RU2295363C1 - Method for draining lateral ventricles in newborns on intraventricular hemorrhage occasions - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves setting draining means like silicon tube or umbilical catheter No5 into anterior horns of lateral ventricles, tube diameter being equal to 2,2 mm. Their fixation is carried out with counteraperture. 2-3 hours later after patient condition having been stabilized, one of draining tubes is connected to the inflow system designed as bottle having measuring scale, connected to infusion pump. The second draining tube is connected to outflow system, representing the second a bottle having measuring scale. Continuously active physiological saline infusion containing antibacterial and fibrinolytic preparations is carried out into ventricular system at a rate of 1-2 ml/h until full liquor sanitation is achieved.

EFFECT: simplified method; accelerated surgical intervention process.

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Description

The present invention relates to medicine, namely to pediatric surgery, and can be used for drainage of the lateral ventricles in newborns with intraventricular hemorrhage.

The most common among cerebral lesions in newborns are peri- and intraventricular hemorrhages (PIVC) in the projection of the germinal matrix. According to different authors, the incidence among newborns with a gestational age of 38-43 weeks is 1.6%, while in 55-60% it is observed at a period of 24-30 weeks, in patients with a body weight at birth more than 1500 g PIVC are observed in 10 -20%, and with a body weight of less than 1500 g - in 50-65% (Antonov, A.G. Peri-and intraventricular hemorrhages in newborns: prevention of their occurrence and progression / A.G. Antonov // Pediatrics. - 1996. - No. 5. - S.39-42).

The consequences of hemorrhages can be different: at the place of hemorrhage in the germinative matrix, the tissue is destroyed and a cyst is formed, or the accumulated blood breaks the ependymal layer and enters the lateral ventricle, spreading throughout the entire ventricular system, causing secondary occlusal hydrocephalus in 60% of cases with IV and 3 degrees . The problem of correcting the resulting pathological changes in the central nervous system is the impossibility of ventriculoperitoneal bypass surgery immediately after the onset of CPI and the progression of hydrocephalus, due to the development of shunt dysfunction, low body weight of premature infants, which leads to pressure sores in the projection of the pump of the shunt system, and preliminary rehabilitation of hemorrhagic cerebrospinal fluid.

Proceeding from this, the role of surgical correction of CPI with the aim of sanitizing cerebrospinal fluid and restoring cerebrospinal fluid circulation in the ventricular system and thereby reducing the frequency of development of hydrocephalus, improving the prognosis and quality of life of such patients is growing. Known surgical methods for the treatment of CPI are currently represented by lateral ventricular drainage and ventriculosubgaleal drainage. With external drainage, one or two drainages are installed in the lateral ventricles at the discretion of the neurosurgeon, cerebrospinal fluid is sanitized by repeated flushing of the ventricular system with physiological saline with the addition of an antibacterial drug. Remediation of the cerebrospinal fluid is achieved at 2-4 weeks of installation of drainage tubes. The disadvantage of this method is the frequency of rehabilitation, the long drainage tubes lasting up to 15-25 days, which leads to the development of infectious complications, the lack of pressure control in the ventricular system, which can lead to hyperdrainage conditions.

Another common method of treating CPI is subgaleal drainage, where the catheter is fixed to the dura mater and its distal part is located in the subaponeurotic space of the temporal-parietal region (Skoromets A.P. Ventriculosubgaleal drainage in the treatment of severe forms of intraventricular hemorrhage in newborns / A.P. . Skoromets, I.V. Pankratov // The First All-Russian Conference on Pediatric Neurosurgery: Abstracts / under the editorship of A.N. Konovalov - M., 2003. - P.90-91). The disadvantages of this method are a fairly voluminous surgical intervention for a premature newborn, the drainage duration is approximately 45-50 days, an unaesthetic cerebrospinal fluid pillow forms in the temporo-parietal region. The main negative point of the method is the lack of constant rehabilitation of the cerebrospinal fluid with the removal of thrombotic masses, circulating immune complexes, leading to the development of encephalomalacia.

Closest to the invention is a method of drainage of the lateral ventricles, proposed by prof. A. Whitelaw (Whitelaw A., Drainage, Irrigation and Fibrinolythic Therapy for Post-hemorrhagic Hydrocephalus for Newborn Infants Whitelaw, A lan Pople et al. // Trial Protocol Version, January, 2005). The authors developed a method for draining the anterior lateral ventricle and posterior horn from the contralateral side using the Codman system for external drainage of the lateral ventricles (Johnson & Johnson, Piscataway, NJ, USA); tissue plasminogen activator (Actilyse, Boehringer Ingelheim International GmbH, was used as a fibrinolytic) Ingelheim, Germany). The essence of the method is the drainage and rehabilitation of cerebrospinal fluid using fibrinolytic with a constant inflow through the drainage tube of the anterior horn of the lateral ventricle and the outflow of solution through the drainage tube of the posterior horn of the lateral ventricle. According to the authors, the rehabilitation of cerebrospinal fluid is achieved within 72 hours after surgery.

The disadvantages of this method are:

- drainage of the posterior horn of the lateral ventricle, which is technically more complicated and takes more time in the operating room, moreover, IVC are quite rarely localized in the projection of the posterior horn;

- the method requires additional financial costs in the form of acquiring a system for ventricular drainage.

The technical result when using the invention is to simplify the method and reduce the time of surgical intervention.

Common to the proposed object of the invention and method of A. Whitelaw are: neuroimaging using neurosonography when installing drainage in the lateral ventricle of the brain, installing an inlet and outlet system for the rehabilitation of cerebrospinal fluid and excretion of thrombotic masses, circulating immune complexes, early rehabilitation of the cerebrospinal fluid in the range 72-100 hours after installing the drainage system.

The main differences of the proposed method:

1) for drainage use thin silicone drainage tubes with a diameter of 2.2 mm or umbilical catheter No. 5;

2) the installation of drains is carried out in the front horns of the lateral ventricles;

3) to regulate the amount of inflow of the solution using an infusion pump designed for infusion therapy in the intensive care unit and intensive care unit.

The drawing shows a diagram of the proposed method.

The proposed method of drainage is as follows: all patients in the operating room are installing drainages under the control of neurosonography in the projection of the front horns of 1 lateral ventricles. To do this, a 0.5 mm incision is made, 2 cm from the midline in the projection of the coronary suture, the ventricles are punctured with a cerebral cannula, when the mandrin is removed and cerebrospinal fluid is obtained, a drainage tube 2 with a diameter of 2.2 mm or umbilical catheter No. 5 is inserted into the lateral ventricle. The fixation of the drainage is carried out through contraperturation. 2-3 hours after the stabilization of the patient's condition, one of the drainage tubes is connected to the inflow system, representing a vial 3 with a measuring scale, connected to the infusion pump 4. The second drainage tube 5 is connected to the outflow system, representing the second vial 6 with measured data. The child is constantly monitored in the intensive care unit. Active infusion of the solution is carried out at a rate of 1-2 ml per hour continuously until the cerebrospinal fluid is completely rehabilitated.

The proposed method was operated on 68 patients. We present two clinical observations.

Example 1

Patient K., was admitted to the RAO at the age of 7 days with a diagnosis of severe hypoxic hemorrhagic lesion of the central nervous system, IVC grade 3. A child from 1 pregnancy on the background of CKDF, anemia, from 1 preterm birth in a period of 33 weeks, early discharge of amniotic fluid. The mass of the newborn at birth is 1500 g, on the Apgar scale 5-6 points. Deterioration of the condition of the child was observed on the 5th day, became lethargic, stopped sucking, the ictericity of the skin increased. After consultation through the RCC, the child was transferred to RAO 2 RCCH. Upon admission, the child’s condition is serious, the level of consciousness is deeply stunning, the reaction to the examination is reduced, floating movements of the eyeballs are determined, the child does not suck, the cry is quiet, prolonged, tetraparesis, the head is hydrocephalic, the large fontanel is tense, the vascular pattern of the veins of the skin of the head is expressed. The child underwent neurosonography, where the expansion of the ventricular system, IVC of the 3rd degree (thrombus in the right lateral ventricle 47 by 12 mm, in the left 34 by 8 mm, layering on the vascular plexus, hyperechoicity of the periventricular regions) was revealed. After preoperative preparation in the operating room, ventricular drainages were established according to the method described above, the patient is in a serious condition in the postoperative period, after 4 hours, the ventricular drains are connected to the supply and exhaust system using a solution with a fibrinolytic drug and antibacterial. Intensive care unit constantly monitored the volume of fluid entering the drains and discharged, the ultrasound was monitored daily by the central nervous system, the cerebrospinal fluid and coagulogram were analyzed daily. Liquor reorganization was achieved on the 4th day (after 96 hours), the outflow-inflow system was turned off, the drainage tubes were left to control intracranial pressure for the next 3 days, then removed. The child was transferred to the neonatal pathology department for further treatment. An ultrasound study of the brain structures was performed periodically; progressive growth of the ventricles of the brain was not observed. The child was discharged 17 days after admission under the supervision of a neurologist at the place of residence.

Example 2

Patient N., was transferred to the RAW of newborns from the Central District Hospital in serious condition with periodic generalized tonic-type epipristes at the age of 3 days. A child from 5 pregnancies, proceeding against a background of moderate severity anemia, nephropathy, acute respiratory viral infections in the second trimester, 2 preterm births at a gestational age of 28-29 weeks, birth weight 1280 g, baby's Apgar score 4-6-6 points. On admission, a neurosonographic study of the brain was performed, where grade 4 CPI was detected on both sides (the right lateral ventricle is completely filled with thrombotic masses, the lumen is not determined, the thrombus size is 35 by 27 mm in the left lateral ventricle, hyperechoic formation is determined in the temporal-parietal lobe parenchyma) irregular shape with dimensions of 34 by 37 mm, adjacent to the wall of the lateral ventricle in the thrombus projection). Changes detected by ultrasound, confirmed by MRI of the brain. After preliminary preparation, the child was taken to the operating room, where ventricular drains were installed under the control of ultrasound, which were then connected to the inflow-outflow system by the above method. Periodically, hemostasis indicators were monitored, general cerebrospinal fluid analyzes were performed to monitor the rate of rehabilitation and the risk of ventriculitis. Remediation of the cerebrospinal fluid was achieved on the 5th day, drainage was removed on the 7th day. On neurosonography, 3 days after removal of the drainage systems, a moderate expansion of the lateral ventricles was revealed (anterior horn of the right lateral ventricle 7 mm, anterior horn of the left lateral ventricle 8 mm, third ventricle 5 mm, thrombotic masses were not detected, in the temporal-parietal lobe of the left porencephalic cyst communicating with the cavity of the left ventricle, size 25 to 20 mm). The child was discharged on the 24th day after admission in satisfactory condition with a body weight of 1950 g, significant positive dynamics was noted in neurological status: the child is active, does not spit up, there are no rough focal symptoms, a large fontanel is completed, not strained.

Prior to the introduction of this method of early drainage using the active inflow and passive outflow system, the mortality rate in newborn children with grade IV CP was 60-70%.

Thus, the introduction of the proposed method into practice allows the effective rehabilitation of cerebrospinal fluid in newborns with intraventricular hemorrhages of varying severity, timely withdraw thrombotic masses and derivatives of blood, prevent the development of posthemorrhagic hydrocephalus, since the child’s low weight, severe damage to the central nervous system with tamponade of the ventricles of the brain and, as a rule, severe disturbances in vital functions make the treatment of these patients less promising. When using this method, sanitation is achieved 4-6 days after the installation of the drainage system, in contrast to the previously used closed drainage technique for one or both ventricles, where sanitation is achieved on 15-20 days, a decrease in the drainage period leads to a reduction in the patient’s hospital stay, improvement of treatment outcomes for this group of patients, exit of patients without the development of posthemorrhagic hydrocephalus and subsequent bypass surgery.

Claims (1)

A method for draining the lateral ventricles during intraventricular hemorrhage in newborns, including installing drainage tubes in the lateral ventricle of the brain under ultrasound control, installing a supply and exhaust system for the rehabilitation of cerebrospinal fluid and removing blood derivatives using physiological saline with antibacterial and fibrinolytic drugs, characterized in that installed in the front horns of the lateral ventricles, while a silicone tube with a diameter of 2.2 mm or umbilical cord is used as drainage catheter No. 5, and their fixation is carried out through counterperturbation, 2-3 hours after stabilization of the patient's condition, one of the drainage tubes is connected to the inflow system, which is a vial with a graduated scale, connected to the infusion pump, the second drainage tube is connected to the outflow system, which represents the second vial with a measuring scale, active infusion into the ventricular system is carried out at a speed of 1-2 ml / h continuously until the cerebrospinal fluid is completely rehabilitated.