulation. Patients in group 2 had an average volume of infusion therapy of 64 ± 9 mL/kg/day. In addition, patients in group 2 seemed to have a relatively more adequate response to stress. Group 2 patients had average burn surface area of 54.3 ± 16.5%, 3B degree of burn of 11.9 ± 8.9%, and FI of 92.5 ± 20.8 U. In group 3, with an average volume of infusion therapy of 48 ± 11 mL/kg/day, patients showed a correlation between volume of infusion and increased oxygen saturation (0.53), a predominant compensation with paren­teral spills (0.78). However, intravenous infusion did not show a strong correlation with hemodynamic parameters in group 3 patients.

In group 1, which had an average volume of intravenous infusion of 76 ± 7 mL/kg/day, an inverse correlation was found between the volume of infusion therapy and changes in body temperature (-0.8) (Figure 5). In group 2, this inverse correlation was -0.8, reflecting the effectiveness of intravenous detoxification therapy. However, a further increase in water load resulted in negative correlation with systolic blood pressure (-0.7) and mean blood pressure (-0.6), as well as a negative correlation with minute volume of blood circulation (-0.6) and stroke volume (-0.5). In group 1, an inverse correlation was found between volume of infusion therapy and changes in body temperature (-0.8), which was also shown in group 2 (-0.8). These results reflect the effectiveness of intravenous detoxification therapy. However, a further increase in water load in group 1 resulted in a negative correlation with systolic blood pressure (-0.7), mean blood pressure (-0.6), minute volume of blood circulation (-0.6), and stroke volume (-0.5).

We also observed that increases in intrave­nous infusion therapy in group 1 would cause a decrease in myocardial oxygen demand (-0.8), a decrease in tachycardia (-0.7), and a decrease in general vegetative tone (-0.7). Thus, the predominant parenteral compe­nsation in group 1 turned out to be the most optimal, providing a corrective effect on hemodynamic function, autonomic tone, and myocardial oxygen demand. In 2 group, the identified inverse correlation between the volume of intravenous infusion and the dynamics of body temperature (-0.8) and respiration rate (0.7) confirmed the detoxification effect of parenteral fluid admini­s­tration during the period of toxemia. However, the administration level had a stimulating effect on diastolic blood pressure (0.6), mean blood pressure (0.6), and total peripheral vascular resistance (0.7), indicating a possible overload to the circulatory system at the average volume of intravenous admi­n­istration of 65 ± 9 mL/kg/day.

In group 3 (burn surface area of 40.8 ± 5.8%, 3B degree of 21.7 ± 6.7%, and FI of 86.7 ± 12.8 U), the level of parenteral administration increased the mean blood pressure (0.5) and systolic blood pressure (0.6) but reduced the renal excretory function (-0.6), thus demonstrating the stressful orientation of hemodynamic restructuring. We found that, in group 3, it may have been preferable to limit the total water load and reduce intravenous infusion therapy, perhaps suggesting a need for drug correction.

CONCLUSIONS

The average daily volume of infusion therapy in group 1 (FI of 119.4 ± 38.4 U) of 76 ± 7 mL/kg/day, in group 2 (FI of 92.5 ± 20.8 U) of 64 ± 9 mL/kg/day, and in group 3 (FI of 86.7 ± 12.8 ) of 48 ± 11 mL/kg/day seemed to be sufficient. In the fluctuating nature of changes in intravenous infusion, which may occur over 4 to 5 days, there are a number of factors that determine the need to increase or decrease infusion therapy. During the period of toxemia, the hourly renal excretory activity was most pronounced in patients of group 1, which corresponded to a greater volume of water load and severity of burn injury. In group 2 (which had an average volume of infusion therapy of 64 ± 9 mL/kg/day), a preclinical sign of overload of the pulmonary circulation was revealed.

REFERENCES


  1. Yu SV. Pathophysiology of Critical Conditions. ISBN: 978-5-6044262-5-8. Medizdat (St. Petersburg, Russia); 2021:161-185.
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  3. Valerievna AO. Peripheral circulation: significance, anatomy, pathology, treatment of disorders. https://sosudinfo.ru/arterii-i-veny/perifericheskoe-krovoobrashhenie/
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  4. Ahmad OB, Boschi


Volume : 1
Issue : 2
Pages : 60 - 64


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From the 1Department of Combustiology, Republican Research Center of Emergency Medicine; the 2Center for the Development of Professional Qualifications of Medical Personnel; the 3Emergency Surgery Department, Republican Research Center of Emergency Medicine; and the 4New Technologies and External Affairs Department of the Republican Research Center of Emergency Medicine, Tashkent, Uzbekistan

ACKNOWLEDGEMENTS: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.

CORRESPONDING AUTHOR: Khikmat Anvarov or Abdulaziz Fayazov

E-mail: uzkhik@mail.ru or fayazov1960@rambler.ru