NUTRITIONAL SUPPORT FOR SEVERE SEPSIS IN PEDIATRICS AND SURGERY.
Satvaldieva E.A., Ashurova G.Z., Fayziyev O.Yo., Shakarova M.U.
Satvaldieva E.A. Tashkent Pediatric Medical Institute (TasPMI). Head of the department of
anesthesiology and reanimatology, pediatric anesthesiology and reanimatology, doctor of medical
Sciences, professor
Abstract.
Parenteral feeding in children, who are in critic condition, is one of the more
complicated problems in intensive therapy. There are no common opinions in the solution of this
problems not only in practice, also and in the world literature. There are no criteria and
recommendations for using parenteral feeding in children in the intensive therapy unite. The main
indication for conducting of nutritious support in critic conditions is metabolic requirement, also
loss of proteins and nutrients. Nutritious support is directed to prevent development of severe
exhaustion (protein-energetic insufficiency) in the background of hyper catabolism and
hypermetabolism, syndrome of enteral insufficiency at the developing multi-organ dysfunction or
its high probability,
Key words.
Septic shock, phenomenon, nutritional support, sepsis in pediatrics.
Introduction.
Enteral insufficiency is one of the main causes of endogen intoxication,
syndrome
of
systematic inflammation response, septic shock and multi-organ insufficiency. [1]
Developing critic violation of water-electrolyte balance, circulator hypoxia of intestine’s wall,
dysbacteriosis with proximal microbe colonization of intestine, considerable violation of
antioxidant protection, local immunities and barer function of mucous membrane, phenomenon of
progression “bacterial translocation”
-
just not many of these changes, which characterized this
symptom complex.[2]
There is well-known the fact, that the younger child, the more intensity of exchange
processes in him and the more energy is needed for covering expenditure of energy, associated with
intensive growth, development, substances’ exchange and supporting of main vital fiinctions[3]
Therefore, the most important task for assigned nutritive support in intensive therapy is not only
support of important proteins level and energy requirement, also prevent developing multi-organ
insufficiency, creating condition for processes of restoration and up-growth of tissue [4].
All of the above-mentioned gives evidence about extreme importance adequate nutritious
support in children, which are in critic condition [5]. The aim developing standard protocol of
covering energetic demand in children, which are in critic condition, efficiency of which is already
proved in randomized clinic studies in children with purulent-inflammatory processes, intestinal
ileus, peritonitis, intestinal fistulas, necrotic colitis, severe sepsis with multi-organ dysfunction.
Materials and methods.
47 patients with different somatic and surgery pathologies, who had
been treated in the children intensive care unit at Republican research center of emergency medicine
during 2019 - 2020 years, are exanimated and studied. The average age of children
-
1.3 ±0.5 year.
Due to the type of nutritious support, the patients were divided 2 groups:
1
group - nutritious support with full parenteral(Selemin5%,Sepid, glucose 15-20%)
2
group - nutritious support is conducted with artificial special mixtures (or decanted
maternal milk for children till 1 year old)
+
partial parenteral feeding with using amino acids
(Selemin 5%, Imin and 15% glucose).
For valuation efficiency conducting therapy there is conducted measurement of following
characteristics:
A)
anthropometric indexes - measurement of div mass ( 1 time in a day), measurement
circumference of shoulder (1 time per 3-5 days) and thickness of cellulocutaneous cover ( 1
time per day).
B)
biochemical indexes - level of proteins, proportion of protein fractions, level of albumin,
bilirubin, transaminase, triglycerides, acid-base balance and gases of blood (Astrup’s
micromethod).
For valuation of endogen intoxication dynamics, there are studied: lymphocytes, leukocytes,
leukocytic index of intoxication, average molecules level. Also, there are evaluated patient stay
duration in intensive care unite, lethality in groups.
Results
.During calculation of energy demand in children at the different critic conditions, there
is established that, the last one is waved within the limits 30-50 kkal/kg/day (at intensive
hypercatabolism). For effective synthesis of endogen proteins, there is important to keep correlation
of not proteins calorie to general nitrogen in average 1-gram nitrogen to 120-150 kkal.
Carbohydrates are entered in the doses 6 gr/kg/day, with subsequent increasing till 2 gr/kg/day.
Concentration of glucose solution is selected based on the general volume of infusion therapy
(generally 15-20% solutions). By fifth days doses of carbohydrates reached maximally 15-16
gr/kg/day. Control was conducted due to checking out of glucose level in the blood till 2 times per
day. In the case of high glucose level, correction was conducted using insulin 0.5 unit/kg. The high
limit of dedicated glucose - 16.
Demand for protein substrates as general nitrogen load is - 0.20-0.35 gr/kg/day, that
corresponds to requirement for proteins 1.25-2.5 gr/kg/day. The modem standard is using only-
crystalloid amino acid solutions.
We start from 0.5 gr/kg/day with following increasing to 0.5 gr/kg/day, reaching maximally till 2.5
gr/kg/day by 5
lh
day. Control of general protein, residual nitrogen, urea, acid-base balance, alanine
aminotransferase, aspartate aminotransferase is necessary.
For covering grease, we started infusion of “Сепид” with the doses 0.5 gr/kg/day with
following increasing to 0.5 gr/kg/day, reaching till 3 gr/kg/day with mandatory control of
triglycerides, transaminases, bilirubin in plasma.
Discussion.
We use vitamins and microelements from first day of parenteral feeding. Thus,
due to our protocol standard, by 5
th
day from the beginning of parenteral feeding, children is taken
is full valued parenteral nutrition due to balanced system during following 10 days. Afterwards,
due to dynamic of patient’s condition, children start to be given mixture enteral tube feeding and
partial parenteral feeding. For nutritive support, mixture without lactose was used. Using of this
mixture in early after operation period is reasonable, as it is absorbed in upper parts of intestine
maximally, digested fast and supports trophism of enterocytes.
The patients with surgical pathology, who need nutritive support are divided to 2 groups
conditionally:
1.
Patients with peritonitis, ileus. The average duration of full parenteral feeding is 3-5 days,
then change to enteral tube feeding or independent enteral feeding.
2.
Ill children with syndrome “short intestine” (as a result of spacious resection of intestine)
-
high ileus, intestinal fistulas, necrotic enterocolitis. The average duration of full parenteral
feeding is 1-1.5 months.
We assign tire full parenteral feeding in early terms after operation (2-3
rd
days) or after correction
of homeostasis. In both groups with somatic and surgical pathologies, parenteral feeding was
conducted due to analogical protocol standards.
There is established that early nutritive support, during first 24 hours since the moment of
operation or development another critic condition, is more effective as compared with its using
from 4-5
th
days of intensive therapy.
This standard allows possibility to reach more early restoration of nutritive status in children
with somatic and surgical pathologies, that is evident in fast discontinues of loss of div- mass,
general protein and albumin level, fast restoration of intestinal passage. Using of the offered
standard with usage of parenteral and enteral feeding provides patients with nutrients and
energy completely, promotes shorting of stay in the departments of resuscitation and intensive
therapy, optimization of treatment quality in whole.
Referents.
1.
Emrath E. T„ Fortenberry J. D., Travers C. et al. Resuscitation with balanced fluids is associated
with improved survival in pediatric severe sepsis
Crit. Care Med.
-
2017. - Vol. 45. -P. 1177-1183.
2.
Medeiros D.N., Ferranti J.F., Delgado A.F. et al. Colloids for the initial management of severe
sepsis and septic shock in pediatric patients: A systematic review colloids for the initial
management of severe sepsis and septic shock in pediatric patients: A systematic review.
Pediatr.
EmergCare,
2015, vol. 31, pp. 11-16.
3.
Paul R., Melendez E., Stack A. et al. Improving adherence to PALS septic shock guidelines.
Pediatrics, 2014, vol. 133, pp. el358-el366
4.
Schlapbach L.J., MacLaren G., Festa M. et al. Prediction of pediatric sepsis mortality within Ih
of intensive care admission.
Int. Care Med.,
2017, vol. 43, pp. 1085-1096
5.
Ford N., Hargreaves S., Shanks L. Mortality after fluid bolus in children withshock due to sepsis
or severe infection: a SR and MA
PLoS One.
- 2012. -Vol. 7. - P. e43953.
