卷 9, 编号 3 (2019)

Background. Humans are able to compensate for significant blood loss with little change in traditional vital signs, limiting early detection and intervention. We hypothesized that the Compensatory Reserve Index (CRI), a new hemodynamic parameter that trends changes in intravascular volume relative to the individual patient’s response to hypovolemia, would accurately trend each subject’s progression from normovolemia to decompensation (systolic blood pressure < 80) and back to normovolemia in humans. Methods. Men and women, ages 19 years to 36 years, underwent stepwise (~333mL aliquot) removal and replacement of 20% blood volume (men, 15 mL/kg; women, 13 mL/kg) via a large bore intravenous (i. v.) line. During each experiment, subjects were monitored with four CipherOx CRI Tablets. Withdrawn blood was reinfused at the end of each experiment. Results. Forty-two subjects (24 men; 18 women) were enrolled in the study, of which 32 completed the protocol. Seven subjects became symptomatic and collapsed (systolic blood pressure < 80), six never achieving maximum blood loss; each was rescued with a saline infusion followed by reinfusion of their stored blood. The mean CRI at baseline for all 42 subjects was 0.9 ± 0.04. The mean CRI for the 32 subjects while asymptomatic at maximum blood loss was 0.611 ± 0.028. For the asymptomatic subjects, the average blood loss volume was 1018 mL ± 286 mL. In comparison, the mean CRI at maximum blood loss for the seven subjects who collapsed was 0.15 ± 0.007 and their average blood loss volume was 860 ± 183 mL. Mean CRI after reinfusion of blood was 0.89 ± 0.02. In addition symptomatic subjects demonstrated three times larger average decrease in CRI per liter of blood removed, 0.85 versus 0.28 for asymptomatic subjects. Conclusion. CRI trends change in intravascular volume relative to an individual’s response to hypovolemia and is sensitive to the differing risks associated with individuals’ differing tolerance to volume loss. (J Trauma Acute Care Surg. 2017;83: S104–S111. DOI: 10.1097/TA.0000000000001511. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.) Level of evidence. Prognostic study, level II.

Introduction. Intrauterine invagination is one of rare reasons that can result in small bowel atresia. The aim of the study is to demonstrate that laparoscopy can be used to treat the disease. Material and methods. The study describes an experience of endosurgical treatment of a patient with small bowel IIIA type atresia due to invagination that occurred in the prenatal period. The boy was premature; at the moment of birth his gestational age was 2 weeks and his weight was 1,280 g. Technical details of a surgical procedure along with its early and remote results were presented. Results. Intestinal atresia was operated on the 2 nd day of life. They used a soft carboperitoneum with the following carbon dioxide findings: flow of 1.5 L/min, pressure of 8 mm Hg. An optical port was installed into the left iliac region. Two other instrumental ports were located bilateral to the telescope ensuring the triangulation principle. Ileac atresia type IIIA located 8 cm away from the ileocecal valve was found during an abdominal examination. Closed ends of adducent and abducent bowels were resected. An additional formation in the form of an intrauterine intestinal invagination was found in a distal segment lumen during its resection. Completely laparoscopic intracorporeal intestinal anastomosis was performed. The surgery lasted 65 minutes. Enteral feeding was given on the 2 nd day of the surgery. Complete enteral feeding was restored on the 5 th day following the surgery. No signs of anastomotic leak were observed in the early observational period. The infant was discharged from the hospital when he was 28 days old and weighed 1,800 g. No signs of intestinal transit were found during 6 months of observation. Conclusion. Laparoscopic anastomosis performed at a children’s surgical center is an alternative to open surgery during the management of patients with small bowel atresia caused by intrauterine invagination. More extensive multicenter trials are required to determine the role of laparoscopy in treatment of this disease.

A distinct tendency to an increased number of pregnancies and deliveries among young women has been observed lately. Pregnant teenagers with various types of traumas can be admitted to a non-profile pediatric surgical in-patient facility where no gynecologist is available. Purpose. The article describes a clinical case of an injury to the uterus and 33–34-week fetus in 17-year-old pregnant woman after an accidental fall on a kitchen knife. Materials and methods. The patient in a severe condition was admitted to the hospital with a knife in the anterior abdominal wall. Post-hemorrhagic anemia was diagnosed (Hb 95 g/L, RBC3.0 х1012/L). Based on urgent indications of an operating team consisting of a pediatric surgeon and an obstetrician-gynecologist, a midline laparotomy was performed. 2L of blood was removed from the cavity, the cutting edge of a knife was removed from the uterus body. No other damages were found during abdominoscopy. Cesarean section was done in the inferior segment of the uterus, an alive fetus was removed, bilateral ligation of uterine arteries was done and a hemostatic supraplacental suture was applied. A double balloon obstetric catheter was used. The uterine wound was sutured. Total blood loss was about 3 L. It was compensated with red blood cells (1385 ml) and fresh frozen plasma (2740 ml) transfusion. The removed boy had a weight of 2,300 g and 2 Apgar scores. Resuscitation activities were successful. The child was taken to the ICU and put on life support. 2 cm long injury was found in the right axillary region not penetrating into the chest. Its primary surgical debridement was done. Postoperative period in a child and mother who was taken to the maternity home went on without complications. The child was examined in a year. He developed according to the age. Conclusions. It can be possible that pediatric surgical departments are not ready for Cesarean section and elimination of possible complications when dealing with pregnant teenagers with various types of traumatic injuries requiring urgent obstetric intervention. That’s why it’s better when the patients are admitted to maternity homes where a pediatric surgeon is available.

Purpose: to demonstrate cases of effective treatment of a rare manubrio-cartilaginous chest deformity in children. Methods: surgery of manubrio-cartilaginous type of sparrowy chest was performed in three 13–14-yearold adolescents accounting to 2.2% of all patients with SC. An original method of wedge resection at the site of sternum deformity (at the border of the handle and the body), video-assisted longitudinal incomplete sternotomy and elevation of the sternal body using Nuss-procedure that corrects the funnel deformation of the chest was utilized to treat the rare type of deformity. The metal structure that ensured a stable ratio of the sternocostal complex in the corrected position was removed in 1 year. Results: no functional disturbances of the chest were available during SC. The surgery was performed following cosmetic indications. Two adolescents completed their treatment 4 years ago. The chest shape was almost correct. The third patient is receiving treatment with the installed metal construction. In all three cases adolescents and their parents were satisfied with the surgery outcomes and esthetic condition of the anterior chest part. Thus, using the above described therapeutic tactics in this type of chest deformity produced a good cosmetic result.

Purpose. The article deals with modern possibilities of nutritional support following major abdominal surgeries. The author explains why parenteral nutrition and enteral feeding are necessary. Materials and methods. A surgery results in the disturbance of digestion and absorption processes. Following major surgeries, normal functioning of the GIT is more disturbed in children as compared to adults decreasing digestion, absorption and metabolism of administered nutrients. It is necessary to be aware of the principal pathophysiological changes that occur during the post-operational period to arrange for enteral feeding. Resection of the small and large bowels results in the increased secretion of substances into the GIT. The lesser is the residual intestinal length, the more fluid enters the bowel by means of secretion. A doctor comes across the issue of non-correspondence between a significant growth of a child’s need in energy and nutrients and a severe drop of functional intestinal capabilities. Discussion. A doctor needs to provide a child with any necessary nutrients considering organismbased morpho-functional and metabolic disturbances. Due to negative metabolic changes in a surgical pathology, the nutritional problem is treated as an important constituent of posttraumatic management of patients. These sick children have a negative nitrogen balance even when enteral feeding is possible; it means that the basal metabolism is increased and a child has an increased need in nutrients and energy. Conclusion. The principal indication for using nutrition therapy in pediatric practice includes an early restoration postoperative period when usual delivery of nutrients is difficult and/or contraindicated. Surgeons can use modern technologies providing children who underwent a surgery with nutritional support.

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Purpose is to determine the clinical features of severe respiratory failure in newborns whose gestational age was 37 weeks. Methods Design – it was a retrospective, controlled, non-randomized, single-center study. 40 patients satisfied the inclusion and exclusion criteria. 7 (1.1%) children died. Depending on their gestational age, patients were divided into two groups. The basic group (n= 279) included newborns whose gestational age was 37 weeks. Children born at 34–36 weeks of pregnancy were in the group of comparison (n= 361). Patients from the both groups underwent a comparable intensive treatment and had similar values of initial treatment of ALV such as respiratory volume of at least 6 ml/kg, PEEP of 4–6 cm H2O, PRVS mode. BioStat was used for statistical analysis. Results. The rate of episodes of severe respiratory failure is quite comparable between the basic group and the group of comparison. Non-invasive ALV was more frequently used by patients from the basic group (χ2=4.23; p=0.05). Fetal growth restriction and higher pressure in the pulmonary artery was an important feature of respiratory failure course in children whose gestational age was 37 weeks as it resulted in a significantly higher rate of pulmonary hemorrhage episodes (χ2=9.608; р=0.02). Respiratory issues typical of the children can be seen only in those born by Cesarean section. Conclusion. The features of severe respiratory failure at 37 weeks’ gestational age include the children’s development when Cesarean section is used, fetal growth restriction and higher pressure in the right ventricle with more frequent episodes of pulmonary bleeding.

Introduction: necrotic enterocolitis and stomach perforation belong to pressing issues of neonatal surgery and intense therapy. A set of clinical and laboratory values can be interpreted subjectively due to polyetiology of necrotic enterocolitis and stomach perforation. Indications and surgical management of perforation peritonitis in newborns are still contradictory. Purpose: diagnostics objectivization, treatment of perforation peritonitis and organ dysfunction in necrotic enterocolitis, intestinal and stomach perforation in newborns. Materials and methods: a retrospective, observational, cohort study with 46 5–14-days-old newborns (2007–2017). Inclusion criteria: clinical symptoms of necrotic enterocolitis (Bell (1978) modified by Kliegman (1986)), pneumoperitoneum in stomach perforation. Shock syndrome gradation was done based on FEAST (Fluid Expansion as Supportive therapy) (2017) criteria, while organ failure was evaluated using pSOFA (Pediatric Sequential (Sepsis-related) Organ Failure Assessment) score (2017) with lethality prediction (Vincent J. L., 1998). Statistical analysis uses descriptive statistics and non-parametric Mann-Whitney U test (P<0.05). Results: specific diagnostic criteria of perforation peritonitis such as intestinal pneumatosis, multiple levels of air/ liquid, pneumoperitoneum were distinguished, whereas dysfunction of GIT and respiratory system were the principal links of multiple organ dysfunction. Conclusion: midline laparotomy is a basic method of surgical treatment at institutions providing III level medical aid. In newborns with perforation peritonitis, restrictive strategy of GIT dysfunction intensive treatment based on ESICM (2012) recommendations decreased a short-term lethality to 6.3%.

Purpose. To estimate the significance and perspectivity of further using a halothane as an anesthetic in children. Material and methods. PubMed, Scopus, TheCochraneLibrary, CyberLeninka and own observations were used during the analysis. Results. Almost all developed and some developing countries stopped using halothane in clinical anesthesia. However, it is still used in the majority of developing countries appealing to its low cost. On the one hand, objective data on continuous use of the preparation are available along with recommendations ‘not to exclude it from the clinical practice’. On the other hand, many countries hold objective data that recommend to refrain from the use of the preparation at the country level and reasoned statements on uselessness of its subsequent application. Halothane pharmacology, and the cardiodepressive effect and hepatic toxic effect, in particular, is currently an established fact which is well known to practitioners. Pharmacological properties of halothane are far below those of halogenated third generation inhalation anesthetics. Thus, it is reasonable to exclude it from anesthesia practice completely. Conclusion. In spite of low halothane cost as compared to halogenated third generation inhalation anesthetics, the former needs to be limited or completely excluded due to a significant number of negative signs resulting in severe damage of the liver and heart, influencing the immune system, promoting metastasis in oncology, disturbing pulmonary epithelial structure, etc.