PROTOCOL NUTRITION THERAPY OF CRITICALLY ILL CHILDREN.

The Protocol isn't seen as directive. The goal of the Protocol is to define theframes ofdiagnostic criteria and therapeutic action, within which a doctor working in an intensive therapy children have freedom of choice. The Protocol takes into account that the critical and postagressive states are characterized by the features of malnutrition, particularly manifested in the period of intensive growth (first life year). The Protocol submitted by: contraindications to artificial nutricion in any form; indications for parenteral nutrition; components ofparenteral nutrition; calculation of water and energy needs; calculation of substrate requirements; the system of "two in one" and "three in one "; monitoring the effectiveness ofparenteral nutrition; the use of adjuvants and active additives to artificial nutrition, indications for early enteral nutrition, time of the beginning of enteral nutricion and tolerance to it: trial feeding; trophic nutricion; the technique ofprobe feeding; selection offormulas for enteral nutrition; monitoring the effectiveness of enteral nutrition. The Protocol does not discuss the issues of planned nutritional preparation for surgery, nutritional support in chronic malabsorption, sipping.

[MONITORING OF HEMODYNAMICS IN THE CHOICE OF INTENSIVE THERAPY IN THE OPERATED INFANTS].

Noninvasive monitoring in obtaining important and reliable information relevant to pediatric practices, not only in respect of dangers and complications of most invasive techniques, but also because a number of them difficult or even impossible in infants. The aim of this study was to estimate the significance of hemodynamic parameters and capabilities of ECHO and dophlercardiography for analyzing violations hemodynamics in primary diagnosis and conduct drug therapy in infants. The study included the results of a survey of 65 infants aged from 29 to 39 weeks with various surgical pathology, who received the various options the hemodynamic support. In the initial assessment and selecting tactics of therapy for hemodynamic analysis carried out routine monitoring and for evaluation of cardiac contractility used echo- and Doppler exams. All children have pointed out a number of significant changes of haemodynamics, that has required inotropic therapy with dopamine (64% of children with diaphragmatic hernia received additional dobutamine). Validation of expressed pulmonary hypertension children appointed sildenafil, and in the absence ofthe effect used nitrous oxide. Hemodynamic monitoring allows to monitor the status of circulation on the background of the treatment and to make timely changes to the script therapy.

[EPIDURAL ANALGESIA FOR INTRAOPERATIVE AND POSTOPERATIVE CARE IN NEWBORNS].

Anesthesia care in newborns has to be complex, balanced and safe. Nowadays epidural analgesia (EA) in neonates during intra- and postoperative period is widely used in Russia. Modern EA techniques imply the installation of a catheter into epidural space at lumbar or thoracic level as well as different approach to local anesthetics dosage. Newborns have special anatomy, physiology and pharmacodynamics which have to be taken in mind when EA is used. At the present moment Ropivacine (2 mg/ml) is approved for peripheral nerve blocks in newborns.

[Modern approach to the neuromuscular blocking agents use in pediatric patients].

Myorelaxants use decrease trend appeared since the end of 80 years of the 20th century. The trend is connected with use of the new narcotic analgesics (Remifentanil), intravenous (Propofol) and inhalation (Sevoflurane) anaesthetics. These drugs are manageable and predictable, they have not many side effects and can suppress laryngeal-pharyngeal reflex during the tracheal intubation. Furthermore there are other factors such as succinylcholines use when fast intubation is needed, the wrong myorelaxant and dosage choice. Residual curarization and side effects risk increases due to these factors. As a result the patient's activation is delayed. Nevertheless myorelaxants use refusal impairs the tracheal intubation conditions, increases the arterial hypotension and heart failure risk especially in newborns and children with severe pathology. If myorelaxants is not used, comfortable conditions of surgical manipulations impossible without big analgesics and anaesthetics doses use.

[Postoperative analgesia after thoracoscopic surgeries in pediatric patients].

Postoperative pain after thoracic surgeries is characterized by intensity and long duration. The intensity of pain can be moderate or strongly expressed, the duration various from one day to months and years either after thoracotomy (TT) or thoracoscopy (TS). Pain relief is one of the most important problems of postoperative period. Adequate analgesia, lung function and temperate sedation, ventilation must be provided against the general disease, surgical injury and one-lung ventilation. TS is a less invasive method therefore pain syndrome is not very strong. There are several methods of postoperative analgesia in Pediatric patients; however the choice is limited by the patient's age. Postoperative analgesia in Pediatric patients can be provided by narcotic and nonnarcotic analgesics, neuraxial anesthesia: multimodal approach is widely used. Postoperative pain after TS needs adequate analgesia for implications prevention and to reduce the duration of hospital stay.

[Use of venovenous extracorporeal membrane oxygenation in 14 months old child with acute respiratory distress syndrome and pneumonia].

UNLABELLED: Extracorporeal life support (ECLS) is used in pediatric patients with ARDS in recent 20 years with survival rate from 50 to 67% Venovenous ECLS was used in 1 year 2 months old patient with ARDS and pneumonia developed in postoperative period after gastral esophagoplasty. Purposes of ECLS use were stabilization child's condition and normalization of gas composition of blood with relative lungs repose. Indications for ECLS were increasing respiratory failure, hypoxemia, low respiratory index (PaO2/FiO2 ratio 47.3), alveolar-arterial gradient of oxygen (A-aDO) 630 mmHg and absence of positive effect from high frequency oscillation (HFO). MATERIALS AND METHODS: ECLS was used in 1 year 2 months old patient with ARDS and bilateral pneumonia developed in postoperative period after gastral esophagoplasty. Deltasteam system (Medos Medizintechnik AG, Germany) with centrifugal pump and servoregulation of blood flow pressure was used for ECLS. Double-lumen cannula with size 12 French was used ECLS was instituted via right internal jugular vein. RESULTS: The patient did not have expressed heart failure. Thus preference was given to venovenous ECLS and not to venoarterial ECLS. Duration of ECLS use was 72 hours. Auscultation parameters and gas exchange improved haemodynamics stabilized parameters of biochemical and haematological analysis normalized and the dynamics x-ray examination was positive after the ECLS use. Patient was decannulated and extubated. CONCLUSIONS: Venovenous ECLS was an only way of life support in child with heavy ARDS and pneumonia developed in postoperative period More observations are needed for more thorough analysis and recommendations.

[Postoperative analgesia of newborns using local anesthetic administered through wound irrigation catheter of permanent action].

The analysis of publications is devoted to the application of skin conductance monitoring in anesthesiology and intensive care. Rates of skin conductance (baseline values, the amplitude and frequency of the waves) are closely linked with the state of the sympathic nervous system. According to their dynamics it is possible to judge on the pain and stress in patients with whom the contact is difficult: newborns, infants, patients of all age groups during general anesthesia and in critical condition. According to published data monitoring skin conductance showed itself as a sensitive and promising method to identify and determine the severity of pain in all age groups, approaching by its characteristics the theses of the pain assessment perfect tool.

[Supraclavicular block during elbow joint surgeries in children].

The regional methods of analgesia are the "golden standard" of choice during trauma surgeries. The supraclavicular block of the bracheal plexus is the method of choice during the cubital joint surgeries. The purpose of the study is to improve the effectiveness of anesthesia and postoperative analgesia for surgical interventions on the cubital joint in children by developing and implementing the clinical practice of peripheral blockade of the brachial plexus by the supraclavicular access. The study included 40 children aged 5 to 12 years. The children rated as ASA I, came to the clinic on an emergency basis with cubital joint bones injuries. All the children were had surgeries on the cubital joint (closed and open repositions with osteosynthesis) with balanced regional anesthesia, the main analgesic component of which was supraclavicular brachial plexus block (by Kulenkampf-Fursaev technique). The supraclavicular block was performed in conditions of psychological comfort of the child. For the means of premedication age appropriate doses of seduxen or midazolam were intravenously administered. Intraoperative sedation was conducted by the re-introduction of benzodiazepines, and ketamine (up to 1 mg/kg/h). During the study period, the effective intraoperative analgesia, provided by supraclavicular blockade of peripheral nerves, was observed in 31 children. In 9 patients the blockade could be found to be incomplete at the second stage of the surgery (reposition). For this reason, it took the additional administration of tramal in a dose of 2 mg/kg and deepening of sedation with ketamine up to the dose of 2 mg/kg/h. The duration of effective postoperative analgesia due to long-acting local anesthetic (0.5% solution of naropin) was 8-9 hours. There were no complications registered as a result of supraclavicular. Thus, this study proves that the supraclavicular brachial plexus block provides effective intra and postoperative analgesia in trauma operations on the cubital joint in children.

[High-frequency oscillatory lung ventilation in neonatal infants with surgical diseases].

The paper presents data on the varieties and modes of the present artificial ventilation and high-frequency artificial ventilation (AV). It describes the basic impact of various ventilation modes on gas exchange, hemodynamics, and mechanical lung properties. The data on the use of high-frequency AV in neonatal infants with various surgical diseases are given. Its place and indications in malformations, such as diaphragmatic hernia and esophageal atresia, are defined. High-frequency oscillatory AV may be recommended for use as an alternative method in the treatment of respiratory failure in neonates with difuse lung lesion and in those with congenital surgical diseases when it is impossible to ensure adequate gas exchange.

[Method of continuous intravenous postoperative analgesia with promedol in newborn children]. / Posleoperatsionnoe obezbolivanie metodom postoiannoi vnutrivennoi infuzii promedola u novorozhdennykh detei.

Continuous intravenous infusion of promedol, 0.1 mg/kg, with additional boluses, 0.5 mg/kg, was used as postoperative analgesia in 20 newborns. Fifteen (25%) children were operated for congenital gastrointestinal defects or peritonitis, 2 children (10%)--for chylothorax, and tumor was eradicated in 3 (15%) children. On the basis of behavioral reactions, physiological indices (cardiac rate, arterial pressure, SpO2, and respiration rate/artificial pulmonary ventilation--APL) as well as of laboratory "stress" tests (blood glucose and cortisol and acid-base balance) it was proven that analgesia with continuous intravenous promedol infusion was effective. It was shown as possible to administer the promedol infusion in newborns while switching them from APL to independent breathing until the spontaneous breathing with constant positive pressure is ensured provided the pO2, pCO2 and SpO2 respiration indices are satisfactory.

[Nutritional therapy in children during perioperative period]. / Nutritivnaia terapiia u detei v perioperatsionnom periode.

The efficiency of nutritive therapy was analyzed in cases of 37 patients with gastrointestinal pathologies. Group 1 comprised 12 patients with fistulas of different etiologies and localizations; and group 2 comprised 15 patients with esophageal pathologies, including 7 children with esophageal atresia and 8 children with post-burn cicatricial stenosis of the esophagus. A method of nutrition-status correction by means of both enteral and parenteral feeding is suggested on the basis of examination findings comprising both clinical and laboratory-and-instrumental data. Preparations for parenteral feeding, i.e. 10-20% fatty emulsions, 10% amino acids solutions and 15-20% glucose solutions, were made use of. Enteral diets: semi-element oligopeptide solutions, like Nutrilon pepti TSC, Alphare. Balanced mixtures: sour-milk Nan, AL 110, Nutrizon, Nutridrink. Practical recommendations were defined, on the basis of study results, as to the therapeutic feeding schemes during the in-hospital treatment stages.

[Postoperative analgesia with tramal in newborn children using the method of continuous intravenous infusion]. / Posleoperatsionnoe obezbolivanie tramalom u novorozhdennykh detei metodom postoiannoi vnutrivennoi infuzii.

The purpose of the study was to evaluate the efficiency of postoperative analgesia with tramal in the newborns. Analgesia with tramal (5% solution for injections, "Gruonental GmbH", Germany) was administered postoperatively in 20 newborn children. Thirteen children were operated for congenital malformations in the gastrointestinal and urinary tracts, three children were operated for purulent-septic diseases and four children were operated for neoplasms. Hemodynamics indices, i.e. heart rate (HR) and arterial pressure, as well as SaO2, respiratory rate (RR), acid-base condition and behavioral reactions were assessed. Analgesia was implemented by the method of continuous intravenous infusion of tramal, 0.1-0.2 mg/kg.h combined with boluses, 1-2 mg/kg. The newborns were asleep for a major part of time during analgesia with tamal; the stable indices of hemodynamics, acid-base balance, glycemia and of the cortisol level were registered. Arterial hypertension, caused by several factors including the effect produced by tamal, was noted in 70% of children. Dose-dependent hypercapnia was registered in 80% of tests in children at unassisted respiration during the infusion of tamal, which is indicative of that tamal affects the respiratory center during the neonatal period and that it is necessary to monitor thoroughly the respiratory functions, i.e. RR, SatO2, pO2, pCO2, and to choose accurately a preparation dose. The continuous infusion of tamal ensures a sufficient analgesia after different operations and especially after medium-traumatic operations.

[Behavioral response to an acute pain in newborn children with surgical diseases]. / Povedencheskie reaktsii na ostruiu bol' u novorozhdennykh detei s khirurgicheskimi zabolevaniiami.

The article is dedicated to studying the behavioral response to an acute pain in the newborns with surgical pathologies. The videotaped facial activity (a total of 12 parameters), the general locomotive activity (6 parameters) and cry were studied in 93 newborn children with different surgical pathologies. It was found that the newborn children response differentially to the painful and non-painful stimuli. A combination of 6 signs, i.e. frowning eyebrows, tight eyes, aggravated nasolabial folds, open mouth, and motion of foot, was detected in 93.5% of cases (87 of the 93 children) as a response to a painful stimulus. Such behavior indicates the presence of the painful syndrome in the newborn with a sensitivity of 93.5% and with a specificity of 78.5%. The combination of these signs can signify a characteristic painful behavior in the newborn children and it can be used as a criterion of the painful syndrome in the neonatal period.

[Ways to reduce mortality of newborns with developmental defects]. / Puti snizheniia letal'nosti u novorozhdennykh s porokami razvitiia.

Technological progress contributed to progress in surgery on the newborns. However, despite the progress in surgery and intensive care of the newborns, the results of treatment of patients with congenital defects are sometimes disappointing. The priority problems for today are the respiratory distress syndrome, hemodynamic disorders, and renal dysfunction, which can be united into the syndrome of general dysadaptation of the newborns. Based on experience gained in the treatment of newborns in pediatric surgical hospital, protocols of treating newborns with developmental defects (congenital diaphragmatic hernia, esophageal atresia, and gastroschisis) have been developed. These protocols are a stage and a prerequisite for development of more effective methods for treating such patients. Common intensive care should be supplemented by such important measures as maintenance of adequate temperature regimen at all stages of medical transportation and therapy of a newborn, obligatory preoperative preparation for stabilization of vital functions, multicomponent endotracheal anesthesia, use of inotropic agents (dopamine and dobutrex), synchronic prolonged artificial ventilation of the lungs and prolonged analgesia, limitation of indications to the use of blood preparations and wide use of hydroxyethylated starch solutions in infusion therapy, rational antibiotic therapy with constant monitoring of the microecological status, and early detection and correction of concomitant diseases. Solution of these problems will essentially decrease the postoperative mortality of newborns with developmental defects.

[Characteristics of anesthesia in children operated on for extrahepatic portal hypertension]. / Osobennosti anestezii u detei pri operatsiiakh po povodu vnepechenochnoi portal'noi gipertenzii.

Portocaval shunting reliably preventing hemorrhages from esophagogastric veins is most often used in surgery for extrahepatic portal hypertension (EPH) in children. Difficulties of anesthesia for this intervention consists in essential alteration of volume bloodflow as a result of massive outflow of deposited blood to systemic circulation through the new bypass. This necessitates search for an adequate method of general anesthesia and variants of infusion therapy for surgical venous shunting in children with EPH. Sixty-eight children aged 1-15 years with the EPH syndrome were subjected to elective surgery under general analgesia (multicomponent balanced neuroanesthesia with evaluation of some hemodynamic and metabolic parameters). The proposed protocol of general anesthesia in combination with epidural analgesia by local anesthetics and promedole and infusion therapy in the hypervolemic hemodilution mode create the most favorable conditions for adaptation of hemodynamics to increased preloand.

[Pediatric regional anesthesia: rational approaches and practical aspects]. / Pediatricheskaia regionarnaia anesteziia: ratsional'nye podkhody i prakticheskie aspekty.

Regional anesthesia in children is to be carried out with due consideration for anatomy, physiology (specifically, neurophysiology), pharmacology of local anesthetics, and detailed knowledge of pediatric protocols of numerous regional blockades. Age-specific differences in the pharmacokinetics of local anesthetics should be borne in mind when choosing safe doses and protocols. The pharmacokinetic factors may involve the risk of toxic reactions to local anesthetics. The protocols of central neuroaxial blockades in children are characterized by certain differences, concerning the indications, anatomic reference points, choice of special equipment, doses, and schemes of administration.