SUMMARY The values of hourly diuresis in 40 patients with extensive burns were investigated and expressed graphically during the stage of burn shock. By analysis of the values and the patient's condition, a marked effect of the mental state on the course of burn shock and further treatment at the intensive care unit of the Prague Burns Centre was found. On a preliminary basis the effects of some drugs on the values of hourly diuresis were investigated.
Die einstundige Diurese bei welt verbrannten Patienten
Biaha J.
Die Werte der einstundigen Diurese wurden bei 40 weit verbrannten Patienten verfolgt and sie wurden in der Zeit des akuten Brandwundeschocks graphisch ausgedruckt. Anhand der Werteanalyse and des aktuellen Zustandes des Patienten wurde festgestellt ein beduetender EinfluB der Psychik auf den Verlauf des akuten Brandwundeschocks and auf die weitere Behandlung an der Intensivstation der Brandwundeklinik in Prag. Orientierungsweise verfolgte man die Auswirkungen einiger Medikamente auf die Werte der einstiindigen Diurese.
Key words: bum shock, hour diuresis, psychic state
Every patient with extensive burns suffers from shock due to the loss of fluids associated with generalized oedema, caused by the release of multiple mediators influencing cell membranes.
One of the crucial factors used to follow-up the development of burn shock is diuresis. Although the hourly urine output and its specific weight are very sensitive to changes in the general condition of the patient, they cannot be evaluated separately in isolation from other important parameters such as the haematocrit, mineralogram, blood pressure, pulse, respiration rate and quality of respirations, the state of the patient s consciousness etc.
<% immagine "Fig. 1","gr0000020.gif","Model graph to demonstrate the hourly diuresis of a patient with burns on 30-40 % of the body surface. In the initial stage the diuresis is limital, the values are almost stable. Then starts the preparatory stage and shock is terminated by potent diuresis. Later periods with high and optimal diuresis alternate throughout the period of treatment at the intensive care unit.",230 %>The hourly diuresis is monitored carefully in all trauma intensive care units. It is well known,however, that in patients with extensive burns changes in diuresis are extremely marked and from these changes various important facts can be derived that so far, might have escaped attention.
<% immagine "Fig. 2","gr0000022.jpg","Example of the effect. of food intake, visit's, TV and sleep on hourly diuresis.",230 %>The basic postulate in this respect was the rule that a simple picture has a much greater informative value than a group of assembled numerical data. The first indication of this was the experience of recent years, when at the Burn Centre, the effect of Seropram on the course of burn shock was investigated and the value of graphic expression of a numerical series, recorded by the nursing staff in the intensive care unit was noted. The study of the obtained graphs, revealed some order. Only one basic factor was lacking, i.e. finding a unifying denominator common to all patients, not only for patients with burns but also for other patients with severe injuries or diseases. Nothing of that sort was found in the literature. The complicated character of different injuries and the marked individual differences of the affected subjects prevented the finding of a uniform factor.
<% immagine "Fig. 3","gr0000023.jpg","",230 %>During the essential intravenous administration of fluids it is important to take into consideration the state of the cardiovascular system and the danger of acute cerebral and pulmonary oedema. Nevertheless, it is important to treat hypovolaemia, and the fluid intake is carefully monitored with regard to the patient's individual condition. The resuscitation with crystalloids and colloids should keep the hourly diuresis within the range of 0.5 and 1.0 ml urine per kg body weight per hour. For an adult this is 35-100 ml/hour. The hourly diuresis is one of the crucial indicators for orientation as to how the resuscitation is progressing.
<% immagine "Fig. 4a","gr0000024.gif","",230 %> <% immagine "Fig. 4b","gr0000025.gif","",230 %>Figs 3, 4. Examples of hourly diuresis in two suicides. The first case inflicted himself with burns as a demonstration without the true intention of killing himself. The second case committed the same act in depression and with a serious intention to terminate his life.
From a graphic presentation of hourly diuresis, it is apparent that after a certain period of reduced urinary output if the patient is properly resuscitated with fluid the so-called diuretic phase develops, signaling the termination of the burn shock. Also possible changes in the urinary excretion of minerals, i.e. increased potassium and reduced sodium excretion convert. These findings are, however, rare and thus lack standard validity. After termination of the first diuretic stage, further periods of exceptionally high hourly diuresis develop, alternating with lower diuresis varying around 1 ml/kg body weight or slightly more.
If we elaborate a graph sufficiently sensitive to items that are at first close, we reveal a very interesting fact. Before the onset of the diuretic stage proper, very frequently a certain prelude develops and low values alternate with higher ones that are approximately double (Fig. 1).
This condition of unsteady diuresis is of varying duration, but in a well-conducted course of shock treatment it lasts for about 24 hours. There are, however, individual differences, and it is necessary to take into consideration the concurrently administered medication. (The investigation is biased most by frequently administered diuretics, although even these provide some interesting information). If the course of treatment is not disturbed by other traumatizing events, potent diuresis develops exceeding by many times the original values. Its scope depends on the amount of administered fluids during the first days after the burns and their superficial losses. Neverthe less, the author observed repeatedly an up-to-ten fold increase of urinary output, i.e. if before the onset of the diuretic stage the diuresis was cca 70-100 ml/hour, after its onset the values were some 700-1000 ml/hour.
<% immagine "Fig. 5","gr0000026.jpg","Effect of diuretic (Furosemide) during the slow administration of fluids in a patient with burns of the airways and a risk of acute pulmonary oedema. Unless the patient is adequately saturated with fluids, the diuretic has little effect. Later the effect increases greatly but does not influence the diuretic stage terminating the shock period, but rather conceals it.",230 %>In a group of 40 varied patients hourly diure sis was expressed graphically. By analysis of the graphs and a comparison with the records on the condition and activities of the patients, some un expected facts were revealed. When investigating the causes of the sudden increase of urinary out put of patients with burns (during the period be fore as well as during the diuretic stage proper) the following facts became evident (Fig. 2).
Immediately before the increased urinary out put the patient had a meal, had a visit of close relatives or good friends, was given an analgetic, watched an interesting TV programme etc. It may thus be considered that he felt a certain re lief from his complaints, was relieved of certain anxieties, he enjoyed the food which produced pleasant sensations. Diuresis also increases markedly during periods of unrest and disorienta tion of alcoholics and drug addicts in delirium and during the period of withdrawal symptoms.
Similar factors were involved closely before the onset of the potent diuresis which terminated the burn shock. There was proposed a marked influence of the mental state of the patient.
This is even more apparent in the treatment of burns of suicidal subjects (Figs 3, 4). Figs 3, 4. Examples of hourly diuresis in two suicides. The first case inflicted himself with burns as a demonstration without the true intention of killing himself. The second case committed the same act in depression and with a serious intention to terminate his life.These patients can be divided into two groups. If prodromes and the subsequent diuretic stage developsoon after the accident (with regard to the extentof the injury), attempted suicide was intended as a demonstration of a certain objective, which wasachieved. If the suicide was meant seriously, however, the patient is angry with the attending staff who have spoiled his intention, the patient is permanently negativistic, aggressive, does not cooperate in treatment and the diuretic stage do not occur or is delayed. And while in the first case theshock is over in 48 hours, in the second case diuresis develops sometimes only after 14-17 days.Again, a marked inflence of the mental state on the course of the shock period can be seen.
The increase of diuresis may be a sign that the patient is fully aware of his burned body, he becomes reconciled to the given situation and accepts the perspective offered by the medical team as regards recovery. To put it briefly, he finds that the injury can be survived and decides to cooperate. This implies marked mental relief and terminates the stress condition. Additional similar periods continue as therapy proceeds successfully and the patient feels that the staff meets his ideas.
The evaluation of figures is difficult as every patient receives a different medication,and there were very few patients to whome only basic drugs were administered. The graphs of hourly diuresis in alcohol and drug addicts with burns were in structive as they did not differ from each other. This is probably due to the fact that the patient was influenced to such an extent by alcohol or the drug that he was not aware of the burn and therefore extreme amounts of catecholamines which otherwise dominate the stress condition were not released into the circulation. The effect of different drugs used in burn pa tients is rather complicated and it must be ana lyzed on a larger number of patients.
The effect of diuretics depends on the successfull resuscitation with fluids (Fig. 5).
If during this stage furosemide is used to increase the diuresis, it causes practically no response and the optimal effect is achieved only after the adequate fluid replacement. It does not affect the onset of the diuretic stage proper. However, administration of steroids may have an effect on the course of shock period and can reduce its duration. Steroids, how ever, have their limitations and a number of well known disadvantages. The interactions of concurrently administered drugs are remarkable, and a detailed analysis will follow in the future study.
<%
riquadro "Address for correspondence:
Josef Bldha, M. D.Srobdroua 50 100 34 Prague 10 Czech Republic I
" %>