Analiza faktora koji utiče na ishod lečenja prevremeno rođene dece sa prolaznim duktus arteriozusom

Abstract

Postojanje i perzistiranje levo-desnog šanta kroz otvoreni arterijski kanal je udruženo sa brojnim oboljenjima kod prevremeno rođene dece. Cilj rada je da utvrdi da li su oboljenja posledica postojanja šanta, terapije koja se primenjuje za njegovo zatvaranje ili nezrelosti organizma. Sprovedeno je kliničko, opservaciono, neinterventno, analitičko, retrospektivno istraživanje na 237 prevremeno rođene dece koja su lečena u Jedinici intenzivne nege i zahtevala mehaniču ventilaciju ili druge vidove ventilatorne potpore i oksigenoterapiju, a kod kojih je ehokardiografski dijagnostikovan hemodinamski značajan prolazni ductus arteriosus (hz PDA). Deca koja nisu imala hz PDA činila su kontrolnu grupu. Analizirali smo uticaj prenatalnih, neonatalnih, postnatalnih faktora i primenjenih terapijskih mera na pojavu hz PDA. Od 192 prevremeno rođene dece koja su razvila hz PDA i bila tretirana po protokolu za otvoreni arterijski kanal istraživali smo efekte varijabli otvorenog arterijskog kanala (dužina trajanja duktalnog šanta u danima i način zatvaranja PDA) na incidenciju sledećih oboljenja: bronhopulmonalna displazija, nekrotični enterokolitis, intrakranijalna hemoragija, retinopatija prematuriteta i letalni ishod. Kontrolnu grupu su činila deca bez simptomatskog duktusa (45 dece). Analizirali smo u obe grupe uticaj prenatalnih, neonatalnih, postnatalnih faktora rizika i primenjenih terapijskih mera na pojavu pojedinačnih komplikacija, zbirnih komplikacija i smrtnog ishoda. Deca koja su razvila hz PDA bila su prosečne PTM 1106,52± 351,28 gr i GS 28,04 ±2,57 GN, a deca u kontrolnoj grupi 1114,18 ± 196,96 gr i 27,85±1,05 GN što nije bilo statistički značajno za razvoj hz PDA. Pojedinačnom analizom uticaja postnatalnih faktora na pojavu hz PDA, RDS je pokazao visoku značajnost ( r= 0,007), kao i plućna hemoragija (r=0,036) i sepsa (r= 0,053). Analizom pojedinačnog uticaja primenjenih terapijskih mera na pojavu hz PDA našli smo da je visoko statistički značajna dužina primena mehaničke ventilacije (r=0,014), primena dopamina, furosemida i prekomerni intravenski unos tečnosti (r=0,000). Za pojavu BPD kao nezavisni faktor rizika izdvojila se dužina primene MV (p=0,033), dok su dužina trajanja šanta i GS bile značajne. Analizom udruženog uticaja svih faktora rizika za nastanak IVH, dobili smo da je najznačajnija GS (p=0,030) i primena dopamina (r=0,001), zbog hipotenzije kao ranog pokazatelja prisustva simptomatskog PDA. Nezavisni faktor rizika za razvoj NEK je sama nezrelost (r=0,034), a dužina izloženosti duktalnom šantu je samo doprinoseći faktor uz nezrelost za razvoj NEK. Najznačajniji faktori rizika za razvoj ROP je PTM (r=0,011) i broj primljenih transfuzija koncentrovanih eritrocita (r=0,012). Analizom udruženog uticaja svih ispitivanih faktora rizika za smrtni ishod, kao najznačajniji faktor izdvojila se PTM (r=0,002), dok su visoku statističku značajnost pokazali GS, stepen RDS, pojava plućne hemoragije i sepse. Dobili smo da deca, koja su bila duže na MV zbor težeg stepena RDS, PDA i drugih komplikacija, imala su 1,2 puta veći rizik za smrtni ishod. Incidencija hz PDA kod dece sa respiratornim distres sindromom u našoj ispitivanoj grupi iznosila je 81,7%. Nezavisni faktor rizika za razvoj hz PDA su RDS i sepsa, a od primenjenih terapijskih mera, davanje furosemida i povećan venski unos tečnosti. Hemodinamski značajan prolazni ductus arteriosus je bio značajan kao faktor rizika za razvoj intraventrikularne hemoragije, nekrotičnog enterokolitisa i 104 BPD. Najznačajniji faktori rizika za letalni ishod su nezrelost organizma deteta, opsežna intraventrikularna hemoragija, sepsa i hz PDA.

The existence and persistence of left-right shunt through the open arterial channel is associated with a number of diseases in premature infants. The aim is to determine whether the disease is a consequence of peristence of shunt, shunt therapy applied for closure or immature organism. Conducted a clinical, observational, neinterventno, analytical, retrospective study in 237 preterm infants who were treated in the intensive care unit and required mechanical ventilation or other forms of ventilatory support and oxygen therapy, and who had, echocardiography confirmed diagnosis of hemodynamically significant patent ductus arteriosus (PDA). Children who did not have a PDA consisted of a control group. We analyzed the impact of prenatal, neonatal, postnatal factors and principal therapeutic measures on the occurence of PDA. Of 192 premature infants who developed PDA and was treated according to the protocol for the open arterial channel, we investigated the effects of the variables of an open arterial channels (duration of the ductal shunt in the days and way of closing PDA) on the incidence of the following diseases: bronchopulmonary dysplasia, necrotizing enterocolitis, intracranial hemorrhage, retinopathy prematurity and death. The control group consisted of children without symptomatic ductus (45 children). We have analyzed in both groups the impact of prenatal, neonatal, postnatal risk factors and principal therapeutic measures on the occurence of individual complications, associated complications and death. Children who have developed a PDA had average body weight at birth 1106.52 ± 351.28 g and gestation average 28.04 ± 2.57 week, and children in the control group, 1114.18 ± 196.96 g and 27.85 ± 1.05 week which was not statistically significant for the development of the PDA. Individual analysis of the impact of postnatal factors on the occurrence PDA, RDS showed high significance (p= 0.007), like a pulmonary hemorrhage (p = 0.036) and sepsis (р= 0,053). The analysis of the individual effect of the therapeutic measures to the occurrence PDA, we have found that were statistically significant: length of use of mechanical ventilation (p= 0.014), the use of dopamine, furosemide and excessive intravenous fluid intake (p= 0.000). For the occurrence of BPD, as an independent risk factor, set aside the application of MV (in days) (p = 0.033), while the length of the shunt and GA were significant. The analysis of the joint impact of all risk factors for IVH, we get to the most important GA (p = 0.030) and the use of dopamine (p = 0.001), due to hypotension as early indicators of the presence of symptomatic PDA. Independent risk factor for the development of NEC is immaturity (p= 0.034), and the length of exposure ductal shunt is a contributing factor to the immaturity of the development of NEC. The most important risk factors for the development of ROP is PTM (p= 0.011) and the number of received transfusions of concentrated red cells (p = 0.012). The analysis of the joint influence of all investigated risk factors for death, as the most important factor set aside the PTM (p = 0.002), while the high statistical significance showed GA, degree of RDS, the occurrence of pulmonary hemorrhage and sepsis. We get, that the children who required longer use of mechanical ventilation, assembly severe degree of RDS, PDA and other complications, they had 1.2 times higher risk of death. Incidence PDA in children with respiratory distress syndrome in our study group was 81.7%. Independent risk factor for the development PDA are: RDS and sepsis, and the applied therapeutic measures that are: administration of furosemide and excessive intravenous fluid intake. Hemodynamically significant patent ductus arteriosus is an important risk factor for the development of intraventricular hemorrhage, necrotizing enterocolitis, and BPD. The 107 most important risk factors for the lethal outcome are: the immaturity, extensive intraventricular hemorrhage, sepsis and PDA.