Rane komplikacije liječenja novorođenčadi s prirođenom dijafragmalnom kilom

master's thesis

• Title (english): Early complications in the treatment of newborns with congenital diaphragmatic hernia
• Author: Ena Pritišanac
• Mentor: Tomislav Luetić (mentor)
• Committee member: Boris Filipović-Grčić (predsjednik povjerenstva)
• Committee member: Tomislav Meštrović (član povjerenstva)
• Committee member: Tomislav Luetić (član povjerenstva)
• Granter: University of Zagreb; School of Medicine; (Department of Surgery); Zagreb
• Defense date and country: 2014-07-15, Croatia
• Scientific / art field, discipline and subdiscipline: BIOMEDICINE AND HEALTHCARE; Clinical Medical Sciences; Surgery

Abstract

Prirođena dijafragmalna kila (PDK) je razvojni defekt dijafragme koji omogućuje prolaps abdominalnih organa u prsište. Unatoč napretku intenzivne skrbi novorođenčadi rezultati liječenja i u najboljim centrima dosežu stopu preživljenja od svega 50%. Ovakav nezadovoljavajući rezultat pripisuje se upravo komplikacijama same bolesti u ranom novorođenačkom periodu. Najteži rezultat hernijacije abdominalnih organa jest razvitak plućne hipoplazije, zbog čega novorođenče ima povećani rizik razvitka perzistirajuće plućne hipertenzije (PPHN). Ova se komplikacija prezentira se u prva 24h znakovima respiratornog distres sindroma. Kod sumnje na PPHN provodi se probir pulsnom oksimetrijom, a definitivna dijagnoza postavlja se pomoću ultrazvuka srca. Liječenje perzistirajuće plućne hipertenzije novorođenčeta uključuje osnovnu potpornu terapiju kardiorespiratornog sustava volumenom, inotropnim lijekovima i kisikom te korekciju acidoze, a u liječenje se po potrebi uključuju i dodatne mjere kao što su vazodilatacijski lijekovi i potpora izvantjelesnom membranskom oksigenacijom (ECMO). Novi protokol liječenja PDK temelji se na preoperativnoj stabilizaciji plućne hipertenzije te poštednoj mehaničkoj ventilaciji malim volumenima, visokom frekvencijom i reduciranim vršnim tlakom radi sprečavanja barotraume pluća. Unatoč velikim očekivanjima od ECMO potpore, novije studije pokazuju da se prednosti korištenja ECMO očituju tek u teškim slučajevima PDK kada su konvencionalne terapijske mogućnosti iscrpljene.Najteža poslijeoperacijska komplikacija jest povratak plućne hipertenzije. Od drugih postoperativnih komplikacija češće se susreće hilotoraks, a temeljni pristup u liječenju jest smanjiti produkciju limfe, drenirati i obliterirati pleuralni prostor, nadoknađivati tekućinu i nutritivne tvari i zbrinjavati disanje.

Abstract (english)

Congenital diaphragmatic hernia (CDH) is a developmental defect of the diaphragm that allows abdominal viscera to herniate into thoracic cavity. Despite of the improvements in the intensive neonatal care results of the treatment of this condition remain rather poor with an overall survival rate estimated at 50%. These unsatisfactory results stem from the complications which appear in the early neonatal period. The most difficult outcome of herniation is development of the pulmonary hypoplasia and an increased risk of persistent pulmonary hypertension of newborn (PPHN). This is seen already in the first day of life as newborn shows signs of respiratory distress syndrome. Should CDH be suspected, a screening with pulse oximetry should be conducted and final diagnosis based on findings of echocardiography. Current treatment of the persistent pulmonary hypertension of newborn includes general supportive therapy of cardiorespiratory system with volume, inotropic agents and oxygen as well as treatment of the underlying acidosis. When needed, treatment can also involve supplemental therapy such as vasodilator agents and extracorporeal membrane oxygenation (ECMO). New treatment protocol focuses on preoperative stabilization of pulmonary hypertension and lung protective mechanical ventilation using small volumes, high frequency and low peak inspiratory pressure. Despite high expectations of ECMO support, it has recently been showed that ECMO is of critical importance only in severe cases for which conventional measures remain insufficient. An operation of diaphragmatic defect follows after clinical stabilization. Recurrence of the pulmonary hypertension presents the most difficult postoperative complication. Other postoperative complications include chylothorax, which is best treated with reduction of lymph production, drainage and obliteration of pleural space. In addition, the patient should be supported with fluid, electrolytes and nutrients and respiratory stabilized.

• Keywords: prirođena dijafragmalna kila; perzistirajuća plućna hipertenzija; mehanička ventilacija; izvantjelesna membranska oksigenacija; hilotoraks
• Keywords (english): congenital diaphragmatic hernia; persistent pulmonary hypertension; mechanical ventilation; extracorporeal membrane oxygenation; chylothorax
• Language: croatian
• URN:NBN: urn:nbn:hr:105:071558
• Study programme: Title: Medicine; Study programme type: university; Study level: integrated undergraduate and graduate; Academic / professional title: doktor/doktorica medicine (doktor/doktorica medicine)
• Type of resource: Text
• File origin: Born digital
• Access conditions: Open access
• Created on: 2015-11-03 13:56:34