RU2411002C1 - Method for prediction of health deterioration and failure in infants - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, to paediatrics in particular. Newborns are examined for haemodynamic values of a cardiovascular systems that is followed with statistical data processing and postneonatal follow-up. An infant in critical condition is additionally examined for cardiac rhythm variability values: by spectrogram - total spectral power (ms²), by RR intervalogram - mode amplitude (%), rhythm variability (s), tension index (standard units), very-low spectral modes (ms²), low spectral modes (ms²), by RR intervalogram - mode amplitude (%), rhythm variability (s), tension index (standard units). If the derived values are as follows: total spectral power -120.4±9.87; mode amplitude - 96.5±7.91; rhythm variability - 0.04±0.003; tension index -4783.1±392.14, high-risk group of health deterioration and failure is identified.

EFFECT: method provides higher reliability of predicting due to using the cardiac rhythm variability values.

2 cl, 1 tbl, 2 ex

Description

The invention relates to medicine, namely to pediatrics.

The child’s health is determined by both the age-related capabilities of the growing organism and the influence of a whole range of factors on it. The level of health directly depends on the body's ability to adapt to various influences. There is no doubt that the state of health of young children is affected by the transferred critical state in the neonatal period. Among this contingent of children, neurological consequences of hypoxia occurred in 76%, sepsis in 86%, and pneumonia developed in 72% (Ivanov D.O., Results of substitution therapy with the natural drug Kurosurf in newborns with severe lung lesions / D.O. Ivanov, V.A. Lyubimenko, N.P. Shabalov // Children's Hospital. - 2002. - No. 2. - P.38-44). According to a number of authors, disability is determined in every fifth child who has undergone critical conditions (Aronskind E.V. Health status of children who have undergone critical conditions in the neonatal period / Aronskind E.V., Ufimtseva A.A. // Pediatrics. - 2004. - No. 1 - S.39-42). In this regard, it is relevant to develop criteria for newborns in critical condition that can predict a decrease in the level of health and an adverse outcome, which will allow timely implementation of the necessary measures to correct the state of health.

As a prototype, a method for predicting the level of health of children from mothers with overcome tubal-peritoneal infertility was selected, including determining the hemodynamic parameters of the cardiovascular system in newborns, followed by statistical processing "Diagnostic and prognostic value of the adaptive potential of the circulatory system in assessing the health status of children born from mothers with tubal peritoneal infertility. ” - Collection of scientific papers dedicated to the 70th anniversary of prof. A.F. Vinogradova. - Tver, 2009 .-- S.164-172). The adaptive potential of the circulatory system in the early neonatal period in the offspring of mothers who have undergone tubal-peritoneal infertility, allows us to predict the unsatisfactory adaptation of these children in the 1st year of life.

The adaptive potential of the circulatory system, proposed by A.A. Aydaraliev et al. (1988), calculated as follows:

AP = 0.011 (heart rate) +0.014 (SBP) +0.008 (DBP) +0.014 (B) +0.009 (MT) -0.009 (P) -0.27, where:

- Heart rate - heart rate in beats per minute;

- GARDEN and DBP - systolic and diastolic blood pressure in mmHg;

- In - age in months;

- MT - body weight in kg;

- P - growth in m.

Based on the values of the adaptive potential of the circulatory system that exceed the "threshold" level (2.41 points) at 3-7 days of life, a risk group for reducing the level of health in the first year of life can be identified. Observation of children at risk in the first year of life showed that a decrease in the level of health was manifested by a low level of resistance, the development of chronic pathology and a longer course of neurological disorders.

However, this method has some disadvantages, because adaptive potential may change throughout the day and heart rate is variable. The potential can have a different level in children with low and high body weight at birth, which also makes it difficult to evaluate. It can be mainly used to assess the state of the cardiovascular system and adaptation of the child and cannot predict an unfavorable outcome of the disease.

The objective of the invention is to increase the reliability of the forecast of the level of health and reduce the adverse outcome in young children.

The result of the development of the method is to increase the information content of forecasting and the use of indicators of heart rate variability, non-invasiveness of the study, with the simplicity of forecasting through the use of known devices, the possibility of prediction for the entire early period of childhood, as well as use in children in extremely serious condition, no dependence on anthropometric data , the possibility of reviewing treatment and drawing up an individual program of rehabilitation measures.

The task and its result are achieved by the fact that in the method for predicting a decrease in the level of health and adverse outcome in young children, which includes determining hemodynamic parameters of the cardiovascular system in newborns, followed by statistical processing of data and monitoring children under one year of age, according to the invention in newborns in critical condition further define the parameters of heart rate variability: the spectrogram - total spectrum power (ms ²⁾ cardiointervalogram - amp fashion itudu (%), rhythm variability (c), the voltage index (conv. units), and the following values of their

- total spectrum power - 120.4 ± 9.87;

- fashion amplitude - 96.5 ± 7.91;

- rhythm variability - 0.04 ± 0.003;

- stress index - 4783.1 ± 392.14, and allocate a risk group to reduce the level of health and adverse outcome. In this case, the examination of newborns is carried out mainly at the age of 5 days of life.

The introduction of new indicators in determining the prediction of a decrease in the level of health of newborns and an unfavorable outcome allows us to more accurately determine the severity of the functional state of the body, because heart rate variability (HRV) is seen as an indicator of this condition. In the critical group of newborns, the HRV indices were heterogeneous; revealed children whose rhythm characteristics sharply differed from the majority of those surveyed with transcendental values of sympathetic activity and the almost complete absence of the influence of the vagus, which allowed us to divide all newborns in critical condition into 2 groups. Observation in the dynamics in the first year of life confirmed the differences identified in terms of health and outcome of the disease. The studies were conducted at the age of 5 days of life, which is associated both with the admission of children to the intensive care unit, and some stabilization of their vital functions. Of all the indicators of HRV, reliable ones are presented, which significantly differ in groups of children in critical condition with further different outcomes of the disease in the first year of life: cardiointervalogram indicators (mode amplitude, rhythm variability, voltage index) and spectrograms — total spectrum power; these indicators have more than 85% -90% sensitivity and specificity in detecting an adverse outcome of a critical condition.

Heart rate variability was studied by the method of VNS spectrography using a vegetotest with the Polyspectrum program of the Neurosoft firm (Russia). From 300 to 500 cardiocycles were recorded with a piezo sensor recording a pneumogram in order to determine the contribution of vagal activation of respiration to the sympatho-parasympathetic balance. The initial vegetative tone was estimated by the indicators of the cardiointervalogram: mode amplitude (AMo), rhythm variability index (ΔX), voltage index (IN), and spectrograms: total spectrum power (TP).

Statistical data processing included the following methods: determination of numerical characteristics (descriptive statistics), verification of the distribution of the elements of the sample of indicators to the normal law according to the asymmetry characteristics, excess and Lilliefors test, statistical hypothesis testing for one-dimensional samples was carried out by the non-parametric Wilcoxon test, the method of one-dimensional one-factor analysis was implemented in two options - parametric (ANOVA) and non-parametric Kruskal-Walls (Kruskal-Walls), the level is significant ti was determined at p <0,05.

In the course of processing the material, we used an Intel Pentium II personal computer using the Excel, Matlab 6.5 application packages with the Statistic Toolbox expansion pack. A statistical study showed the absence of a normal distribution of indicators of heart rate variability, in connection with which the data were processed by non-parametric methods with the determination of the Chi-square (table 1).

A method for predicting a decrease in the level of health and an adverse outcome in young children is illustrated by the following examples.

We examined 55 critically ill newborns at the age of 5 days of life who were treated at the Department of Anesthesiology and Intensive Care at the Children's Clinical Hospital No. 1 of Tver.

Born in a state of severe asphyxia with an Apgar score of less than 3 points, 42.1% of the newborns examined and 8.8% had a low score at 10 minutes of life. In these children, the condition was extremely serious from birth, in 54.4% of newborns, the condition worsened on the first day of life. Artificial ventilation of the lungs (mechanical ventilation) from birth was carried out to 9 (15.6%) children; on the 1st day, mechanical ventilation was required for 32 (56.1%) newborns; in a coma from birth, there were 17 (29.8%) children, in a soporous state - 19 (33.3%). All children were transferred to the Department of Anesthesiology and Resuscitation of the Children's City Hospital No. 1 in Tver in the first three days of life.

The clinical picture of newborns in critical condition was characterized by multiple organ failure with damage from 2 to 6 systems in one child. The most commonly affected were the nervous (100%), urinary (75%), respiratory and digestive (50%) systems. On the part of the nervous system, inhibition syndrome prevailed, and convulsive syndrome was noted in 40%. On neurosonography, all children showed symptoms of cerebral edema. Among the causes of damage to the central nervous system hypoxic prevailed, which were exacerbated by hemorrhagic and traumatic manifestations. Radiologically, in almost half of the newborns pneumonia was detected, in every 6th - signs of respiratory distress syndrome, in every 10 - atelectasis. Hypoxic kidney damage was manifested by edematous syndrome in 2/3 of the children, a decrease in urine output of less than 1 ml / kg / h and an increase in creatinine and urea in more than half of the examined groups. Hemodynamic parameters in newborns were as follows: heart rate - 137.3 ± 3.84 beats per minute, SBP - 74.6 ± 2.09 mm Hg and DBP - 48.2 ± 1.35 mm Hg.

As it turned out, in the group of newborns in critical condition, the heart rate variability indicators were heterogeneous, children were identified whose rhythm characteristics sharply differed from the majority of those examined by the outrageous values of sympathetic activity and the almost complete absence of the influence of the vagus, there were 14 such children. This made it possible to divide all newborns in critical condition at the age of 5 days of life in 2 groups. Observation in the dynamics in the first year of life confirmed the differences identified.

Further monitoring of the health status of children in the first year of life who had a critical condition in the neonatal period was carried out at the age of 1, 3, 6, 9, and 12 months of life. We studied physical, neuropsychic development, neurological status (the effects of hypoxia), acute morbidity in the first year of life, and studied heart rate variability. Among children observed in the follow-up history, 14 had an unfavorable outcome (2 children died, two children were diagnosed with cerebral palsy at the age of 6 months, 10 children had extensive leukomalacia by 1 month of age); they made up group 2. The remaining children (group 1 - 41 children) had a favorable prognosis: 1/3 to one year of life - neurologically healthy, 2/3 - with compensated consequences of hypoxia without impaired psychomotor development.

Table 1 presents significantly different indicators of heart rate variability in newborns in critical condition in two groups at the age of 5 days of life.

Table 1 Heart rate variability in newborns with a critical condition at the age of 5 days of life with a different outcome - background sample (M ± m) 1 group
Favorable outcome
n = 41 2 group
Adverse outcome
n = 14 Reliability (p) TP, ms ² 745.7 ± 26.85 120.4 ± 9.87 0,03 AMo,% 79.5 ± 2.86 96.5 ± 7.91 0.009 ΔX, c 0.12 ± 0.004 0.04 ± 0.003 0.005 IN, conv. units 1497.6 ± 53.91 4783.1 ± 392.14 0.004 Note: p - significance of differences between indicators in 2 groups.

As can be seen from the data in Table 1, the total spectrum power in newborns with an unfavorable outcome is 6.2 times lower than in the 1st group, which indicates the concentration of the rhythm, that is, almost complete absence of rhythm variability. Of the indicators of cardiointervalography, the indicator of sympathetic activity turned out to be reliable - the amplitude of the mode, which increases in children of the second group by 1.2 times; and the stress index is 3.2 times, while the rate of parasympathetic activity drops 3 times.

An analysis of the table shows that heart rate variability significantly decreases in the group of newborns with health problems or who died in the first year of life, not only due to a significant increase in sympathetic activity, but also a decrease in parasympathetic activity, which is accompanied by a depletion of regulatory processes and a breakdown in adaptation.

Thus, the study made it possible to identify a risk group among newborns in critical condition for reducing the level of children's health in early ontogenesis and an adverse outcome. Critical newborns with heart rate variability indicators corresponding to the second group will be at risk for lowering their health level and adverse outcome, which will require a review of treatment measures and an individual rehabilitation program.

Clinical example No. 1. Adverse outcome.

Kurganov’s child (maiden) № i.b. 28/2012; Date of birth: 01/29/08 Girl from 3 pregnancies, 2 urgent deliveries. The mother was not observed during pregnancy in the antenatal clinic. The birth is protracted, acute hypoxia. The baby was born in an extremely serious condition. Apgar score 1b / 2b / 4b for 1, 5 and 10 minutes of life. Weight at birth 2670. On the 1st day, she was transferred to the anesthesiology and intensive care unit. From birth on mechanical ventilation. Dysfunction of the central nervous system, respiratory, urinary, digestive, cardiovascular systems was observed. Heart rate - 92 beats / min, GARDEN - 75 mm Hg. Art., DBP - 49 mm Hg. Art.

Indicators of heart rate variability at the age of 5 days of life: TP-124 ms ² , AMo-100%, ΔX-0.042 s, IN-4710 srvc. units

In terms of heart rate variability at the age of 5 days of life, the child was assigned to the risk group for poor prognosis and impaired health. Neurometabolic therapy has been enhanced. In the future, the child required monthly follow-up by a neurologist and long-term rehabilitation treatment. She was treated in the intensive care unit for 34 days. The final diagnosis: Ischemic hemorrhagic lesion of the central nervous system 3 degrees. Oppression Syndrome. Coma. Leukomalacia. Hypertensive hydrocephalic syndrome. Pneumonia, hepatitis. DIC syndrome. Ischemic nephropathy. Severe respiratory distress. Intrauterine growth retardation by hypoplastic type.

Clinical example No. 2. Favorable outcome.

The child of Torubarov (small). The medical history No. 41/2002. Date of birth: 07/12/07.

A boy from 2 pregnancies with an increase in blood pressure, anemia, gestosis. Childbirth 2, fast (3 hours 20 minutes), birth weight - 3120 g. At birth, the condition is extremely serious. Apgar score 2/4/5 points. From birth on mechanical ventilation. On the 3rd day, the boy was transferred to the anesthesiology and intensive care unit of the children's city hospital 1. The child had multiple organ failure with damage to the central nervous system, respiratory, cardiovascular, digestive systems. Hemodynamic indicators: heart rate - 128 beats / min, SBP - 75 mm Hg, DBP - 46 mm Hg.

Indicators of heart rate variability at the age of 5 days of life: TP-762 ms ² , AMo-77.9%, ΔX-0.12 s, IN-1481 conventional units

At the age of 5 days of life, the child was predicted to enter group 1 - with a favorable prognosis. With positive dynamics, he was discharged home from the department on day 32 with a diagnosis of severe RD, multiple atelectases. Cerebral ischemia of 3 degrees of severity (coma, hypertensive hydrocephalic syndrome). Vomiting Syndrome. Hypoxic cardiopathy.

By 1 year - HTTP by age. Up to 6 months - hypertensive syndrome persisted, by 1 year - neurologically healthy.

The proposed method for predicting a decrease in the level of health and adverse outcome in young children confirms the high information content, non-invasiveness of the study, technical simplicity, research using well-known and widely used ECG devices, the possibility of prediction for the entire early period of childhood, the ability to use in children in extremely serious condition, and also independent of anthropometric data. Criteria can be used to draw up an individual program of treatment and rehabilitation measures. The obtained criteria make it possible to establish the presence or absence of a functional reserve for adaptation.

The present invention is currently in clinical trials.

Claims (2)

1. A method for predicting a decrease in the level of health and an unfavorable outcome in young children, including determining hemodynamic parameters of the cardiovascular system in newborns, followed by statistical processing of data and monitoring children under one year of age, characterized in that in newborns in critical condition, indicators are additionally determined heart rate variability: spectrograms - total spectrum power (ms ² ), cardiointervalograms - mode amplitude (%), rhythm variability (s), voltage index (conv. units) very low waves of the spectrum (ms ² ), low waves of the spectrum (ms ² ), cardiointervalograms - mode amplitude (%), rhythm variability (s), voltage index (conv. units), and at their following values :
total spectrum power 120.4 ± 9.87,
fashion amplitude 96.5 ± 7.91,
rhythm variability of 0.04 ± 0.003,
voltage index 4783.1 ± 392.14.
identify a risk group for reducing health and adverse outcomes. 2. The forecasting method according to claim 1, characterized in that the examination of newborns was performed at the age of 5 days of life.