Annals of Burns and Fire Disasters - vol. X - n. 2 - June 1997

INTRAPORTAL INJECTION TREATMENT IN EXTENSIVE BURNS

Atyasov N. I.

Medical Faculty, Morclovian State University, Saransk, Russia

SUMMARY. The intraportal injection method (injections in the venous bed through recanalized umbilical vessels is rarely used in the treatment of burn patients suffering from post-burn complications. This work presents a study of this method for the treatment of deep burns. It was found that haemostasis disorders, intra- and extracorporeal circulation malfunctions, hypoxia, capillary hyperpermeability, and hepatic lymph hyperproduction increase portal vein pressure. The degree of portal hypertension and blood and lymph deposition in the regional system depends on the area and depth of the burn, the patient's age, and the time period after the burn. The present report provides a detailed description of the surgical management of 554 patients aged up to 81 years with deep burns in up to 85% total body surface area, together with experimental data. Patients treated with intraportal infusions achieved stable nonspecific immunity sooner than patients treated with standard methods. It is therefore concluded that infusion therapy has profound therapeutic possibilities in the treatment of burn disease.

The surgical perspective of the intraportal injection method (injections in the venous bed through recanalized umbilical vessels) has been demonstrated in several publications. The early onset of disorders in organs and systems functionally linked with the liver and of haemolymph flow malfunctions in patients with burns has aroused interest in the intraportal injection technique. This method is still however rarely used in burn patient treatment.
Our study has shown that post-traunia haemostasis disorders, intra- and extracorporeal circulation malfunctions, hypoxia, capillary hypermeability, and hepatic lymph hyperproduction increase portal vein pressure to 1.83-11 kpa and thoracic lymph duct (TLD) pressure to 6.66-3.87 kpa in 82.7-3.7% of the patients. The degree of portal hypertension and blood and lymph deposition in the regional system depends on the area and depth of a burn, the patient's age, and the time after the burn.
The disorders detected led to hepatodystrophy, renal and hepatic insufficiency, metabolism malfunctions, fluid and alburnin disproportion, the spreading of intestinal microflora through the portal vein (54.8 ± 4.9% of patients) and TLD (82.5 ± 0. 1%), the appearance of ulcers and erosions in the gastrointestinal tract, intoxication, cachexia, and secondary immunodeficiency (50.6 ± 4.2% of patients).
Haemolymph flow malfunctions, together with retention of metabolic toxins in tissues, the lymph system, and the regional blood collector, caused a relative delay in clinical manifestations of the development of pathogens. The present report describes data on the surgical management of 554 patients aged up to 81 years with deep burns in up to 85% total body surface area, together with experimental data.
Two hundred and eighty-seven burn patients wore infused through recanalized umbilical veins and 262 through branches of the vena cava; 198 patients received infusion therapy accompanied by various treatment methods: haemo-, lympho-, plasma- and enterosorption, external lymph lead from TLD, purified erythrocyte transfusion, and plasmapheresis (including regional plasmapheresis). In addition we studied in detail the case records of 24 well-controlled burn patients subjected to the most complete single-type treatment.
Three hundred and twenty-seven catheterizations were performed (including 111 in umbilical veins) using intravascular catheters. Femoral and subclavian veins were catheterized by the Seldiger method, umbilical vessels by the Ostroverskov method, and TLD according to our new technique.
Nineteen liquid media were administered for infusion therapy, including blood and blood components, as well as various medical solutions.  In this study 204 patients received 5593 injections (vol., 1651 1), excluding injections of glucose and physiological salt solutions. During the treatment period each patient was injected 27.4 ± 2.3 times (vol., 8.93 ± 1.70 1). Infusion therapy included immunomodulators, antibiotics, hormones, vitamins, desensitizing agents, antihistaminics, respiratory drugs, analeptics, cardiac glycosides, transaminase inhibitors, antioxidants, autolymph, autoplasma, and purified erythrocytes.
Comprehensive microbiological analysis of the blood outflow from the gastrointestinal tract (blood samples were obtained by direct inlet into the portal system) showed that this is a major channel of endogenous infection. We performed microbiological analyses of the lymph in TLD, biopsy punctates of deep burn layers, and the association of  lymph formula (in TLD) with portal blood culture changes. The result of this investigation suggested the idea of endolymphic antibacterial therapy using a recanalized umbilical vein. Penetration of antibacterial agents from blood capillaries into lymph capillaries and TLD caused their concentration in the central lymph on the path of intestinal microflora migration. This resulted in the suppression of lymph microflora in TLD, which until then was unattainable by standard treatment methods. The ratio of portal blood sterilization was 97.6:2.4, with a 4.1-fold reduction of antibiotic consumption.
We compared the results of stomach and duodenum endoscopy and endoscopic biopsy with the data of portonoinetry, lymphodonometry, and measurements of the pressor gradient in the lymphovenous anastamosis area. The data obtained showed that the appearance of gastrointestinal erosions and ulcers is associated with portal hypertension, pathological blood deposition in the splanchnic area, and hypoxia of splanchnic cavity organs. The level of portal hypertension accompanied by hypertension in TLD directly depended on the pressor gradient level. The increase in lymph production rate (five times above normal) and malfunctions of excessive lymph outflow from TLD into the caval system resulted in lymph collector failure and lymph and blood congestion in the hepatoportal system. Lymphatic vessels and hepatic veins compressed by intrahepatic branches of the portal veins interfered with blood outflow and inflow in the liver.' Disse's oedema increased blood flow malfunctions.
After burn trauma, portal hypertension and pathological stasis in the portal vein thus resulted in intra- and extrahepatic circulation damage that led to erosions and ulcers in the gastrointestinal tract. In a case presenting hypertension we used portocaval shunts (umbilical and femoral veins were connected by vessel catheters in order to discharge a portal channel). If necessary we used extracorporeal arterioportal transcatheter shunts (mostly femoro-umbilical) to heal liver hypoxia with stasis in the portal system.
Haemo and plasmabsorption of portal blood led to a sharp decrease in nitric residues, pigments, and ferment concentrations, which resulted in the emptying of the portal basin and the purification of liver blood inflow from intestinal toxins. As a consequence there was an improveinent the patients' general condition and in burn repair.
Infusion therapy accompanied by external lymph from TLD demonstrated the most profound and durable effects (especially with the use of haemo-, plasma-, and lymph absorption). As a result we observed the involution of ulcers and erosions in the stomach and duodenum. Infusions administered during the earliest post-traumatic period slowed down the development of ulcers and erosions.
The emptying of portal flow and hepatic lymph flow improved kidney function. No obliguria or anuria was observed in subjects treated with infusions in the subcutaneous vein lumens. Intraportal infusions indicated filtrable properties of the liver. Comparison of the results of treatment in two distinct groups (one receiving haemotransfusions in umbilical veins, the other in the vena cava) showed that pulmonary complications were three times less frequent in the first group. The data were confirmed by histomorphological analyses performed on 27 cats.
Microlots infused into the superior vena cava remained in pulmonary tissue capillaries, causing pulmonary hypertension, the opening of arteriovenous shunts, overload of left and then right parts of the heart, and development of cardiopulmonary insufficiency, causing death. When intraportal infusions of microlot suspensions were used, we observed their absolute retention in peripheral sections of the intrarenal portal collector. Owing to the normal functioning of the liver proper artery capillary collector, microlots were filtered in the sinuatrial system without damage to the sinusoidal flow.' Hepatographic analyses demonstrated the absence of liver ischaemia, which may be explained by dual hepatic circulation.' Intraportal infusions resulted in increased respiratory function. Even after mass infusions we did not observe pulmonary hypertension, which may occur after injections in subcutaneous veins.
Intraportal infusions were also used to deliver glucose directly into hepatic cells, where glueogen synthesis was disrupted by the burn disease.' Histomorphological analyses of the liver indicated rapid glucogen saturation after intraportal infusions of 5-10% glucose solution, which resulted in a decrease in parenchyrnal oedema, the recovery of normal alburnin and lymph ratio in the blood, and the disappearance of central lymph haemorrhage. We have determined that when L~tocopherol transumbilical infusions are used, L-tocopherol is delivered directly to cells and basilar membranes of the liver microcirculatory channels.
Intraportal infusions of protein hydrolysates, peptides, aminoacids, and proteins were more effective than infusions in subcutaneous veins. This is explained by the fact that the natural path from the intestine into the organism is through the portal system, where assimilation and adaptation for the organism take place, since the liver synthesizes most of the plasma and alburnin.` In the intrauterine state the path from mother to foetus is through the umbilical vein. Intraportal parenteral feeding is therefore the most physiological manner. The combined use of umbilical veins and TLD was effective and reduced the loss of fluid and alburnin from the burn surface. It was noted that the greater the lymph outflow through the external TLD drain, the smaller the loss of fluid and alburnin. In many cases the use of the external TLD drain led to a decrease in burn exudations. After TLI) lymph purification by selective sorbents it was reinfused through an umbilical vein, and it was found that: there was a decrease in fluid and alburnin as a result of lymph outflow, burns were drained, with the formation of crusts that prevented penetration of infection and decreased toxic absorption toxins, bacteria, and autoaggressive cells ran off the organism with the outflowing lymph owing to the running-off of immunoglobulins with lymph we were able to regulate immunity by using this suppressive effect, so necessary when purulent processes occur in burn wounds during epidermoplasty
Patients treated with intraportal infusions achieved stable nonspecific immunity sooner than patients treated with standard methods. The use of combined immunomodulators, anatoxins, immunoplasma and immunoglobulins, lymph absorption and external lymph leads from TLI), and intraportal haemotransfusions led to an increase in immunoglobulin concentration in peripheral blood, T-lymphocyte activity, and 13-lymphocyte counts.' When toxic and serum hepatitis developed, intraportal injections were more effective.
The infusion therapy programme ran for 7.1 ± 1.2 days, depending on the patient's general condition.
Infusion therapy has profound therapeutic possibilities in the treatment of burn disease. The use of infusion therapy in the earliest hours after deep burns prevented the appearance of ulcers and erosions in the stomach and duodenum, portal hypertension, anaemia, and pathological blood stasis; it decreased hypoxia and liver degeneration; it prevented intestinal microflora migration and metabolic and microbic intoxication in tissues, lymph, and regional blood flow collectors; and it helped water balance without portal haemodynamic malfunction.' The use of regional (intraumbilical) infusion therapy decreased mortality by 17.8 ± 7.2% and treatment time by 14.5 ± 3.6 days; the time period before the first epidermatoplastic operation by 7.3 ± 1.1 days; the number of epidermatoplastie operations from 2.7 ± 0.1 to 1.9 ± 0.3 (p <0.05); transfusions 4.1 times; and the biochemical index normalization period by 11.7 ± 1.8 days. We did not observe any complications provoked by this method.

RESUME. La méthode de l'injection intraportale (injection dans le système veineux à travers des vaisseaux ombilicaux recanalisés) est employé rarement dans le traitement des complications des brûlures. Les Auteurs présentent une étude détaillée de cette méthode dans le traitement des brûlure profondes. Ils ont trouvé que les l'incrément de la pression de la vein porte cause des problemes pour l'hémostase, le mauvais fonctionnement de la circulation intra- et extracorporelle, l'hypoxie, la perméabilité capillaire, et l'hyperproduction de la lymphe hépatique. Le degré de l'hypertension portale et de la déposition de sang et de lymphe dans le système régionale dépend de l'extension de la surface brûlée et de la profondeur, de l'âge du patient, et du délai après la brûlure. Les Auteurs fomissent les résultats du traitement chirurgical de 554 patients âgés jusqu'à 81 ans atteints de brûlures dans jusqu'à 85% de la surface corporelle, avec les données expérimentales. Les patients qui ont reçu les infusions intraportales ont manifesté une immunité stable non spécifique plus rapidement que les patients traités avec les méthodes de routine. Les Auteurs concluent que la thérapie perfusive offre des possibilités très importantes dans le traitement de la maladie des brûlés.

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