Method for the prevention and treatment of inhibition of renal function in neonates with severe malformations requiring surgical correction in the first hours or days of life

 

(57) Abstract:

The invention relates to medicine, namely to the prevention and treatment of inhibition of renal function in neonates with severe congenital defects requiring urgent surgical correction. To do this, as in pre-and postoperative periods reveal renal or perenially character kidney damage, assess the performance of the Central and peripheral hemodynamics and extent of infectious toxicosis. Then when impaired kidney, Central and peripheral hemodynamics and in the presence of infectious toxicosis II or III degree is administered crystalloid preparations of 0.5% solution of dopamine at a dose of 3 to 20 µg/kg per minute and fresh frozen plasma in a dose of 15 to 30 ml/kg of body weight per day. When the value of these indicators within limits imposed only crystalloid preparations. If possible extend the preoperative period to the most complete recovery of kidney function. The method allows to reduce the number of postoperative complications, edema, cardiovascular collapse, the degree of toxicity. Early diagnostics and prevention of oppression of the kidney can reduce mortality from acute renal negie.

The known method of prevention and treatment of acute renal failure in the postoperative period in newborns with malformations (Ashcraft K. U., holder T. M., pediatric surgery. 1996. The ECP. Hartford., St. Petersburg, T. 1., pages 72-80). The authors found that in the pathogenesis of postoperative acute renal failure (ARF) in newborns with malformations of the reduction in renal perfusion in an early phase leads to a fall in glomerular filtration rate. In response to these violations increases the reabsorption of sodium and water reabsorption. This clinical condition is defined as prerenalnaja azotemia. Prerenalnaja azotemia can be corrected by improving perfusion, perform intravascular fluid volume or increase in cardiac output. Recovery of renal function was shown to increase urine output and normalize the concentration of urea and serum creatinine. But when long-existing hypoperfusion or under the influence of any nephrotoxic factors may develop parenchymal (renal) renal failure. When perenlei azotemii on the background of hypovolemia was intravenously injected 20 ml/kg saline, if after Vvedenie 5 mg/kg of body weight per day. Most neonates underwent conservative therapy, but some peritoneal dialysis or long arterio-venous hemofiltration, however, the mortality of children in this group was 38 - 60%. The authors did not investigate the status of renal function in newborns prior to surgical intervention. In addition, the use of diuretics child with perenlei by oliguria, hypovolemia and regional hypoperfusion, in our opinion, violates for natural compensatory processes, affects the overall hemodynamic situation, leads to worsening hypovolemia. So the use of furosemide in overhydration, except for a weak positive inotropic effect, caused a significant reduction in creatinine clearance and disturbance reabsorption of electrolytes and water at normal or moderately reduced diuresis and increased the degree and duration of renal failure (see drawing).

As the prototype accepted method for the prevention and treatment of acute renal failure in the postoperative period in the newborn with developmental anomalies of non-renal origin (C. A. lubimenko, thesis of candidate of medical Sciences, Leningrad, 1978). The author has the nature of the phase outlet the traditional period is divided into two phases - the restriction period (lasting on average for 48 h and is characterized by low values of minute dieresis) - the kidneys to excrete hypertonic in relation to serum urine diuretic response is virtually absent; and the period of reconstruction and stabilization vadovedyelare kidney (lasts for 3 to 7 days after surgery and is characterized by high values of minute dieresis) - diuretic response with distinct maximum in 60 - 90 minutes, the kidneys to excrete hypotonic with respect to the serum or urine. In addition, the dependence of the degree of inhibition of the functional activity of the kidneys from the severity of the operation and nature of postoperative course and recommended tactics infusion therapy in neonates with different pathology development in the postoperative period.

The method is as follows.

Assess the condition of the newborn in the postoperative period, which determines the severity of the operative trauma, the nature of the postoperative period. Conduct examination of the urine and blood of a newborn, defining indicators vadovedyelare ability of the kidneys - minute diuresis, diuretic response to load liquid, Catala conduct therapy with different doses of crystalloid preparations for example a 0.9% saline and 5% glucose solution. The authors believe that the indicators vadovedyelare ability of the kidneys (minute diuresis, diuretic response to load liquid) are a reliable criterion in the assessment of the patient and the effectiveness of the treatment. However, the known method has a number of disadvantages. The sole criterion for assessing the condition of the newborn and the treatment are indicators vadovedyelare kidney function. The method does not allow for study reasons in violation of kidney function before and after surgery. Environmental degradation, accumulation of additional information in recent years, much has changed in view of the condition of the newborn. Currently, the correction only vadovedyelare renal function, severity of toxicity and the presence of polygenically renal failure, lack of preventive and therapeutic measures. Newborns develop such postoperative complications as edema, cardiovascular collapse, the activation of the secondary flora. A high percentage of mortality. According to the authors it was at the height of the surge arrester of 31.8% (held stating method for the prevention and treatment of acute renal failure in newborns with malformations, you can reduce the number of postoperative complications and mortality rate.

The invention is a method for prevention and treatment of acute renal failure in newborns with malformations, including urinalysis and blood of the newborn in the postoperative period, followed by the definition of partial indicators of kidney function minute diuresis, diuretic response to load liquid, creatinine clearance and relative reabsorption of sodium and water ingestion by newborn crystalloid preparations, lasiks and symptomatic therapy, further define the partial indicators of kidney function - index of renal failure, fractional extractio sodium secreted fraction of sodium, potassium and osmolarity, which assess the degree of kidney damage, identifying renal or perenially character renal failure, determine the indices of Central and peripheral hemodynamics, as well as the degree of toxicity, and when the deviation of the obtained figures from the norm and the presence of II or III degree of infectious toxicosis in newborn infants perfusion enter solution of 0.5% of dopamine and crystalloid administered drugs, and when perinaldo the nature of the failure introduction lasixa exclude, and all studies conducted in the postoperative and preoperative period, which possibly lengthen.

In the preoperative period a solution of 0.5% Tomatina injected at a dose of 3-5 μg per 1 kg of weight in one minute.

In the postoperative period, a solution of 0.5% dopamine is administered at a dose of 7.5 to 20 mg per 1 kg of weight in one minute.

The use of the invention allows to obtain the following technical result. The method allows to reduce the number of postoperative complications, edema, cardiovascular collapse, the degree of toxicity. Early diagnosis and timely provision of adequate therapy significantly reduces the severity of acute renal failure.

The method allows to reduce mortality at the height of the arrester 2.4 times.

The method can be successfully used for the prevention and treatment of newborns with malformations, and in neonates with somatic diseases.

The technical result is achieved due to the fact that the authors have developed a new diagnostic criteria, which are used in cooperately character. The authors found that renal failure in newborns with malformations detected at 1 day of life. Newborn conduct blood and urine tests and on the performance of partial kidney, Central and peripheral hemodynamics and degree of toxicity appoint timely and adequate therapy. Introduction dopamine eliminates lasixa, causing the development of renal kidney failure. Thus, at the expense of therapeutic activities in accordance with objective picture of the status of the newborn is achieved restoration of renal perfusion before and after surgery.

The method is as follows.

The newborn received by the Department of resuscitation and intensive therapy, in parallel with the abnormalities are conducting a study of blood and urine to determine the partial indicators of kidney function - hourly urine output, creatinine clearance, relative reabsorption of sodium, potassium, water; secreted fraction of sodium, potassium, water; an index of renal failure, fractional excretion of sodium.

This is done using a computer program (E. N. Bayburina, A. P. bayburina, A., Andalucian indicators from the norm diagnosed with renal or perenially character renal failure. Conduct research indices of Central and peripheral hemodynamics with the calculation of indicators of cardiac index, stroke index, heart rate, peripheral resistance, circulating blood volume, the volume of circulating plasma volume, extracellular fluid using apparatus "Bo-Med" and "Rheography-4M by the method of A. S. of Maleckova (Diss. Prof. the honey. of Sciences, Moscow, CIO, 1987). Determine the degree of toxicity by the method of C. A. Romanenko (Diss. doctor of medical Sciences, Chelyabinsk, 1987). You get a performance history, mass, temperature, variant circulation, condition of the lungs, heart, abdominal organs, they will judge the presence and degree of toxicity.

Studies conducted from the first to the life of the newborn in the preoperative and postoperative periods. When the deviation of the main indicators from the norm and the presence of II or III degree of toxicity newborn perfusion enter solution of 0.5% of dopamine and fresh frozen plasma in a dose of 15 to 30 ml per 1 kg of body weight per day. When the value of these indicators within the norms of crystalloid administered drugs, such as 10% glucose solution. The preoperative period if possible extend. And when perinaldo character p is changed at a dose of 3 - 5 μg per 1 kg of weight in one minute for indirect recovery of microcirculation in the postoperative period 7.5 to 20 mcg/kg per minute increases cardiac output and glomerular filtration rate. Depending on the clinical symptoms symptomatic therapy. In the presence of hypothermia create mode temperature comfort during hypoxia - oxygen therapy in any way. When the severity degree of toxicity spend antibiotic, immunokorrigiruyuschuyu therapy.

Clinical trials of the method performed at the Department of pediatric surgery, Ramapo, on the basis of resuscitation and intensive therapy DMCB St. Vladimir.

For the period from 1989 to 1994 the analysis of 240 histories of children neonatal age with severe malformations (diaphragmatic hernia, esophageal atresia with tracheo-esophageal fistula, congenital abnormalities of the intestinal malformations of intestine with perforation of a hollow organ, developmental defects of the anterior abdominal wall malformations of the urinary system), requiring surgical correction in the first hours or days of life. For the period from 1995 to 1996 he held a solid clinical examination 52 neonatal surgery in the ICU, the SLA entered in the control group therapy.

The survey taken by the group of newborns with various severe malformations (table. 1).

After processing performance history, clinics, partial renal function and hemodynamics homogeneity of the data made it possible to combine the cases into the following 4 groups; group 1 - atresia of the esophagus and malformations of intestine; group 2 - peritonitis and gastroenteritis; group 3 - diaphragmatic and embryonic hernia; group 4 - malformations of the urinary system.

The children were examined at 1 day of life (at admission), 2 - 5th day of life (early adaptation period, the period of surgical intervention), 6 - 10 days of life (early postoperative period), 10 - 28 days of life (late postoperative period).

Regardless of the pathology, the degree of toxicity is divided into group a and B (table. 2).

Group a consisted of 25 infants (48%) with toxemia of I - II degree. At 17.3% of children identified clinic precipice, 30.8% of children septicaemia. Group B included 27 infants (52%) with toxemia of III degree. In 9.6% of children identified clinic septicemia in 42.2% of the clinic septicopyemia. In group a mortality rate of 3.8%, in group B - 25%.

According to the table. 3 shows that at admission, 1 day of life in 57.1% of patients ha is my therapy, the ratio of renal and prerenalnaja kidney lined up. If two weeks of life did not come to restore kidney function, 64,1% of cases the lesion again wore renal character.

According to our research, in newborns with malformations, subject to surgical correction, with the first hours of life begins corrective infusion therapy for partial indicators of renal function and hemodynamics (table. 4).

The use of dopamine 0.5% at a dose of 5 mcg/kg/min helps to restore microcirculation and perfusion of the kidneys; the dose of 7.5 to 20 mcg/kg / min helps to restore cardiac output and increase in the rate of glomerular filtration (table. 5).

Example.

Group B. the Boy F., aged 2 hours of life specialized ambulance in a very serious condition transferred from the maternity hospital with the diagnosis; esophageal Atresia, tracheo-esophageal fistula, NMC (cerebrovascular accident) - II degree, intrauterine infection. According to the statement, the child from the mother is 19 years old, female, long lived in the radiation area, pregnancy II, proceeded with the toxicity and anemia in the first half. Childbirth I 40 week, anhydrous is tion, in parallel with detection of disease development, conducted a study of blood and urine specific as partial indicators of renal function (decrease in hourly urine output, creatinine clearance, relative reabsorption of sodium at normal relative reabsorption of water; index of renal failure and fractional excretion of sodium increased), which gave the opportunity to identify renal character renal failure.

The severity of the condition at admission due to clinic toxicity grade III (burdened history, respiratory failure with decompensation in KOS (acid-base status), nervous system (coma I degree), hypothermia (rectal temperature of 35.2oC) violation of microcirculation (leather grey with maceratesi, swelling of the I degree), LEAH (leukocyte index of intoxication) in the first days significantly increased in crops meconium flora of selected Pseudomonas aeruginosa from sputum Golden and epidermal Staphylococcus, from the blood of the flora is not identified; according to the indices of Central and peripheral hemodynamics revealed geodinamicheskii option circulatory hypovolemia (BV (blood volume) 80%, CGO (volume of circulating plasma the ducks, from the first day of life, in the preoperative period the child is injected with a solution of 0.5% of the dopamine in a dose of 5 μg per 1 kg of body weight per minute, and fresh frozen plasma in a dose of 15 to 30 ml per 1 kg of body weight per day; conducted comprehensive symptomatic therapy (creating a temperature comfort, oxygenation, with translation into ventilation (mechanical ventilation) 85% O2in a video nonventilated, antibacterial therapy (Fortum, amikacin and metronidazole with regard to creatinine clearance), immunotherapy transfusion of Pentaglobin).

After the stabilization, restoration of microcirculation, perfusion of the kidneys, consciousness), on the 2nd day of life made right rear-side thoractomy, liquidation of tracheo-esophageal fistula and esophagoplasty. In the first days after surgery, the severity of the condition mainly attributable to the persistent clinic toxicity III degree with renal insufficiency renal character. Given the deterioration of the Central and peripheral hemodynamics, the dose of dopamine was increased to 20 mg/kg in 1 min continue infusion of fresh frozen plasma to 30 ml/kg of body weight per day, complex symptomatic therapy. The introduction of these drugs in the baby's body p is the eyeglasses, reduced creatinine, increased creatinine clearance and improvement canalave violations. On the 11th day of life the child is transferred to spontaneous breathing, stopped the introduction into the body of a newborn with a 0.5% aqueous solution of dopamine, but continued infusion of crystalloid preparations (10% glucose solution). On the 19th day of life (under normal diuresis, increased creatinine clearance and moderately reduced relative reabsorption of sodium) for further treatment of the newborn is transferred to the second stage of nursing in specialized surgical ward for newborns.

Method for the prevention and treatment of inhibition of renal function in neonates with severe malformations requiring surgical correction in the first hours or days of life, including the introduction of crystalloid preparations, symptomatic therapy, characterized in that it further, as in the preoperative and postoperative periods, identify indicators, establishing renal or perenially character kidney, Central and peripheral hemodynamics and extent of infectious toxicosis with renal or perinaldo renal injury, disorders of the Central, periphericals 3 - 20 µg/kg in 1 min, fresh frozen plasma in a dose of 15 to 30 ml/kg of body weight per day, and when the value of these parameters within normal limits impose only crystalloid preparations, while the preoperative period is lengthened to stabilize the condition of the newborn.

 

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SUBSTANCE: one should perform puncturing of epidural space at Th12-L1 level. Through the lumen of puncture needle one should introduce catheter to move it cranially at the depth of 3 cm. After that one should inject 10 ml 05%-marcaine solution to perform repeated injections per 5.0 ml every 4 h during 1-8 d. The effect is achieved due to unloading minor cycle of circulation.

EFFECT: higher efficiency of therapy.

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