The osmotic link between hypoglycaemia and hypovolaemia.

OBJECTIVE: Hypoglycaemia is regularly accompanied by hypovolaemia. To suggest a mechanism for this phenomenon, we reviewed data from eight studies conducted by our group and examined the circumstances under which rebound hypoglycaemia develops after intravenous infusion of glucose solutions. MATERIAL AND METHODS: Forty healthy volunteers and 40 patients received a total of 122 infusions of glucose solutions at different rates, volumes and concentrations. Plasma glucose and the haemodilution were measured repeatedly during and for at least 2 h after the infusions ended. Glucose kinetics was calculated using a one-compartment turnover model and the plasma volume expansion was estimated from changes in Hb. RESULTS: A strong linear correlation was found between the glucose level and the plasma volume expansion in all series of experiments (p<0.001). After infusion, there was a risk of hypoglycaemia and hypovolaemia developing in healthy volunteers with a high glucose clearance and when infusing glucose solutions of higher concentrations than 2.5 %. Few and mild hypoglycaemic events occurred in patients with insulin resistance, such as in diabetics and in those undergoing surgery. The immediate linear relationship between hypoglycaemia and hypovolaemia suggests an osmotic link between the two parameters. More specifically, infused fluid accompanies glucose during uptake into the cells, while volume expansion by the same fluid has already elicited an effective diuretic response. CONCLUSION: Hypovolaemia is a consequence of hypoglycaemia after intravenous infusion of glucose solution and is caused by the osmotic translocation of fluid from the extracellular to the intracellular fluid space that occurs despite effective renal elimination.

Volume kinetics of glucose 2.5% solution and insulin resistance after abdominal hysterectomy.

BACKGROUND: We hypothesized that volume kinetics can be used to predict the rate of infusion of glucose 2.5% solution required to yield any predetermined plasma glucose level and degree of plasma dilution during the postoperative period. METHODS: In 15 women, mean age 50 yr (range 37-63), 2 days after an abdominal hysterectomy, a volume kinetic analysis was performed on an i.v. infusion of 12.5 ml kg(-1) ( approximately 900 ml) of glucose 2.5% given over 45 min. The insulin resistance was measured by a glucose clamp, and it was compared with daily bioimpedance analyses, which indicated the hydration of the intra/extracellular body fluid spaces. RESULTS: The clearance of glucose was 0.42 litre min(-1) (0.60 litre min(-1) is normal) while the other five parameters in the kinetic model were similar to those obtained in healthy volunteers. Computer simulations indicated that in a 70-kg female, at steady state, the rate of infusion (ml min(-1)) should be three times the allowed increase in plasma glucose (mmol litre(-1)). To maintain a predetermined plasma dilution the corresponding rate factor was 160. The glucose uptake during clamping was 3.9 mg kg(-1) min(-1) (7.0 is normal), which, during the second day after hysterectomy, correlated with the dehydration of the intracellular space (r=0.77; P<0.002) and with the protein catabolism as indicated by the urinary excretion of 3-methylhistidine (r=-0.76, P<0.002). CONCLUSION: The anaesthetist can prescribe postoperative administration of glucose 2.5% to reach any desired plasma glucose level and dilution by using the two presented nomograms. Insulin resistance correlated with intracellular dehydration and protein catabolism.

Pharmacokinetics of budesonide and its major ester metabolite after inhalation and intravenous administration of budesonide in the rat.

Fatty acid esterification of budesonide (BUD) has previously been documented in vitro as well as in large airway tissues after in vivo administration. This reversible esterification has the potential to prolong the anti-inflammatory effect of BUD and improve its airway selectivity. In the present study we characterized the plasma and tissue kinetics of BUD in the rat after inhalation and intravenous administration, and fitted a semiphysiological compartment model to the data. After inhalation, BUD half-life was longer (8.2 h) in trachea than in plasma (3.7 h), with similar data after intravenous dosing. BUD-oleate was formed in all tissues and had a longer half-life than BUD in trachea (18-20 h) but a similar half-life in plasma and muscle. Although the major fraction of BUD and BUD-oleate in the body was found in muscle, the airways, especially trachea, possessed a high capacity to form BUD-oleate. According to steady-state simulations, BUD-oleate accumulated in trachea, giving rise to persistent and higher concentrations of active BUD as compared with a situation wherein esters were not formed. BUD esters had no effect on plasma levels of BUD at steady state, however. BUD and BUD-oleate were shown to have a 2-fold and 10- to 50-fold selectivity, respectively, in airways as compared with muscle tissue after intravenous administration. After inhalation, the corresponding figures for selectivity were 10 and 50 to 1000, respectively.

Advanced family nursing with the control-congruence model.

This article describes family nursing with the control-congruence model (CC-model) developed at Wayne State University. The model is appropriate for clinical nurse specialists of all nursing disciplines who assist families to improve functioning together in order to cope with stress. Nursing care focuses on four dimensions of family functioning: system maintenance; system change; togetherness; and individuation. Two assessment tools are used: the assessment of strategies in families--functioning, which measures the emphasis on each of the four dimensions and the assessment of strategies in families--satisfaction, which assesses the satisfaction with family functioning. The paper cites four cases, one relative to each dimension, with examples of nursing care aimed at strengthening effective family strategies and introducing new behaviors. The examples include the interpretation of assessment of strategies in families scores before and after treatment.

Albumin metabolism and gastrointestinal loss of protein in chronic renal failure.

The catabolism of albumin labelled with 125I has been studied in 10 patients with advanced renal failure and in 5 with nephrotic syndrome. In 10 patients the gastrointestinal protein loss was studied simultaneously by determing the faecal excretion during 7 days of 51Cr after i.v. administration of 51Cr-labelled chromic chloride. The results were related to a control group in which 12 subjects were studied with respect to albumin catabolism and 17 with respect to the gastrointestinal protein losses. The results showed that: 1) In the two patient groups the means for serum albumin concnetration and the intravascular albumin pool, expressed as g or g/kg b.wt., were significantly decreased compared with those of the control group. 2) The two patient groups had an increased extravascular albumin pool as well as an elevated ration between extra- and intravascular pools. 3) The mean albumin catabolic rate was not increased in the renal insufficiency group, expressed as a percentage of the intravascular pool/24 h or as g/24 h. In the patients with nephrotic syndrome, however, it was significantly increased. 4) The renal insufficiency group had a mean cumulative 51Cr excretion during 7 days of 1.6+/- 0.80% of the given dose, the control group 0.63+/- 0.30%. This difference is highly significant. The patients with nephrotic syndrome did not differ from the control group.

[The effect of teat dipping with jodophores on udder health and the iodine content of the milk (author's transl)]. / Effekten av spendoppning med jodoforpreparat på juverhälsan och jodhalten i mjölken

The effect of teat-dipping with iodophore preparations on the incidence of mastitis was investigated for a period of 13 months in (i) 7 herds averaging 52 cows with an iodophore solution (JO-BAC¿ Superdip, 0.5 % active iodine) and in (ii) 9 herds averaging 47 cows with an iodophore solution (F 1042, 0.33 % active iodine). Teat-dipping was performed after each milking. The udder health of 8 herds averaging 28 cows was followed as a control (iii). Udder health was studied by CMT and bacterial examination of udder quarter samples every 10th week and by electronic cell counts of bulk milk every month. The mean incidence of infection at the beginning and end of the trial, the incidence of newly infected cows and quarters during the trial for each group was (i) 13.0 leads to 8.8 % of cows, 9.3 % of cows, 2.7 % of quarters; (ii) 17.4 % leads to 8.6 % of cows, 10.2 % of cows, 3.9 % of quarters; and (iii) 9.1 % leads to 15.6 % of cows, 13.7 % of cows and 4.5 % of quarters, respectively. Mean cell content of the three first and last cell counts were (i) 380.000 leads to 260.000 (ii) 310.000 leads to 280.000 and (iii) 250.000 leads to 260.000 cells/ml, respectively. The effect of teat-dipping with iodophore solution on the iodine content of bulk milk was investigated simultaneously in the above herds at monthly intervals. A further 26 herds (iiii) which did not employ iodine-containing teat-dips, were also studied. The mean iodine contents for the groups were (i) 127 mug/l, (ii) 152 mug/l; (iii) 94 mug/l and (iiii) 89 mug/l. The effect of teat-dipping with iodophore solution on the iodine content of bulk milk was also investigated in 13 herds where all delivered milk was examined for iodine content during 3 successive 14-day periods, namely (a) a control period without teat-dipping, (aa) a period using a weak iodine solution (0.1 % active iodine), and (aaa) a period using the recommended concentration. The mean iodine content in the 13 herds during period (a) varied from 14 to 266 mug/l and the mean for all herds was 65 mug/l. Corresponding figures for period (aa) were 30--291 and 88 mug/l and for period (aaa) 66--404 and 146 mug/l.

Haem biosynthesis studied in patients with rheumatoid arthritis.

In a study of the urinary excretion of haem precursors in patients with rheumatoid arthritis, iron-deficiency anaemia, and in healthy controls, certain differences were found. In iron-deficiency anaemia the excretion of both porphobilinogen and delta-aminolevulinic acid was increased, whereas in patients with rheumatoid arthritis only the porphobilinogen excretion was increased.A further study on the erythrocyte activity of delta-aminolevulinic acid dehydrase showed a higher activity in the erythrocytes from patients with rheumatoid arthritis compared with healthy controls.