RESUMEN
Primary peritoneal drainage (PPD) was initially introduced as a method for the pre-operative resuscitation of critically ill infants with complicated necrotising enterocolitis (NEC). Some have recommended it as definitive strategy for a select group of extremely low birth weight babies. The role of laparotomy in neonates who do not respond to initial PPD has also been challenged. With this background, we analysed our experience with the use of PPD in babies with NEC over an 18-year period. We retrospectively reviewed all patients with NEC who had PPD as their initial surgical management over an 18-year period. A total of 122 babies with NEC were treated surgically, of whom 42 had PPD as the initial procedure. There were 28 survivors (67%) in the PPD group, of whom 7 recovered without laparotomy. Twenty-nine infants (69%) had a good clinical response to PPD with 80% (23/29) survival, compared to a 27% survival (3/11) in those who did not respond to drainage. Six patients underwent rescue laparotomy after a poor response to PPD and three of these survived. Six of the 28 pts who underwent laparotomy had isolated intestinal perforation and their clinical characteristics were no different from those with typical NEC. PPD is a useful option in the management of complicated NEC. It is difficult to recognise with certainty those infants who will not require a subsequent laparotomy and therefore we do not support the concept of PPD solely as a definitive strategy. The response to PPD is a good prognostic indicator for ultimate survival. Despite a low salvage rate of 27% in non-responders compared to 80% in responders, there is a role for early laparotomy for those infants who do not respond to PPD.
Asunto(s)
Drenaje/métodos , Enterocolitis Necrotizante/cirugía , Humanos , Recién Nacido , Laparotomía , Pronóstico , Estudios RetrospectivosRESUMEN
BACKGROUND AND AIMS: Patients receiving parenteral nutrition are at risk of septicaemia. Intestinal dysmotility and impaired gut immunity due to parenteral nutrition promote bacterial overgrowth. Gut overgrowth with aerobic Gram-negative bacilli (AGNB) impairs systemic immunity. The aim of this study was to determine the potential role of gut overgrowth with AGNB in the pathogenesis of septicaemia related to parenteral nutrition. METHODS: A prospective 5 y study of surgical infants less than 6 months of age was undertaken. Surveillance samples of the oropharynx and gut were obtained at the start of parenteral nutrition and thereafter twice weekly, to detect AGNB carriage. Blood cultures were taken on clinical indication only. RESULTS: Two-hundred and eight infants received parenteral nutrition for 6271 days (median 13 days, range 1-512 days). The incidence of AGNB carriage was 42%, whilst the septicaemia rate was 15%. Eighty-four percent of septicaemic infants carried AGNB, whilst 16% never carried AGNB (P<0.005). Carriage developed significantly earlier than septicaemia. CONCLUSIONS: The incidence of septicaemia was significantly greater in the subset of abnormal carriers. Although gut overgrowth with abnormal flora reflects illness severity, the fact that it preceded septicaemia implicates AGNB overgrowth, per se, as a contributory factor in the development of septicaemia related to parenteral nutrition. Prevention is unlikely to be successful if it ignores the abnormal flora.
Asunto(s)
Infecciones por Bacterias Gramnegativas/etiología , Enfermedades Intestinales/cirugía , Nutrición Parenteral/efectos adversos , Bacteriemia/epidemiología , Bacteriemia/microbiología , Peso al Nacer , Estudios de Cohortes , Femenino , Edad Gestacional , Bacterias Aerobias Gramnegativas , Infecciones por Bacterias Gramnegativas/epidemiología , Infecciones por Bacterias Gramnegativas/microbiología , Humanos , Lactante , Recién Nacido , Enfermedades Intestinales/microbiología , Enfermedades Intestinales/terapia , Masculino , Estudios Prospectivos , Factores de TiempoRESUMEN
We performed a prospective, observational, cohort study on 208 surgical neonates and infants between 1992 and 1997. Surveillance cultures of the oropharynx and rectum were obtained at the start of parenteral nutrition and thereafter twice weekly. Blood cultures were taken on clinical indication only. Microbial translocation was diagnosed when the micro-organisms in the blood were not distinguishable from those carried in the oropharynx and/or rectum. Liver function was monitored weekly and when septicaemia was suspected. The incidence of septicaemia was 15%. The predominant micro-organisms (86%) were the low-level pathogens, coagulase-negative staphylococci and enterococci. Potential pathogens, including aerobic Gram-negative bacilli, were responsible for the remainder. Microbial translocation was responsible for 84% of septicaemic episodes in 76% of patients. The potential pathogens caused septicaemia significantly later than coagulase-negative staphylococci, at a time when liver function was significantly more impaired. In neonates and infants receiving parenteral nutrition, septicaemia is mainly a gut-derived phenomenon and requires novel strategies for prevention.
Asunto(s)
Bacteriemia/epidemiología , Bacteriemia/etiología , Infección Hospitalaria/epidemiología , Infección Hospitalaria/etiología , Fungemia/epidemiología , Fungemia/etiología , Nutrición Parenteral/efectos adversos , Bacteriemia/prevención & control , Traslocación Bacteriana , Catéteres de Permanencia/efectos adversos , Infección Hospitalaria/prevención & control , Inglaterra/epidemiología , Femenino , Fungemia/prevención & control , Hospitales Pediátricos , Humanos , Incidencia , Lactante , Recién Nacido , Control de Infecciones/métodos , Pruebas de Función Hepática , Masculino , Pruebas de Sensibilidad Microbiana , Faringe/microbiología , Estudios Prospectivos , Recto/microbiología , Factores de RiesgoAsunto(s)
Circuncisión Masculina/estadística & datos numéricos , Fimosis/cirugía , Procedimientos Innecesarios/estadística & datos numéricos , Adolescente , Distribución por Edad , Niño , Preescolar , Errores Diagnósticos , Inglaterra , Medicina Basada en la Evidencia , Humanos , Lactante , Recién Nacido , Masculino , Pene/patología , Fimosis/patologíaAsunto(s)
Bacteriemia/etiología , Traslocación Bacteriana , Bacterias Aerobias Gramnegativas/fisiología , Infecciones por Bacterias Gramnegativas/etiología , Intestinos/microbiología , Nutrición Parenteral/efectos adversos , Bacteriemia/inmunología , Peso al Nacer , Estudios de Cohortes , Femenino , Fungemia/tratamiento farmacológico , Fungemia/etiología , Motilidad Gastrointestinal , Edad Gestacional , Infecciones por Bacterias Gramnegativas/inmunología , Humanos , Inmunidad Mucosa , Lactante , Recién Nacido , Intestinos/inmunología , Masculino , Observación , Estudios Prospectivos , Sepsis/etiología , Índice de Severidad de la Enfermedad , Procedimientos Quirúrgicos OperativosAsunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo , Nutrición Parenteral Total , Carbohidratos de la Dieta/administración & dosificación , Carbohidratos de la Dieta/metabolismo , Grasas de la Dieta/administración & dosificación , Grasas de la Dieta/metabolismo , Proteínas en la Dieta/administración & dosificación , Proteínas en la Dieta/metabolismo , Anomalías del Sistema Digestivo , Metabolismo Energético , Humanos , Recién NacidoRESUMEN
OBJECTIVE: To explore whether episodes of endogenous septicemias due to microbial translocation are clinically relevant in neonates and infants who are receiving long-term parenteral nutrition (PN). DESIGN: Prospective observational cohort study of 2 years. SETTING: Neonates and infants who underwent surgical procedures and required PN because of gastrointestinal abnormalities. MEASUREMENTS: Surveillance cultures of the oropharynx and gut were obtained at the first of PN and thereafter twice each week. These cultures were processed for all microorganisms, except for coagulase-negative staphylococci, in a semiquantitative manner to detect overgrowth. A blood sample was taken for culture from both the central venous line and peripheral vein on clinical indication only. Microbial translocation was diagnosed when the microorganisms that were isolated from the blood sample were also carried in the throat and/or rectum within the 2 weeks preceding the episode of septicemia. MAIN RESULTS: Of 94 infants, 10 (11%) experienced 24 episodes of septicemia (ie, 7.3 septicemic episodes per 1000 days of PN). Six infants experienced 15 episodes of microbial translocation due to enteric microorganisms, including Escherichia coli, Klebsiella, Candida species, and enterococci. Microbial translocation occurred after a median of 58 days of PN (range, 32 to 286 days). The enteric organisms that caused septicemia were always present in the throat and/or rectum and in high concentrations ( > 10(5) colony-forming units per gram [ie, overgrowth]) in 60% of the translocation episodes. All but one episode occurred in infants with an abnormal serum bilirubin level ( > 17 mumol/L [0.99 mg/dl]). CONCLUSIONS: In neonates and infants who are receiving PN, septicemia may be a gut-related phenomenon.
Asunto(s)
Traslocación Bacteriana , Nutrición Parenteral , Músculos Abdominales/anomalías , Músculos Abdominales/cirugía , Bacteriemia/etiología , Bacterias/aislamiento & purificación , Candida/aislamiento & purificación , Candida/fisiología , Cateterismo Venoso Central/instrumentación , Cateterismo Periférico/instrumentación , Estudios de Cohortes , Recuento de Colonia Microbiana , Enterococcus/aislamiento & purificación , Enterococcus/fisiología , Escherichia coli/aislamiento & purificación , Escherichia coli/fisiología , Fungemia/etiología , Hernia Umbilical/cirugía , Humanos , Hiperbilirrubinemia/sangre , Hiperbilirrubinemia/complicaciones , Lactante , Recién Nacido , Obstrucción Intestinal/congénito , Obstrucción Intestinal/cirugía , Intestinos/microbiología , Klebsiella/aislamiento & purificación , Klebsiella/fisiología , Orofaringe/microbiología , Nutrición Parenteral/efectos adversos , Estudios Prospectivos , Recto/microbiología , Factores de TiempoRESUMEN
OBJECTIVE: To test the hypothesis that testicular maldescent is rarely congenital in the absence of a complete hernial sac. PATIENTS AND METHODS: The study comprised 110 boys undergoing orchidopexy. Operative findings (complete hernial sac versus no hernial sac) were compared with recorded testicular descent at birth. RESULTS: Among 70 testes recorded as maldescended neonatally there was no example without a complete hernial sac at orchidopexy. Among 60 recorded as descended neonatally, 43 had no sac at orchidopexy. CONCLUSIONS: The findings are consistent with the hypothesis, though not with the proposition, that the presence of a complete hernial sac at orchidopexy constitutes proof of congenital testicular maldescent.
Asunto(s)
Criptorquidismo/etiología , Cavidad Peritoneal/anomalías , Factores de Edad , Criptorquidismo/patología , Hernia Inguinal/congénito , Humanos , MasculinoRESUMEN
The aim of this study was to define the prevalence of hypoalbuminaemia (HA), its predisposing factors, and its effect on outcome in infants. Fifty-six consecutive infants receiving parenteral nutrition (PN) for gastrointestinal disease were divided into two groups according to their lowest measured serum albumin level. The reference range (27.9 to 50.9 g/L) for serum albumin was derived from measurements taken in 37 (22 term and 15 preterm) normal enterally fed newborn infants. HA group (serum albumin < 27.9 g/L) included 15 infants (27%); NA group (serum albumin > or = 27.9 g/L) included 41 infants (73%). HA infants received more albumin than NA infants (median 66 versus 14 mL/kg; P = .005). There was no significant difference between HA and NA groups in gestational age, postmenstrual age at time of start of PN, composition of PN, nor mean weight gain. HA was unrelated to biochemical signs of liver dysfunction, C-reactive protein elevation, septicaemic episodes, or time from operation. HA occurred within the first week of starting PN in 10 infants and returned to normal values within 5 days. HA was a recurrent phenomenon in three patients. Mortality was higher in the HA group (33.3%) than in the NA group (4.9%; P = .02) but was apparently causally unrelated to the low serum albumin level. Hypoalbuminaemia is a common finding in neonates on PN despite the administration of exogenous albumin. Monitoring serum albumin levels in surgical infants on PN seems to be of little clinical value.
Asunto(s)
Enfermedades Gastrointestinales/terapia , Nutrición Parenteral , Albúmina Sérica/deficiencia , Albúminas/uso terapéutico , Estudios de Casos y Controles , Causalidad , Enfermedades Gastrointestinales/sangre , Enfermedades Gastrointestinales/cirugía , Humanos , Recién Nacido , Prevalencia , Valores de Referencia , Resultado del TratamientoRESUMEN
The aim of this study was to determine the effect of different glucose/fat ratios on protein metabolism kinetics in newborn infants receiving total parenteral nutrition (TPN). Eighteen studies were done on 14 infants receiving TPN (weight 3.15 +/- 0.22 kg [mean +/- SEM]; gestational age 37.8 +/- 0.9 weeks; postnatal age 14.0 +/- 3.7 days). There were two study groups. Group A infants (n = 9) received 10.0 g/kg/d of dextrose and 4.0 g/kg/d of fat; group B infants (n = 9) received 19.0 g/kg/d of dextrose and 0.5 g/kg/d of fat. Caloric intake (86 kcal/kg/d) and amino-acid intake (2.5 g/kg/d) were the same in the two groups. There was no difference between the groups with regard to weight, gestational age, and postnatal age. Intravenous diet was constant during the 3-day study period. Timed urinary nitrogen excretion was determined. On day 3 of the study, each infant received a priming dose of 15 mumol/kg of [13C]leucine followed by a 6-hour infusion at 6 mumol/kg/h. Plasma and breath samples were taken at hourly intervals, and CO2 production was measured by indirect calorimetry. Plateau levels of plasma [13C]-alpha Ketoisocaproic acid (KIC) enrichment and expired 13CO2 enrichment were determined by gas chromatograph mass spectrometry. Protein metabolism kinetics were calculated. Results were: nitrogen balance 0.27 +/- 0.01 g/kg/d, total protein flux 10.38 +/- 0.34 g/kg/d, total protein synthesis 9.64 +/- 0.31 g/kg/d, total protein breakdown 7.86 +/- 0.38 g/kg/d, and total protein oxidation/excretion 0.92 +/- 0.04 g/kg/d.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Carbohidratos de la Dieta/administración & dosificación , Emulsiones Grasas Intravenosas , Glucosa/administración & dosificación , Recién Nacido/metabolismo , Nitrógeno/metabolismo , Nutrición Parenteral Total , Proteínas/metabolismo , Ingestión de Energía , Metabolismo Energético/fisiología , Femenino , Humanos , MasculinoRESUMEN
It is essential that adequate calories are provided to newborns to cover their energy expenditure. This is difficult to measure and varies significantly between individuals. The aim of this study was to develop an equation to predict the basal energy requirements of stable surgical infants, using easily measurable parameters. Resting energy expenditure (REE) was measured using computerized open-circuit indirect calorimetry. One hundred twenty-two measurements were made on different days in 46 stable nonventilated infants. The measured REE was 34.41 +/- 0.46 cal/kg/min; (mean +/- SEM). Three body-size measurements correlated significantly with REE (cal/min): weight in kilograms (r = .87; P < .00001), body surface area in square meters (r = .86; P < .00001), and lean body mass in kilograms (r = .81; P < .00001). Five other independent variables correlated significantly with REE (cal/kg/min): heart rate in beats per minute (r = .60; P < .00001), postnatal age in days (r = .49; P < .00001) caloric intake in cal/kg/min (r = .44; P < .00001), gestational age in weeks (r = .43; P < .00001), and rectal temperature in degrees Celsius (r = .19; P = .04). Weight, heart rate, age, gestational age, and temperature were regarded as independent predictor variables of REE for the multiple stepwise regression analysis. Three variables entered this highly significant equation: REE (cal/min) = -74.436 + (34.661 x weight in kg) + (0.496 x heart rate in beats/min) + (0.178 x age in days) (r = .92; F = 230.07; significance, F < .00001).(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Metabolismo Energético/fisiología , Recién Nacido/fisiología , Procedimientos Quirúrgicos Operativos , Superficie Corporal , Peso Corporal , Ingestión de Energía , Femenino , Edad Gestacional , Frecuencia Cardíaca/fisiología , Humanos , Masculino , Matemática , DescansoRESUMEN
OBJECTIVE: To perform bladder neck suspension simultaneously with augmentation cystoplasty in female patients where sphincteric incompetence was not the sole cause of impaired functional bladder capacity. PATIENTS AND METHODS: During an 8-year-period, 26 female patients (mean age 14, range 5-39) were treated with a Marshall-Marchetti plus cystoplasty (Liverpool) or a colposuspension plus clam cystoplasty (Sheffield). All had marked sphincteric incompetence compounded by detrusor hyper-reflexia and/or non-compliance. The patients were followed up for a mean period of 30 months (range 8-80). RESULTS: There were no major complications. At follow-up 23 (88%) were dry by day on a regime of intermittent self-catheterization. Nine patients were taking adjuvant medication, usually for prevention of nocturnal enuresis. CONCLUSION: The results compare tolerably with those of all alternative procedures, including the more elaborate reconstructions (e.g. Kropp procedure) and the expensive artificial urinary sphincter.
Asunto(s)
Vejiga Urinaria Neurogénica/cirugía , Vejiga Urinaria/cirugía , Incontinencia Urinaria/cirugía , Adolescente , Adulto , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Complicaciones Posoperatorias , Periodo Posoperatorio , Resultado del Tratamiento , Vejiga Urinaria/fisiopatología , Vejiga Urinaria Neurogénica/fisiopatología , Incontinencia Urinaria/fisiopatología , Micción , Urodinámica , Urología/métodosRESUMEN
A criterion for successful hydrostatic reduction of intussusception is reflux into the terminal ileum. In our practice, absence of reflux into the terminal ileum is not an indication for laparotomy if the radiographic appearances suggest edema of the ileocecal valve. The aim of this study was to validate our approach. We reviewed the case notes of patients with a diagnosis of intussusception (n = 107; age 11.74 +/- 1.48 months; mean +/- SEM) treated from 1987 to 1991. Eleven required primary laparotomy for peritonitis. Ninety-six patients who had a contrast enema were studied. Edema of the ileocecal valve was defined as a persistent filling defect in the cecum after apparently complete hydrostatic reduction, without reflux of contrast into the distal small bowel. In 59 patients hydrostatic reduction was successful: 11 (18.6%) had edema of the ileocecal valve and no reflux contrast into the terminal ileum (group B). All improved clinically after the enema and needed no further treatment. In 37 patients hydrostatic reduction of the intussusception was unsuccessful and an operation was performed: 26 (70.3%) required manual reduction of the intussusception (group C) and 11 (29.7%) underwent bowel resection (group D). None of the patients with edema of ileocecal valve required further treatment or developed recurrent intussusception. In none of the patients who had an operation was the intussusception found to have been reduced by the contrast enema. There were no deaths.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Sulfato de Bario , Enema , Válvula Ileocecal/diagnóstico por imagen , Intususcepción/terapia , Laparotomía , Femenino , Humanos , Enfermedades del Íleon/diagnóstico por imagen , Enfermedades del Íleon/cirugía , Enfermedades del Íleon/terapia , Lactante , Intususcepción/diagnóstico por imagen , Intususcepción/cirugía , Masculino , Radiografía , RecurrenciaRESUMEN
A new oral formulation of iopamidol, "Gastromiro", was evaluated as a bowel contrast agent during abdominal computed tomography (CT). Comparison was made with the well established agents sodium/meglumine diatrizoate ("Urografin 370") and dilute barium sulphate ("E-Z CAT") in a randomized, blind study of 150 consecutive patients undergoing abdominal and/or pelvic CT. Parameters assessed included quality of bowel opacification, artefact generation, contrast-medium palatibility, side effects and cost. No significant difference was found between the three contrast media in stomach- or small-bowel opacification. E-Z CAT was superior at opacifying the caecum/ascending colon. No compelling reason to choose a particular agent was found in the other assessed parameters, but cost is a significant factor.