HBO
IN COMPLEX TREATING OF INFANTILE PERITONITIS.
Practical recommendations.
Appendicular peritonitis still
remains one of the principle reasons for complications and lethality. That is
caused by specifications of infantile body as well as by the complicity of
diagnosis and too late start of treating.
Application of operations;
antibiotics and other medicines isn't enough effective: lethality can be from
2,5% to 20,7%; complications - 4,2 - 85%.
In literature of the latest time
hypoxia (first - circulatory; then tissue one) is mentioned as a compulsory
element of peritonitis pathogenesis. It deals with metabolism transgressions;
function of paremchymatous organs; intoxication; reduction of hemodynamics;
shifts of acid-alkaline balance; intestine paresis; etc.
The sicks of infantile age suffer
from all of these diseases more severely; the pathology is developing more
quickly - this is caused by greater necessity in oxygen (by 3 times) of a
young body.
Inclusion of
HBO in complex therapy of peritonitis is acquitted for its tremendous
abilities of supplying of body with oxygen - this results in diminishment of
oxygental deficiency; improvement of metabolism and micro circulation;
prevention of vascular thrombosis and inflation; activation of parenchymatous
organs and intestine. All this normalizes the homeostasis and improves the
results of treating of peritonitis.
Clinical observation of 152 sicks
of age less than 14 years in Lvov Medical Institution can confirm the
efficiency of HBO in treating of infantile peritonitis.
Indications
and method of treating.
HBO can be beneficial in
prophylaxis or treating therapy of peritonitis. It could be applied
in pre-operational and early after-operational period of II and III
degrees of disease; especially for young people.
HBO is applied in early
after-operational period of I degree of disease; application in case of
limited peritonitis is permitted individually.
The conditional contraindications
for its application are otorhinolaryngologic diseases; caverns in lung;
epilepsy; hypertension. In case of pneumonia, which often accompanies
peritonitis, the approach to the indication of HBO would be individual. The
success of application of HBO directly depends on the optimal selection of
values of parameters of procedure. These depend on many characteristics of
sick; age is one of them.
The average clinical figures for
HBO are: pressure - 0,8-1,2ATI (for sicks younger 3 years) and 1,5-2ATI for
older ones; period - 60 min.; 2 procedures in first day and one -next 1-4 days.
The preparation to procedure also
depends on many values: indications; kind of hypoxia; complications after the
operation; accompanying diseases and individual sensitivity.
Preparation of sick to the
procedure.
The otorhinolaryngologist's
consultation is compulsory. For the very little children nose would be cleaned
by the stuff. For prophylaxis
application of boro-adrenaline
drops or 2-3% ephedrine is desirable. Gastric tube can be applied in case of I
degree; if the pathology is harder, tube is compulsory to prevent the
aspiration; especially in period of compression and decompression. If the
chamber is constructed with oxygental mask, the existence of tube violates the
isolation; sequenty a special hole would be done in mask.
III degree of peritonitis often
requires parenteral inlets; this would be done with low frequency of dropping;
especially in compression and decompression periods to avoid transgressions of
that frequency. If normal regime of parenteral inputting can't be provided,
the inlet would be temporary interrupted.
Any oil and creams would be
cleaned off; when selecting the dress frequent uresis and defecation of such
sicks of that age would be taken into account.
The improved temperature, if any,
would be reduced in ordinary way: during HBO the temperature usually
additionally improves. The sedatives are required for children during the
procedure; for this sodium oxybutyrate can be used: usually the dose of 80-120
mg/kg of body in 30-40 ml. of 10% glucose solution is enough for the whole
time of procedure. If doctor wishes to contact with sick, the dose would be 60
mg/kg. Aminasine or pipolphen can
also be used. Older children would be instructed on their behavior in chamber.
Gauges are used for control of
patient during the procedure. The most important are: cardiogram;
encephalogram; respiratory frequency;
phonoentherography and
temperature of body. All of them would be checked each 10 min. The values for
micro climate in chamber would also be permanently controlled.
The patient would be placed
horizontally; if the stomach is enlarged, the head would be posed upper than
legs.
PERSUING OF PROCEDURES.
The rules of security would be
permanently fulfilled. For younger children the speed of compression would be
0,05 ATI/min.; if pressure above 0,5ATI is permitted, the speed after that
level can be improved to 0,1ATI/min. At pressure above 1ATI the shape of
breath can change to tachypnea; this phenomena disappears after reduction of
pressure to 0,5-0,8ATI. The sicks with III degree of disease often represent
the change of respiration on restrictive type; the respiratoric deficiency
takes place. These sicks are more sensitive to the compression; the pressure
for them wouldn't be above 0,8-1ATI. With recreation the loyalty to
hyperpressure improves.
Decompression for younger
children would be done with the speed of 0,05ATI/min.; for older -
0,1ATI/min., when the pressure is lower 1ATI, and 0,2ATI/min., when the
pressure is above 1ATI. For sicks with the III degree it would be done with
the speed of 0,05 - 0,03 ATI/min. Switching of oxygen takes place at 0,8-1ATI
for younger children; 2ATI for older.
About micro climate during the
procedure: the moisture would steadily improve at 30-35% and achieve the 100%
level at the end of procedure; temperature would improve only during the
isopression period at 5 C and achieve 28 C.
For younger children the climate
changes are less sharp: 1-2 C and about 15% of moisture. The regularity of
procedures depends on the state of sick and the achieved effects: usually that
is twice in first day (as an exclusion - 3 times!); second day and later on once
a day.
HBO is applicable when the
compensatory systems are yet repairable and functional changes are reversible.
Later application is less useful. Absence of bettering after 2-3 procedures
displays the unreversible violations of immunosystem. Further worthening of
state displays the existence of complications (purulent foci; commisural
ileus), to be treated operationally.
CONTROL OF THE EFFICIENCY OF HBO.
Previous therapy, age, degree of
disease would be taken into account during the HBO. Treating is efficient if
the intoxication significantly reduces in first 2-3 days and majority of
functional violations are mastered in 3-5 days. Already in the process of
procedure the bettering can be observed: after 15-20 min. skin becomes pale;
respiration -deep and regular; pulse index lessens. Arterial pressure doesn't
change significantly. the diameter of stomach lessens by 5-6 sm.; frequent
uresis and defecation appear; bile is outputted through the gastric tube. The
sick becomes more still and less excited.
Kidney investigations present the
improvement of diuresis; filtration and stream; these are completely
normalized after the course for sicks of I and II degree. HBO prevents sharp
kidney deficiency in early after-operation period. Reograms of liver present
the improvement of circulation - that supplies the regularity in functioning
of the whole body.
Phonoenterogram would present the
normalization of acoustic activity of intestine 1 day after; sometimes - 3
days after first procedure. This is the result of reduction of hypoxia in
intestine, bettering of circulation and lessening of pressure there.
HBO restores acid-alkaline
balance already in the process of procedure; but steady normalization of this
can be the result of only the whole course.
Tension in venose circulation
normalizes already after the first procedure.
To estimate the efficiency of HBO
in complex treating of peritonitis the analysis of far-off sequences of
application are also required.
Professor
A. Troshkov,
Doctor V. Grochovsky.