Does administering albumin to postoperative gastroschisis patients improve outcome?

OBJECTIVES: Newborns who undergo surgery for gastroschisis correction may present with oliguria, anasarca, prolonged postoperative ileus, and infection. New postoperative therapeutic procedures were tested with the objective of improving postoperative outcome. PATIENTS AND METHODS: One hundred thirty-six newborns participated in one of two phases. Newborns in the first phase received infusions of large volumes of crystalloid solution and integral enteral formula, and newborns in the second phase received crystalloid solutions in smaller volumes, with albumin solution infusion when necessary and the late introduction of a semi-elemental diet. The studied variables were serum sodium and albumin levels, the need for albumin solution expansion, the occurrence of anasarca, the length of time on parenteral nutrition, the length of time before initiating an enteral diet and reaching a full enteral diet, orotracheal intubation time, length of hospitalization, and survival rates. RESULTS: Serum sodium levels were higher in newborns in the second phase. There was a correlation between low serum sodium levels and orotracheal intubation time; additionally, low serum albumin levels correlated with the length of time before the initiation of an oral diet and the time until a full enteral diet was reached. However, the discharge weights of newborns in the second phase were higher than in the first phase. The other studied variables, including survival rates (83.4 percent and 92.0 percent, respectively), were similar for both phases. CONCLUSIONS: The administration of an albumin solution to newborns in the early postoperative period following gastroschisis repair increased their low serum sodium levels but did not improve the final outcome. The introduction of a semi-elemental diet promoted an increase in body weight at the time of discharge.

Evolution of critically ill patients with gastroschisis from three tertiary centers

OBJECTIVES AND INTRODUCTION: Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20-30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers. METHODS: From January 2003 to June 2009, the following patient data were collected retrospectively: (A) Background maternal and neonatal data: maternal age, prenatal diagnosis, type of delivery, Apgar scores, birth weight, gestational age and sex; (B) Surgical modalities: primary or staged closure; and (C) Hospital course: levels of serum sodium and levels of serum albumin in the two first postoperative days, number of ventilation days, other postoperative variables and survival. Statistical analyses were used to examine the associations between some variables. RESULTS: 163 newborns were included in the study. Primary closure of the abdominal defect was performed in 111 cases (68.1 percent). The mean serum sodium level was 127.4¡6.7 mEq/L, and the mean serum albumin level was 2.35¡0.5 g/dL. Among the correlations between variables, it was verified that hyponatremia and hypoalbuminemia correlated with the number of days on the ventilator but not with the number of days on total parenteral nutrition (TPN); mortality rate correlated with infection. The final survival rate was 85.9 percent. CONCLUSION: In newborns with gastroschisis, more aggressive attention to hyponatremia and hypoalbuminemia would improve the outcome.

Qual é a melhor solução de hidratação parenteral a ser utilizada no tratamento pós-operatório de recém-nascidos com gastrosquise?: experiência do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP / Which is the best solution for parenteral infusion in the postoperative treatment for newborns with gastroschisis?: experience of Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP

Objetivos: Recém-nascidos (RN) com gastrosquise apresentam oligúria, anasarca, íleoadinâmico prolongado e infecção. O objetivo desse estudo foi utilizar nova abordagem para melhora da evolução pós-operatória. Método: Estudo com 103 RN foi dividido em duas fases: 1ª - infusão de grandes volumes de solução cristalóide, introdução precoce de fórmulas integrais e colocação de cateter venoso central com duplo-lúmen; 2ª - administração de soluções cristalóides em menores volumes, com infusão de colóides quando necessário, introdução tardia de dieta semi-elementar e colocação decateter PICC. Foram estudadas diferentes variáveis e feitas correlações com níveis séricos de sódio e albumina, necessidade de expansão com solução colóide, tempo de nutrição parenteral, período de tempo para início da dieta enteral e dieta plena, tempo de intubação oro-traqueal (IOT) e de internação, necessidade e tipo de cateter venoso central, complicações e sobrevida. Resultados: O nível de natremia da 2ª fase foi maior que da 1ª. Houve forte correlação entre hiponatremia e aumento do tempo de IOT. Necessidade de expansão com solução colóide se associou a maior tempo de IOT, tempo para início da dieta e tempo de internação. Frequênciade infecções nos RN com cateter central foi maior na 1ª fase. Os índices de sobrevida nas duas fases foram semelhantes (83,4% e 91,8%). Conclusões: Restrição da infusão de cristalóides com administração criteriosa de soluções colóides pode prevenir hiponatremia, a qual se relaciona a períodos de IOT mais prolongados. Cateteres do tipo PICC se associam a menor frequência de infecções.

Objectives: Newborns with gastroschisis display oliguria, anasarca, prolonged gastrointestinal dysfunction and infections. We proposed a different approach, aiming to improve postoperative outcome. Methods: The study with 103 newborns was divided in two phases: 1st - infusion of large volumes of crystalloid solution, milk formulae were early introduced and double lumen catheters were inserted; 2nd - maintenance fluids were restricted and colloid solutions were administered when necessary, late introduction of semi elemental formulae and PICCs were precociously inserted. Several data were evaluated and correlated with serum levels of sodium and albumin, necessity of colloid solutions infusion, time of parenteral nutrition, time to fisrt and full feeds, number of ventilation and inhospital days, need and kind of central catheter, complications and survival in both phases. Results: Natremia levels were higher in the 2nd than in the 1st phase. There was a strong correlation between hyponatremia and increased number of days on mechanical ventilation. Need of colloid solution boluses were associated with prolonged intubation periods, time to first feed and hospitalization. Frequency of systemic infections in patients with central catheters was higher in the 1st phase. Survival rates were similar (83.4% and 91.8%). Conclusions: In newborns with gastroschisis, restriction of crystalloid solutions infusion and judicious administration of colloids can prevent hyponatremia, which correlates with prolonged orotracheal intubation periods. Early insertion of PICCs is associated with less systemic infections than venous dissection.

Prenatal tracheal ligation or intra-amniotic administration of surfactant or dexamethasone prevents some structural changes in the pulmonary arteries of surgically created diaphragmatic hernia in rabbits

PURPOSE: Characterization of the structural changes occurring in the pulmonary arteries resulting from surgically produced congenital diaphragmatic hernia in rabbits, with particular emphasis on the preventive effects of prenatal tracheal ligation or administration of intra-amniotic dexamethasone or surfactant. METHODS: Twenty rabbit fetuses underwent surgical creation of a left-sided congenital diaphragmatic hernia on the 24th or 25th gestational day. They were divided according to the following procedures: congenital diaphragmatic hernia (n = 5), congenital diaphragmatic hernia plus tracheal ligation (n = 5), congenital diaphragmatic hernia plus intra-amniotic administration of dexamethasone 0.4 mg (n = 5) or surfactant (Curosurf 40 mg, n = 5). On gestational day 30, all the fetuses were delivered by caesarean section and killed. A control group consisted of five nonoperated fetuses. Histomorphometric analysis of medial thickness, cell nuclei density, and elastic fiber density of pulmonary arterial walls was performed. RESULTS: Arteries with an external diameter > 100 mum have a decreased medial thickness, lower cell nuclei density, and greater elastic fiber density when compared with arteries with external diameter <= 100 mum. Congenital diaphragmatic hernia promoted a significant decrease in medial thickness and an increase in cell nuclei density in artery walls with external diameter > 100 mum. Prenatal treatments with tracheal ligation or intra-amniotic administration of dexamethasone or surfactant prevented these changes. In arteries with external diameter <= 100 mum, congenital diaphragmatic hernia promoted a significant increase in medial thickness and in cell nuclei density and a decrease in elastic fiber density. The prenatal treatments with tracheal ligation or intra-amniotic administration of dexamethasone or surfactant prevented these changes, although no effect was observed in elastic fiber density in the congenital diaphragmatic hernia plus dexamethasone group. CONCLUSIONS: Congenital diaphragmatic hernia promoted different structural changes for large or small arteries. The prenatal intra-amniotic administration of dexamethasone or surfactant had positive effects on the lung structural changes promoted by congenital diaphragmatic hernia, and these effects were comparable to the changes induced by tracheal ligation