[Intensive care for newborns and babies of the first year of life with acute heart failure after cardiosurgical interventions].

After cardiosurgical interventions, the incidence of low cardiac output syndrome (LCOS) is 3-10% depending on age and surgery. The basis for management of patients with LCOS and high pulmonary hypertension is to maintain low total peripheral vascular resistance and to exclude volume overload. Due to the fact that the Russian Federation lacked phosphodiesterase (PDE) III inhibitors that are basic intensive care drugs in pediatric surgery in the West, levosimendan was used as an inodilator in the complex intensive care for postoperative LCOS in 75 infants aged 3 days to 2 years 10 months in October to December 2007. Before drug infusion, left ventricular ejection fraction (LVEF) varied from 17 to 29% (21 +/- 7%), left atrial pressure (LAP) was 25 +/- 2.82 (16-30 mm Hg). During levosimendan administration, the authors analyzed the following hemodynamic parameters: rate, blood pressure, central venous pressure (CVP), LAP, and LVEF by echocardiography, as well as the frequency of side effects and mortality rates. During levosimendan infusion after transient hypotension at the beginning of the drug administration, following 12 hours there was a significant increment in mean BP from 42 to 53 mm Hg (p < 0.05). Left ventricular (LV) preload changes as a significant reduction in LAP (from 25 to 17 mm Hg; p < 0.05) developed much earlier: 6 hours after initiation of levosimendan administration. During the drug administration, CVP values were unchanged. LVEF significantly rose from 21 to 27% following 12 hours of levosimendan therapy start. The major adverse reaction was a tendency towards systemic hypotension within the first hour of levosimedan infusion requiring bolus injection of 20% albumin in 11 cases and infusion of epinephrine (0.03-0.05 microg/kg/min) in 14 cases. Thus, levosimedan may be used as an inodilator in pediatric cardiosurgery as an alternative to PDE III inhibitors in LCOS after surgical correction for congenital heart disease (CHD), accompanied by LV hypoplasia, after surgical correction of CHD with baseline low LVEF, as well as a basic drug during extracorporeal circulation and after its cessation.

[Intensive care for newborns and infants after anatomic correction of transposition of great vessels].

A retrospective study was made in 48 babies undergone an arterial switching operation at the Bakulev Research Center of Cardiovascular Surgery in January 2004 to September 2005. Their age at surgery was 5 days to 11 months; body weight, 3.9 +/- 1.1 kg (2.4-8.7 kg). According to the course of a postoperative period, the patients were divided into 2 groups: 1) 28 (58.3%) neonates with simple transposition of great vessels (TGV) and older babies (above 3 weeks of life) with simple TGV; 2) 20 (41.6%) patients with TGV + ventricular septal defect. The postoperative management of all the patients was based on the delayed bringing the sternum together in babies at risk for close mediastinum syndrome, on the reduction in left and right ventricular afterload with the mean blood pressure (BPmean) minimally sufficient to maintain adequate coronary blood flow and diuresis, by using inodilatators and nitric oxide (II) and by limiting the volume of administered fluid. The sternum was primarily brought together in 20 (41.6%) patients, in 13 (27.1%) on day 2. Sternal separation was required in 1 patient from Group 1 on postoperative day 2. The duration of artificial ventilation was 3.3 +/- 5.2 days (0.7-15 days); the length of stay in an intensive care unit was 4.8 +/- 8.2 days (1-20 days). There were 9 (18.7%) deaths. Left ventricular failure, high pulmonary hypertension, and coronary insufficiency were causes of death in 2 (4.8%), 1 (2.4%), and 2 (4.8%) patients, respectively. After arterial switching, the optimum management of patients with low cardiac output is to maintain low peripheral resistance and to restrict preload and to use FDE III inhibitors as the drugs of choice.

[Use of the exogenous surfactant curosurf in combined therapy for acute respiratory failure in children after cardiosurgical interventions].

This study was undertaken to evaluate the effectiveness and safety of use of an exogenous surfactant in combined therapy for acute respiratory failure in children after cardiac surgery. In 2003 to 2004, the A. N. Bakulev Research Center of Cardiovascular Surgery, Russian Academy of Medical Sciences, used Curosurf in 58 infants undergone cardiac surgery. The infants' age ranged from 1 day to 27 months (4.6 +/- 0.75 months); the body weight was 1.1 to 14.8 kg (4.9 +/- 0.69 kg). According to the indications for replacement therapy with Curosurf, all the patients were divided into 4 groups: 1) 19 patients with acute pulmonary lesion syndrome; 2) 12 patients with bilateral pneumonia; 3) 22 infants with recurrent atelectases, and 4) 5 patients with paresis of the cupula of the diaphragm. Group 1 patients receiving the exogenous surfactant showed a significant increase in oxygenation and Cdyn, which allowed a significant reduction in the level of respiratory support. Group 2 patients were found to have similar changes, less pronounced as they were, in gas exchange and the mechanics of respiration. In most patients with recurrent atelectases, a steady-state smoothing-out of the latter could be achieved. In Group 4 patients, the exogenous surfactant did not affect the duration of artificial ventilation. Complications due to the administration of the exogenous surfactant (pneumothorax, short-term blood desaturation) were encountered rarely and readily arrested. As a whole, Curosurf is an effective component of combined intensive therapy for acute respiratory failure in pediatric cardiosurgery.

[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.

[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.