Phẫu Thuật Bỏng: Tiếp Cận Và Phương Pháp Điều Trị Từ Trung Quốc (Chinese Burn Surgery)

13/10/2026 • by Bs CKI Phẫu thuật tạo hình, tái tạo và thẩm mỹ Trương Hoài Anh •

Tổng hợp những kinh nghiệm lâm sàng và phương pháp điều trị bỏng tiên tiến từ nền y học Trung Quốc. Cuốn sách bao quát từ hồi sức cấp cứu bỏng, xử lý hoại tử, ghép da vi mảnh đến phẫu thuật phục hồi chức năng và thẩm mỹ sẹo di chứng bỏng.

📂 Chuyên mục: Tài liệu thẩm mỹ, Phẫu thuật tái tạo, Điều trị sẹo

🏷️ Từ khóa: phẫu thuật bỏng, điều trị bỏng, tái tạo sẹo bỏng, burn surgery, ghép da

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123
Chinese Burn Surgery
Zongcheng Yang
Editor

Chinese Burn Surgery

(Trang không có chữ)

Zongcheng Yang
Editor
Chinese Burn Surgery

ISBN 978-94-017-8574-7 ISBN 978-94-017-8575-4 (eBook)
DOI 10.1007/978-94-017-8575-4
Springer Dordrecht Heidelberg New York London
Jointly published with People’s Medical Publishing House
ISBN: 978-7-117-13844-4, People’s Medical Publishing House
Library of Congress Control Number: 2014958183
© Springer Science+Business Media Dordrecht and People's Medical Publishing House 2015
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a speciﬁ c statement, that such names are exempt from the relevant protective laws and
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Printed on acid-free paper
Springer is part of Springer Science+Business Media ()
Editor
Zongcheng Yang
Third Military Medical University
Chongqing
China

This book is dedicated to the following professors who have made great
contributions to the establishment of Chinese Burn Medicine:
Professor Ao Li
Professor Jixiang Shi
Professor Liangneng Wang
Professor Zhayang Fang

(Trang không có chữ)

vii
Burn care was not deﬁ ned as a discipline but a branch subject of general surgery in China until
the 1940s. I vividly remember being told categorically by my senior surgeons that death was
inevitable for a patient with a burn injury involving over 30 % of total body surface area
(TBSA) when I was a surgical resident in the 1940s. We did our best to smear the burn wounds
with tannic acid and silver nitrate to prevent the absorption of “burn toxin”; nevertheless, most
patients died of sepsis in a few days. There was only one patient with large burn surface area
who survived. Our knowledge about ﬂ uid replenishment, burn sepsis, and organ failure was
meager at that time.
In 1957, to our great delight, a steel worker sustaining a burn injury covering 78 % TBSA
was successfully cured by experts from the Second Medical College of Shanghai and the
Guang Ci Hospital (renamed Rui Jin Hospital) with close collaborating. This success in
salvaging such a serious burned patient fanned the embers of interest of all the surgeons
nationwide to participate in taking care of burn patients with a renewed conﬁ dence that with
meticulous care and bold innovations in the treatment strategies, patients suffering from
major burns could be saved. Furthermore, after the wounds healed with transplantation of
allogeneic and autologous skin, scar contractures and disﬁ gurements as resulted from the
injury could be alleviated with rehabilitation treatment and plastic surgery. However, with
rapid advances in burn treatment, it was soon recognized that one should fully grasp the sci-
ence of the underlying pathophysiological mechanisms which rendered the unfortunate vic-
tims of burn injury so vulnerable to multiple fatal complications due to faltering homeostasis
and extreme susceptibility to infections. To fulﬁ ll these demands, institutes devoted to study
basic problems were soon established one after another in medical colleges and large-sized
hospitals, and all of them made signiﬁ cant and valuable contributions to the knowledge cov-
ering basic problems in burn injury and also improvements in burn care. Consequently, a
broadening of the realm of burn care was witnessed, which in turn resulted in a deepening
understanding in burn injury, improvements in the treatment, and lowering of mortality, with
improvement in the quality of victims’ life after recovery of the acute injury. Herein, the
students who are devoting themselves to a burn care profession shouldn’t forget the names
of the predecessors in this ﬁ eld such as Ao Li, Jixiang Shi, Liangnen Wang, Zhiyang Fang,
Changye Wang, etc., who had made such remarkable contributions to science and treatment
strategies in the realm of burn care in this country to raise our standard of burn care to a par
of that of advanced countries. This monograph, as I understand, is a compilation of works of
these mentors and their disciples. The broad scope of the chapters of this monumental work
is reﬂ ected in the concern of basic understanding of the pathological, physiological, bio-
chemical, and immunological changes produced by a burn injury as well as its technical
therapeutic modalities, complications, sequelae, and rehabilitation. The contents reﬂ ect
fully that the skin, as the largest organ by weight of the body, should not be viewed in isola-
tion. The idea of fragmentation of the body systems or organs must be abandoned before one
Pref ace

viii
is able to address the problems arising in the course of burn care. As a nonagenarian and also
a veteran in burn surgery, I am exceedingly glad to introduce this monograph to all surgeons
who are interested in burn care. My hearty congratulations to all the authors of this valuable
monograph!
Beijing, People’s Republic of China
Zhiyong Sheng , MD

Preface

ix
1 Development of Burn Medicine in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
Zongcheng Yang
2 The Alterations of Microcirculation in Burns. . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Keseng Zhao and Qiaobing Huang
3 Burn Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31
Zhenrong Guo and Zhaofan Xia
4 Infection in Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57
Guangxia Xiao and Weishi Xu
5 Bacterial Endotoxin and Exotoxin in Severe Burns . . . . . . . . . . . . . . . . . . . . . . .
89
Yongming Yao
6 Advances in Burn Immunology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Daizhi Peng
7 Burn Wound Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Bi Chen, Zhenjiang Liao, Zhenrong Guo, Xiaoyuan Huang , and Yiping Zhou
8 Reconstruction of Burn in the Late Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Bi Chen and Xiaoyuan Huang
9 Burn Wound Healing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Shuliang Lu
10 Growth Factors and Stem Cells for Wound Repair
and Tissue Regeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Xiaobing Fu
11 Inhalation Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Zongcheng Yang, Guohui Li
12 Electrical Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Yonghua Sun
13 Combined Radiation–Burn Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Tianmin Cheng
14 Postburn Multiple Organ Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Jiake Chai and Zhiyong Sheng
15 Metabolism in Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Shiliang Wang and Shilin Deng
Contents

x
16 Nutrition in Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Shiliang Wang and Shilin Deng
17 Pathological Changes of Visceral Organs and Endocrine
Glands After Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
Yisheng Chen and Jingquan Shi
Contents

xi
Editor-in-chief
Zongcheng Yang, Prof. Burn Institute, Southwest Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Associate Editors-in-chief
Bi Chen, Prof. Burn Center, Xi Jing Hospital, Fourth Military Medical University , Xi’an ,
People’s Republic of China
Yonghua Sun, Prof. Burn Institute, Ji Shui Tan Hospital , Beijing ,
People’s Republic of China
Shiliang Wang, Prof. Burn Institute, Southwest Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Zhenrong Guo, Prof. Burn Institute, First Hospital Afﬁ liated to Chinese
PLA General Hospital , Beijing , People’s Republic of China
Honorary Editors-in-chief
Zhiyong Sheng, Prof. Burns Institute, First Hospital Afﬁ liated to Chinese
PLA General Hospital , Beijing , People’s Republic of China
Tianmin Cheng, Prof. Combined Radiation Wound Institute, Third Military Medical
University , Chongqing , People’s Republic of China
Editor Board
Zongcheng Yang, Prof. Burn Institute, Southwest Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Kesen Zhao, Prof. Department of Physiopathology , Nan Fang Hospital, Southern Medical
University , Guangzhou , People’s Republic of China
Zhenrong Guo, Prof. Burn Institute, First Hospital Afﬁ liated to Chinese PLA General
Hospital , Beijing , People’s Republic of China
Contributors

xii
Zhaofan Xia, Prof. Burn Institute, Changhai Hospital, Second Military Medical University ,
Shanghai , People’s Republic of China
Guangxia Xiao, Prof. Burn Institute, Southwest Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Weishi Xu, Prof. Burn Institute, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong
University , Shanghai , People’s Republic of China
Yongming Yao, Prof. Burn Institute, First Hospital Afﬁ liated to Chinese PLA General
Hospital , Beijing , People’s Republic of China
Daizhi Peng, Prof. Burn Institute, Southwest Hospital, Third Military Medical University ,
Chongqing , People’s Republic of China
Bi Chen, Prof. Burn Center, Xi Jing Hospital, Fourth Military Medical University , Xi’an ,
People’s Republic of China
Zhenjiang Liao, Prof. Burn Institute, Rui Jin Hospital, School of Medicine, Shanghai Jiao
Tong University , Shanghai , People’s Republic of China
Xiaoyuan Huang, Prof. Burn Center, Xiang Ya Hospital, Central South University ,
Changsha , People’s Republic of China
Yiping Zhou, Prof. Burn Center, Nan Fang Hospital, Southern Medical University ,
Guangzhou , People’s Republic of China
Shuliang Lu, Prof. Shanghai Burn Institute, Rui Jin Hospital , Shanghai , China
School of Medicine, Shanghai Jiao Tong University , Shanghai , People’s Republic of China
Xiaobing Fu, Prof. Burn Institute, First Hospital Afﬁ liated to Chinese PLA General
Hospital , Beijing , People’s Republic of China
Guohui Li, Prof. Burn Institute, First Hospital Afﬁ liated to Nan Chang University ,
Nanchang , People’s Republic of China
Yonghua Sun, Prof. Burn Institute, Ji Shui Tan Hospital , Beijing ,
People’s Republic of China
Tianmin Cheng, Prof. Combined Radiation Wound Institute, Third Military
Medical University , Chongqing , People’s Republic of China
Jiake Chai, Prof. Burn Institute, First Hospital Afﬁ liated to Chinese PLA General Hospital ,
Beijing , People’s Republic of China
Zhiyong Sheng, Prof. Burn Institute, First Hospital Afﬁ liated to Chinese
PLA General Hospital , Beijing , People’s Republic of China
Shiliang Wang, Prof. Burn Institute, Southwest Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Shilin Deng, Prof. Burn Institute, Tian Jin Fourth Hospital , Tian Jin ,
People’s Republic of China
Yisheng Chen, Prof. Department of Pathology , Third Military Medical University ,
Chongqing , People’s Republic of China
Jingquan Shi, Prof. Department of pathology , Third Military Medical University ,
Chongqing , People’s Republic of China
Contributors

xiii
Contributors
Daxin Cao Professor, Burn Institute, Ji Shui Tan Hospital , Beijing , People’s Republic of
China
Jiake Chai Professor, Burn Institute, First Hospital Afﬁ liated to Chinese PLA General
Hospital , Beijing , People’s Republic of China
Bi Chen Professor, Burn Center, Xi Jing Hospital, Fourth Military Medical University ,
Xi’an , People’s Republic of China
Yisheng Chen Professor, Department of Pathology , Third Military Medical University ,
Chongqing , People’s Republic of China
Tianmin Cheng Professor, Combined Radiation Wound Institute, Third Military Medical
University , Chongqing , People’s Republic of China
Shilin Deng Professor, Burn Institute, Tian Jin Fourth Hospital , Tian Jin ,
People’s Republic of China
Yanling Dong Professor, Department of Biochemistry , Third Military Medical University ,
Chongqing , People’s Republic of China
Erfan Xie Department of Burns and Plastic Surgery , Suzhou Municipal Hospital
(North Branch) , Suzhou , People’s Republic of China
Jinfeng Fu Professor, Department of Burn Surgery , Kunming Second People Hospital ,
Kunming , People’s Republic of China
Xiaobing Fu Professor, Burn Institute, First Hospital Afﬁ liated to Chinese PLA
General Hospital , Beijing , People’s Republic of China
Jianchuan Gao Department of Burn Surgery, Beijing You’anmen Hospital , Beijing , China
Shengde Ge Professor, Institute of Burn Research, Changhai Hospital, The Second Military
Medical University , Shanghai , China
Guanghua Guo Professor, Burn Institute, First Hospital Afﬁ liated to Nan Chang University ,
Nanchang , People’s Republic of China
Zhenrong Guo Professor, Burn Institute, The First Hospital Afﬁ liated to Chinese PLA
General Hospital , Beijing , People’s Republic of China
Chunmao Han Professor, Department of Burn Surgery , Second Afﬁ licated Hospital,
Zhejiang University , Hangzhou , People’s Republic of China
Lixin He Department of Burn Surgery , Beijing You’anmen Hospital , Beijing , China
Dahai Hu Professor, Department of Burns and Cutaneous Surgery , Burn Center of PLA,
Xijing Hospital, The Fourth Military Medical University , Xi’an , People’s Republic of China
Xiaoyan Hu Institute of Burn Research, Changhai Hospital, The Second Military
Medical University , Shanghai , People’s Republic of China
Sha Huang Wound Healing and Cell Biology Laboratory , Institute of Basic
Medical Sciences, General Hospital of PLA , Beijing , People’s Republic of China
Xiaoyuan Huang Professor, Burn Center, Xiang Ya Hospital, Central South University ,
Changsha , People’s Republic of China
Contributors

xiv
Qiaobing Huang Professor, Department of Physiopathology , Nan Fang Hospital, Southern
Medical University , Guangzhou , People’s Republic of China
Feng Li Burn Institute, The First Hospital Afﬁ liated to Chinese PLA General Hospital ,
Beijing , China
Guohui Li Professor, Burn Institute, First Hospital Afﬁ liated to Nan Chang University ,
Nanchang , People’s Republic of China
Ligen Li Professor, Burns Institute, The First Hospital Afﬁ liated to Chinese PLA General
Hospital , Beijing , China
Qiao Liang Burn Institute, Rui Jin Hospital, School of Medicine, Shanghai Jiao
Tong University , Shanghai , People’s Republic of China
Zhenjiang Liao Professor, Burn Institute, Rui Jin Hospital, School of Medicine,
Shanghai Jiao Tong University , Shanghai , People’s Republic of China
Jie Liu Professor, Department of Physiopathology , School of Medicine, Shenzhen
University , Shenzhen , People’s Republic of China
Yingkai Liu Burn Institute, Rui Jin Hospital, School of Medicine, Shanghai Jiao
Tong University , Shanghai , People’s Republic of China
Shuliang Lu Professor, Shanghai Burn Institute, Rui Jin Hospital, School of Medicine,
Shanghai Jiao Tong University , Shanghai , People’s Republic of China
Pengfei Luo Institute of Burn Research, Changhai Hospital, The Second Military
Medical University , Shanghai , China
Xihua Niu Department of Burn Surgery, Zhengzhou First Hospital , Zhengzhou ,
People’s Republic of China
Yiwen Niu Shanghai Institute of Burns, Shanghai Research Center of Wound Repair,
Ruijin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , China
Daizhi Peng Professor, Burn Institute, Southwestern Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Xi Peng Professor, Burn Institute, Southwestern Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Shunzhen Qi Department of Burns and Plastic Surgery , Bethune International Peace
Hospital of PLA , Shijiazhuang , China
Zhiyong Sheng Professor, Burn Institute, First Hospital Afﬁ liated to Chinese PLA
General Hospital , Beijing , People’s Republic of China
Jingquan Shi Professor, Department of Pathology , Third Military Medical University ,
Chongqing , People’s Republic of China
Yonghua Sun Professor, Department of Biochemistry , Third Military Medical University ,
Chongqing , People’s Republic of China
Yinling Tan Professor, Department of Biochemistry , Third Military Medical University ,
Chongqing , People’s Republic of China
Fengjun Wang Professor, Burn Institute, Southwest Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Shiliang Wang Professor, Burn Institute, Southwest Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Contributors

xv
Zhanke Wang Pathology and Laboratory Department, 94 Hospital of PLA , Nanchang ,
People’s Republic of China
Xiqiao Wang Burn Institute, Rui Jin Hospital, School of Medicine, Shanghai Jiao
Tong University , Shanghai , People’s Republic of China
Zhaofan Xia Professor, Burn Institute, Changhai Hospital, Second Military Medical
University , Shanghai , People’s Republic of China
Guangxia Xiao Professor, Burn Institute, Southwest Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Ting Xie Ninth People’s Hospital Afﬁ liated Shanghai Jiao Tong University
School of Medicine , Shanghai , People’s Republic of China
Linshui Xu Professor, Department of Biochemistry , Third Military Medical University ,
Chongqing , People’s Republic of China
Mingda Xu Professor, Department of Burns and Cutaneous Surgery , Burn Center of PLA,
Xijing Hospital, The Fourth Military Medical University , Xi’an , People’s Republic of China
Weishi Xu Professor, Burn Institute, Rui Jin Hospital, School of Medicine, Shanghai Jiao
Tong University , Shanghai , People’s Republic of China
Hongming Yang Professor, Burn Institute, First Hospital Afﬁ liated to Chinese PLA General
Hospital , Beijing , People’s Republic of China
Zongcheng Yang Professor, Burn Institute, Southwest Hospital, Third Military Medical
University , Chongqing , People’s Republic of China
Yongming Yao Professor, Burn Institute, Chinese PLA General Hospital , Beijing ,
People’s Republic of China
Jiang Yuzhi Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine ,
Shanghai , People’s Republic of China
Keseng Zhao Professor, Department of Physiopathology , Nan Fang Hospital,
Southern Medical University , Guangzhou , People’s Republic of China
Yun Zhao Burn Institute, Southwest Hospital, Third Military Medical University ,
Chongqing , People’s Republic of China
Yiping Zhou Professor, Burn Center, Nan Fang Hospital, Southern Medical University ,
Guangzhou , People’s Republic of China
Xiongxiang Zhu Burn Center, Xi Jing Hospital, Fourth Military Medical University ,
Xi’an , People’s Republic of China
Juntao Han Professor, Burn Center, Xi Jing Hospital, Fourth Military Medical University ,
Xi’an , People’s Republic of China
Contributors

1
Z. Yang, Chinese Burn Surgery, DOI 10.1007/978-94-017-8575-4_1,
© Springer Science+Business Media Dordrecht and People’s Medical Publishing House 2015
Belonging to general surgery, burns did not become a specialty
until World War II. The attack of atomic bombs over the
Japanese cities of Hiroshima and Nagasaki resulted in tens of
thousands of burned casualties in an instant, which attracted
worldwide attention to burns with the ﬁ rst Burns Center
established by the US army. Whereas in China, people only
started to attach importance to burns during the Korean War
when the US troops used enormous incendiary weapons that
led to an increasing incidence of burns in the Chinese volun-
teer forces, so that more and more training courses for burns
and plastic surgery were organized. In 1952, the Academy of
Military Medical Sciences set up Burns Research Team. In
1957, Second Military Medical University and Academy of
Military Medical Sciences cofounded Emergency Surgical
Hospital with a Burns Unit. The period of the “Great Leap
Forward” in 1958 saw many severely burned patients. In
August 1958, Shanghai Guang Ci Hospital accomplished the
world’s ﬁ rst successful rescue for a patient with over 80 %
of burned area and set up a burns treatment unit. Soon after
various provincial and municipal hospitals, military univer-
sities, General Hospital and Military General Hospital all
established burns wards. Thus, China started extensive and
profound research on burns and launched the construction
of Burns Medical Science, leading to rapid improvement in
burns prevention and treatment. In December 1958 and in
January 1959, the State Ministry of Health and the Health
Bureau of PLA General Logistics Department convened ﬁ eld
meetings of experience exchanges in which burns treatment
protocols were drawn up. In 1962, the Burns Professional
Team of CPLA was established with Third Military Medical
University as the leading unit. Since then, Army Conferences
on Burns have been held every 2 years except for the period
of the Cultural Revolution. Till now 20 such conferences
have been organized and have played a promoting role in
the development of burns research in China. By the begin-
ning of the 1980s, the level of burns prevention and treat-
ment in China had signiﬁ cantly improved over 20 years
of endeavor. As many burns specialists had been trained
and quite a few high-level bases for burns prevention and
treatment had been set up, it won a great reputation within
the medical ﬁ elds in China and had a considerable impact
among the international peers. The senior experts in burns
area, such as Shi Jixiang and Li Ao, suggested that we should
initiate Burns Associations and start publications in order to
further advance the academic study. In 1982, the experts
from Shanghai Ruijin Hospital; Second, Third, and Fourth
Military Medical Universities; PLA General Hospital; and
Jishuitan Hospital made a joint proposal for the establish-
ment of Burns Association. In 1983, Burns Group of Surgery
Society of Chinese Medical Association was founded in
Shanghai upon the approval of the State Ministry of Health
and Chinese Medical Association. In 1986, Burns Society
of Chinese Medical Association was established in Tianjin
upon the approval of China Association for Science and
Technology and Chinese Medical Association. These facili-
tated the organization of academic exchanges and the pro-
motion of academic development, so that the system of burns
treatment gradually formed a network, which in turn played
a critical role in the rescue for emergent events and the treat-
ment for mass burned casualties.
In China, various academic activities have been persis-
tently held for a rather long time, but few exchanges of stu-
dents with foreign countries had been made until the end of
the Cultural Revolution. In 1971, in behalf of China, Wang
Changye from Beijing Jishuitan Hospital and Fang Chunhui
from Beijing Medical College were invited to attend the
Convention of International Surgical Society in Romania
and gave a speech on the conclusive reports of the ten
cases with over 90 % of burned area and over 70 % at third
degree cured in Shanghai Ruijin Hospital, Third Military
Medical University, Jishuitan Hospital, and PLA General
Hospital. The report was highly considered by the foreign
peers in the convention and the long-term closed state that
lacked contacts with international peers was changed. Since
1978 when China started the policy of reform and open-
ing up, the international exchanges in burns discipline
have also been enhanced. In June 1981, Shanghai Ruijin
Hospital successfully held the 1st International Symposium
Development of Burn Medicine
in China
Zongcheng Yang
1

2
on Burns. In October 1985, Third Military Hospital held
the 1st China-US International Conference on Burns with
100 odd participants from more than ten countries includ-
ing the USA, the UK, France, Italy, Russia, Japan, Turkey,
Yugoslavia, and India; since then this conference has been
held every 4 years. In 1996, China-Japan International
Conference on Infections was held in Chongqing. In 1998,
China-Japan International Conference on Burns was held
in Beijing. In 1998, International Symposium on Electric
Burns was held in Shanghai. Meanwhile, after the 1980s,
personnel working in burns ﬁ eld also went abroad to par-
ticipate in international conferences on burns and the related
professions, so a considerable number of young and middle-
aged burns specialists have the experience of overseas study
or visit. Also, many foreign burns experts came to China to
visit, give lectures, or carry out international collaborative
research. This gradually fostered each other’s understanding
and friendship and the foreign peers started to appreciate the
achievements made by China in burns. In 1988, Shi Jixiang
was conferred with Evans Award that is speciﬁ cally given
away by American Burn Association to foreign outstanding
burns experts. In 1994, Li Ao became the recipient of Evans
Award, too.
In 1985, “Chinese Journal of Burns and Plastic Surgery”
was initiated as advocated by the plastic surgery experts
Song Ruyao and Li Ao, and Song Ruyao was assigned as
chief editor. In 2000, burn surgery was separated from plastic
surgery in the journal and was renamed as “Chinese Journal
of Burns” with Xiao Guangxia as chief editor. This journal
has made great contributions to the development of burns
discipline.
In China, a comprehensive and a systematic study of burns
prevention and treatment was started from 1958. Different
levels of burns units were established afterward, including
burn institute, burn center, burn division and burn treatment
group; almost all of the major hospitals, afﬁ liated hospitals
of medical colleges, and some grass-roots hospitals started
to carry out burns treatment practices and relevant research,
forming a network of burns treatment. A number of burns
treatment bases that had remarkable inﬂ uence on both domes-
tic and foreign related ﬁ elds were established. For instance,
Burn Institute of Third Military Medical University and that
of Second Military Medical University were successively
listed as the national key units of universities; the former
was also listed as a state key laboratory. A number of burns
institutes and key laboratories were founded in the army and
in many provinces and cities, which became burns treatment
centers and/or research bases. After 50 years of efforts, a
large number of burns specialists who have profound profes-
sional knowledge, excellent therapeutical skills, and noble
occupational ethics were trained. Li Ao, Sheng Zhiyong, and
Fu Xiaobing were sequentially elected as Academicians of
Chinese Academy of Engineering. At present, some senior
experts who have been ﬁ ghting against burns for more than
40 years are still making every endeavor for the development
of this ﬁ eld; furthermore, many very talented young and
middle-aged academic leaders have already emerged.
Research on burns has been emphasized in China and for-
eign countries not only due to its high incidence but also
because of its complexity, so it is the best subject for study-
ing the primary issues of surgery (such as shock, infection,
wound healing, immunity, metabolism, and so on). Since
comprehensive and systematic burns research was initiated
in China in 1958, a whole set of complete, innovative, and
effective treatment protocols have been formed. The overall
cure rate for burns in China is generally beyond 95 % and the
burns bases have reached 98–99 %. LD 50 is generally beyond
80 % and that of the burns bases is above 90–95 %. A num-
ber of the cases that had a total burn area of over 90 % with
80–90 % of third-degree burns have been cured.
In the past 50 years, burns discipline has rapidly devel-
oped and the treatment has been constantly improved,
remaining in the front ranks of the world. However, this path
was not smooth; it was full of hardships and had also experi-
enced slumps. Therefore, burns prevention and treatment
work does not only come with valuable experience but also
painful lessons. In the past 50 years, the burns history of
China can be divided into three stages.
1.1
Stage of Founding and Exploration
(1958–1965)
From 1958 to the mid-1960s prior to the Cultural Revolution
was the stage of founding and exploration. Due to the “Great
Leap Forward” in 1958, there was a jump in the number of
burned patients. As burns was not yet a specialty in China
back then, the involved doctors had little experience in the
rescue of patients with a large area of burns. Then Shanghai
Guang Ci Hospital succeeded in curing a patient with 89 %
of burned area, which greatly inspired the conﬁ dence of the
burns professionals. In addition, they concluded the experi-
ence timely and provided a set of treatment protocols, lead-
ing to a rapid jump in the burns treatment level in China.
But affected by the aggressive thoughts of the “Great Leap
Forward” at that time, the treatment for burns also adopted
some aggressive measures. For example, the volume of ﬂ uid
input was blindly increased at early stages, which caused
pulmonary and cerebral edema, even sudden cerebral hem-
orrhagic death; thorough debridement was made before the
large area of burns underwent effective recovery, so that
the shock got worse; a large area of escharectomy was con-
ducted without a skin covering, which was soon complicated
with systematic infection. These “aggressive” measures
failed to treat the patients effectively, but got into difﬁ culties.
In January 1960, a timely nationwide experience exchanges
1 Development of Burn Medicine in China

3
meeting was held in Chongqing by the State Ministry of
Health, in which many hospitals concluded their experience
and reﬂ ected on the blind and aggressive lessons, starting to
realize the mistakes where the local was overemphasized but
the whole was neglected. In 1961, China’s economy encoun-
tered a severe recession and the industries basically stag-
nated; with a sharp drop in the number of burned patients,
many burns wards closed down and most of the burns per-
sonnel changed their profession. Fortunately, China’s several
major burns bases and the key academic leaders persisted in
the research on burns prevention and treatment. They made
use of the time when there was no burned patients to com-
prehensively analyze the cases and conscientiously sum up
the experience and lessons, so as to form a complete set of
scientiﬁ c protocols of burns treatment. This rapidly reversed
the initial confusion in burns treatment, raised the therapeu-
tical level, and assisted in curing a number of patients with
over 30–50 % of burned area at third degree.
The surface of wound is a fundamental pathological basis
for burns, and excision of eschar should be an ideal treatment
approach. But extensive burns lack autologous skin source,
so the wound cannot be covered after escharectomy, acceler-
ating the condition’s progression. In 1965, Shanghai Ruijin
Hospital created the approach – “to embed small pieces of
skin into the holes of a large sheet of allogeneic skin,” which
was later recognized as the “Chinese approach” internation-
ally. This approach essentially resolved the foresaid prob-
lem. Meanwhile, it was found that the scalp skin can be taken
multiple times, providing a very good source of autologous
skin. So the hospital carried out the operations that excised
the eschar of extensive burns in multiple times, which rap-
idly improved the cure level for extensive deep burns. Also,
the hospital cured a patient with over 90 % area of third-
degree burns for the ﬁ rst time. Even in the event of wound
sepsis, “urgent excision” was adopted to save the dying
patient. Since then graded eschar excision has become a rou-
tine approach in the treatment for burns in China, sustaining
China’s cure rate of burns among the top ranks in the world.
With the participation of the fundamental medical sci-
ence, China started fundamental theoretical research from
the 1960s. Unfortunately, as the Cultural Revolution began,
the research on burns was interrupted and the development
of burns profession in China became stagnant.
1.2
Stage of Stagnation and Recovery
(1965–1978)
All of the industries in China were destroyed during the
Cultural Revolution, so was the burns profession. Many
burns units closed down with the main leader transferred to
do labor work; many burns professionals changed their jobs
and the only remaining burns units were too badly managed
to conduct normal work. What’s worse, guided by the
immature leftist thoughts, the unscientiﬁ c approach of “one
needle, wisp of grass” was introduced to make burns treat-
ment simplistic and pseudo-scientiﬁ c. Fortunately, a set of
effective treatment protocols had already been concluded
and widely used before the Cultural Revolution. During the
Cultural Revolution, the few major burns bases in China
were still adhering to normal work and resisted the interfer-
ence; a group of middle-aged key experts were still striving
for burns treatment, basically maintaining China’s burns
treatment level.
After 1969, the social chaos largely ceased with all of the
industries to be recovered. Burns profession entered the
recovery stage. At that time, the most pressing task was to
re-popularize the measures of burns treatment in China and
to improve the capability of many new burns professionals or
the ones who had rusted their skills for long. In 1970, the
burns divisions of Seventh, Second, and Fourth Military
Medical Universities and PLA 301 Hospital summarized the
main therapeutic experience in China and compiled the book
focusing on China’s own materials – Burns Treatment . This
book played a very important role during the recovery stage.
It won the prize on 1978 National Science and Technology
Conference and its republication won the Third Prize of
National Science and Technology Advancement.
After 1970, China’s burns profession recovered quickly
as a number of burns treatment units were rebuilt and a group
of young professionals joined. The treatment protocols were
constantly improved and the cure rate reached a new high-
point. According to statistics, 16 units of the army admitted
48,978 burns cases from 1958 to 1979; the cure rate reached
95.07 %, LD 50 75.93 %, and LD 50 46.19 % for third-degree
burns.
1.3
Stage of Innovation
and Development (1978–)
The National Science and Technology Conference held in
1978 brought about the spring of science and inspired the
passion of the scientists. The burns professionals realized
that although China’s burns treatment level had been ranked
top in the world, the theoretic research lagged behind com-
pared with the advanced countries, so we must enhance the
experimental theoretic research in burns. In 1978, Third
Military Medical Hospital ﬁ rstly set up burns laboratory and
soon conducted theoretic research in such areas as inhalation
injury, burns infections, burns immunity, burns metabolism,
skin graft, and phosphorus burns. Subsequently, Shanghai
Ruijin Hospital, Second Military Hospital, and Beijing 304
Hospital also founded their laboratories in order to carry out
comprehensive burns research. Meanwhile, China resumed
postgraduate degree education and many burns institutes
1.3 Stage of Innovation and Development (1978–)

4
became China’s ﬁ rst batch of authorized units for master’s
and doctoral degrees. Postgraduate students became an
important force in burns research and promoted rapid devel-
opment of burns in China. In addition, collaborative work
had always been valued in burns research in China, so the
experts from fundamental disciplines also made contribu-
tions to burns research. More than 20 years of effort saw a lot
of innovative achievements and China’s level of burns
research is now close to that of advanced countries in the
world. The major achievements are brieﬂ y described as
follows:
Since burns research is closely integrated with clinical
practices in China, the research achievements can be of guid-
ance for clinical practices or converted into innovative mea-
sures, so as to constantly improve and perfect China’s unique
treatment protocols to ensure our burns treatment level is
always among the top ranks in the world. Academician Li
Ao analyzed the cases admitted in the military units: 16 units
admitted 48,978 cases from 1958 to 1978; 29 units admitted
64,320 cases from 1980 to 1992; and 28 units admitted
48,085 cases from 1993 to 1998. The analysis shows that
China’s burns treatment level has been gradually improved
with a higher cure rate (Tables 1.1 and 1.2 ) and lower shock
and infection rates (Tables 1.3 and 1.4 ).
After 1978, a comprehensive study was carried out on
burns, accomplishing many innovative results. It was found
that early damage is a key factor for treatment of severe
burns. Myocardial damage and cardiac dysfunction that
occur soon after severe burns are one of the causes for
inadequate blood perfusion after an injury. It was made
clear that vascular endothelial cells play an important role
in the pathogenesis of burns. The pathogenesis and preven-
tive measures for postburn enterogenous infection and sep-
sis were also systematically explored. A comprehensive
and systematic study was conducted on such postburn
organ complications as MODS (multiple organ dysfunc-
tion syndrome). There were also many innovative mea-
sures for the treatment of burns wounds, such as early
escharectomy that was successfully performed in the mid-
1960s; escharectomy during the shock stage has been
introduced in recent years, and the operators found there
are a variety of toxic substances under the eschar and the
subeschar ﬂ uid is a “storage bank of toxins,” so they car-
ried out early debridement and one-time repair of such
damaging burns as electric burns with different types of
ﬂ aps, muscle ﬂ ap, and composite tissue ﬂ ap. In addition,
the theory and techniques of plastic surgery were applied
to the early treatment for burns, which integrated early
treatment, late repair, functional recovery, and cosmetic
surgery of burns, reducing the incidence of mortality and
late deformity. Rejection mechanism for embedding small
pieces of autologous skin into the holes of a large sheet of
allogeneic skin was clariﬁ ed, and extensive research on tis-
sue engineering of the skin was conducted. Meanwhile, the
pathogenesis of inhalation injury was expounded in a com-
prehensive and systematic manner, and with the explora-
tion of a whole set of control measures, the treatment level
of inhalation injury was improved. Furthermore, based on
Table 1.1 Cure rate for different burned areas in the three stages (%)
Stage
TBSA < 50 %
TBSA50~
TBSA70 %~
1958–1978
97.48
71.84
27.68
1980–1992
97.55
89.21 [ 1 ]
62.80 [ 1 ]
1993–1998
97.41
89.58 [ 1 , 2 ]
62.89 [ 1 , 2 ]
p < 0.01 vs Stage 1, p > 0.05 vs Stage 2
Table 1.2 LA 50 comparisons in the three stages
Stage
Total LA 50
With third-degree LA 50
1958–1978
75.93
46.19
1980–1992
96.99 [ 1 ]
90.87 [ 1 ]
1993–1998
94.84 [ 1 , 2 ]
90.91 [ 1 , 2 ]
p < 0.01 vs Stage 1, p > 0.05 vs Stage 2
Table 1.3 Shock incidence for TBSA > 50 % patients in the three
stages (%)
Stage
Without third-degree
TBSA%
With third-degree TBSA%
50~
70~
50~
70 ~ (age)
1958–1978
58.85
62.93
63.75
78.50
1980–1992
48.71 [ 1 ]
49.24 [ 1 ]
51.50 [ 1 ]
62.01
1993–1998
23.49 [ 1 , 2 ] 26.54 [ 1 , 2 ] 44.30 [ 1 , 2 ] 59.49 [ 1 , 2 ]
p < 0.01 vs Stage 1, p > 0.05 vs Stage 2
Table 1.4 Incidence of systematic infection for TBSA > 50 % patients
in the three stages (%)
Stage
Without third-degree
TBSA%
With third-degree TBSA%
50~
70~
50~
70~ (age)
1958–1978
37.97
56.41
67.54
64.58
1980–1992
20.14
29.44
34.21
51.20
1993–1998
17.73 [ 1 , 2 ] 23.40 [ 1 , 2 ] 35.96 [ 1 , 2 ] 46.07 [ 1 , 2 ]
p < 0.01 vs Stage 1, p > 0.05 vs Stage 2
1 Development of Burn Medicine in China

5
extensive research on postburn metabolisms and nutri-
tional support, the burns professionals proposed a new
concept of “enterogenous hypermetabolism,” provided the
calorie supply formula for burned adults, and carried out
the experiments and clinical research on early enteral feed-
ing after burns.
References
1. Yang ZC. Major advances in burns research by China’s military
medical units. Med J Chin People Lib Army. 1991;4:274–7.
2. Li A. Achievements of study on treatment of burns in recent 40
years in China. Chin J Traumatol. 1998;15:325–7.
References

7
Z. Yang, Chinese Burn Surgery, DOI 10.1007/978-94-017-8575-4_2,
© Springer Science+Business Media Dordrecht and People’s Medical Publishing House 2015
2.1
Alteration of Microvascular
Permeability in Burn Injury
Qiaobing Huang
2.1.1
Introduction
The increase in the vascular permeability is the most impor-
tant pathological event in the pathogenesis of a burn injury.
A massive leakage of ﬂ uid from the vascular space leads to a
loss of blood plasma and a decrease in the effective circula-
tory blood volume, resulting in the formation of severe tissue
edema, hypotension or even shock in a severe burn injury
[ 1 ]. Fluid resuscitation has been the only valid method of
sustaining a burn patient’s blood pressure for a long time
owing to the lack of an overall and profound understanding
of the mechanisms of a burn-induced vascular hyperperme-
ability response.
The burn-induced hyperpermeability response occurs not
only at the location of a burn insult but also in distant organs
and tissues, attributed to the release and circulation of vari-
ous permeability-increasing cytokines and inﬂ ammatory
mediators such as thrombin, bradykinin, histamine, radical
oxygen species, vascular endothelial growth factor (VEGF),
tumor necrosis factor alfa (TNF-α), and lipopolysaccharide
(LPS)[ 1 , 2 ]. Endothelial barrier dysfunction is one of the
major reasons for the higher vascular permeability.
The notion of vascular permeability includes two differ-
ent aspects: the ﬁ ltration of water and hydrophilic substances
through intact capillaries and microvessels under normal
physiological conditions; and the massive leakage of macro-
molecules, such as plasma protein albumin, and subsequent
ﬂ uid from venules under acute and chronic inﬂ ammatory
conditions.
The endothelium controls the ﬂ ux of ﬂ uid, solutes across
the vessel wall, and is highly regulated by different transport
pathways, including transcellular and paracellular (or inter-
cellular) pathways. While many researchers over- emphasized
the pathway of their own interest, a generally accepted belief
is that the transport of protein and liquid in quiescent endo-
thelium occurs via the transcellular pathways, i.e., through
the movements of caveolae in capillary endothelial cells
(ECs) and vesiculovacuolar organelles (VVOs) in the endo-
thelium of venules and small veins. However, the intrinsic
and extrinsic stimulating mediators force the endothelium to
open up the paracellular gap by additional signaling regula-
tion that allows transport of solutes through interendothelial
junctions (IEJs) [ 2 ]. The endothelial barrier dysfunction is
accompanied by cellular morphological alteration, intercel-
lular gap formation, and transendothelial permeability aug-
mentation [ 3 ]. The underlying mechanisms involved in
endothelial barrier dysfunction include the activation of mul-
tiple endothelial signaling pathways and alterations of endo-
thelial structures and functions.
Agonist-induced hyperpermeability is usually reversible [ 4 ].
The recovery process of the barrier function may emerge
with the re-annealing of previously open interendothelial
junctions and the strengthening of the adhesion of ECs to
extracellular matrix that result from the re-equilibrium of
competing contractile and adhesive forces generated by the
cytoskeletal proteins and the adhesive molecules. Some sta-
bilizing mediators play positive roles in enhancing interen-
dothelial junctional connections and preventing the increase
in vascular permeability [ 2 , 5 ].
As early as 1966, we reported that the vascular permeabil-
ity increased in skin and muscle injury and in the injury of
distant organs, such as liver, spleen, and kidney, even in the
very early stages of a severe burn. This increase in permea-
bility may be prevented by pretreatment with cortisone [ 6 ].
We continued to explore the pathogenesis of endothelial dys-
function in shock and inﬂ ammation over the last decade.
This chapter mainly discusses the alteration in the organi-
zation of interendothelial junctions, and the motivation of the
contractile force of actomyosin during inﬂ ammation and
burn shock. It also covers some of the important signal path-
ways involved in those morphological and functional modi-
ﬁ cations. The emphasis is placed on a tight junction, the
The Alterations of Microcirculation
in Burns
Keseng Zhao and Qiaobing Huang
2

8
adherens junction, and the contractile forces of the ECs. The
effects of several signaling prokinases, including Rho kinase
(ROCK), prokinase C (PKC), and mitogen-activated proki-
nase (MAPK) are stressed. The contributions of some stabi-
lizing mediators of endothelial barrier function, such as
sphingosine 1-phosphate (S1P), are mentioned.
2.1.2
The Characteristics of Vascular
Permeability Alteration After
Burn Injury
It has been noticed that clinically, massive tissue edema usu-
ally occurs between 4 and 12 h after the burn or thermal
insult. However, our in vivo and in vitro studies demon-
strated that vascular permeability increases much earlier than
obvious tissue edema. Immediately after thermal injury in
the dorsal skin of rats, venules were isolated from thermal
area and perfused through cannulation. Venular permeability
was measured using a ﬂ uorescence ratio technique. The
result revealed a remarkable elevation in the permeability
coefﬁ cient of albumin (Pa) compared with venules of control
rats (Fig. 2.1 ) [ 7 ]. The in vivo detection of mesenteric venu-
lar permeability showed that only 15 min after dorsal ther-
mal injury, the vascular permeability in this distant nonburn
tissue was also increased [ 8 ]. The early increased permeabil-
ity in the thermal area may result from the direct effect of
heating and the subsequent protein denaturation. It may also
be the result of the immediate release of proinﬂ ammatory
mediators from injured cells and from activated neutrophils,
which rapidly accumulate in the injured dermis.
When we isolated normal mesentery venules and per-
fused them with burned plasma obtained 3–6 h after thermal
injury in rats, the venular permeability coefﬁ cient of albumin
increased 10 min after the perfusion and was sustained for
about 6 h [ 8 ]. This late effect of burned plasma on vascular
permeability would be the result of the second phase of syn-
thesis and release of cytokines from much more activated
inﬂ ammatory cells. The inﬂ ammatory mediators and cyto-
kines not only disrupt the endothelial barrier and increase the
outﬂ ux of macromolecules and ﬂ uid from vessels in the local
injured area, they also affect vascular permeability in distant
nonburn tissue and organs through circulation of the blood.
These factors are the major reasons for the massive tissue
edema in severe burn patients. By binding to their speciﬁ c
receptors, those cytokines or mediators target ECs and result
in morphological and functional alterations in endothelial
barrier function. It is of utmost important to elucidate the
mechanisms controlling this barrier function.
2.1.3
Junctional Structures Controlling
Vascular Permeability
The endothelium acts as a permeability barrier and an active
interface between the blood and the underlying tissues. The
integrity of ECs helps to maintain the vascular tone, throm-
boresistance and selective permeability to cells and pro-
teins. Normally, ECs are tightly connected through various
proteins that regulate the organization of a intercellular
junctional complex. The junctional structures then bind to
cytoskeletal proteins or cytoplasmic interaction partners
that allow the transfer of intracellular signals and govern the
barrier function of ECs under normal or inﬂ ammatory con-
ditions. It is the capillaries that fulﬁ ll the ultimate exchange
function of the circulation system, whereas postcapillary
venules, characterized by their high sensitivity to an inﬂ am-
matory mediator, play a more important role in the altera-
tion of vascular permeability during the inﬂ ammatory
processes.
2.1.3.1 Tight Junctions
The main structures responsible for the endothelial barrier
properties are tight junctions (TJs). TJs act as a primary bar-
rier to the diffusion of solutes through the intercellular space,
and create a boundary between the apical and the basolateral
plasma membrane domains. On a molecular level, TJs are
composed of integral membrane proteins and cytoplasmic
proteins. The integral membrane proteins of TJs include
junctional adhesion molecules (JAM1, -2), occludin, clau-
din- 1, -2, and -5. They polymerize linearly within lipid bilay-
ers between two apposing endothelial membranes of adjacent
cells, and then associate with cytoplasmic zonula occludens-1,
-2, and -3 (ZO-1, ZO-2, ZO-3) and cingulin. By recruiting
various cytoskeletal and signaling molecules at their cyto-
plasmic surface, ZOs and cingulin provide a direct link
between TJ strands and cytoskeleton, especially actin
Fig. 2.1 Venules isolated from dorsal skin showed higher permeability
minutes after thermal injury

2 The Alterations of Microcirculation in Burns

9
ﬁ laments, and play an essential role in developing and stabi-
lizing TJs.
Recently, we demonstrated that the assembling of ZO-1,
displayed by immunoﬂ uorescence, formed a smooth line
along the EC border both in cultured cells and in intact ves-
sel, showing a tight connection between adjacent cell mem-
branes. When cells were stimulated with plasma from rat
with burn shock, ZO-1 deviated from the junctional area
and internalized into the cytoplasm, accompanied by inter-
cellular gap formation on cultured human umbilical vein
endothelial cells (HUVECs). The monolayer permeability
of cultured HUVECs revealed a concomitant increase with
the opening of interendothelial junction. Similar damage
was seen in mesentery microvessels from dorsally burn-
injured rats. These data not only suggest that burned plasma
affects the endothelial intercellular structures in distant tis-
sue and organ, but also reveal the important role of TJs in
maintaining the integrity of the endothelial barrier during
burn injury.
During other pathological processes, the maintaining of
endothelial barrier function also partially relies on the accu-
rate distribution of ZO-1. Advanced glycation end products
(AGEs) are one of the most important mediators in the devel-
opment of diabetic microvasculopathy. AGEs bind to spe-
ciﬁ c receptors and activate MAPK pathways, and trigger the
oxidative stress response [ 9 , 10 ]. Increased vascular perme-
ability is a crucial characteristic in the early stages of various
diabetic complications. Our previous study showed that the
application of AGEs on cultured ECs induced a disruption of
labeling ZO-1 on cellular borders and the formation of an
intercellular gap. However, unlike burn serum stimulation,
the insult of AGEs on cells did not cause obvious ZO-1 inter-
nalization in cytoplasm [ 11 ]. The mechanisms for this differ-
ence are yet to be explored.
2.1.3.2 Adherens Junctions
Adherens junctions between ECs are centered on the trans-
membrane
molecule
vascular
endothelial-cadherin
(VE-cadherin), and form intercellular homodimers in the
presence of Ca 2+ and play a pivotal role in endothelium integ-
rity and in the control of vascular permeability [ 12 ]. Ca 2+
here not only facilitates the formation of an adherens junction
but also protects the multicellular conﬁ guration by prevent-
ing the cadherin from undergoing hydrolysis. The cytoplas-
mic carboxyl portion of VE-cadherin is connected to
β-catenin/α-catenin or plakoglobin/α-catenin complexes and
then directly linked to actin, leading to strong cell–cell inter-
action. Other catenins, p120 and the p120-related protein
p0071, bind to an identical juxtamembrane intracellular
domain of VE-cadherin and exert various functions, such as
the regulation of cadherin levels by controlling cadherin
internalization and degradation in addition to cadherin clus-
tering at the junction.
The disruption or disassembly of VE-cadherin-based
adherens junctions is involved in response to proinﬂ amma-
tory mediators, and contribute to the increase in endothelial
permeability. Our study showed that the intervention of cul-
tured EC with burn serum could cause a noticeable alteration
of VE-cadherin spreading at the cellular border, displaying a
blurred distribution in the location of original sharp lining
around the cells without burn serum stimulation. This change
was accompanied by increased permeability in cultured
endothelial monolayer [ 13 ].
Under some other inﬂ ammatory circumstances, VE-
cadherin also plays a crucial role in the alteration of vas-
cular permeability. LPS is the major nosogenetic compo-
nent of Gram-negative bacteria. LPS induces a complicated
inﬂ ammatory cascade response when it enters into the blood
stream and could lead to sepsis, or even septic shock [ 14 ].
Our study showed that at a concentration of 400–500 μg/L,
LPS induced the obvious disorganization of VE-cadherin in
cultured primary HUVECs with the formation of remark-
able serrata along the cellular border and enlargement
of the intercellular gaps, which was apparently different
from the smooth lining of immunoﬂ uorescence staining of
VE-cadherin in adjacent HUVECs under a quiescent state
[ 15 ]. Data also revealed that the application of AGEs caused
a signiﬁ cant change in VE-cadherin distribution in cultured
ECs, accompanied by enhancement of ﬂ uorescein isothio-
cyanate (FITC)-labeled albumin transﬂ ux through the EC
monolayer [ 16 ].
Apart from their vascular permeability modulation
effects, the abovementioned cell–cell contacts also play mul-
tiple and diverse roles in regulating various cellular func-
tions, such as signaling, communication, differentiation,
migration, proliferation, shape, polarity, and development.
2.1.4
Role of Actomyosin in Modulating
Vascular Permeability
Filamentous actin (F-actin) and myosin are, respectively, the
track and motor components that comprise one of the major
systems for molecular movement in the cell [ 17 ]. Actin may
also be more than a simple structural component of the junc-
tions. In fact, there are ample ultrastructural data that impli-
cate the temporal expression, dynamic organization, and
spatial distribution of the actin cytoskeleton in altering the TJ
and AJ complex under various conditions [ 18 ]. Therefore,
actin is likely to play a critical role in modulating the integ-
rity of the endothelial barrier function.
Under normal conditions, F-actin forms a prominent
peripheral actin rim (PAR) at the outer area of ECs and
apparently delineates the cell-to-cell borders [ 7 ]. The phos-
phorylation of myosin light chain by myosin light chain
kinase (MLCK) triggers the formation of actomyosin
2.1 Alteration of Microvascular Permeability in Burn Injury

10
complex and produces contractile force in the cells that is
symbolized by polymerization of actin and the emergence of
stress ﬁ bers [ 17 ].
The actin cytoskeleton of nonmuscle cells responds to
extracellular stimuli through spatially and temporally reg-
ulated series of polymerization and depolymerization
reactions. Our study revealed that cells stimulated with rat
burned plasma showed obvious stress ﬁ ber formation with
a time- dependent enhancement, along with the disappear-
ance of PAR structure at the cellular border. We previously
reported that the inhibition of MLC phosphorylation with
an MLCK inhibitor, ML-7, modulated the venular basal
barrier function and signiﬁ cantly attenuated the increase in
vascular permeability in response to permeability enhanc-
ers such as PMA or neutrophils [ 19 ]. Another study show-
ing that the inhibition of MLCK attenuated the burn-evoked
hyperpermeability in microvasculature provides evidence
that endothelial cell contraction induced by MLCK-
mediated MLC phosphorylation is also involved in thermal
injury-induced alteration of endothelial barrier function
[ 8 ]. This effect was conﬁ rmed in in vitro studies by pre-
treating cultured HUVECs with ML-7 that prevented the
formation of cellular stress ﬁ ber after burned plasma expo-
sure. Furthermore, ML-7 may also reverse the actin reor-
ganization in ECs pretreated with burned plasma [ 20 ].
When F-actin and related proteins are double-stained with
speciﬁ c ﬂ uorescence probes and relative antibodies, the
abovementioned junctional molecular maldistribution is
always concomitant with F-actin reorganization, indicat-
ing the intimate interaction of actin and junctional
proteins.
Lipopolysaccharide stimulation also causes the forma-
tion of stress ﬁ bers in cultured ECs. High concentration of
LPS caused the appearance of broken F-actin dots, indi-
cating the disruptions of F-actin [ 21 ]. This result is con-
sistent with Chakravortty’s report, which described the
assembly and excessive polymerization of actin ﬁ lament
and, ﬁ nally, their disruptions after a high-concentration
LPS treatment.
The marked actin disorganization and the formation of
stress ﬁ bers and intercellular gaps are accompanied by a
time- and dose-dependent decrease in F-actin content and
an increase in the globular actin (G-actin) pool [ 21 ]. G-actin
is another form of actin. Determined by the concentration of
G-actin in the steady stage, G-actin and F-actin transform to
each other by polymerizing or depolymerizing to maintain a
dynamic balance. While G-actin is normally seen in peri-
nuclear and nuclear areas in control cells, G-actin dots
appear in the cytoplasmic region under LPS stimulation
[ 15 ]. The transformation between F- and G-actin is related
to the need of the cell for structural rigidity or functional
motion. LPS- induced appearance of G-actin knots in ECV-
304 cytoplasm and the increase in the G-actin pool may be
attributed to the great depolymerization of F-actin and new
actin synthesis. The synthesis of new actin may be one of
the cellular protective responses to LPS stimulation to main-
tain the integrity of actin cytoskeleton and endothelial bar-
rier function.
2.1.5
The Signaling of Vascular
Permeability Regulation
The tethering power produced by junctional structures and
the contractile strength generated by actomyosin cross-
bridging are two major opposing forces contributing to the
maintenance of endothelial barrier integrity. The imbalance
of these forces evokes an increase in vascular permeability
under inﬂ ammatory conditions. Different intracellular sig-
naling processes have been proposed, and considerable evi-
dence suggests that endothelial cytosolic calcium and various
protein kinases, including ROCK, MAPK, and prokinase C
(PKC), might be involved in the regulation of endothelial
barrier function.
2.1.5.1 Effects of RhoA in Vascular
Hyperpermeability Response
to Burn Shock
The Rho family of small GTPase, with the major compo-
nents of RhoA, Cdc42, and Rac, has been shown to play a
key role in the control of the assembly of the actin-based
cytoskeleton and in the regulation of cadherin-based inter-
cellular junctions. It has been demonstrated that RhoA pro-
teins regulate the formation of stress ﬁ bers and focal
adhesions, Rac proteins manipulate the formation of lamel-
lipodia and membrane rufﬂ es, and Cdc42 proteins adjust the
formation of ﬁ lopodia [ 22 ]. The activation of RhoA is indi-
cated to increase endothelial permeability, while Rac func-
tion is required to maintain integrity and normal barrier
function [ 23 ] and the activation of Cdc42 in parallel with the
time course of endothelial barrier recovery [ 24 ].
RhoA, through its downstream effecter ROCK, stimulates
the phosphorylation of myosin light chain phosphatase
(MLCP or PP1) regulatory subunit, which attenuates phos-
phatase activity, hence resulting in a net increase in phos-
phorylated MLC and the sustenance of endothelial cell
contractile response. Our study agreed that isolated and can-
nulated scalding skin venules had increased the permeability
value to about threefold, compared with normal skin venules,
in 120 min. The peripheral actin rim in burned group vessels
showed a less organized and less remarkable interruption
with a large amount of FITC-albumin leakage. Inhibition of
Rho kinase activity with Y-27632 dose-dependently attenu-
ated the hyperpermeability responses to scalding and induced
a recovery of actin ﬁ lament arrangement in the venule wall
after scalding (Fig. 2.2 ) [ 7 ]. In cultured HUVECs, actin
2 The Alterations of Microcirculation in Burns

11
ﬁ laments displayed primarily in the cortex in normal cells.
The exposure to burned plasma caused a rapid assembly of
prominent stress ﬁ bers in cultured cells, which could also be
partially inhibited by Y27632 [ 20 ]. These results indicate
that burn damage leads to an increase in dermal venular per-
meability with endothelial cytoskeleton depolymerization
and disruption. The RhoA/ROCK signal transduction path-
way is involved in these responses.
2.1.5.2 Involvement of MAPK in the Modulation
of Vascular Permeability
Mitogen-activated prokinase is a major signaling system that
transduces a variety of extracellular signals through a cas-
cade of intracellular protein phosphorylation and plays an
important role in the regulation of cell growth, differentia-
tion, apoptosis, and cellular response to environmental stress.
In mammals, four major subgroups of MAPK super-family
members have been identiﬁ ed: the extracellular signal-
regulated kinase (ERK), the c-Jun N-terminal kinase (JNK),
p38 MAPK, and ERK 5 [ 25 – 27 ].
We found that three major MAPKs, i.e., p38 , ERK, and JNK,
were all activated in thermally stressed ECs, but only pharma-
ceutical inhibition with SB203580 for p38 and/or PD98059
for ERK MAPKs could abolish burned plasma- induced EC
stress ﬁ ber formation [ 28 ]. To distinguish whether p38 and
ERK are equally important in this respect, we then visualized
a paracellular tight junction protein, ZO-1, and found that only
p38 MAPK inhibitors were able to prevent venule EC junction
damage [ 28 ]. Exposure of ECs to constructs with dominant
negative isoforms of p38 MAPK showed that the suppression
of both p38 α or p38 δ activation could prevent F-actin disor-
ganization upon burned plasma stimulation in cultured ECs,
although the preventive effect of the dominant negative p38 δ
was greater than p38 α. Using adenovirus-based constructs
containing interfering kinases to block p38 α and p38 δ kinases,
or their upstream effecter kinases (MKK3 and MMK6), the
venular hyperpermeability that resulted from exposure of iso-
lated vessels to burned plasma was prohibited. The depression
of these kinases also signiﬁ cantly enhanced the survival of
burned rats during the critical ﬁ rst 72 h (Figs. 2.3 and 2.4 ).
Apart from the activation of MLCK, p38 MAPK may have
other ways of regulating actin rearrangement. Borbiev et al.
reported that p38 MAPK inhibitor SB203580 decreased
thrombin-induced EC actin stress-ﬁ ber formation, while
dominant negative p38 had no effect on thrombin-induced
myosin light chain diphosphorylation [ 29 ]. Thrombin- induced
total and site-speciﬁ c caldesmon phosphorylation (Ser789),
as well as dissociation of the caldesmon–myosin complex,
was found to be attenuated by SB203580 pretreatment. These
results suggest the involvement of p38 MAPK activities in
caldesmon phosphorylation and an MLCK- independent reg-
ulation of thrombin-induced EC permeability.
These results may call for the further investigation of the
downstream substrates of p38 α and p38 δ kinases, especially
those of p38 δ, which are not well studied. Currently, several
p38 MAPK-regulated kinases have been identiﬁ ed as down-
stream substrates of p38 , such as MSK, PRAK, MAPKAPK-2,
and MAPKAPK-32. PRAK and MAPKAPK-2 have also
been reported to be kinases of HSP27. The activation of
HSP27 is another mechanism (rather than phosphorylation
of MLC) that regulates actin polymerization in ECs and thus
their barrier function.
Fig. 2.2 ROCK inhibition abolished burn-induced disruption of
F-actin distribution in dermal venules from injury rat. ( a ) Rhodamine-
phalloidin stained showed the endothelial peripheral actin rim (PAR) in
venule ( arrow with a circle at the end and the disrupted PAR ( arrows )
with cave-like appearance. ( b ) Combined image of FITC-albumin and
rhodamine-phalloidin staining. Note disrupted endothelial actin _bers
associated with FITC-albumin leakage in cave-like place. ( c ) a decrease
in PAR disruption after Y-27632 treatment
a
b
c

2.1 Alteration of Microvascular Permeability in Burn Injury

12
The morphological study in our lab showed that sup-
pressing the activities of MK2 and PRAK by transfecting
the cells with their dominant negative forms alleviated the
formation of stress ﬁ ber induced by burned plasma, while
constitutively activation of MK2 induced obvious rear-
rangement of F-actin. The result of Western blotting dem-
onstrated that burned plasma stimulation increased the
phosphorylation of HSP27, while both MK2 and PRAK
activation with transfection of their constitutively active
forms could also phosphorylate HSP27. The inhibition of
MK2 and PRAK by transfecting the cells with their domi-
nant negative forms before burned serum administration
diminished the phosphorylation of HSP27. Our data indi-
cated that burned plasma induced rearrangement of
endothelial cytoskeleton F-actin through the p38/MK2/
PRAK/HSP27 pathway, and p38 also participated in dam-
age to the tight junction structure triggered by thermal
injury.
Fig. 2.3 Effects of MAPK pathway in burn-induced morphological and functional alteration in cultured ECs ( a ) and in isolated venules ( b )
a
b

2 The Alterations of Microcirculation in Burns

13
2.1.5.3 Protein Kinase C Plays a Role
in Vascular Permeability Regulation
Protein kinase C has been known to be an important second
messenger in the regulation of microvascular barrier func-
tion during stimulation by phorbol esters, diacylglycerol
(DAG), thrombin, bradykinin, and platelet-activating factor
[ 30 , 31 ]. Inhibition of PKC with H7 and calphostin could
abolish the increased vascular permeability induced by those
proinﬂ ammatory mediators.
In isolated and perfused porcine coronary venules, we
ascertained that phorbol myristate acetate (PMA) evoked a
rapid increase in permeability coefﬁ cient (Pa) and that this
Fig. 2.4 Effects of PKC on
microvascular permeability
regulation. ( a ) PKC activator
PMA induced a remarkable
increase in isolated vessels. PKC
inhibitor BIM block its effect.
( b ) The PMA-induced
hyperpermeability could be
attenuated by NOS inhibitor
L-NMMA
a
b

2.1 Alteration of Microvascular Permeability in Burn Injury

14
effect was blocked by a selective PKC inhibitor bisindolyl-
maleimide (BIM). Another PKC inhibitor GF-109203X was
also able to decrease the hyperpermeability response trig-
gered by the typical inﬂ ammatory mediator histamine [ 32 ].
In cultured HUVECs, we detected an increase in phosphory-
lated PKC content, and a translocation of PKC from cyto-
plasm to inner membrane after stimulating the cells with
PMA or burn serum. The attenuation of PKC activity with an
inhibiting polypeptide (PKC19-36) could block this translo-
cation and downregulate the phosphorylation of PKC [ 33 ].
The molecular mechanism responsible for the upregula-
tion of PKC has not been fully speciﬁ ed. A potential reason
for the lack of understanding is that the enzyme consists of at
least eight isoforms that may respond to different signals and
exert different actions on the downstream proteins [ 34 ].
Generally, it is accepted that phospholipase C (PLC) hydro-
lysis of phosphatidylinositol bisphosphate produces DAG,
leading to PKC activation [ 35 ].
Protein kinase C has been reported to activate the
endothelial contractile apparatus by inducing MLC phos-
phorylation, polymerization of actin and intermediate ﬁ la-
ments, and activation of actin-binding proteins [ 36 , 37 ]. We
then tested various PKC inhibitors for their inﬂ uence on the
disturbance of venular endothelium tight junctions and cyto-
skeleton reorganization induced by serum from burned rats.
Indeed, inhibition of PKC by Ro-31-7549 partially inhibited
EC actin rearrangement, although it was not as potent as
inhibition by p38 MAPK in reducing damage to the tight
junctions of venular ECs [ 28 ]. It is also ascertained that some
PKC isozymes, such as PKCα, activate Rho A by inducing
rapid phosphorylation of GDP dissociation inhibitor (GDI),
indicating that RhoA is one of the important substrates of
PKC [ 38 , 39 ]. Our previous study also suggested that NOS
was a potent substrate of PKC, while inhibition of the nitric
oxide synthase (NOS) with speciﬁ c blocker NG-monomethyl-
L- arginine (L-NMMA) greatly attenuated the hyperperme-
ability effect of PMA, indicating that PKC may alter
endothelial permeability by acting directly on endothelial
structural proteins and/or indirectly by modulating the
activity of the common signaling protein NOS [ 32 ].
2.1.5.4 The Relationship Between Different
Signaling Pathways in Modulating
Endothelial Barrier Function
The abovementioned signal pathways may not work inde-
pendently during the regulation of cellular functions. There
has been some evidence showing that there is a cross-talk
between Rho/ROCK and p38 MAPK pathways, while most
of the reports demonstrated that ROCK is the upstream regu-
lator of p38 MAPK activation [ 40 , 41 ]. The results of our
study already showed that inhibition of Rho kinase with
Y-27632 may attenuate the phosphorylation of p38 MAPK
induced by burned plasma stimulation, suggesting the inter-
action of ROCK and p38 MAPK. As mentioned above,
RhoA may be one of the important substrates of PKC [ 38 ,
39 ]. These data re-stress the pivotal role of the Rho/ROCK
pathway in the modulation of endothelial barrier function. In
contrast, while PKC also restrained the formation of stress
ﬁ ber in burned serum-treated ECs, the inhibition of PKC
with RO31-7549 did not attenuate the phosphorylation of
p38 after burned plasma administration, implying that PKC
has a p38 -independent effect on endothelial morphological
regulation.
2.1.5.5 The Mediator-Enhanced Recovery
of Vascular Permeability
A concept has emerged in recent years that some so-called
stabilizing mediators play positive roles in enhancing
interendothelial junctional connections and in preventing
the increase in vascular permeability [ 2 , 3 ]. These media-
tors, such as cAMP, ATP, adenosine, adrenomedullin, and
S1P, may be released in response to proinﬂ ammatory
mediators and serve to restore endothelial barrier function.
Some of these stabilizing mediators are important even in
a quiescent state because they preserve basal vascular per-
meability at a low level [ 3 , 5 ].
Produced by phosphorylation of sphingosine, S1P is an
abundant lipid mediator in plasma that regulates numerous
physiological functions of vascular and immune cells.
Platelet is an important source of plasma S1P not only
because of the rich presence of the S1P synthesis enzyme,
sphingosine kinase (SPHK), but also because of the absence
of S1P lyase, which is responsible for the degradation of
S1P. Endothelial cells are another contributor to plasma S1P
as they secrete S1P in a constitutive manner. By binding to
its multiple receptors on endothelia, S1P serves as a barrier
stabilizer via actin organization and intercellular and cell
matrix adherence is strengthened [ 42 ].
It has been reported that there is a signiﬁ cant blood plate-
let decrease and a known platelet dysfunction in severely
burned patients. This platelet deﬁ ciency correlates with
higher mortality after severe trauma and sepsis in humans. In
platelet depletion mice, mortality increased remarkably after
thermal injury [ 43 ]. The underlying mechanisms associated
with these observations are not yet fully understood.
We undertook a study based on the hypothesis that the
consumption of platelets by activation and aggregation at the
early stage of thermal injury exhausts the storage of S1P,
leaving the vascular ECs more vulnerable to various
permeability- increasing mediators released after severe burn
injury, and eventually results in the exudation of ﬂ uid and
protein from the vascular space to the interstitium. The pur-
pose of the study was to observe the effects of S1P on distri-
butions of a major adherens junction protein, VE-cadherin
and cytoskeletal F-actin in ECs upon the stimulation of
burned plasma, and to evaluate the role of exogenous S1P on
2 The Alterations of Microcirculation in Burns

15
hyperpermeability response in venules isolated from a ther-
mal model of rats.
In this study, cultured HUVECs, with the addition of
1 μmol/L or 5 μmol/L S1P to the medium, showed a clearer
peripheral actin rim and a tighter intercellular junction
compared with control cells. The inhibition of S1P synthesis
by the sphingosine kinase inhibitor DMS caused obvious dis-
organization of F-actin and junctional proteins in cultured
HUVECs, accompanied by the increases in vascular permea-
bility in isolated venules [ 13 ]. These data are consistent with
reports by Garcia et al. that S1P-mediated enhancement of
endothelial junctional integrity involved the formation of a
strong cortical actin ring [ 44 ]. These results imply that, under
quiescent condition, S1P might play a role in maintaining basal
endothelial barrier function and that its physiological amount
might be sufﬁ cient for this purpose. The decline in S1P produc-
tion hampers the integrity of the vascular wall, resulting in an
increase in albumin leakage from the vessel space.
We showed here that burned plasma stimulation also
caused a time-dependent disturbed distribution of the inter-
cellular adherens junction protein VE-cadherin. This mor-
phological alteration was attenuated by the pre- or
post-addition of S1P in incubated medium. S1P stabilized
and restored the cortical distribution of the F-actin ring and
the continuous lining of VE-cadherin in the endothelial
membrane area upon the challenge of burned plasma [ 13 ]. It
is consistent with the results of Lee et al. [ 45 ] that S1P
enhanced the assembly of adherens junctions. Paralleling
with this cultured cell study, the observation in isolated
venules displayed similar effects of S1P on the organization
of F-actin in vascular ECs. The hyperpermeability response
of isolated venules exposed to burned plasma was also inhib-
ited by the administration of S1P, coincident with its above-
mentioned morphological alteration. Our previous in vivo
study also demonstrated that exogenous applications of S1P
attenuated the leakage of albumin in postcapillary venules
within 20–50 min after burn injury in a mouse model [ 46 ].
While an appropriate or physiological level of S1P acts
as a stabilizer for endothelial barrier function by preventing
the inﬂ ammatory hyperpermeability response, excessive
S1P evokes the activity of different receptors and the cellu-
lar signaling pathway, resulting in active cytoskeleton rear-
rangement and barrier disruption. This diversity of S1P
effects is due to the activations of different S1P receptors
upon different concentrations of S1P [ 47 ]. Calcium is
believed to play an important role in these controversial
processes.
2.1.5.6 The Effect of Calcium in Endothelial
Barrier Functional Regulation
There have been numerous reports showing that increases in
cytosolic calcium (Ca 2+ ) are sufﬁ cient to initiate the cytoskel-
etal reorganization that increases cell tension and disrupts cell
junctions, resulting in the retraction of endothelial cell bor-
ders, and to increase macromolecular permeability [ 32 ]. To
resolve whether Ca 2+ release from the endoplasmic reticulum
(ER), or Ca 2+ entry across the plasma membrane, is required
to disrupt the endothelial cell barrier, inﬂ ammatory agonists
have been used to activate the endothelium in the absence of
extracellular Ca 2+ [ 48 ]. Under these experimental conditions,
most studies ﬁ nd no signiﬁ cant increase in endothelial cell
permeability, illustrating that Ca 2+ entry across the plasma
membrane, and not Ca 2+ release from the ER, is required to
disrupt the endothelial cell barrier [ 48 ]. The differentiated
effects of this simple Ca 2+ ion may be due to the incredible
versatility of Ca 2+ signaling, whereby Ca 2+ can act in the vari-
ous contexts of space, time, and amplitude and achieve speci-
ﬁ city, and activates only a subset of those targets. While most
of the Ca 2+ -endothelium-related studies only detected the
global cytosolic Ca 2+ concentration [Ca 2+ ] i or bulk Ca 2+ , the
intracellular spatiotemporal dynamics of Ca 2+ may play a
more critical role in manipulating the endothelial response to
various mediators. It is proposed that the appropriate amount
or physiological level of S1P binds to S1P receptor 1 and
induces Ca 2+ release from the ER, resulting in the phosphory-
lation of Rac GDP. The activation of Rac signaling enhances
the formation of lamella podia and the assembly of adhesion
and tight junctions, leading to the strengthening of the barrier.
In contrast, excessive S1P combines with S1P receptor 2 or 3
and promotes the phosphorylation of RhoA GDP, accompa-
nied by the entry of Ca 2+ across the plasma membrane. The
activation of the RhoA/ROCK pathway triggers the actin–
myosin-driven contraction and stress ﬁ ber formation, leading
to the disruption of adhesion and tight junctions, resulting in
endothelial barrier dysfunction and vascular hyperpermeabil-
ity. This theory needs to be conﬁ rmed by exploring the intra-
cellular spatiotemporal dynamics of calcium in S1P-stimulated
ECs and comparing with the alterations of the subcellular
localizations and functional changes of the protein family
Rho GTPases, especially Rac and RhoA.
2.1.6
Summary
According to our research in the past decade, and with refer-
ence to the results of others’ great experiments, we inferen-
tially delineate a schematic signal pathway that regulates
vascular permeability during inﬂ ammation and shock. Burn
insult, inﬂ ammation, and other traumatic injuries trigger the
release of various vascular permeability-increasing media-
tors, including reactive oxygen species, cytokines (platelet-
activating factor, tumor necrosis factor, etc.), and other
inﬂ ammatory mediators (histamine, bradykinin, etc.). The
changes in hemorheology, such as the slowing down of the
blood ﬂ ow, and the adhesion of leukocytes to the vascular
wall also evoke the activation of ECs. By binding to their
2.1 Alteration of Microvascular Permeability in Burn Injury

16
speciﬁ c chemical receptors or mechanosensors, these media-
tors activate multiple signal pathways through second mes-
sengers and protein kinases. Speciﬁ cally, PKC, RhoA, and
different MAPKs and their downstream substrates play very
crucial roles in regulating the cell–cell contacts and the cel-
lular contraction. The opening of a tight junction and an
adherens junction and the increasing contractile force
through actin–myosin interaction widen the intercellular
gaps, allowing the transﬂ ux of large molecular substances
and leakage of mass ﬂ uid from the vascular space, resulting
in an increase in permeability and tissue edema.
The semipermeable property of the endothelium is main-
tained through the equilibrium of competing contractile and
adhesive forces generated by the cytoskeletal proteins and the
adhesive molecules located at cell–cell and cell–matrix con-
tacts. One aspect that we do not discuss in this section is the
alteration of cell–matrix contact that supplies an anchoring
site for the contracting cell, which includes the activation of
various integrins and their interacting partners [ 49 , 50 ].
While focusing on the paracellular junctional regulation
in the control of mediator-triggering of the vascular hyper-
permeability, we could not ignore the fundamental role of
transcellular pathways under basal conditions, whilst the
transport of albumin and liquid mostly depends on the traf-
ﬁ cking of caveolae in capillary endothelia and vesiculovacu-
olar organelles (VVOs) in the endothelia of venules and
small veins. This process of transcytosis involves a series of
interactions between plasma membrane proteins and cyto-
plasmic signaling molecules. We do not expand the discus-
sion in this chapter since we have yet to set foot in this
territory. Readers should refer to certain comprehensive
reviews [ 2 , 51 ] in which these emerging principles have been
extensively discussed.
2.2
Thrombosis in Microvessels
of Burned Skin
Keseng Zhao
2.2.1
Three Concentric Zones
of Microcirculatory
Disorder in Burned Tissue
There are three concentric zones of microcirculatory disorder
in burned skin (Fig. 2.5 ) [ 52 , 53 ]: in the center is an area of
coagulated protein completely stopping the microcirculation;
in the middle is a stagnant area of blood with partial capillary
stasis; in the outer is an area of hyperemia. In the clinic, it is
not always possible to determine the depth of burning on the
ﬁ rst day. The color and appearance are not always good
guides as to whether the burn consists of partial- thickness or
whole-thickness skin loss. For example, a reddish bleb usu-
ally means partial-thickness skin loss, but it occasionally
becomes full skin necrosis, which should be treated with skin
transplantation; on the other hand, a white or even black
charring of the affected skin cannot always indicate full-
thickness skin loss, as it has only charred the outer few cell
layers of the epidermis, with spontaneous healing several
weeks later. The reasons for these phenomena include that
although the coagulation zone is superﬁ cial at the onset of
the burn injury, the later extension of the stasis zone to full-
thickness skin, completely stopping the blood ﬂ ow in capil-
laries with full skin necrosis. However, if the microcirculation
disorder in the stasis zone can be improved, a part of whole
skin loss, which is believed to exist early after burn onset,
may be changed to partial skin loss. Therefore, the stasis
zone is standing at a crossroads, and may move around in two
different directions for the pathogenesis of the depth and area
in burns. Studying the development the stasis zone in burns is
of great signiﬁ cance.
2.2.2
Skin Microcirculation Observed
with the Ear Chamber Technique
Transparent rabbit ear chamber(Fig. 2.6 ) was prepared in
order to observe changes in microcirculation under
microscope and electron microscope [ 54 , 55 ]. Under local
anesthesia, a piece of inside ear skin about 1.2 cm in diame-
ter was cut off and under the incised skin, the inner cartilage
membrane and conchal cartilage were carefully cut off to
maintain the intact microvessels located between the outer
cartilage membrane and the outside ear skin. Three small
holes were made around the incised skin, and the base plate
and cover plate of the ear chamber were put on both sides of
the incised ear and ﬁ xed with three screws through the three
Fig. 2.5 Three concentric zones of microcirculatory disorder in burned
tissue

2 The Alterations of Microcirculation in Burns

17
holes. Both base plate and cover plate were made of titanium
and round mica sheet inlays measuring 1.0 cm in diameter
were placed in the center of each plate for microscopic
observation. Two days after the operation, the base plate was
taken off and the skin of the chamber was scalded for 1 min
using a copper water heater at 65 °C. Then the base plate of
the ear chamber was reassembled and microscope observa-
tion was made soon after scalding.
2.2.3
Relationship Between Microthrombosis
and the Types of Microvessel Response
in Burned Skin
The microvessel response in burned skin can be divided into
two types [ 56 , 57 ], vasoconstriction and vasodilatation.
2.2.3.1 Vasoconstriction Type
The constriction of small vessels in the skin took place imme-
diately following scalding (Fig. 2.7 ). The diameter of arterioles
and venules visibly reduced and almost no open capillaries
could be seen with locally pale skin. The blood in the arterioles
and venules began to ﬂ ow 10–20 min later. White thrombi, how-
ever, occurred in some vessels, which led to partial or complete
obstruction of these arterioles and venules. Blood stasis could
still be seen in most of the capillaries. Thrombosis remained
unchanged 24–48 h after burns. A full thickness or third degree
burn was found in pathological section 7 days postscalding.
2.2.3.2 Vasodilatation Type
The arterioles and venules dilated soon after scalding or they
contracted transiently, followed by vasodilatation with fast
blood ﬂ ow and local reddish skin. There was no thrombosis
in two thirds of animals. Thrombosis in venules occurred in
one third of animals and in one of them the thrombi were
ﬂ ushed away by the fast blood ﬂ ow 5 h later (Fig. 2.8 ).
Partial-thickness skin loss was found without thrombosis by
pathological study 7 days after scalding and full-thickness
skin necrosis took place in the animals with thrombosis.
Therefore, the reason for blood ﬂ ow from stasis to cessation
in the stagnant area of burned tissue is thrombosis, which
leads to enhancement of the area and depth in skin burns.
The diverse depth of burns may be reproduced in animals
with the same high temperature and duration of scalding,
because of the difference in the two types of vessel response
with the different trends in thrombosis (Fig. 2.7 ).
2.2.4
The Pathogenesis of Microthrombosis
in Burned Skin
According to our research, the genesis of microthrombosis in
burned skin is related to the damage of the vessel wall, slow
blood ﬂ ow, and the aggregation of blood cells [ 55 – 59 ].
Fig. 2.6 Transparent rabbit ear chamber
Fig. 2.7 Vasoconstriction type in burned skin
Fig. 2.8 Thrombosis of arteriole in burned skin

2.2 Thrombosis in Microvessels of Burned Skin

18
2.2.4.1 Damage of the Microvessel Wall
The ECs of microvessels in burned skin were seriously
injured under electron microscopic observation, which
included enhanced size of ECs, edema of cytoplasm, the dis-
appearance of Golgi bodies and mitochondria, some endo-
thelia falling away with the rough surface of the vessel wall,
gap formation among endothelial junctions, and rupture of
the base membrane. Endothelial damage led to activation of
factor XII with triggering of the internal coagulation path-
way, and the damaged endothelia also released tissue throm-
boplastin and ADP with platelet aggregation and thrombosis
(Fig. 2.9 ).
2.2.4.2 The Slow Blood Flow
It was easy to obtain thrombosis in the vasoconstriction type
of burned skin with slow, even transient cessation of blood
ﬂ ow. The blood ﬂ ow was recovering, but the white thrombi
were already formed 10–20 min after scalding (Fig. 2.10 ). If
another ear chamber was made near the burned skin, the
white thrombi could be discharged by the blood ﬂ ow passing
through the vessel, which appeared early at 24 min post-
scalding and continued even up to 13 days after burning. In
contrast to the vasoconstriction type, arterioles and venules
dilated immediately or constricted for a very short time fol-
lowed by vasodilatation in the vasodilatation type of burned
skin. Under this condition, blood ﬂ owed into the arterioles
very quickly with apparent vasomotion, which led to the
blood cell aggregation rushing out and microthrombosis,
resulting in slight thrombosis. Therefore, vasoconstriction
and slow blood ﬂ ow are important factors for the genesis of
thrombosis in burns.
2.2.4.3 Concentration of Blood
and Aggregation of Blood Cells
It was seen in rabbit ear chamber that white smoke-like or
belt-like substances (perhaps the aggregation of platelets or
leukocytes) passed through into venules in the vasodilatation
type of burned skin. These white belt-like substances did not
obstruct the lumen of the venules, as they were ﬂ ushed away
by the fast blood ﬂ ow.
2.2.5
The Effect of Polydatin
on the Microcirculation
in Burned Skin [ 56 , 57 ]
Polydatin (PD) was injected into the vein on the other side of
the rabbit ear (5–7.5 mg/kg PD in 20 ml of normal saline)
20 min after scalding, which led to dilatation of the arterioles
and venules in the vasoconstriction-type response of burned
skin, but there was no dilatation effect on the vessels with the
vasodilatation-type response, i.e. the vasoconstriction-type
response changed to a vasodilatation type (Table 2.1 ).
Besides vasodilatation, a pulsatile blood movement appeared
in part of the experiment, which ﬂ ooded off the thrombi and
produced aggregation of RBC in microvessels, increasing
the opening capillaries. The appendage (sebaceous glands
and hair follicles) and deep tissue of the skin had remained
intact 7 days later, which indicated a second-degree burn. A
similar effect was also observed in the group treated topi-
cally with PD tincture. The blue vessel, which was caused by
blood stasis in the burned skin, turned reddish after topical
application of PD tincture. In the ear chamber white emboli
were found to be passing through the venules, restarting the
ceased blood ﬂ ow in arterioles, and increasing the number of
open capillaries.
Fig. 2.9 Damage of endothelia with microthrombus in pathological
section
Fig. 2.10 White thrombi formation in ear chamber skin after scalding

2 The Alterations of Microcirculation in Burns

19
2.3
Leukocyte Adherence
in Microcirculation After Burns
Keseng Zhao
2.3.1
The Stage of Burn Shock
According to the changes in blood pressure and microcircu-
lation, burn shock of the rat was caused by scalding with
80 °C water for 30 s (about 35–40 % TBS) and could be
divided into three stages [ 54 ]:
1. Excitation stage, starting from the beginning of scalding
and lasting for 5–30 min with animal excitation, struggle,
speed respiration, raised blood pressure, vasoconstriction,
and ischemia of the microcirculation.
2. Compensated stage: the blood pressure and respiration were
recovering and the diameter of the arterioles returned to near
normal, with few open capillaries. This stage lasted for 1–3 h.
3. Decompensated stage: animal blood pressure was con-
tinuously falling and arterioles and venules dilated with
slow blood ﬂ ow and RBE aggregation. Finally, the blood
ﬂ ow in the microcirculation appeared to show a pendu-
lum movement before stopping completely. This stage
also lasted for 1–3 h.
2.3.2
Leukocyte Adherence on the Venule Wall
There may be a few leukocytes rolling in the venules, but no
white blood cells (WBCs) adhering to the venule wall under
normal conditions. It was difﬁ cult to count the number of
adherent leukocytes in burns, as they appeared layer by layer.
WBC adherence in venules (diameter 30–40 μm) was semi-
quantitatively divided into three degrees [ 60 ]. The ﬁ rst
degree was a few adherent leukocytes, the second less than
ten adherent leukocytes, and the third a large, uncountable
number of adherent leukocytes. Many leukocytes roll and
adhere to venules of rat spinotrapezius muscle 15 min after
scalding (Fig. 2.11 ). It was in the compensated stage of burn
shock with MAPK (112.6 ± 5.6) mmHg, while the third
degree of leukocyte adherence occurred in all the venules
observed, which looked like a large quantity of small stones
paved on a river bottom on microscopic TV. In another group
of experiments the leukocytes adhering to 60 μm of the
length of the third branch vein (V 3 diameter 29–35 μm) of
the spinotrapezius muscle were counted, which showed a
few rolling leukocytes, but no adherent WBCs under normal
conditions, and (5.2 ± 1.2) WBCs/60 μm and (14.4 ± 2.5)
WBCs/60 μm occurred 1 h (Fig. 2.12 ) and 3 h postburns
respectively. Leukocyte adherence in venules led to an
Table 2.1 The effect of polydatin on the diameter of vessels in burned skin
Type of response
Arteriole (μm)
Venule (μm)
Preburn
Postburn
Post-treatment
Preburn
Postburn
Post-treatment
Vasoconstriction
20.3 ± 1.6
15.7 ± 1.9
24.6 ± 2.2*
29.4 ± 2.9
16.0 ± 1.9
25.0 ± 0.7
Vasodilatation
20.9 ± 1.6
25.0 ± 1.8
28.0 ± 2.1*
33.5 ± 2.5
38.8 ± 1.5
39.4 ± 2.7
* p < 0.05 vs postburn value
Fig. 2.11 Several leukocytes rolling in a venule during the early stages
of burn shock ( Arrow indicates leukocyte in blood vessel)
Fig. 2.12 Leukocytes adhering to the venule wall in burn shock
( Arrows indicate leukocyte in blood vessel)

2.2 Leukocyte Adherence in Microcirculation After Burns

20
increase in blood resistance with capillary stasis. The num-
ber of open capillaries in spinotrapezius muscle was nor-
mally (5.16 ± 0.37) pieces/3,600 μm 2 and the number had
much decreased to (2.83 ± 0.69) pieces/ 3,600 μm 2 at 0.5 h
postburn. At 2.5 h postburn, the number had decreased to one
third of the normal number [(1.75 ± 0.75) pieces/3,600 μm 2 ],
while animals remained at the compensated stage of burn
shock with blood pressure more than 100 mmHg, which
indicated that the reduced open capillaries were caused by
enhanced vessel resistance instead of decreased drive pres-
sure. Leukocyte adherence was an important event for the
enhanced vessel resistance, as it was shown that with the
amount of adherent WBCs increasing to 20 times that of the
control, the vessel conductance (the reversal of vessel resis-
tance) reduced to 23.2 % of the control and the volume of
blood ﬂ ow was decreased by 91.1 % of the control 0.5 h after
bleeding in hemorrhagic shock.
2.3.3
The Mechanism of Leukocyte
Adhesion in Burn Shock
2.3.3.1 Increased Leukocyte–Endothelium
Adhesivity
The curve of the leukocyte adhesive rate was obtained under
different shear stresses using the cell ﬂ ow chamber technique
[ 61 , 62 ], in which a conﬂ uent monolayer of ECs was cultured
on the surface of a glass slide and a suspension of polymor-
phonuclear leukocytes (PMNs) was pumped into the ﬂ ow
chamber by a peristaltic pump running for 1 min under differ-
ent shear stresses with the channel wall. Then the number of
PMNs adhering to the wall was counted and the adhesion rate
calculated. It was shown in Fig. 2.12 that leukocyte adhesion
increased in rats of the burn group. Under 1.96 dyn/cm 2 and
3.41 dyn/cm 2 of shear stress, the PMN adhesion rate was
58.8 % ± 4.6 % and 46.5 % ± 4.3 % in the normal group respec-
tively; meanwhile, it increased to 81.2 % ± 4.1 % and
63.4 % ± 5.1 % in the burned group respectively, and reduced
to near normal (62.4 % ± 5.4 % and 41.3 % ± 5.9 % respec-
tively) in the polydatin group. Even under high shear stress
(14.7 Pa), 30.0 % ± 6.5 % of the PMN adhesion rate still
involved ECs in the burned group, while only 19.5 % ± 3.2 %
in the normal group and 13.2 % ± 1.8 % in the polydatin group.
It was also demonstrated that leukocyte–endothelium adhe-
sion was negatively related to the survival time of burn shock
animals, i.e., the lower of the adhesion rate, the longer the
survival time. The leukocyte adhesion rate was signiﬁ cantly
reduced in the polydatin group, in which the survival time was
four times longer than in the simple burned group and 5 out of
8 rats in the polydatin group survived over 24 h, which was
much higher than 1 out of 8 in the simple burned group.
Interestingly, the only rat that survived over 24 h in the burned
group had a lower leukocyte adhesion rate, which was close to
the value in the polydatin group (Figs. 2.13 and 2.14 ).
2.3.3.2 Leukocyte Activation
The precursor of WBC adhesion is leukocyte activation,
which leads to enhancement of adhesive molecule synthesis,
translocation of adhesive protein from the cytosol to the
cellular surface, and conformational changes of adhesive
protein from low afﬁ nity to high afﬁ nity. The PMN activa-
tion of rats after burn injury can be measured by nitro-blue
tetrazolium (NBT) test, which consisted of counting the per-
centage of circulating neutrophils that showed a spontaneous
Normal group
Burn group
0
100
80
60
40
20
0.78
3.41
7.16
8.99
12.5
14.7
Polydatin-treated group
Adhesive Rate of PMN (%)
Fig. 2.13 Adhesive feature
curves of granulocyte–endothe-
lial cells in rats with severe burns

2 The Alterations of Microcirculation in Burns

21
reduction of pace yellow NBT to blue–black formazan crys-
tals in PMN cytosol as a positive index for the NBT test [ 63 ].
It was shown that the NBT-positive rate of neutrophils was
2.3 % ± 1.6 % in normal control rats and the activated neutro-
phils gradually increased in number after a burn. In the sim-
ple burn group, the NBT-positive rate changed from
2.8 % ± 0.8 % of the preburn value to 7.7 % ± 2.0 % and
10.9 % ± 3.4 % of the postburn value in 2 h and 5 h
respectively. The NBT-positive rate in 5 h after a burn was
negatively related to the survival time of burned animals
(Fig. 2.15 ). There were three types of neutrophil activation in
burns (Fig. 2.16 ):
1. The NBT-positive rate was within the normal range
(2–3 %) at preburn and remained the same at 2 h and 5 h
after the burn. The average survival time was longer
(22.0 ± 2.7 hours) under this condition;
Normal group
Burn group
Polydatin-treated group
Adhesive Rate of PMN(%)
100
80
60
40
20
0
1.96
3.41
Fig. 2.14 Effect of shear stress
on the adhesion of granulocytes to
the endothelial cells
Survival Time (h)
NBT Positive rate (%)
40
30
Y=22.58–0.56X
20
10
0
0
10
20
30
40
Fig. 2.15 The relationship between the nitro-blue tetrazolium (NBT)-
positive rate at 5 h postburn and the survival time
Preburning
2 h Postburning
5 h Postburning
Survival time (h)
8.5 ± 1.4
5
10
15
20
25
0
22.0 ± 2.7
29.5 ± 6.5
NBT Positive Rate(%)
Fig. 2.16 Three different courses of neutrophil activation and its sur-
vival time in burns

2.3 Leukocyte Adherence in Microcirculation After Burns

22
2. The NBT-positive rate increased to a high level ﬁ rst
(14.2 % ± 2.6 % at 2 h after the burn), then decreased to
lower than normal (1.0 % ± 0.1 % at 5 h after the burn).
The average survival time was also longer (29.5 ± 6.5 h).
There was no signiﬁ cant difference compared with the
ﬁ rst group ( p > 0.05);
3. The NBT-positive rate increased continuously after the
burn, i.e., 7.8 % ± 2.0 % and 22.3 % ± 3.8 % in 2 h and 5 h
after burns respectively. Under these conditions the sur-
vival time was quite short, only (8.5 ± 1.4 h, which was
obviously much shorter than the survival time of the
above two types ( p < 0.01).
2.3.3.3 The Enhanced Function of Adhesive
Proteins
The monoclonal antibody of leukocyte adhesive protein
LFA-1 was made for the ﬁ rst time in China, and was used to
measure LFA-1 expression of leukocytes in rats after burns.
It was shown that the LFA-1 expression of leukocytes tended
to decrease instead of increase 1 h after scalding, but this was
not statistically signiﬁ cant [ 64 – 67 ]. However, in the positive
control group, adhesive protein expression was increased
with the top level at 15 min after treatment of PMN with
FMLP, which indicated that the methods of measurement of
adhesive protein, including monoclonal antibody, a ﬂ uores-
cent probe, and the confocal microscope technique, were
believed to be valid. The LFA 1 expression of PMNs in 6
patients (4 of them with traumatic shock, 2 with burn shock)
was also demonstrated to be decreased by electron micro-
scope with immune colloidal gold staining. However, the
leukocyte–endothelium adhesivity of burn shock rat was
raised by cell ﬂ ow chamber measurement and the number of
adherent leukocytes in venules was signiﬁ cantly reduced
after treatment of the LFA-1 monoclonal antibody in rabbits
with endotoxic shock [ 68 ], which indicated that the adhesive
feature of LFA-1 was increased under shock. Therefore,
under the conditions of trauma, burns, and shock, it was
believed that leukocyte adherence could be mediated by both
the high amount of leukocyte adhesive protein (β 2 integrin)
expression (e.g., Mac-1, CD18), or the enhanced function of
the adhesive molecule (LFA 1 ) from the molecular conforma-
tion alterations instead of a high amount of expression. The
conformation change was caused by a stimulator, which led
to β 2 integrin recognizing the ligand, called “activation of
integrin” or “functional up-regulation” [ 69 ].
2.3.3.4 Cytokine Action
It was shown in our laboratory that the TNFα level of plasma
in rats increased to four times of that of the control and the
amount of leukocytes adhering to the venule wall increased
to eight times that of the preburning level 1 h after scalding.
The number of adherent leukocytes could signiﬁ cantly
reduce with an increase in open capillaries 0.5 h after treat-
ment of TNFα monoclonal antibody [ 70 ], as it was well
known that TNFα could activate the leukocyte integrin and
increase the expression of adhesive proteins in endothelia
(ICAM-1, VCAM), resulting in the enhancement of WBC
adhesion in burns. To counter diverse toxins in plasma (cyto-
kines, myocardial depressant factor, hyperkalemia, etc.), it
was also shown in our laboratory that peritoneal dialysis
could treat burn shock [ 71 ]. The rat MAPK decreased to
69.6 ± 9.2 mmHg 5 h after burning; then, peritoneal dialysis
was given with 1.0–1.5 ml/min of balanced salt solution, and
2–3 h later animal MAPK returned to near normal with rapid
blood ﬂ ow in the microcirculation, attenuated RBC aggrega-
tion and WBC adherence, and prolonged survival time.
2.4
Abnormal Calcium Signaling in Burn
Generated Cardiac Dysfunction
Jie Liu and Keseng Zhao
Cardiac dysfunction is one of the most critical complications
in patients with severe burns. However, the underlying mech-
anisms are not fully understood [ 72 – 74 ]. Previous studies
have demonstrated that burn-generated cardiac dysfunction is
associated with abnormal Ca 2+ handling. Horton et al. reported
that burn injury markedly increased resting Ca 2+ in cardiac
myocytes [ 74 – 76 ], resulting in cardiac injury and abnormal
energetic metabolism, and consequently led to diminished
cardiac contractility. In another study, Horton’s group illus-
trated that the expression levels of sarcoplasmic reticulum
Ca 2+ -ATPase (SERCA) and sarcolemmal Na + -Ca 2+ exchanger
(NCX) in heart from burn rats were decreased. Based on this
ﬁ nding, it is proposed that the downregulation of Ca 2+ trans-
porters might be an important mechanism for the accumula-
tion of intracellular Ca 2+ [ 72 ]. Furthermore, it has been
suggested that the intracellular Ca 2+ overload might be associ-
ated with the abnormal activity of ryanodine receptors
(RyRs). Several lines of evidence are in support of this notion.
First, the open probability of RyRs in burn- traumatized car-
diomyocytes has been shown to be increased, despite the
expression level of RyRs not being remarkably altered 4–24 h
postburn [ 76 ]. Furthermore, dantrolene, a RyR antagonist,
has been found to diminish intracellular Ca 2+ accumulation
and protect the heart from burn injury [ 72 ]. However, a recent
study by Kawai et al. argued against the Ca 2+ overload and its
contribution to reduced cardiac contractility in burns [ 77 ]. In
contrast to the study by Horton et al. [ 74 ], the authors found
that the resting Ca 2+ remained unaltered in burn-traumatized
cardiomyocytes. However, the systolic Ca 2+ transient was
dramatically decreased, resulting in diminished cardiac con-
tractility. Furthermore, it revealed that the decreased Ca 2+
transient is attributed to less Ca 2+ inﬂ ux owing to reduced
L-type Ca 2+ channel (LCC) density [ 77 ].
Ca 2+ is an ubiquitous intracellular second messenger that
regulates vital physiological processes, ranging from synap-
2 The Alterations of Microcirculation in Burns

23
tic transmission, muscle contraction, hormone secretion to
cell survival, and cell death [ 78 , 79 ]. Under physiological
conditions,
the
intracellular
Ca 2+
concentration
is
~100 nM. During the process of cardiac excitation–contrac-
tion coupling (EC coupling), action potential (AP) elicited
Ca 2+ entry through sarcolemmal L-type Ca 2+ channels
(LCCs). This part of Ca 2+ contributes to ~10 % of total sys-
tolic intracellular Ca 2+ . The Ca 2+ inﬂ ux triggers a large
amount of Ca 2+ releasing from sarcoplasmic reticulum (SR)
through the Ca 2+ -induced Ca 2+ release (CICR) mechanism.
The increased Ca 2+ combines with troponin, triggering myo-
ﬁ lament contraction. In the diastolic phase, the increased
intracellular Ca 2+ is recycled into SR via SERCA and, to a
lesser extent, expelled extracellularly through the sarcolem-
mal Na + –Ca 2+ exchanger (NCX) [ 80 ]. Ca 2+ dissociates from
the troponin with the decrease in intracellular Ca 2+ , leading
to myoﬁ lament relaxation.
We resorted to the techniques of patch clamp and confo-
cal Ca 2+ imaging to systematically study the alteration of
Ca 2+ signaling in burn-traumatized cardiomyocytes and
found that SR leakage is likely a major candidate mechanism
underlying burn-associated acute heart failure, in which an
SR leak caused SR Ca 2+ depletion, resulting in a decrease in
SR Ca 2+ transients and subsequently a reduction of cardiac
contractility.
2.4.1
Burn Injury Impairs Cardiac Function
in Rats
The lower trunk and extremities of rats were immersed in
92 °C water for 18 s to produce full-thickness cutaneous
burning of about 40 % of the total body surface area
(TSBA) as described previously [ 81 ]. Sham rats were sub-
jected to an identical procedure except that they were
immersed in room temperature water. All burned animals
received standard ﬂ uid resuscitation consisting of 4 ml/
kg/% of burn lactated Ringer solution, with one half of this
calculated volume given intraperitoneally immediately
after completion of the burn injury and the remaining vol-
ume given 8 h postburn. Two to four hours after burn injury,
left ventricular systolic pressure (LVSP), +dP/dt max, and
−dP/dt max degraded progressively over the entire obser-
vation period. The earliest signiﬁ cant reductions in LVSP
and ± dP/dt max were observed at around 6 h after the burn
injury (Fig. 2.17 ).
Cardiac function 12 h after burn exhibited overt clinical signs
of heart failure: LVSP, +dP/dt max and -dP/dt max decreased
from 130.45 ± 3.37, 4,836 ± 322, and 4,327 ± 235 mmHg in
the control group ( n = 9) to 64.09 ± 8.91, 1,330 ± 501, and
1,023 ± 354 mmHg in the burn group ( n = 10, p < 0.01), suggest-
ing cardiac dysfunction by burn injury.
2.4.2
Burn Injury Decreases AP-Elicited
Ca 2+ -Transient and Cellular Contractility
Ventricular cardiomyocytes were isolated 12 h postburn,
according to the method described by Isenberg et al. [ 82 ].
Myocytes loaded with Ca 2+ indicator ﬂ uo-4 AM (5 μmol/L,
for 8 min) (Invitrogen) were placed in a recording chamber.
After the cells reached a steady state with ﬁ eld stimulation
(1 Hz), confocal line scan imaging was performed at 488 nm
excitation and 505 nm collection with a Zeiss 510 inverted
confocal microscope (Carl Zeiss) with 40× oil immersion
lens (NA 1.3). Line scan images were acquired at a sampling
rate of 3.84 ms per line, along the longitudinal axis of the cell.
The cells were stimulated with ﬁ eld stimulation at 1 Hz using
YC-2 stimulator. Myocyte contraction was measured by
detecting the length of two edges along with the time of stim-
ulation. The cell contractility was indexed by a percentage of
maximal cellular shortening (l precontraction − l maximal contraction /
l precontraction ). Myocytes were superfused with external solution
containing (mmol/L): NaCl 137, KCl 5.4, CaCl 2 1.0, MgCl 2
1.2, NaH 2 PO 4 1.2, HEPES 20, glucose 10, and the pH
adjusted to 7.4 with NaOH.
–dp/dt max (mmHg/sec)
∗∗
∗∗
∗∗
∗
Time (h)
5000
4000
3000
2000
1000
0
0
2
4
6
8
10 12
6000
Time (h)
+dp/dt max (mmHg/sec)
∗
∗∗
∗∗
∗∗
5000
4000
3000
2000
1000
0
0
2
4
6
8
10 12
140
120
100
80
60
40
20
0
Time (h)
Sham
Burn
LVSP (mmHg)
∗∗
∗∗
∗∗
∗
0
2
4
6
8
10 12
Fig. 2.17 Burn injury impairs cardiac function in rats

2.4 Abnormal Calcium Signaling in Burn Generated Cardiac Dysfunction

24
Figure 2.18 demonstrated that the cellular contractility was
dramatically decreased in burn-traumatized cardiomyocytes in
comparison with controls (Fig. 2.18c, g ). The average maxi-
mal contractility was decreased from 10.51 ± 0.39 % ( n = 123)
in the sham group to 5.75 ± 0.18 % ( n = 123, p < 0.01) in the
burn group. Consistent with the alteration in contractility, the
AP-elicited Ca 2+ transient was signiﬁ cantly decreased by
24.2 % (Fig. 2.18b, d ). The Ca 2+ transient (indexed by Δ F / F 0 )
decreased from 4.01 ± 0.08 ( n = 123) in the sham group to
3.04 ± 0.07 ( n = 159, p < 0.01) in the burn group. In contrast,
the rise time and relaxation of Ca 2+ transient were unaltered in
burns (Fig. 2.18e, f ). The rise time and half-time of decay ( T 0.5 )
of Ca 2+ transient in the sham and burn groups were 63.4 ± 1.6 ms
and 120.1 ± 2.2 ms, 58.7 ± 1.9 ms and 121.7 ± 2.7 ms respec-
tively ( p > 0.05), indicating that the synchrony of Ca 2+ release
and SR Ca 2+ recycling remain intact in a burn.
2.4.3
Burn Injury Reduces Cardiac Excitation–
Contraction Coupling Efﬁ ciency
The amplitude of systolic Ca 2+ transient was determined by
the amount of Ca 2+ inﬂ ux and intracellular SR Ca 2+ release. To
investigate the mechanism for decreased systolic Ca 2+ tran-
sient, we simultaneously recorded depolarization-evoked
Ca 2+ inﬂ ux and intracellular Ca 2+ transient with a patch clamp
and confocal microscope. Figure 2.19a shows that the Ca 2+
transient signiﬁ cantly decreased along the voltage range from
−20 mV to +40 mV, whereas the Ca 2+ current density remained
unaltered in burns (Fig. 2.19b ), suggesting that the decrease in
cardiac contractility was due to diminished SR Ca 2+ release,
rather than alteration of LCC activity (Fig. 2.19c ).
Furthermore, this result implied that a burn decreased the efﬁ -
ciency of EC coupling. Consistent with the alteration in Ca 2+
transient, the cellular contractility was similarly decreased at
voltages ranging from −20 mV to +40 mV in a burn
(Fig. 2.19e ). The ratio of the cellular shortening to related
Ca 2+ transient remained unaltered in burns in comparison with
controls (Fig. 2.19f ), suggesting that burn injury might have
no effect on the Ca 2+ sensitivity of cardiac myoﬁ lament.
2.4.4
Burn Injury Depletes SR Ca 2+ Content
It is known that the SR Ca 2+ content is a major determinant
of intracellular Ca 2+ release [ 83 , 84 ]. We thus measured SR
Ca 2+ content to explore the reason for diminished SR Ca 2+
release. Given that the resting SR Ca 2+ content is relatively
saturated in rat cardiomyocytes, we measured SR Ca 2+ con-
tent under ﬁ eld stimulation of 1 Hz by measuring the peak of
caffeine-elicited Ca 2+ transients to index the SR Ca 2+ content.
As shown in Fig. 2.20 , caffeine-elicited Ca 2+ transient was
signiﬁ cantly reduced by 22.1 %, from 4.71 ± 0.09 ( n = 153) in
the control group to 3.67 ± 0.07 ( n = 256, p < 0.01; Fig. 2.20a )
in the burn group. The result indicates that a burn causes SR
Ca 2+ depletion. It is noteworthy that the EC coupling efﬁ -
ciency of sham and burn is virtually identical when the gain
function was normalized by its corresponding SR Ca 2+ load
0
12
6
Sham
Burn
**
Shortening (%)
Length(µm)ΔF/F0
4
0
120
110
1 sec
a
b
c
e
f
g
d
50µm
Sham
Burn
6
3
0
ΔF/F0
**
3
T1/2(ms)
0
100
200
Sham
Burn
Burn
Sham
80
20
0
Rise time (ms)
40
60
Fig. 2.18 Burn reduces systolic
Ca 2+ transient and cardiac
contractility. ( a ) Line scan
image of cardiomyocytes under
ﬁ eld stimulation (1 Hz). ( b )
Time course of Ca 2+ transient.
( c ) Cell contractility indexed by
cellular shortening in response
to ﬁ eld stimulation (1 Hz). ( d – f )
Statistical analysis of the
amplitude and kinetics of Ca 2+
transient. ( g ) Percentage (%) of
maximum shortening

2 The Alterations of Microcirculation in Burns

25
20
0
-40
a
c
b
d
e
*
*
*
*
*
*
*
0
-10
-20
10
20
30
40
Membrane potential (mV)
*
Sham
Burn
2
1
Gain (A.U)
0
*
*
*
*
*
*
*
*
*
*
*
*
*
*
2
4
Peak Ca2+ transient (ΔF/F0)
*
*
*
*
*
*
*
40
60
-20
Membrane potential (mV)
Sham
Burn
0.5
Normalized gain
0
-20
20
40
Membrane potential (mV)
Sham
Burn
-20
-6
-8
-40
0
20
40
60
Membrane potential (mV)
ICa (pA/pF)
-2
-4
Sham
Burn
-20
Normalized shortening
4
3
2
1
-40
0
20
40
60
Membrane potential (mV)
Sham
Burn
9
12
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
0
3
6
Shortening (%)
*
*
*
*
*
*
*
*
0
20
40
60
20
40
Membrane potential (mV)
Sham
Burn
f
Fig. 2.19 Burn injury reduces
cardiac excitation–contraction
coupling efﬁ ciency. ( a )
Amplitude of Ca 2+ transient.
( b ) Current–voltage (I-V)
relationship of L-type Ca 2+
current. ( c ) EC coupling
efﬁ ciency (indexed by the ratio
of Ca 2+ transient to related I Ca .
( d ) Ratio of EC coupling
efﬁ ciency to sarcoplasmic
reticulum (SR) Ca 2+ content.
( e ) Average cell shortening as a
function of membrane
potential. ( f ) Normalized cell
shortening by corresponding
peak Ca 2+
a
0
4
8
Sham
Burn
**
SR Ca2+Load (ΔF/F0)
b
0
500
1000
1500
T1/2(ms)
Sham
Burn
Fig. 2.20 Burn injury partially
depletes SR Ca 2+ content. ( a )
Amplitude of caffeine-elicited
Ca 2+ transient. ( b ) Average half
decay time ( T 0.5 ) of Ca 2+
transient

2.4 Abnormal Calcium Signaling in Burn Generated Cardiac Dysfunction

26
(Fig. 2.19d ). Hence, the reduction in the gain of EC coupling
in a burn is largely accounted for by the depletion of SR Ca 2+
content, rather than defective intermolecular signaling
between LCCs and RyRs.
In the presence of caffeine, SR Ca 2+ re-accumulation is
blocked owing to the leakage through RyRs, and the decay of
Ca 2+ transient mainly reﬂ ects extrusion of Ca 2+ from the cell by
NCX. Kinetic analysis of the caffeine-elicited Ca 2+ transient
demonstrated that the decay of Ca 2+ transient remained
unchanged (Fig. 2.20b ). T 0.5 in sham and burn was
958.3 ± 37.8 ms and 1006.9 ± 34.2 ms ( p > 0.05) respectively.
This result suggests that NCX activity might be intact in a burn.
2.4.5
Burn Injury Increases RyR Reactivity
Ca 2+ sparks are elementary intracellular Ca 2+ release units,
which are formed by the stochastic opening of four to six
adjacent RyRs residing in the SR [ 85 , 86 ]. Study of Ca 2+
sparks provides a window to observe RyR activity in intact
cells. We therefore examined the rate of Ca 2+ spark occur-
rence, the peak amplitude, and other speciﬁ c characteristics
of the Ca 2+ spark. It was found that Ca 2+ spark production
was dramatically increased in a burn: the frequency of sparks
was 2.5 ± 0.0 Hz/100 μm line scan (926 sparks in 168 cells
from 6 rats) in the burn group, which was 1.4-fold higher
than that in the sham group (1.1 ± 0.1 Hz/100 μm line scan,
n = 299 sparks in 132 cells from 6 rats, p < 0.01; Fig. 2.21 ).
These results indicate that RyRs in intact cells become
hyperactive after burn injury. Meanwhile, we observed that
the sparks’ amplitude ( F / F 0 ) was signiﬁ cantly reduced from
2.3 ± 0.0 in sham to 2.1 ± 0.0 in burn (Fig. 2.21 ). The kinetics
of sparks indexed by the rise time and full duration of half
maximum (FDHM) were unaltered in burn versus sham. The
full width of half maximum (FWHM) of Ca 2+ sparks was
slightly but signiﬁ cantly increased from 2.5 ± 0.0 μm in sham
to 2.6 ± 0.0 μm in burn ( p < 0.01). These results collectively
indicate that burn injury increases RyR reactivity.
2.4.6
Burn Injury Causes Ca 2+ Instability
The above result indicates the instability of the SR function
and increased SR Ca 2+ leak, suggesting increased sponta-
neous Ca 2+ wave or store overload-induced Ca 2+ release
(SOICR) under a higher resting Ca 2+ level. We thus studied
the production and propagation of Ca 2+ waves under the con-
dition of Ca 2+ overload produced by increasing extracellu-
lar Ca 2+ (10 mM). The results demonstrated that Ca 2+ waves
were more likely to be stimulated in a burn. The rate of Ca 2+
waves was 1.17 ± 0.07/100 μm·s ( n = 131) in burn, in con-
trast to 0.40 ± 0.03/100 μm . s, n = 109, p < 0.01; Fig. 2.22a ).
Furthermore, most of the Ca 2+ waves in a burn were broken
or tortured and the propagation velocity was decreased, sug-
gesting that the function of RyRs might be damaged. Under
the stimulation of 10 mmol/L Ca 2+ , the rate of Ca 2+ sparks was
also remarkably increased from 2.09 ± 0.56 events/100 μm . s
( n = 67) in a sham group to 5.25 ± 0.81 events/100 μm/s
( n = 65, p < 0.01) in the burn group (Fig. 2.22b ). These results
conﬁ rm that burn trauma reduces the SR Ca 2+ stability in
cardiomyocytes.
In summary, we propose a working hypothesis of the
abnormal Ca 2+ handling mechanism underlying burn-
generated cardiac dysfunction (Fig. 2.23 ) burn injury enhances
500 ms
20µm
a
b
c
µ m
ms
F/F0
Amplitude (F/F0)
1
2
3
0
d
**
Sham
Burn
**
0
1
2
3
**
Frequency
(Hz/100µm scanline)
e
f
FDHM (ms)
0
10
20
30
40
FWHM(µm)
1
0
2
3
g
**
Sham
Burn
Sham
Burn
Sham
Burn
Fig. 2.21 Burn increases Ca 2+
spark frequency in burn
traumatized cardiomyocytes.
( a – c ) Line scan image of Ca 2+
sparks and 3D reconstruct ﬁ gure.
( d – g ) Statistics of amplitude,
rate, and kinetics of Ca 2+ sparks

2 The Alterations of Microcirculation in Burns

27
b
**
0
4
8
Sham
Burn
Frequency of spark
(Hz/100µm scanline)
a
**
0
Sham
Burn
Frequency of wave
(Hz/100µm scanline)
0.5
1.0
1.5
Fig. 2.22 Burn enhances the
production of Ca 2+ wave in
cardiomyocytes
Burn
Abnormal RyR function
SRCa2+ leak↑
SRCa2+ depletion
Intracellular Ca2+
Intracellular Ca2+ release↓
(E-C coupling efficiency↓)
Cardiac injury
AP-elicited Ca2+
Cardiac contractility
Cardiac dysfunctiobn
Fig. 2.23 Schematic diagram of
burn-generated cardiac dysfunc-
tion related to enhanced SR Ca 2+
leak

2.4 Abnormal Calcium Signaling in Burn Generated Cardiac Dysfunction

28
the Ca 2+ spark-mediated SR Ca 2+ leak. On the one hand, the
SR leak results in partial depletion of the SR Ca 2+ store, which
causes insufﬁ ciency of systolic intracellular Ca 2+ release and
subsequently a decrease in cardiac contractility. On the other
hand, SR leak induces intracellular Ca 2+ accumulation, lead-
ing to cardiomyocyte injury. Both mechanisms promote each
other, resulting in burn-generated cardiac dysfunction [ 87 ].
Acknowledgment
This work was supported by several sources:
Chinese National Natural Scientiﬁ c Foundation grant 30028008,
30771028 and 30971201; National Key Foundation for Basic Science
Research of China (grant G2005CB522601); Natural Science
Foundation of Guangdong, China (grant 4020373).
References
1. Demling RH. The burn edema process: current concepts. J Burn
Care Rehabil. 2005;26(3):207–27.
2. Mehta D, Malik AB. Signaling mechanisms regulating endothelial
permeability. Physiol Rev. 2006;86:279–367.
3. Dejana E, Tournier-Lasserve E, Weinstein BM. The control of vas-
cular integrity by endothelial cell junctions: molecular basis and
pathological implications. Dev Cell. 2009;16(2):209–21.
4. Komarova YA, Mehta D, Malik AB. Dual regulation of endothelial
junctional permeability. Sci STKE. 2007;(412):re8.
5. Van Nieuw Amerongen GP, van Hinsbergh VW. Targets for phar-
macological intervention of endothelial hyperpermeability and bar-
rier function. Vasc Pharmacol. 2002;39:257–72.
6. Zhao KS, Guo YW, Zhou LD. Effects of cortisone on vascular per-
meability in early stage of severe burn. Acta Physiologica Sinica.
1966;29:70–3.
7. Zheng HZ, Zhao KS, Huang QB, et al. Role of Rho kinase and actin
ﬁ lament in the increased vascular permeability of skin venule in rat
after scalding. Burns. 2003;29(8):820–7.
8. Huang Q, Xu W, Ustinova E, et al. Myosin light chain kinase-
dependent microvascular hyperpermeability in thermal injury.
Shock. 2003;20(4):363–8.
9. Wautier JL, Zoukourian C, Chappey O, et al. Receptor-mediated
endothelial cell dysfunction in diabetic vasculopathy: soluble
receptor for advanced glycation end products blocks hyperperme-
ability in diabetic rats. J Clin Invest. 1996;97:238–43.
10. Guo XH, Huang QB, Chen B, et al. Mechanism of advanced glyca-
tion end products-induced hyperpermeability in endothelial cells.
Acta Physiol Sino. 2005;57:205–10 (Chinese, English abstract).
11. Li Q, Guo XH, Zhu YJ, et al. The mechanism of advanced glyca-
tion end products-induced morphological changes of tight junction
in endothelial cells. Chin J Arterioscler. 2006;14:499–502.
12. Breviario F, Caveda L, Corada M, et al. Functional properties of
human vascular endothelial cadherin (7B4/cadherin-5), an
endothelium- speciﬁ c cadherin. Arterioscler Thromb Vasc Biol.
1995;15:1229–39.
13. Liu XL, Wu W, Li Q, et al. Effect of sphingosine 1-phosphate on
morphological and functional responses in endothelia and venules
after scalding injury. Burns. 2009;35:1171–9.
14. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/
ACCP/ATS/SIS international sepsis deﬁ nitions conference. Crit
Care Med. 2003;31:1250–6.
15. Song L, Huang QB, Zhao KS, et al. Effects of LPS on the organiza-
tion and localization of VE-cadherin and F-actin in cultured endo-
thelial cells. Chin J Pathophysiol. 2003;19:150–2.
16. Wang ZH, Guo XH, Liu XL, et al. The morphological changes of
vascular endothelial cadherin in human umbilical vein endothelial
cells induced by advanced glycation end products. Chin J
Arterioscler. 2008;16:505–9.
17. Geeves MA, Holmes KC. Structural mechanism of muscle contrac-
tion. Annu Rev Biochem. 1999;68:687–728.
18. Lai CH, Kuo KH, Leo JM. Critical role of actin in modulating BBB
permeability. Brain Res Rev. 2005;50:7–13.
19. Yuan Y, Huang Q, Wu HM. Myosin light chain phosphorylation:
modulation of basal and agonist-stimulated venular permeability.
Am J Physiol. 1997;272(3 Pt 2):H1437–43.
20. Chen B, Guo XH, Wang Y, et al. Myosin light chain kinase contrib-
utes to cytoskeletal alteration of endothelial cells by rat burn serum.
J 1st Mil Med Univ. 2004;24:481–4.
21. Huang QB, Song L, Zhao KS, et al. Effects of lipopolysaccharide
on actin reorganization and actin pools in endothelial cells. Chin J
Traumatol. 2004;7:195–200.
22. Hall A. Rho GTPase and the actin cytoskeleton. Science. 1998;279:
509–14.
23. Waschke J, Baumgartner W, Adamson RH, et al. Requirement of
Rac activity for maintenance of capillary endothelial barrier
properties. Am J Physiol Heart Circ Physiol. 2004;286:
H394–401.
24. Kuroda S, Fukata M, Nakagawa M, et al. Role of IQGAP1, a target
of the small GTPase Cdc42 and Rac1, in regulation of E-cadherin-
mediated cell-cell adhesion. Science. 1998;281:832–5.
25. Widmann C, Gilson S, Jarpe MB, et al. Mitogen-activated protein
kinase: conservation of a three-kinase module from yeast to human.
Physiol Rev. 1999;79:143–80.
26. Zarubin T, Han JH. Activation and signaling of the p38 MAP kinase
pathway. Cell Res. 2005;15:11–8.
27. Murphya LO, Blenisb J. MAPK signal speciﬁ city: the right place at
the right time. Trends Biochem Sci. 2006;31:268–75.
28. Huang Q, Zhao M, Wang Sh Y, et al. The role of p38 alpha and p38
delta MAP kinases in the genesis of increased vascular permeabil-
ity in burns. Microcirculation. 2007;14:506.
29. Borbiev T, Birukova A, Liu F, et al. p38 MAP kinase-dependent
regulation of endothelial cell permeability. Am J Physiol Lung Cell
Mol Physiol. 2004;287:L911–8.
30. Johnson A, Hocking DC, Ferro TJ. Mechanisms of pulmonary
edema induced by a diacylglycerol second messenger. Am J Physiol
(HeartCirc Physiol 27). 1990;258:H85–91.
31. Murray MA, Heistad DD, Mayhan WG. Role of protein kinase C in
bradykinin-induced increases in microvascular permeability. Circ
Res. 1991;68:1340–8.
32. Huang Q, Yuan Y. Interaction of PKC and NOS in signal transduc-
tion of microvascular hyperpermeability. Am J Physiol. 1997;273(5
Pt 2):H2442–51.
33. Yang T, Huang QB. The activation and translocation of protein
kinase C induced by burn serum. Chin Crit Care Med. 2001;13:
427–9.
34. Dempsey EC, Newton AC, Mochly-Rosen D, et al. Protein kinase
C isozymes and the regulation of diverse cell responses. Am J
Physiol Lung Cell Mol Physiol. 2000;279:L429–38.
35. Bell RM. Protein kinase C activation by second messengers. Cell.
1986;45:631–2.
36. Garcia JGN, Davis HW, Patterson CE. Regulation of endothelial-
cell gap formation and barrier dysfunction-role of myosin
light- chain phosphorylation. J Cell Physiol. 1995;163:510–22.
37. Larsson C. Protein kinase C and the regulation of the actin cytoskel-
eton. Cell Signal. 2006;18:276–84.
38. Knezevic N, Roy A, Timblin B, et al. GDI-1 phosphorylation
switch at serine 96 induces RhoA activation and increased endothe-
lial permeability. Mol Cell Biol. 2007;27:6323–33.
39. Mehta D, Rahman A, Malik AB. Protein kinase C-alpha signals
rho-guanine nucleotide dissociation inhibitor phosphorylation and
rho activation and regulates the endothelial cell barrier function. J
Biol Chem. 2001;276:22614–20.
40. Bogatcheva NV, Adyshev D, Mambetsariev B, et al. Involvement of
microtubules,
p38,
and
Rho
kinases
pathway
in
2- methoxyestradiol-induced lung vascular barrier dysfunction. Am
J Physiol Lung Cell Mol Physiol. 2007;292:L487–99.
2 The Alterations of Microcirculation in Burns

29
41. Marinissen MJ, Chiariello M, Gutkind JS. Regulation of gene
expression by the small GTPase Rho through the ERK6
(p38 gamma) MAP kinase pathway. Genes Dev. 2001;15(5):
535–53.
42. McVerry BJ, Garcia JG. In vitro and in vivo modulation of vascular
barrier integrity by sphingosine 1-phosphate: mechanistic insights.
Cell Signal. 2005;17:131–9.
43. Fujimi S, MacConmara MP, Maung AA, et al. Platelet depletion in
mice increases mortality after thermal injury. Blood. 2006;107(11):
4399–406.
44. Garcia JG, Liu F, Verin AD, et al. Sphingosine 1-phosphate pro-
motes endothelial cell barrier integrity by Edg-dependent cytoskel-
etal rearrangement. J Clin Invest. 2001;108(5):689–701.
45. Lee MJ, Thangada S, Claffey KP, et al. Vascular endothelial cell
adherens junction assembly and morphogenesis induced by
sphingosine- 1-phosphate. Cell. 1999;99:301–12.
46. Liu XL, Wang H, Li Q, et al. Effects of sphingosine-1-phosphate on
vascular permeability in scalding injury. J Chin Microcirc.
2008;12(5):267–70.
47. Alewijnse AE, Peters SL. Sphingolipid signalling in the cardiovas-
cular
system:
good,
bad
or
both?
Eur
J
Pharmacol.
2008;585(2–3):292–302.
48. Moore TM, Chetham PM, Kelly JJ, et al. Signal transduction and
regulation of lung endothelial cell permeability. Interaction between
calcium and cAMP. Am J Physiol. 1998;275:L203–22.
49. Wu H, Huang Q, Yuan Y, et al. VEGF induces NO-dependent
hyperpermeability
in
coronary
venules.
Am
J
Physiol.
1996;271:H2735–9.
50. Wu MH. Endothelial focal adhesions and barrier function. J
Physiol. 2005;569(Pt 2):359–66.
51. Tuma PL, Hubbard AL. Transcytosis: crossing cellular barriers.
Physiol Rev. 2003;83:871–932.
52. Zhao KS. Microcirculation in burns: microcirculatory changes in
burned skin. Chin J Burn Reconst. 1987;3:15–57.
53. Zhao KS. The microcirculatory alterations in burns. Peoples Mil
Surg. 1979;1:35–9.
54. Zhao KS, Zhu ZG, Wu GY, et al. The role of microcirculatory dis-
order in the genesis of burn shock. Med J Chin Lib Army.
1984;9:18–20.
55. Wu GY. The application of rabbit ear chamber technique in micro-
circulatory research of burned skin. The selection of Scientiﬁ c
Research (First Military Medical University). 1979;5:31.
56. Zhao KS, Wu GY, Tian Y, et al. The effect of polydatin on the
change of microcirculation of burned skin. Med J Chin Lib Army.
1980;5:75–8.
57. Zhao KS, Woo GY, Tian Y, et al. The effect of polygonum cuspida-
tun on the microcirculation of burned skin. In: Chang HM et al.,
editors. Advances in Chinese medicinal materials research. World
Scientiﬁ c Pub: Singapore; 1985. p. 591–5.
58. Wu GY, Zhao KS, Zhu ZJ, et al. The electron microscopic observa-
tion of microvessels in burned skin. J First Mil Med Univ.
1984;4:49–51.
59. Zhao KS. The advances of microcirculatory research in burns. J
First Mil Med Univ. 1984;4:131–8.
60. Zhao KS, Wu GY, Zhu ZG, et al. The role of leukocyte in microcir-
culatory disorder of shock. Chin J Med. 1986;10:722–5.
61. Wu XB, Zhao KS, Huang XL. The change of leukocyte adhesive
feature in rat with severe burns. Chin J Med. 1994;74:312–4.
62. Zhao KS, Wu XB, Wang YC. Effect of polygonum cuspidatum on
the leukocyte activation and adhesion of rat during burn shock. In:
Niimi H et al., editors. Progress in microcirculation research.
Oxford: Elsevier Science Ltd; 1994. p. 55–68.
63. Wang YC, Zhao KS, Wu XB. The prognostic implication of deter-
mination of activation of leukocyte in severe burns. Chin J Burn
Reconst. 1994;10:286–5.
64. Wang YC, Zhao KS. The surface expression of LFA-1 on leukocyte
in shock. Microcirc Tech. 1997;1:9–11.
65. Zhao ZH, Zhao KS, Zhu ZJ. Study on the expression of L-selectin
at transcription level in severe burn shock rat. Chin J Pathophysiol.
1998;14:43–5.
66. Zhao KS. The research on leukocyte behavior of microcirculation
in shock. J Microcir. 1992;2:40.
67. Zhao KS. Advances in the study on rheological behavior of leuko-
cyte during severe shock. Chin Med J. 1996;109:110–1.
68. Wu XB, Huang QB, Zhao KS. The effect of LFA-1 monoclonal
antibody on the microcirculatory disturbance of endotoxin shock in
rabbit. Chin J Trauma. 1986;12:25–7.
69. Zhao KS. Integrin family and leukocyte adhesion. In: Zhao KS, Jin
L, editors. Cellular and molecular basis of shock. Beijing: Scient
Pub; 2002. p. 11–4.
70. Wu KY, Huang QB, Zhao KS. The effect of TNF monoclonal anti-
body on leukocyte adhesion and hemodynamic of microcirculation
in rat with burn shock. Chin J Pathophysiol. 1996;12:425–7.
71. Wu KY, Zhao KS, Zhu ZJ, et al. Burn shock can be treated with
peritoneal dialysis. Chin J Pathophysiol. 1987;3:88–91.
72. Ballard-Croft C, Carlson D, Maass DL, et al. Burn trauma alters
calcium transporter protein expression in the heart. J Appl Physiol.
2004;97:1470–6.
73. Horton JW. Left ventricular contractile dysfunction as a complica-
tion of thermal injury. Shock. 2004;22:495–507.
74. Horton JW, White DJ, Maass D, et al. Calcium antagonists improve
cardiac mechanical performance after thermal trauma. J Surg Res.
1999;87:39–50.
75. Murphy JT, Giroir B, Horton JW. Thermal injury alters myocardial
sarcoplasmic reticulum calcium channel function. J Surg Res.
1999;82:244–52.
76. White DJ, Maass DL, Sanders B, et al. Cardiomyocyte intracellular
calcium and cardiac dysfunction after burn trauma. Crit Care Med.
2002;30:14–22.
77. Kawai K, Kawai T, Sambol JT, et al. Cellular mechanisms of burn-
related changes in contractility and its prevention by mesenteric lymph
ligation. Am J Physiol Heart Circ Physiol. 2007;292:H2475–84.
78. Berridge MJ, Bootman MD, Roderick HL. Calcium signalling:
dynamics, homeostasis and remodelling. Nat Rev Mol Cell Biol.
2003;4:517–29.
79. Berridge MJ, Lipp P, Bootman MD. The versatility and universality
of calcium signalling. Nat Rev Mol Cell Biol. 2000;1:11–21.
80. Bers DM, Perez-Reyes E. Ca channels in cardiac myocytes: struc-
ture and function in Ca inﬂ ux and intracellular Ca release.
Cardiovasc Res. 1999;42(2):339–60.
81. Zhao KS, Zhu ZJ, Wu KY, et al. Importance of enhancing cardiac
function in the treatment of burn shock-effect of crystal NO4 of
polygonum cuspidatum. In: Sheng CY, editor. Advances in burns.
Beijing: International Academic Publishers; 1992. p. 31–8.
82. Moore RL, Yelamarty RV, Misawa H, et al. Altered Ca 2+ dynamics
in single cardiac myocytes from renovascular hypertensive rats. Am
J Physiol. 1991;260:C327–37.
83. Hasenfuss G, Pieske B. Calcium cycling in congestive heart failure.
J Mol Cell Cardiol. 2002;34:951–69.
84. O’Rourke B, Kass DA, Tomaselli GF, et al. Mechanisms of altered
excitation-contraction coupling in canine tachycardia-induced
heart failure, I: experimental studies. Circ Res. 1999;84:562–70.
85. Fill M, Copello JA. Ryanodine receptor calcium release channels.
Physiol Rev. 2002;82(4):893–922.
86. Meissner G. Ryanodine receptor/Ca 2+ release channels and their
regulation by endogenous effectors. Annu Rev Physiol.
1994;56:485–508.
87. Deng J, Wang G, Huang Q, et al. Oxidative stress induced leaky
sarcoplasmic reticulum underlying acute heart failure in severe
burn trauma. Free Radical Biol Med. 2008;44:375–85.
References

31
Z. Yang, Chinese Burn Surgery, DOI 10.1007/978-94-017-8575-4_3,
© Springer Science+Business Media Dordrecht and People’s Medical Publishing House 2015
3.1
Early Fluid Replacement
Post-burn Injury
Zhenrong Guo and Lixin He
Shock is the ﬁ rst critical step during the cure of patients with
severe burns owing to the exosmosis of plasma fractions and
the destruction of blood cells within 48 h after the injury,
which tends to result in hypovolemic shock . The burn shock
has a considerable effect on the whole course, although it
occurs at an early stage. Over the last 20 years, the morbid-
ity and mortality of shock were directly due to the shock
decreasing with as the level of resuscitation during the shock
phase increases [ 1 ]; however, it does not mean that problems
regarding shock have been resolved because the complica-
tions affecting the internal organs caused by shock are still
tough to treat [ 2 ]. It is especially apparent in some grass- roots
units that the vague recognition with regard to treatment dur-
ing the shock phase is still to be clariﬁ ed. In summary, the
necessary content to be deﬁ ned includes the patterns and
compositions of transfusion and the combined treatment in
addition to ﬂ uid infusion during the shock phase.
3.1.1
How Should the Fluid Infusion
Be Conducted During the Shock Phase?
It is certain that ﬂ uid infusion is required for severe burns;
however, the method of ﬂ uid infusion has not often been rea-
sonably deﬁ ned, and there is still less satisfaction regarding
scientiﬁ c and rational ﬂ uid infusion and the recovery of
blood volume in these patients.
3.1.1.1 Various Aspects of the Problems Regarding
Fluid Infusion During the Shock Phase
1. Limit ﬂ uid infusion and pass with low criteria. Apply the
infusion formula for the shock phase established in 1970
automatically and do not exceed the volume stated in the
formula [ 3 ]. Be careful of ﬂ uid infusion during the shock
phase, infuse a lower volume rather than a greater vol-
ume, and consider the countershock to be successful if
the patient lives for 48 h. Always be careful as a slightly
higher volume than the calculated volume may aggravate
the edema, malabsorption, and even induction of compli-
cations such as cerebral edema, pulmonary edema, etc.
The patients with limited infusion cannot obtain satis-
factory resuscitation, even if they live through the shock
phase, and the lingering effects of different degrees of
hypoxia may become predominant in the infection phase
followed by various complications. Previously, there have
been complaints that “the infection occurs too fast”. The
hypoxia that occurs during the shock phase is where it
originates.
2. Take a conservative approach with regard to patients with
delayed resuscitation. Do not apply rapid and high-
volume ﬂ uid infusion, but still follow the routine formula
and speed of ﬂ uid infusion. The patients have already lost
the “golden time” for ﬂ uid infusion during early resusci-
tation owing to the delayed admission; thus, the lesions
resulting from hypoxia induced by hypovolemia could
not be corrected as soon as possible if the hypernormal
rapid ﬂ uid infusion was not performed 2–3 h after admis-
sion, which greatly increases the difﬁ culty of cure,
increases the incidence of complications and multiple
organ dysfunction, and the mortality is signiﬁ cantly
higher than that of the early resuscitation group.
3. Understand ﬂ uid infusion to be the main treatment during
the shock phase in a one-sided way without a good under-
standing of the content, amount, and arrangement of the
infusion, neglect the components of the ﬂ uid and the
contents and signiﬁ cance of combined treatment during
the shock phase.
4. Break through the formula and succeed in ﬂ uid infusion.
In the last several years, almost all cured patients with
extensive burns were infused with quantities greater than
those calculated from the traditional formula during the
Burn Shock
Zhenrong Guo and Zhaofan Xia
3

32
shock phase. Most patients live through the shock phase
smoothly with fewer complications during the infective
phase and a signiﬁ cantly increased recovery rate, which
results in blind pursuit of the amount of infusion. Some
ﬂ uid infusions were too large or too rapid; meanwhile,
too great an infusion of electrolytes and water, but less
colloid results in a decrease in colloid osmotic pressure,
which leads to “leakage during the infusion.” The result
of overloading ﬂ uid infusion causes systematic edema;
in particular, complications including cerebral edema,
pulmonary edema, pleural and peritoneal effusion, are
more harmful, and may lead to celiac space syndrome
and even hypourocrinia. The doctors may erroneously
identify this as insufﬁ cient ﬂ uid infusion and keep accel-
erating the speed of ﬂ uid infusion, which results in a
“vicious cycle” and more severe hypourocrinia, and
aggravates the shock.
Many people are still confused regarding appropriate
ﬂ uid infusion, which can not only recover the blood volume
effectively, but also avoids overloading infusion. Over sev-
eral decades, burn specialists have been attempting to deﬁ ne
the optimal resuscitation program during the shock phase for
patients with burns [ 4 ].
3.1.1.2 Arrangement of Fluid Infusion
During the Shock Phase
Fluid infusion may be performed via intro- and extro-
gastrointestinal routes. However, a large amount of ﬂ uid
infusion is required during the shock phase, and oral adminis-
tration cannot been chosen as the main route of ﬂ uid infusion
owing to the microcirculation disturbance and malfunction-
ing of the gastrointestinal tract except for the requirement
for early feeding; thus, the ﬂ uid should be supplied via an
extra-gastrointestinal route. For convenient ﬂ uid infusion
during the shock phase, foreign and domestic groups have
established formulas for ﬂ uid infusion within the ﬁ rst 48 h.
These formulas all provided an important reference for ﬂ uid
infusion during the shock phase during a certain period;
however, subsequent researchers have been modifying these
formulas and proposing new infusion formulas, because
the originals were not perfect. In the process of continuous
development, the infusion formulas gradually came to meet
patients’ requirements.
Brief Introduction to the Infusion Formulas
The amount of body ﬂ uid exudating during the shock phase
after burns has the closest relationship with the burn surface
area and body weight. The main components of exudates are
electrolytes and plasma. To conveniently calculate the infu-
sion amount, many groups have proposed infusion formulas
during the shock phase (Table 3.1 ).
Evaluation of Various Fluid Infusion Formulas
1. A review of history indicated that foreign experts have
carried out a great deal of research into ﬂ uid infusion dur-
ing the shock phase since the 1940s. Professor Evans
(USA) has made a large contribution. He thought that
exudation in the early stages of a burn resulted in a great
loss of plasma; thus, ﬂ uid infusion should also include
colloid, taking plasma as the main component in addition
to electrolytes. He also established the Evans formula [ 6 ]
in 1952 based on the changes in plasma volume observed
in burns experiments in dogs. For the ﬁ rst time, he sug-
gested taking the body weight and the burn surface area as
the basis for calculation and advised infusing electrolytes
and colloids in the ﬁ rst 24 h at 1 ml/kg (1%TBSA) at a
ratio of 1:1, and 2,000 ml water (5 % glucose). Half of the
scheduled amount is required to be infused within 8 h
after the burn, one quarter of the total amount should be
infused in the following 16 h. The amount of crystalloid
and colloid is halved in the second 24 h after the burn and
the amount of water is the same as that in the ﬁ rst 24 h.
The Evans formula has had a great effect on resuscitation
during the shock phase after burns in many countries.
Currently, the formulas containing electrolytes and col-
loid applied in the clinical work are all derived from the
Evans formula.
The establishment of this formula originates from
animal experiments; thus, its defect is that, for patients
with a burn surface area of over 50 %, the amount of
infusion is still calculated as for those with a burn sur-
face area of 50 % and the total amount within the ﬁ rst
24 h should not exceed 10,000 ml. It is obvious that
these restrictions result in an insufﬁ ciency of ﬂ uid infu-
sion in some patients with extensive and deep burns,
which may be the main reason for the high incidence of
shock and mortality in burns at that time. Evans reported
that the mortality of patients with a burn surface area of
over 50 % was 85 % and none of the patients with a burn
surface area of over 80 % survived, which may be
related to insufﬁ cient resuscitation during the shock
phase.
2. The Brook formula is a modiﬁ cation of the Evans formula
from the trauma research institute of the American mili-
tary Brook Medical Center, in which the amount of col-
loid is halved and the physiological saline is replaced by
sodium lactated Ringer solution 1.5 ml/kg (1%TBSA) for
crystalloid, which is more consistent with the physiologi-
cal requirement; meanwhile, the amount of infusion is
calculated according to the actual area for the patients
with a burn surface area of over 50 %, which is closer to
the amount actually required than that from the Evans
formula.
3 Burn Shock

33
3. The Parkland formula was proposed by Baxter (of the
American Parkland Medical Center) in 1968 [ 7 ]. He sug-
gested that the increase in exudation on the ﬁ rst day is
mainly due to a sodium and water deﬁ cit in the extracel-
lular ﬂ uid and that the crystalloid osmotic pressure is not
recovered unless a large amount of sodium is supplied.
However, the colloid supplement is not beneﬁ cial since it
cannot remain in the blood vessels to maintain colloid
osmotic pressure and penetrate into tissue spaces to affect
the absorption of the tissues. Therefore, only sodium lac-
tated Ringer solution 4 ml/kg (1 %TBSA) is infused in
the ﬁ rst 24 h. Half of the scheduled amount is infused
within 8 h after the burn; the remaining amount during
the following 16 h. The infusion in the second 24 h has
5 % glucose as the main component with no electrolyte
solution. Five hundred to two thousand milliliters of col-
loid may be added if there is insufﬁ cient capacity for cir-
culation, and it can also be infused at 0.3 ml/kg
(1 %TBSA).
Sodium lactated Ringer solution contains 130 mmol/L
sodium. One thousand milliliters of the solution can sup-
plement 130 mmol of sodium; meanwhile, 80–100 ml of
water is also supplemented simultaneously; thus, no more
water is required. The function of the semipermeable
membrane of the blood capillaries recovers at about 18 h
after the burn; therefore, most of the infused colloid solu-
tion can remain in the blood vessels to maintain colloid
osmotic pressure during the second 24 h.
The Parkland formula refers to regions that are short
of colloid (plasma, etc.) and the cure of burn patients in
group and patients with severe burns on the battleﬁ eld.
Its disadvantages include a large amount of infusion,
aggravation of edema, and the potential risk of inducing
heart and lung complications in patients with a poor
load tolerance. The incidence of cerebral edema, pul-
monary edema, pleural effusion, and celiac space syn-
drome are higher in comparison. The edema of the
wound surface and separated parts are both more severe,
which is disadvantageous for the maintenance of a scab,
and the liquefaction and infection of an eschar and sep-
sis during the resorption phase comprise a threat of
infection.
4. The Hypertonic saline formula was proposed by Monafo
(USA) in 1974. Hypertonic saline 3 ml/kg (1 %TBSA)
containing 250 mmol/L of sodium, 150 mmol/L of chlo-
rine, and 100 mmol/L of lactic acid is infused during the
shock phase. Two thirds of the total amount is infused
within the ﬁ rst 24 h, and the remaining amount is infused
during the second 24 h. To prevent rebound edema result-
ing from the infusion of isotonic solution after 48 h, the
solutions containing 220 mmol/L and 190 mmol/L
sodium may be infused in the second and third 8 h respec-
tively, and the solution containing 150 mmol/L sodium is
infused in the second 24 h.
The outstanding characteristic of this formula is to
induce hypertonicity of the extracellular ﬂ uid to result in
intracellular dehydration in order to produce extracellular
ﬂ uid expansion, which saves one third of the amount of
ﬂ uid compared with that calculated from the Parkland
formula. A lower amount of infusion can reduce the ﬂ uid
load so that it is suitable for patients with a higher load on
the heart and lungs. Hypertonic lactate solution contain-
ing 250 mmol/L plus 6 % dextran was once applied in the
resuscitation unit in Changhai Hospital [ 9 ], and the results
Table 3.1 Examples of infusion formulas during the shock phase
Formula (Era)
Evans
(1952)
Brooke
(1953)
Parkland (1968)
Monafo (1973)
The Third
Military Medical
University (1962)
Ruijin
Hospital [ 5 ]
(1965)
304 Hospital
(1995)
The ﬁ rst 24 h electrolyte
solution (ml/kg·L
1 %TBSA)
1.0
Sodium
lactated
Ringer
solution 1.5
Sodium lactated
Ringer solution
4.0
Hypertonic saline 3.0
containing Na 250 mmol/L Cl
150 mmol/L lactic acid
100 mmol/L
1.0
Sodium
lactated
Ringer
solution 0.75
0.9–1.0
Colloid (ml/kg,
1%TBSA)
1.0
0.5
(–)
(–)
0.5
0.75
0.9–1.0
Water, 5 % glucose (ml) 2,000 2,000
(–)
(–)
2,000
3,000–4,000 3,000–4,000
The second 24 h
electrolyte (ml/
kg·L %TBSA)
Halve Halve
(–)
Continuous administration of
hypertonic saline to maintain
urine volume 30–40 ml/h
Halve
Halve
0.7–0.75
Colloid (ml/kg,
1%TBSA)
Halve Halve
500–2,000 ml
(–)
Halve
Halve
0.7–0.75
Water 5 % glucose (ml)
2,000 2,000
Maintain urine
volume
30–50 ml/h
(–)
2,000
3,000–4,000 3,000
3.1 Early Fluid Replacement Post-burn Injury

34
conﬁ rmed that it can improve cardiac pump function and
tissue perfusion, decrease the production of lactic acid,
and reduce the volume load and edema. Some have also
proposed using hyperosmotic/high-colloid solution dur-
ing resuscitation, and 7.5 % dextran produced the best
result; however, these solutions have not been applied in
the treatment of burns [ 10 ].
Although the application of hypertonic saline for-
mula can decrease the amount of infusion and reduce
edema, the conditions of the patients should be moni-
tored closely and the serum sodium should not exceed
160 mmol/L. Moreover, the blood osmotic concen-
tration should also be monitored and it should not be
>330 mmol/L to prevent hyperosmotic anhydration and
even coma.
5. The infusion formulas applied in China draw on the expe-
rience of the Evans formula and continue to study the
ﬂ uid infusion for resuscitation during the shock phase.
According to the actual measurements of different popu-
lations, Chinese specialists in burns proposed two simple
methods of calculating body surface area, the “modiﬁ ed
rule of Nine” and the “rule of palm,” which provide con-
venient methods for the calculation of ﬂ uid infusion dur-
ing the shock phase. The “ current formula, ” generally
accepted by Chinese specialists, was proposed in 1970
[ 11 ]. The formula requests the amounts of electrolytes
and colloid to be 1.5 mLKg –1 per 1 % TBSA plus 2,000 ml
of water (5 % glucose) in 24 h, and the ratio of crystalloid
and colloid is 2:1 or 1:1 (third degree, large burn surface
area). Each component should be infused alternately to
prevent an imbalance of ﬂ uid infusion and severe edema.
A great deal of clinical practice has indicated that
strictly adhering to the previous infusion formulas cannot
achieve stability during the shock phase, in which the low
perfusion and insidious shock still exist. The facts proved
that all successful cures exceeded the amounts prescribed
by the formulas.
6. The 304 Hospital formula [ 12 ]. The Swan–Ganz catheter
is used to monitor hemodynamics [ 13 ]. The new infu-
sion formula is established based on the total amount
of integrating electrolytes, colloid, and water needed to
maintain the normality of various hemodynamic indexes.
The total amount of ﬂ uid infusion is 2.6–3.0 mLKg –1 per
1% TBSA in the ﬁ rst 24 h, to convert into the infusion
formula is that, in the ﬁ rst 24 h, 0.9–1.0 mLKg –1 per 1%
TBSA electrolytes and colloid and 3,000–4,000 ml (more
water should be infused for patients with greater body
weight, with third-degree burns, and with a large burn
surface area) should be infused respectively; in the sec-
ond 24 h, 0.7–0.75 ml/kg (1 %TBSA) electrolytes and
colloid should be infused respectively, and the amount of
water is the same as the former. Performing ﬂ uid infusion
according to this formula can not only recover the hemo-
dynamic indexes rapidly, but also maintains the urine vol-
ume at 80–100 ml/h or 1–2 ml/(kg·h). At this time, the
patient is conscious, the heart rate decreases to 100–110
beats/min, the feeling of thirst is signiﬁ cantly reduced, the
patient’s blood pressure is normal without nausea or vom-
iting, the breathing frequency is about 20 times/min, the
hemoglobin is ≤150 g/L, and the hematocrit (packed red
cell volume) is ≤0.50; these results indicate that the hemo-
concentration has already been corrected and that the vol-
ume of blood has been substantially normal. Therefore,
the recovery of these clinical indexes can be taken to be
important references for satisfactory resuscitation [ 14 ].
7. Fluid infusion in pediatric burns. The amounts of infused
crystalloid and colloid are usually 1 ml/kg 1 %, in the ﬁ rst
24 h for infants below 3 years old respectively, and the
amount of infused water is 120 ml/(kg·day); for children
over 3 years old, 0.9 ml/kg 1 % crystalloid and colloid as
well as 80–100 ml/(kg·day) are infused; in the second 24 h,
the infused crystalloid and colloid are both 0.75 ml/kg 1 %,
and the amount of water is the same as in the ﬁ rst 24 h. The
main indexes observed during the shock phase for children
are: consciousness, 1–2 ml/(kg·h) of urine volume, heart rate
120–140 beats/min, ﬁ ne peripheral circulation (including
skin color, temperature of acra), hematocrit ≤0.4 for 0- to
3-year-old infants and ≤0.45 for 4- to 12-year-old children.
At present, too little or too much ﬂ uid infusion should be
avoided in resuscitation during the shock phase, and the fol-
lowing targeted resuscitation (Targeted Resuscitation) and
end point (End Point) should be achieved: the maintenance
of satisfactory hemoperfusion, effective oxygen delivery to
the tissues, the elimination of oxygen debt, the recovery of
normal aerobic metabolism, and the termination of cell
death. The vital signs are normal, the base excess (BE) in
blood gas analysis is <−6, the cardiac stroke volume is recov-
ered, DO 2 (oxygen delivery) is >500 ml/m 2 , and the pH value
of the gastric mucosa recovers to the normal level [ 15 ].
3.1.1.3 How to Arrange Fluid Infusion
During the Shock Phase
The Arrangement of the Amount and Time of Infusion
The burn surface area is calculated as the sum of second- and
third-degree burn areas in all infusion formulas. The pre-
ferred ratio of electrolytes and colloid in the infusion for-
mula for extraordinarily extensive burns is 1:1. The traditional
distribution is that half of the amount to be infused in the ﬁ rst
24 h should be administered during the ﬁ rst 8 h, and the
amount of water is the same as those mentioned above. The
distribution ratio is determined on the basis of previous
recognition of the regular pattern of body ﬂ uid exudation.
It was once considered that 6–8 h after the burn was the peak
of exudation; thus, half of the amount should be infused
3 Burn Shock

35
within the ﬁ rst 8 h. Actually, the most rapid exudation pres-
ents within 0.5–2 h after the burn. In the study conducted by
the Southwest Hospital in dogs with third-degree burns of
30 %, the speed of the decrease in plasma volume within the
ﬁ rst 2 h was 5.5 ml/(kg·h), the cardiac output decreased 30 %
and the speed of the decrease in plasma volume within 3–8 h
after the burn was 0.85 ml/(kg·h) [ 16 ]. Changhai Hospital
reported that the blood volume decreased 50 % at 2 h after
the burn, the cardiac output and the cardiac index reduced to
40 % and 45.7 % of the levels before the burn respectively,
and the total blood volume decreased to the lowest level
within 4–6 h after the burn [ 9 ]; therefore, 2–3 h after the burn
is the critical phase for ﬂ uid infusion. Based on the results of
hemodynamic monitoring, 304 Hospital prefers rapid infu-
sion of 1,000–2,000 ml of ﬂ uid via intravenous injection (or
intravenous push) after admission until the mind is improved,
the urine volume recovers to the normal level, and the heart
rate decreases. To be consistent with the actual requirements,
30 % and 60–65 % of the infusion amount should be admin-
istered within 3–4 h and 8 h after the burn respectively [ 12 ].
In the process of ﬂ uid infusion during resuscitation, the sat-
isfaction of the infusion amount can be ensured with the use
of hemodynamic monitoring [ 17 ]; however, the central
venous pressure may also be monitored to guide the ﬂ uid
infusion to maintain it within a 4- to 10-cm water column if
hemodynamic monitoring cannot be performed.
Do Not Stick to the Formulas
For the convenience of calculation, the infusion formula can
only provide a basic amount as the primary reference; thus,
do not infuse according to the formula inﬂ exibly. It is impos-
sible to integrate many variables into one formula, because
for example:
1. Many patients cannot say what their body weight was
before burn very accurately, and the ward is usually lacking
the equipment for measuring body weight with the patient
lying in bed; thus, the body weight can only be estimated.
2. The calculation of the burn surface area cannot be com-
pletely accurate, and the experience of the doctors and the
diversity of body shapes of the patients usually lead to
estimation errors.
3. The current infusion formula only contains two variables,
body weight and area, but no distinction with regard to
the depth of the burn. The depth of burn actually affects
the amount of infusion to a great degree; the extent and
degree of exudation in second-degree burns are much
lower than in third- and fourth-degree burns. Even within
the same third-degree burns, compared with burns from
molten steel, burning sulfuric acid or hot ﬂ uid has a com-
pletely different depth and amount of ﬂ uid loss.
4. The ratio of the body surface area and the body weight of
children are greater; the extracellular ﬂ uid volume in chil-
dren is comparatively larger, and the capability to main-
tain body ﬂ uid equilibrium and to tolerate dehydration is
weaker; the physiological functions and the functions of
each system of the aged decreased signiﬁ cantly, the capa-
bility for stress reaction and tolerance of hypoxia are dif-
ﬁ cult to represent in the infusion formula.
5. The accompanying inhalation injury or combined injury
can also affect blood volume owing to exudation, edema,
and bleeding. Take inhalation injury as the example, ﬂ uid
infusion during the shock phase was limited before 1970
to avoid pulmonary edema. The Third Military Medical
University proposed that, in patients with inhalation
injury, the ﬂ uid infusion should add the ﬂ uid amount lost
by the respiratory system rather than limiting the infu-
sion, as the exudation and evaporation through the respi-
ratory tract increased [ 18 , 19 ].
6. The time and speed for starting ﬂ uid infusion both directly
affect the effect of resuscitation. The 2–3 h after the burn
is the “golden time” for ﬂ uid infusion during the shock
phase. At this time, ischemia and hypoxia do not take
very long and the reaction of body is comparatively sensi-
tive; thus, to perform ﬂ uid infusion at this time obtains
satisfactory resuscitation.
7. The health status and the individual difference between
the patients before the burn are different, and lead to sig-
niﬁ cantly different reactions. Even in the same batch of
patients with a similar severity of burn there are different
reactions to the treatment; therefore, “individualized infu-
sion” should be performed according to the various con-
ditions of each patient [ 3 , 20 ]. Based on consideration of
the factors mentioned above, the infusion formula can
only be taken as the primary program of the treatment,
and the treatment should be regulated in time according to
the clinical manifestations.
3.1.2
What Are the Components of Fluid
Infusion During the Shock Phase
3.1.2.1 Colloid Solution
Chinese and European burn surgery doctors have insisted
that ﬂ uid infusion during the shock phase should contain col-
loid. The amount of exudation has chronergy, although part
of the colloid infused in the early stages of a burn may exu-
date from the blood vessels. The exudation tends to decrease
about 3 h after the burn and the changes in vascular permea-
bility are different in various parts; thus, part of the infused
colloid will remain. Besides, the molecular weight of colloid
is high and the molecules have some negative charges; thus,
the colloid can remain in blood vessels longer and improve
the low colloid osmotic pressure caused by the loss of plasma
to realize ﬂ uid expansion. The common colloids include
3.1 Early Fluid Replacement Post-burn Injury

36
plasma, albumin, whole blood, and artiﬁ cial colloids such as
dextran, low molecular dextran, modiﬁ ed liquid gelatin
(Gelofusine), hydroxyethyl starch (Hetastarch, haes-steril,
voluven), etc.
1. Plasma: supplementing plasma is ideal, as the main com-
ponent of exudate is plasma. However, in the regions
where plasma cannot be provided in sufﬁ cient amounts,
the combined utilization of various colloids is advocated
and it is unnecessary to painstakingly infuse a great
amount of plasma because of the insufﬁ cient fresh plasma
resources, because it is unsuitable for long-term storage
and transportation, and also because there is the possibil-
ity of transferring hepatitis and acquired immunodeﬁ -
ciency syndrome. It is ﬁ ne to infuse 600–1,000 ml of
plasma during the ﬁ rst 24 h.
2. Albumin: the maintenance of colloid osmotic pressure
mainly relies on albumin, and the content of albumin in
the exudates is about 90 % of that in the plasma; thus, the
amount of loss is considerable. Therefore, it is critical to
supplement albumin to maintain colloid osmotic pres-
sure, and albumin contributes 80 % in the maintenance of
colloid osmotic pressure; it is thus an excellent plasma
substitute [ 21 ]. The capability to retain the water in the
circulation of 5 g of infused albumin is equal to that of
100 ml of plasma or 200 ml of whole blood [ 22 ]. The 6 %
albumin is applied in clinical practice, and is slightly
higher than the plasma concentration of albumin; thus, it
increase colloids osmotic pressure and decreases edema
more effectively. Infusing 10 g of albumin can increase
the blood volume by 200 ml within 45 min.
3. Whole blood: severe burns result not only in the loss of
plasma fractions but also in the destruction of a large
amount of blood cells; thus, the transfusion of whole
blood should be conducted during the shock phase [ 23 ].
The experience of 304 Hospital is to start transfusing
whole blood at 6–8 h after the burn. At the start of resus-
citation, the electrolyte, water, and colloids except for
whole blood should be infused as soon as possible, and
the whole blood is transfused when the hemoconcentra-
tion has reduced gradually over 6–8 h after the burn,
which is more beneﬁ cial to the blood circulation. The
amount of transfused whole blood should be about
5–10 % of the total daily amount. The requirement for the
whole blood is that it should be fresh and the storage time
should not be more than 1–2 weeks to avoid harm to the
microcirculation caused by the increase in cell debris
resulting from long-term storage. At present, whole blood
is not supplied any longer and only isolated red blood
cells can be utilized.
4. Dextran is a kind of high molecular glucose polymer. The
molecular weight of medium molecular dextran is about
70,000 Da, and 500 ml of 6 % medium molecular dextran
can lead to 600 ml of ﬂ uid expansion. The daily dose
should not exceed 1,000 ml. This solution cannot be
infused too much because it also contains high molecular
dextran, whose function is to block the reticulo-
endothelial system, and even penetrates into the tissue
space to result in the delay in the resorption of the edema.
The application of low molecular dextran (molecular
weight: 20,000–40,000 Da) and dextran 10 (molecular
weight: about 10,000 Da) can not only maintain the circu-
lation volume but also reduce blood viscosity, relieving
erythrocyte aggregation, improving microcirculation and
diuresis. It can only maintain blood pressure for 3 h
because of its low molecular weight and rapid elimina-
tion. The comparison showed that the low molecular dex-
tran is better and the daily dose is 1,000–1,500 ml.
The adverse effects of dextran include allergy, renal
damage, hemorrhagic tendency, effect on blood group
examination, etc., and the incidence of these adverse
effects is higher for the dextran with a larger molecular
weight. The dextran cannot be infused continuously,
500 ml at a time, and is separated by the other ﬂ uids.
5. Gelofusine is a kind of colloidal plasma substitute that is
mainly composed of modiﬁ ed liquid gelatin with the
molecular weight of 22,500 Da. It has equal oncotic pres-
sure and pH value, which are similar to those of plasma,
and meet the physiological requirement; thus, it will not
result in dehydration of the tissue. Its colloid osmotic
pressure corresponds to that of human albumin and its
effect of maintaining blood volume is equal to 4–4.5 %
albumin solution. Its biological half-life is about 4 h; thus,
it can maintain the blood volume well. This drug can sig-
niﬁ cantly increase blood pressure, pulmonary wedge
pressure, cardiac index, stroke volume index, and the
oxygen-carrying capacity of erythrocytes, and improve
hypoxia status. It has safe, has no effect on the coagula-
tion system, does not accumulate in organs, and has no
toxicity. Its pH value is about 7.4 ± 0.3, the osmotic con-
centration is 274 mmol/L, and it also has ideal vascular
tolerance. The daily infusion amount is 1,000–3,000 ml.
6. Six percent % hydroxyethyl starch (Hetastarch): its
molecular weight is close to that of human albumin. It has
the functions of ﬂ uid expansion, increasing the negative
charges on the surface of red blood cells and decreasing
blood viscosity. It affects the immune function of the
body owing to its effect of blocking the reticulo-
endothelial system; thus, the dose cannot be too large, and
the daily dose is about 1,000 ml.
7. Haes-Steril
Haes-Steril is also hydroxyethyl starch. The resource
is waxy corn. It is safe and has a satisfactory effect of ﬂ uid
expansion; 4–8 h of infusion has a 100–140 % effect of
ﬂ uid expansion. It can improve hemodynamic indexes; in
particular, it can effectively increase blood volume, car-
diac stroke volume, and cardiac index; thus, it improves
3 Burn Shock