Uterine rupture: a complication of midtrimester abortion

The intraamniotic injection of prostaglandin F2alpha and/or hypertonic saline may be associated with serious uterine and cervical trauma. Multiparity and superimposed uterotonic stimulation by oxytocin are generally thought to be contributory. A patient is described who failed to abort vaginally after an uneventful intraamniotic infusion of prostaglandin F2 alpha in combination with hypertonic saline; 48 hours later she evacuated the uterine contents into the peritoneal cavity through a rent in the uterine fundus. The uterine rupture occurred even though there had been no uterotonic stimulation by oxytocin.     

Epinephrine Improves the Efficacy of Nebulized Hypertonic Saline in Moderate Bronchiolitis: A Randomised Clinical Trial

Background and Aims

There is no evidence that the epinephrine-3% hypertonic saline combination is more effective than 3% hypertonic saline alone for treating infants hospitalized with acute bronchiolitis. We evaluated the efficacy of nebulized epinephrine in 3% hypertonic saline.

Patients and Methods

We performed a randomized, double-blind, placebo-controlled clinical trial in 208 infants hospitalized with acute moderate bronchiolitis. Infants were randomly assigned to receive nebulized 3% hypertonic saline with either 3 mL of epinephrine or 3 mL of placebo, administered every four hours. The primary outcome measure was the length of hospital stay.

Results

A total of 185 infants were analyzed: 94 in the epinephrine plus 3% hypertonic saline group and 91 in the placebo plus 3% hypertonic saline group. Baseline demographic and clinical characteristics were similar in both groups. Length of hospital stay was significantly reduced in the epinephrine group as compared with the placebo group (3.94 ±1.88 days vs. 4.82 ±2.30 days, P = 0.011). Disease severity also decreased significantly earlier in the epinephrine group (P = 0.029 and P = 0.036 on days 3 and 5, respectively).

Conclusions

In our setting, nebulized epinephrine in 3% hypertonic saline significantly shortens hospital stay in hospitalized infants with acute moderate bronchiolitis compared to 3% hypertonic saline alone, and improves the clinical scores of severity from the third day of treatment, but not before.

Trial Registration

EudraCT 2009-016042-57     

Potent stimuli for vasopressin release,hypertonic saline and hemorrhage,cause antipyresis in the rat

Two potent stimuli for AVP release into the blood, hemorrhage and hypertonic saline, were evaluated for their antipyretic effects in the rat. Hemorrhage of 20% of estimated blood volume reduced brain temperature of febrile but not afebrile rats confirming earlier research in the sheep. Hypertonic saline was also antipyretic in the rat. Hypertonic urea was somewhat less antipyretic whereas hypertonic glucose had no effect on febrile temperatures. AVP release into the peripheral circulation showed the relationship saline > urea > glucose and parallelled the antipyretic effectiveness of these solutes. The antipyresis caused by hypertonic saline was not significantly different in rats passively immunized intravenously with AVP antiserum than in rats which received hypertonic saline alone. These results provide indirect evidence that endogenous AVP is released in the brain following hemorrhage or hypertonic challenge and that this endogenous AVP can affect central febrile pathways.     

Hypertonic sodium resuscitation after hemorrhage improves hemodynamic function by stimulating cardiac, but not renal, sympathetic nerve activity

Small volume hypertonic saline resuscitation can be beneficial for treating hemorrhagic shock, but the mechanism remains poorly defined. We investigated the effects of hemorrhagic resuscitation with hypertonic saline on cardiac (CSNA) and renal sympathetic nerve activity (RSNA) and the resulting cardiovascular consequences. Studies were performed on conscious sheep instrumented with cardiac (n=7) and renal (n=6) sympathetic nerve recording electrodes and a pulmonary artery flow probe. Hemorrhage (20 ml/kg over 20 min) caused hypotension and tachycardia followed by bradycardia, reduced cardiac output, and abolition of CSNA and RSNA. Resuscitation with intravenous hypertonic saline (1.2 mol/l at 2 ml/kg) caused rapid, dramatic increases in mean arterial pressure, heart rate, and CSNA, but had no effect on RSNA. In contrast, isotonic saline resuscitation (12 ml/kg) had a much delayed and smaller effect on CSNA, less effect on mean arterial pressure, no effect on heart rate, but stimulated RSNA, although the plasma volume expansion was similar. Intracarotid infusion of hypertonic saline (1 ml/min bilaterally, n=5) caused similar changes to intravenous administration, indicating a cerebral component to the effects of hypertonic saline. In further experiments, contractility (maximum change in pressure over time), heart rate, and cardiac output increased significantly more with intravenous hypertonic saline (2 ml/kg) than with Gelofusine (6 ml/kg) after hemorrhage; the effects of hypertonic saline were attenuated by the β-receptor antagonist propranolol (n=6). These results demonstrate a novel neural mechanism for the effects of hypertonic saline resuscitation, comprising cerebral stimulation of CSNA by sodium chloride to improve cardiac output by increasing cardiac contractility and rate and inhibition of RSNA.     

高渗盐水联合沙丁胺醇雾化治疗小儿毛细支气管炎的疗效比较

目的:观察高渗盐水联合沙丁胺醇雾化吸入治疗小儿毛细支气管炎疗效。方法:选取2012年1月~2013年2月在我院接受治疗的毛细支气管炎患儿78例,随机分为治疗组和对照组,每组各39例。两组均采用综合性治疗及对症处理,在此基础上,对照组给予生理盐水联合沙丁胺醇雾化吸入,治疗组给予3.6%高渗盐水联合沙丁胺醇雾化吸入。观察两组痰液炎性细胞计数差值及临床疗效。结果:治疗组总有效率94.87%(37/39),对照组总有效率82.05%(32/39),显著差异有统计意义(P0.05)。治疗组患儿雾化吸入前和治疗5 d后痰液细胞总数、淋巴细胞数和中性淋巴细胞数均低于对照组(P0.01)。结论:联合使用3.6%的高渗盐水和雾化吸入沙丁胺醇,可有效减少炎症细胞数量,缓解气道水肿与阻塞,缓解临床症状,缩短病程,值得推广。     

Randomised Controlled Trials May Underestimate Drug Effects: Balanced Placebo Trial Design

Background

It is an inherent assumption in randomised controlled trials that the drug effect can be estimated by subtracting the response during placebo from the response during active drug treatment.

Objective

To test the assumption of additivity. The primary hypothesis was that the total treatment effect is smaller than the sum of the drug effect and the placebo effect. The secondary hypothesis was that non-additivity was most pronounced in participants with large placebo effects.

Methods

We used a within-subject randomised blinded balanced placebo design and included 48 healthy volunteers (50% males), mean (SD) age 23.4 (6.2) years. Experimental pain was induced by injections of hypertonic saline into the masseter muscle. Participants received four injections with hypertonic saline along with lidocaine or matching placebo in randomised order: A: received hypertonic saline/told hypertonic saline; B: received hypertonic saline+lidocaine/told hypertonic saline; C: received hypertonic saline+placebo/told hypertonic saline+pain killer; D: received hypertonic saline+lidocaine/told hypertonic saline+pain killer. The primary outcome measure was the area under the curve (AUC, mm²) of pain intensity during injections.

Results

There was a significant difference between the sum of the drug effect and the placebo effect (mean AUC 6279 mm² (95% CI, 4936–7622)) and the total treatment effect (mean AUC 5455 mm² (95% CI, 4585–6324)) (P = 0.049). This difference was larger for participants with large versus small placebo effects (P = 0.015), and the difference correlated significantly with the size of the placebo effect (r = 0.65, P = 0.006).

Conclusion

Although this study examined placebo effects and not the whole placebo response as in randomised controlled trials, it does suggest that the additivity assumption may be incorrect, and that the estimated drug effects in randomised controlled trials may be underestimated, particularly in studies reporting large placebo responses. The implications for randomised controlled trials and systematic reviews need to be discussed.     

Comparison of Normal Saline,Hypertonic Saline Albumin and Terlipressin plus Hypertonic Saline Albumin in an Infant Animal Model of Hypovolemic Shock

Introduction

In series of cases and animal models suffering hemorrhagic shock, the use of vasopressors has shown potential benefits regarding hemodynamics and tissue perfusion. Terlipressin is an analogue of vasopressin with a longer half-life that can be administered by bolus injection. We have previously observed that hypertonic albumin improves resuscitation following controlled hemorrhage in piglets. The aim of the present study was to analyze whether the treatment with the combination of terlipressin and hypertonic albumin can produce better hemodynamic and tissular perfusion parameters than normal saline or hypertonic albumin alone at early stages of hemorrhagic shock in an infant animal model.

Methods

Experimental, randomized animal study including 39 2-to-3-month-old piglets. Thirty minutes after controlled 30 ml/kg bleed, pigs were randomized to receive either normal saline (NS) 30 ml/kg (n = 13), 5% albumin plus 3% hypertonic saline (AHS) 15 ml/kg (n = 13) or single bolus of terlipressin 15 μg/kg i.v. plus 5% albumin plus 3% hypertonic saline 15 ml/kg (TAHS) (n = 13) over 30 minutes. Global hemodynamic and tissular perfusion parameters were compared.

Results

After controlled bleed a significant decrease of blood pressure, cardiac index, central venous saturation, carotid and peripheral blood flow, brain saturation and an increase of heart rate, gastric PCO₂ and lactate was observed. After treatment no significant differences in most hemodynamic (cardiac index, mean arterial pressure) and perfusion parameters (lactate, gastric PCO₂, brain saturation, cutaneous blood flow) were observed between the three therapeutic groups. AHS and TAHS produced higher increase in stroke volume index and carotid blood flow than NS.

Conclusions

In this pediatric animal model of hypovolemic shock, albumin plus hypertonic saline with or without terlipressin achieved similar hemodynamics and perfusion parameters than twice the volume of NS. Addition of terlipressin did not produce better results than AHS.     

高张NaCl溶液对失血大鼠血压代偿的作用

使麻醉大鼠在5min 内失血,致使动脉血压下降至25mmHg,然后静脉注射1/10失血量的高张 NaCl 溶液(Hypertonic solution,HS,7.5%NaCl)或生理盐水(NS)。静脉注射少量 HS 能明显促进失血后血压回升,这个作用能为6-羟多巴胺或巯甲丙脯酸显著减弱,若将这两个药物同时应用,则 HS 的升压作用完全被解除。HS 使血浆 Na~+浓度明显升高,而 NS使之下降。侧脑室微量注射 HS 后也明显促进动脉血压的恢复。这些实验结果表明失血后静脉注射少量 HS 可升高血浆 Na~+浓度,高 Na~+作用于中枢神经系统,激活交感神经系统和肾素-血管紧张素系统,从而促使血压迅速恢复。     

Termination of Pregnancy with Intra-amniotic Hypertonic Saline

Successful therapeutic abortion was performed consecutively by an intra-amniotic injection of hypertonic saline in 102 out of 110 patients in whom the size of the uterus corresponded with a pregnancy of 16 weeks or more.A spontaneous abortion of the fetus followed the injection alone in 92 of the cases, and the overall injection-delivery interval was 39·75 (range 11-98) hours. In 10 women intravenous oxytocin injection was used as an additional uterine stimulant because contractions were not established after 48 hours. Complete spontaneous expulsion of the placenta occurred in 71 cases, and evacuation of the placenta under general anaesthesia was required in the other 31.No major complication occurred among the 110 patients.     

In vitro protoscolicidal effects of hypertonic glucose on protoscolices of hydatid cyst

To evaluate the protoscolicidal effects of various concentrations of hypertonic glucose, live protoscolices of sheep were exposed to 10%, 15%, 25% and 50% glucose solutions. Cetrimide (0.5%), silver nitrate (0.5%) and hypertonic saline (20%) were used as positive controls, while physiological saline was used as a negative control. After 1, 2 and 5 min, the protoscolicidal effects were determined by 1% eosin. A 25% glucose solution had no significant protoscolicidal effect. However, a 50% glucose solution revealed higher protoscolicidal effect than 0.5% silver nitrate but weaker effect than 0.5% cetrimide; the effect was comparable with that of 20% hypertonic saline. The results showed that hypertonic glucose solution is highly effective in killing protoscolices of Echinococcus granulosus in vitro.     

The effects of injection of water or hypertonic saline on ornithine decarboxylase activity of neonatal rat heart and brain

Intraperitoneal injection of deionized water (0.25ml/10 g body wt) produced a large increase in ornithine decarboxylase activity in cerebral cortex and heart of 6 day old rats, but had no effect on those activities in the 20 day old rat. Injection of the same dose of hypertonic (1.8%) saline caused a marked decline in the activity of this enzyme in both cerebral cortex and heart of the 6 day old rat and in the heart of 20 day old rats. In neonatal rats, the increase in heart ornithine decarboxylase elicited by the injection of water and the decline in activity which follows the injection of hypertonic saline were both evident within 30 minutes after injection; both effects were maximal two hours post-injection and both persisted for longer than four hours after injection. A decline in enzyme activity observed after injection of hypertonic saline was also found following the injection of hypertonic glucose, suggesting that osmotic effects, rather than specific ion effects, were mediating the loss of activity. The K_M of ornithine decarboxylase in neonatal heart decreased following hypertonic saline injection, whereas that of cerebral cortex did not, supporting previous suggestions that the ornithine decarboxylase in heart may have unique regulatory controls.     

Heart atrial auriectomy reduces the diuretic and natriuretic responses to a hypertonic saline load

Acute bilateral atrial auriectomy in anesthetized dogs reduced diuresis and natriuresis induced by both extracellular fluid volume expansion with isotonic saline and a hypertonic saline load. Since a hypertonic saline load, in contrast to isotonic saline infusion, was not accompanied by a significant increase in central venous pressure it is proposed that either increased plasma osmolality or plasma sodium concentration (or both) participate in the modulation of the atrial natriuretic mechanism.     

Suppression by naloxone of water intake induced by deprevation and hypertonic saline in intact and hypophysectomized rats

Naloxone, an opiate antagonist, was administered to intact and hypophysectomized male rats following hypertonic saline pretreatment or 12 hr water deprivation. Water intake following hypertonic saline or water deprevation was reduced by 0.01 – 10 mg/kg of naloxone in a dose-related fashion in both intact and hypophysectomized rats. Water consumption induced by hypertonic saline administration appeared to be more susceptible to the suppressant effects of naloxone than did that evoked by water deprevation. These results demonstrate that naloxone reduces water intake in the rat following intracellular dehydration by hypertonic saline administration, as well as after general dehydration induced by water deprevation. Furthermore, the suppressant effects of naloxone on water intake do not appear to involve pituitary endorphins, although a possible involvement of antidiuretic hormone in these effects cannot be excluded.     

The trajectory of sensory pathways from the lamina terminalis to the insular and cingulate cortex: a neuroanatomical framework for the generation of thirst

The pathways involved in the emotional aspects of thirst, the arousal and affect associated with the generation of thirst and the motivation to obtain satiation, have been studied but remain poorly understood. Rats were therefore injected with the neurotropic virus pseudorabies in either the insular or cingulate cortex. After 2 days of infection, pseudorabies-positive neurons were identified within the thalamus and lamina terminalis. In a separate group of rats, the retrograde tracer cholera toxin subunit b (CTb) was used in combination with either isotonic (0.15 M NaCl) or hypertonic (0.8 M NaCl) saline (1 ml/100 g body wt ip). Rats injected with CTb in the insular cortex and stimulated with hypertonic saline had increased numbers of Fos/CTb double-positive neurons in the paraventricular, rhomboid, and reuniens thalamic nuclei, whereas those rats injected with CTb in the cingulate cortex and challenged with hypertonic saline had increased numbers of Fos/CTb double-positive neurons in the medial part of the mediodorsal, interanteromedial, anteromedial, and ventrolateral part of the laterodorsal thalamic nuclei. Rats injected with CTb in the dorsal midline of the thalamus and challenged with hypertonic saline had increased numbers of Fos/CTb double-positive neurons within the organum vasculosum of the lamina terminalis (OVLT), median preoptic nucleus, and insular cortex but not the subfornical organ. A small proportion of the CTb-positive neurons in the OVLT were immunopositive for transient receptor potential vanilloid 1, a putative osmoresponsive membrane protein. These results identify functional thalamocortical pathways involved in relaying osmotic signals to the insular and cingulate cortex and may provide a neuroanatomical framework for the emotional aspects of thirst.     

Hemodynamic effects of hypertonic saline in the conscious rat

The present study examines the role of vasopressin and the sympathetic nervous system on the hemodynamic effects of an infusion of hypertonic saline (NaCl 1.5 M) in conscious rats. The cardiovascular response to hypertonic saline was similar in both untreated and hexamethonium-pretreated rats. Mean arterial pressure increased by 15 mmHg as a consequence of the elevation of total peripheral resistance, while cardiac index was decreased. The administration of an antagonist to the pressor activity of vasopressin in rats with intact reflexes, partially decreased mean arterial pressure and total peripheral resistance and increased cardiac index toward basal values. In contrast, the hemodynamic response to hypertonic saline was totally reverted when the vasopressin antagonist was injected in the hexamethonium-pretreated rats. The results of the present study indicate that the hypertensive response induced by hypertonic saline in conscious rats is due to the vasoconstrictor effects of both vasopressin and the sympathetic nervous system.     

Cardiovascular changes induced by central hypertonic saline are accompanied by glutamate release in awake rats

To elucidate neurochemical mechanisms responsible for cardiovascular responses induced by central salt loading, we directly perfused the paraventricular nucleus (PVN) of the hypothalamus region with hypertonic saline (0.3 or 0.45 M) by using an in vivo brain microdialysis technique. We then measured the extracellular concentrations of glutamate in the PVN region in conscious rats along with the blood pressure and heart rate. Blood pressure, heart rate, and glutamate levels were increased by perfusion of 0.45 M saline; however, they did not change by perfusion of 0.3 M saline. Next, we examined the possible involvement of glutamate in the cardiovascular responses induced by hypertonic saline. Dizocilpine, a noncompetitive antagonist of the N-methyl-D-aspartate (NMDA) receptor, attenuated the increases of blood pressure and heart rate, although 6-cyano-7-nitroquinoxaline-2,3-dione, an antagonist of the non-NMDA receptor, did not affect the blood pressure and heart rate. Our results show that local perfusion of the hypothalamic PVN region with hypertonic saline elicits a local release of glutamate, which may act via NMDA-type glutamate receptors to produce cardiovascular responses.     

Induction of therapeutic abortion using either extra-amniotic prostaglandin F2α or hypertonic saline followed by oxytocin : A clinical comparison of the two methods

PGF_2α or hypertonic (20 per cent) saline followed by oxytocin was used to terminate pregnancy in 160 women between the 10th and 20th weeks of gestation.In the patients treated with PGF_2α minor side-effects were reported in about 50 per cent of the cases, however, the method was superior to hypertonic saline with regard to the number of complications and the length of stay in hospital.     

Serotonergic mechanisms of the lateral parabrachial nucleus and cholinergic-induced sodium appetite

Central cholinergic mechanisms are suggested to participate in osmoreceptor-induced water intake. Therefore, central injections of the cholinergic agonist carbachol usually produce water intake (i.e., thirst) and are ineffective in inducing the intake of hypertonic saline solutions (i.e., the operational definition of sodium appetite). Recent studies have indicated that bilateral injections of the serotonin receptor antagonist methysergide into the lateral parabrachial nucleus (LPBN) markedly increases salt intake in models involving the activation of the renin-angiotensin system or mineralocorticoid hormones. The present studies investigated whether sodium appetite could be induced by central cholinergic activation with carbachol (an experimental condition where only water is typically ingested) after the blockade of LPBN serotonergic mechanisms with methysergide treatment in rats. When administered intracerebroventricularly in combination with injections of vehicle into both LPBN, carbachol (4 nmol) caused water drinking but insignificant intake of hypertonic saline. In contrast, after bilateral LPBN injections of methysergide (4 microg), intracerebroventricular carbachol induced the intake of 0.3 M NaCl. Water intake stimulated by intracerebroventricular carbachol was not changed by LPBN methysergide injections. The results indicate that central cholinergic activation can induce marked intake of hypertonic NaCl if the inhibitory serotonergic mechanisms of the LPBN are attenuated.     

Gastrointestinal osmoreceptors and renal sodium excretion in humans

The hypothesis that natriuresis can be induced by stimulation of gastrointestinal osmoreceptors was tested in eight supine subjects on constant sodium intake (150 mmol NaCl/day). A sodium load equivalent to the amount contained in 10% of measured extracellular volume was administered by a nasogastric tube as isotonic or hypertonic saline (850 mM). In additional experiments, salt loading was replaced by oral water loading (3.5% of total body water). Plasma sodium concentration increased after hypertonic saline (+3.1 +/- 0.7 mM), decreased after water loading (-3.8 +/- 0.8 mM), and remained unchanged after isotonic saline. Oncotic pressure decreased by 9.4 +/- 1.2, 3.7 +/- 1.2, and 10.7 +/- 1.3%, respectively. Isotonic saline induced an increase in renal sodium excretion (104 +/- 15 to 406 +/- 39 micromol/min) that was larger than seen with hypertonic saline (85 +/- 15 to 325 +/- 39 micromol/min) and water loading (88 +/- 11 to 304 +/- 28 micromol/min). Plasma ANG II decreased to 22 +/- 6, 35 +/- 6, and 47 +/- 5% of baseline after isotonic saline, hypertonic saline, and water loading, respectively. Plasma atrial natriuretic peptide (ANP) concentrations and urinary excretion rates of endothelin-1 were unchanged. In conclusion, stimulation of osmoreceptors by intragastric infusion of hypertonic saline is not an important natriuretic stimulus in sodium-replete subjects. The natriuresis after intragastric salt loading was independent of ANP but can be explained by inhibition of the renin-angiotensin system.     

Behavioral characteristics in mice with brain lesions induced by hypertonic saline

Behavioral and histopathological characteristics were studied in mice treated repeatedly with hypertonic saline. In passive avoidance response using a step-through-type shuttle box, the mice treated with hypertonic saline showed shorter latency than control mice. No changes were observed in active avoidance response using a two-way-type shuttle box, spontaneous motor activity or motor function. Histopathological examination revealed marked and frequent degeneration and loss of neurons in the hippocampus as compared with animals after single treatment. The animals with severe hippocampal lesions showed impairment of passive avoidance response. The present brain lesions resulting from repeated treatment with hypertonic saline in mice are considered to be a possible model for memory disorders caused by hippocampal lesions in humans.