УДК: 616-073.175
Болаларда периоператиф даврда биоимпенданс қўллаш орқали
инфузион терапияни баҳолаш бўйича замонавий кўриниши.
Александрович .Ю.С., Расулова Х.А., Шорахмедов Ш.А., Ортиқбоев Ж.О
Тошкент педиатрия тиббиёт институти, Ўзбекистон
В статье изложен современный взгляд на инфузионную терапию
периопеционного периода основанный на биоимпедансометрии при
анестезиологическом обеспечении у детей. Проведен анализ исследований и
указаны более уязвимые части изучаемой тематики. Поставлена тактика
работа для дальнейшего более глубокого изучения.
Калит сўзлар:
биоимпеданс таҳлил, анестезиология, инфузион
терапия,ёш болалар .
Cовременный взгляд на оценку инфузионной терапии путем
применения биоимпендансометрии в периоперационный период у детей.
Александрович .Ю.С., Расулова Х.А., Шорахмедов Ш.А., Ортиқбоев Ж.О.
Ташкентский педиатрический институт, Узбекистан.
Резюме
В статье изложен современный взгляд на инфузионную терапию
периопеционного периода основанный на биоимпедансометрии при
анестезиологическом обеспечении у детей. Проведен анализ исследований и
указаны более уязвимые части изучаемой тематики. Поставлена тактика
работа для дальнейшего более глубокого изучения.
Ключевые слова
: биоимпедансный анализ, анестезиология, инфузионная
терапия, детский возраст.
A modern look at the assessment of fluid therapy by using bioimpedance
measurement in the perioperative period in children.
Aleksandrovich Y.S, Rasulova K.A., Shorakhmedov Sh.A., Ortikboyev J.O.
Tashkent Pediatric Institute, Uzbekistan.
Summary
The article presents a modern view of the infusion therapy of the perioperative
period based on bioimpedansometry for anesthesia in children. An analysis of the
studies is carried out and the more vulnerable parts of the studied topic are indicated.
The tactics of work are set for further deeper study.
Key words:
bioimpedance analysis, anesthesiology, infusion therapy, children's
age.
Relevance
Infusion therapy in children with anesthetic management is a difficult task, since
their hydration status is difficult to assess. Markers such as invasive are widely used,
the resulting intravascular pressure is recognized to have serious deficiencies as a
measure of hydration and does not provide any information about the extravascular
or intracellular state of the fluid. Many methods are invasive, which makes them not
applicable in pediatric practice. Modern medicine requires non-invasive but precise
methods.
In the whole world medicine at the moment one of the important problems is infusion
therapy. By the beginning of the XXI century in Europe and the USA, the main
provisions of a multidisciplinary method for accelerated recovery of surgical
patients after elective operations were formulated. A new concept has appeared in
the English-language literature, denoted by two terms: "Fast-Track Surgery" (FTS)
and "accelerated recovery after surgical operations" (Enhanced Recovery After
Surgery - ERAS). In these protocols, special attention is paid to fluid therapy and
perioperative fasting. should be emphasized that fasting before surgery, starting at
midnight, has become firmly established in clinical practice. This approach was
justified by the risk of food and water retention in the stomach with the subsequent
occurrence of regurgitation and aspiration during induction of anesthesia. The side
effects of such a limitation are obvious: the possibility of hypovolemia, depletion of
glycogen stores and hypoglycemia, metabolic stress, which led to the emergence of
the above mentioned protocols in world practice and a more detailed study of this
issue.
M. S. Brady et al. (2010) published a meta-analysis of 22 randomized studies
of preoperative fasting. The results suggested that stopping the intake of fluids,
including juices, water, tea, and coffee, 2 hours before surgery did not increase the
incidence of aspiration complications in elective surgery compared to patients who
fasted from midnight to surgery. In addition, no differences were found in the
amount of gastric contents and its pH [41.]. This point of view was confirmed in
subsequent publications [42]. The European Society of Anesthesiologists
recommends taking clear liquids 2 hours before induction of anesthesia, and also
avoiding solid food for 6 hours [43].
Especially in pediatric practice, where hypovolemia and hypoglycemia can
lead to more formidable complications than in adult patients, in our opinion, requires
careful research. We paid special attention to the problem of the adequacy and
effectiveness of infusion therapy in the perioperative period in children. Since this
task, in our opinion, remains quite relevant at the present time, which is due to both
the anatomical and physiological characteristics of the child's div and the
peculiarities of the surgical intervention. Infusion therapy during anesthesia in
children has remained a subject of debate over the past decades [3,4] Errors in
perioperative fluid administration in children can lead to serious complications and
even death [5]. Accurate monitoring of fluid balance in patients after surgery is
challenging. The most common method for determining the composition of the
human div and its constant perioperative monitoring today is bioimpedance
analysis. The practical application of bioimpedance analysis in anesthesiology and
resuscitation began in the 1960s with the work of the French anesthesiologist A.
Tomasset with the aim of assessing the composition of the human div, water
sectors of the div, and then to study other components of the div composition [7].
One of the researchers (M. Tsukamoto., Et al. (2017)), in his works devoted to
intraoperative fluid administration in pediatric practice using bioelectrical
impedance analysis during dental surgery, indicated that fluid therapy is important
for achieving optimal results in the postoperative period. [8,9,10]. Recently, fluid
restriction has been recommended to reduce complications following major surgery,
but has remained unknown in minimally invasive surgery [8-10].
Other studies have also shown that preoperative oral intake of clear liquids can
be safe up to 2 hours before surgery, and light snacks can be consumed up to 6 hours
before surgery [11, 12]. However, the typical fasting times are often longer than
expected 6-10 hours [11]. Especially, pediatric patients may be more vulnerable to
dehydration because they have a relatively large portion of total div water (TBW)
div weight compared to adults. [13]
E. Itobi ID from the UK, in their study investigated the effect of edema on
recovery after major abdominal surgery and the potential value of multifrequency
bioimpedance measurements. In their opinion, generalized edema is often observed
in patients with acute surgical complications who are in critical condition and require
intensive supportive treatment after surgery [14]. Hanged mortality of patients was
observed with pathological fluid accumulation in the perioperative period [15,16].
Generalized edema can also occur in ward surgical patients who do not show signs
of critical illness [17]. The tendency to accumulate fluid is well known, it is a
physiological response to surgical injury, but the mechanisms leading to generalized
edema are not fully understood, the prevalence of generalized edema after routine
major surgery has not been established [18,19]. But there is anecdotal evidence that
this may be associated with poor clinical outcome, and none of this has been
scientifically evaluated [17]. Mattha¨ and Ernstbrunner et al., In their study
"Bioimpedance spectroscopy for assessing the status of patients before and after
general anesthesia," studied the postoperative fluid distribution. All patients
undergoing anesthesia and surgery usually receive intravenous fluid therapy during
surgery to correct anesthesia and surgery associated with hemodynamic
disturbances. The timing, quantity and specific type of its introduction, however,
remain controversial [20]. Based on the assumption of preoperative dehydration and
significant amounts of intravenous fluid, it is still common clinical practice, although
a positive perioperative fluid balance with postoperative increase in fluid weight on
the basis is associated with major complications [21–25].
Materials and methods.
We have analyzed the modern literature on infusion therapy of the perioperative
period, where the method of research was bioimpedance measurement. Based on
these data, the bioimpedance analysis of div composition was taken as the basis of
their methodology, which is based on the differences in the electrical resistivity of
biological tissues due to the different content of fluid and electrolytes in them. The
analysis allows, based on the measured values of electrical resistance (impedance)
of the human div and anthropometric data, to assess the state of protein, fat and
water metabolism, the intensity of metabolic processes, correlate them with intervals
of normal values of signs, assess the reserve capabilities of the div and the risks of
diseases [2, 10]. Currently, there are quite a few reports in the literature [6,30] about
the possibility of using bioimpedance measurements of the div when it is probed
with currents of different frequencies to control the state of water balance.
Fundamental research on mathematical modeling of bioimpedance measurements
using high-resolution three-dimensional geometric models of the human div made
it possible to visualize the measurement sensitivity areas and confirmed the
importance of the method for assessing changes in div composition and fluid
balance [4]. The BIA VSM data allow to give a comprehensive assessment of the
state of the volume and nutritional status, and the availability of computer support -
to track the results of changes in dynamics. The device is intended for use in clinical
practice, the output protocols of the method contain estimates of the following
parameters:
- volemic status - the volume of total div fluid (OBF), the volume of extracellular
fluid (VF), the volume of intracellular fluid (ECF), the percentage of lack or excess
of extracellular fluid, the ratio of VF / ECF, the level of hypo- or hyperhydration (l);
- nutritional status - lean mass (HM), fat mass (FM), cell mass (BM), lean mass index
(ITM), fat mass index (FFM), div mass index (BMI) [44].
The goal of E. Itobi ID from the UK was to gain a better understanding of the
processes that lead to postoperative edema by using multifrequency bioimpedance
analysis (BIA) to monitor total div water redistribution (TBW) after major
abdominal surgery.
Результаты и обсуждение
Research by M. Tsukamoto., Et al. (2017) patients were 2 to 12 years old, ASA risk
I, preoperative fasting, oral intake of light food allowed until midnight, and clear
liquid until 6:00 am. Patients who were scheduled for induction of anesthesia from
8:15 AM (the first on the surgical day) did not receive a preoperative fluid load.
None of the patients were premedicated. Patients received a crystalloid load of 10
ml / kg / h from the induction of anesthesia before the start of the surgical procedure,
and from 1 to 3 ml / kg / h during the operation [8]. Their research showed that fluid
changes lead to a decrease in intracellular water using BIA during general
anesthesia. The introduction of fluid provides correction of the existing fluid deficit
and to compensate for perioperative fluid shifts between intracellular and
extracellular. And in low-trauma surgery, there is no concern about fluid loss and
fluid shear that may be associated with highly traumatic surgery. [35,36] In this
study, the opinion on highly traumatic surgery remains unclear as indicated by the
author. In addition, there are no specific figures on the amount of infusion load. If
only the general opinion is that low-traumatic operations do not require more
detailed correction of infusion therapy. The author also pointed out that not all
patients had a fasting time of 2-3 hours, in many cases it exceeded [8]. Also, in this
study, extracellular water loss occurred and intracellular water decreased due to
preoperative fasting and low fluid therapy during general anesthesia, although
hemodynamic changes were stable and there were no complications in the
postoperative period [8,34]. All data were taken from a study of 16 patients, which,
in our opinion, cannot bear the recommendatory nature of this method in order to
correct the infusion therapy of the perioperative period..
The study by E. Itobi ID included 38 patients, among them there were no differences
in the sex ratio, the risk assessment of the American Society of Anesthesiologists
[13] between patients, the bioimpedance analysis was measured on days 1, 3 and 5
after surgery. included in the study, but the 20 patients who developed edema were
older than those who did not develop edema (mean 73 (9) versus 63 (14) years; P =
0.007). Fluid intake during the first 5 days after surgery was the same in both groups,
but those with edema excreted less total fluid (16.9 (2.4) versus 19.7 (3.5) liters; P
= 0.022). Edema was associated with delayed transport of solid food (P = 0 001) and
bowel opening (P = 0 020), prolonged hospital stay (mean 17 (range 8–59) versus 9
(range 4–27) days ; P = 0.001) and more postoperative complications (13 of 20
versus four of 18 patients; p = 0.011). The preoperative ratio of whole div
impedance at 200 kHz and impedance at 5 kHz was higher in those who
subsequently developed edema (0 81 (0 03) versus 0 78 (0 02); P = 0 015). Fluid
balance calculations in this study showed that some patients are able to accumulate
large volumes in the postoperative period without developing clinical obvious
edema. Such fluid can accumulate in parts of the div that are not readily available
clinically. Fluid retention within the gastrointestinal tract following major
abdominal surgery has been attributed to a combination of albumin sequestration
and decreased motility with potentially adverse effects [14,15]. The most important
clinical finding from this study is that the presence of edema is associated with
slower postoperative recovery. Patients with edema had significantly more
complications, a slower recovery of bowel function, and a longer hospital stay.
According to our data, the study has several disadvantages. First, the sample size
was small, which means that the risk of type II error was high. Second, although
there was complete agreement between observers in the diagnosis of edema, it is
recognized that the detection of edema may be influenced by factors such as skin
elasticity and interstitial tissue compliance, which are known to be age
dependent.Matth and Ernstbrunner, etc., in their study in 71 women aged 45 ± 15
years with a div weight of 67 ± 13 kg and anesthesia duration of 154 ± 68 minutes,
the preoperative fluid overload increased from 20.7 ± 1.1 L to 0.1 ± 1.0 L, which
corresponds to 25.1 ± 7.5% and 0.8 ± 6.7% of the normal extracellular volume,
respectively (both p 0.001), after patients received 1.9 ± 0.9 L intravenously
crystalloid liquid. Perioperative urinary excretion was 0.4 ± 0.3 L. The increase in
extracellular volume was accompanied by an increase in the total volume of div
fluid, while the intracellular volume increased insignificantly and did not reach
statistical significance (p = 0.15). Net perioperative fluid balance (fluid volume
injected minus urinary excretion) was significantly associated with changes in
extracellular volume (r2 = 0.65), but was not associated with changes in intracellular
volume (r2 = 0.01). Routine intraoperative fluid administration results in a
significant and clinically significant increase in the extracellular compartment. BIS
measurements have yielded plausible results and may be useful to guide
intraoperative fluid therapy in future studies [39]. The results indicate the full use of
the method in the perioperative period in adults. But there is no analysis in pediatric
practice. Which allows us to explore more deeply in pediatric anesthesiology.
Conclusions
At the moment, there is no doubt about the demand for protocols for the infusion of
patients in the perioperative period. That would improve the rapid recovery of
patients in the postoperative period from a medical and economic point of view of
this problem. Bioimpedance monitoring allows continuous monitoring of div
fluids and immediate correction, if necessary, during the entire perioperative period.
In the future, based on the data obtained, it is possible to develop infusion therapy
for the perioperative period in children. In practical medicine, it is possible to
provide data on the infusion of children with anesthesiological support in surgical
practice.
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