ИНТЕНСИВНАЯ ТЕРАПИЯ У ДЕТЕЙ С ОБШИРНЫМИ ОЖОГАМИ В ПЕРВЫЕ 24 ЧАСА ПОСЛЕ ПОВРЕЖДЕНИЯ – РЕЗУЛЬТАТЫ ИНТЕРАКТИВНОГО ОПРОСА

The goal: to study the actual situation related to the intensive care tactics when treating children with severe burns during the first 24 hours after the injury. Subjects and methods. The study was designed based on an anonymous survey among anesthesiologists and emergency physicians, providing care to children with thermal injuries. The interactive questionnaire was developed using the free platform of Google Forms and distributed through medical social media and communities. Respondents were supposed to answer 26 questions on the actual issues of intensive care of burns. The participation in the survey was free and voluntary, no remuneration was paid for it. The survey was performed from August 28 to October 21, 2017. The results were presented in the format of actual numbers and/or percent out of a number of respondents. Pearson's chi-squared test (χ2) was used for defining statistically significant differences, the comparison included departments providing care both to children and adults and children only. The level of statistical significance was ascertained at the probability of error of 0.05. The applied software of Statistica 10 и SAS JMP 11 was used for statistic processing of data. Results. The replies were received from 56 departments, providing care to children with burns. 8 questionnaires were incomplete, the remaining 48 questionnaires were analyzed. The survey demonstrated the lack of the unified approach to the intensive care of children with severe burns. Conclusion. It is necessary to review organizational and methodical approaches in the routing of patients in large children burn centers where many children are concentrated, and it is necessary to continue clinical trials and to develop federal clinical recommendations with consequent development of hospital protocols based on the above. Цель: изучение реальной ситуации с тактикой интенсивной терапии у детей с тяжелой ожоговой травмой в первые 24 ч после повреждения. Материалы и методы. Дизайн исследования основан на анонимном опросе врачей анестезиологов-реаниматологов, оказывающих помощь детям с термическими повреждениями. Интерактивная анкета подготовлена на бесплатной платформе Google Form и распространена через медицинские социальные медиа и сообщества. Перед респондентами были поставлены 26 вопросов по актуальным проблемам интенсивной терапии ожогового повреждения. Участие в опросе было свободным и добровольным, какое-либо вознаграждение за участие в опросе не выплачивалось. Анкетирование проводилось с 28 августа по 21 октября 2017 г. Результаты представлены в виде фактических значений и/или процентах от числа респондентов. Статистическую значимость различных значений для номинальных показателей определяли с использованием критерия хи-квадрат Пирсона (χ2), проводили сравнения между отделениями, оказывающими помощь детям и взрослым, а также только детям. Уровень статистической значимости был зафиксирован на уровне вероятности ошибки 0,05. Статистическая обработка данных выполнена с использованием пакетов прикладных программ Statistica 10 и SAS JMP 11. Результаты. Получены ответы из 56 отделений, в которых оказывают помощь детям с ожоговой травмой. Неполностью заполнены 8 анкет, оставшиеся 48 анкет были подвергнуты анализу. Опрос продемонстрировал отсутствие единых подходов к интенсивной терапии тяжелой ожоговой травмы у детей. Заключение. Требуется пересмотр организационно-методических подходов в маршрутизации пациентов с концентрацией пострадавших детей в крупных детских ожоговых центрах, а также продолжение научно-клинических исследований с разработкой федеральных клинических рекомендаций, с последующим созданием на их основе больничных протоколов.

ЭФФЕКТИВНОСТЬ ОБЕЗБОЛИВАНИЯ НА ДОГОСПИТАЛЬНОМ ЭТАПЕ У ДЕТЕЙ С ТЯЖЕЛОЙ ТЕРМИЧЕСКОЙ ТРАВМОЙ

To describe the frequency and type of EMS analgesic administration to burned children; to describe pain after PICU admission used specific score FLACC and Wong-Baker FACES factors associated with the administration of analgesia by EMS. This was a retrospective study of children (age < 18 years) who were transported by EMS between January 2013 and December 2014 and had a final hospital diagnosis of major burns (20% and more). Receipt of and time of parenteral analgesia were recorded and statistical studied. 232 children met the inclusion criteria. The mean (range) age of this sample was 3.7 (0.1-17) years. Only 201 patients received prehospital analgesia (87%). Opioids received analgesia in the EMS (53.23%). Tramadol received analgesia in the EMS (83.36%). Non-opioids received (nurofen, ketorol) analgesia in the EMS (65.28%). On painful scores, prehospital opioids analgesia was associated with no pain or little bit pain (2.11 ± 1.13), tramadol was associated with banging pain (5.84 ± 1.2), non-opioids group and group without analgesia was associated with really hurts (8.55 ± 0.92 and 8.83 ± 0.69). Statistically significant association was between opioids analgesia group and tramadol, non-opioids and group without analgesia (p ≤ 0.01). The need for strict guidelines for administration of opioids in children with severe burn injury, which ensures an adequate level of analgesia. Parenteral Tramadol can ensure only partial removal of pain. Unacceptable use of only non-narcotic analgesics or start transportation to hospital without analgesia. Key words: burns, pediatric, pain, prehospital.>< 18 years) who were transported by EMS between January 2013 and December 2014 and had a final hospital diagnosis of major burns (20% and more). Receipt of and time of parenteral analgesia were recorded and statistical studied. 232 children met the inclusion criteria. The mean (range) age of this sample was 3.7 (0.1-17) years. Only 201 patients received prehospital analgesia (87%). Opioids received analgesia in the EMS (53.23%). Tramadol received analgesia in the EMS (83.36%). Non-opioids received (nurofen, ketorol) analgesia in the EMS (65.28%). On painful scores, prehospital opioids analgesia was associated with no pain or little bit pain (2.11 ± 1.13), tramadol was associated with banging pain (5.84 ± 1.2), non-opioids group and group without analgesia was associated with really hurts (8.55 ± 0.92 and 8.83 ± 0.69). Statistically significant association was between opioids analgesia group and tramadol, non-opioids and group without analgesia (p ≤ 0.01). The need for strict guidelines for administration of opioids in children with severe burn injury, which ensures an adequate level of analgesia. Parenteral Tramadol can ensure only partial removal of pain. Unacceptable use of only non-narcotic analgesics or start transportation to hospital without analgesia. В нерандомизированное ретроспективное исследование включены 232 ребенка в возрасте от 0 до 18 лет с ожогом площадью 20% и больше поверхности тела, доставленные с места происшествия в период с 1 января 2013 г. по 31 декабря 2014 г. бригадами скорой помощи. В процессе аудита сопроводительной документации выявлено, что обезболивание на догоспитальном этапе получил только 201 ребенок, из них 53 (23%) с использованием фентанила, морфина или промедола (1-я группа); 83 (36%) – трамадола (2-я группа); 65 (28%) – ненаркотических анальгетиков: анальгина, кеторола, нурофена (3-я группа); 31 (13%) ребенок не получил никакого обезболивания (4-я группа). При поступлении в отделение реанимации и интенсивной терапии провели оценку боли в соответствии со шкалой FLACC у детей до 3 лет и шкалой Wong-Baker FACES у детей старшего возраста. При оценке по болевым шкалам получены следующие средние показатели: 1-я группа – 2,11 ± 1,13 (нет боли или незначительная боль); 2-я группа – 5,84 ± 1,20 (боль средней интенсивности), 3-я группа – 8,55 ± 0,92 (сильная боль), 4-я группа без обезболивания – 8,83 ± 0,69 (сильная боль). Для статистической обработки использовали двухвыборочный критерий Стьюдента для несвязанных выборок. Получены следующие значимые статистические взаимоотношения между группами: 1-й и 2-й (tэмп = 18 при tкр = 2,61, p ≤ 0,01), 1-й и 3-й (tэмп = 34 при tкр = 2,61, p ≤ 0,01), 1-й и 4-й (tэмп = 29,9 при tкр = 2,63, p ≤ 0,01), 2-й и 3-й (tэмп = 15 при tкр = 2,61, p ≤ 0,01) и незначимые между 3-й и 4-й группами (tэмп = 1,6 при tкр = 2,63, p ≤ 0,01). Таким образом, продемонстрировано, что адекватное обезболивание может быть достигнуто только с помощью наркотических анальгетиков, а применение трамадола, ненаркотических анальгетиков приводит к недостаточному обезболивающему эффекту.

Application of computational and expert approaches to determining the type of postburn skin scars

Difficulties in choosing anti-scarring tactics are one of the topical problems in the management of children with sequels of burn injury. Therapeutic effectiveness can be enhanced, by making a more accurate diagnosis of the type of scar tissue, which allows the determination of an optimal combination of tools and methods for convalescent burn treatment. Despite that there are recent research works dedicated to the practice of unbiased methods, clinical examination is so far the most widespread method for scar assessment, which shows a high percent of medical errors in view of its subjectivity. The authors of this article propose an algorithm of scar type identification via binary regression and expert approach. The data of 109 clinical examinations of scars in 75 children admitted to the G.N. Speransky Children’s Clinical Hospital with burn scar were reviewed. The developed algorithms showed a high efficiency in identifying the type of a scar and were implemented in software that could define the probability of classifying the scar as one of the clinical and morphological types after entering the clinical exam data and scar age. The program is designed for both combustiology professionals and general practitioners

INTENSIVE CARE OF CHILDREN WITH MASSIVE BURNS DURING THE FIRST 24 HOURS AFTER THE INJURY – RESULTS OF THE INTERACTIVE SURVEY

The goal: to study the actual situation related to the intensive care tactics when treating children with severe burns during the first 24 hours after the injury. Subjects and methods. The study was designed based on an anonymous survey among anesthesiologists and emergency physicians, providing care to children with thermal injuries. The interactive questionnaire was developed using the free platform of Google Forms and distributed through medical social media and communities. Respondents were supposed to answer 26 questions on the actual issues of intensive care of burns. The participation in the survey was free and voluntary, no remuneration was paid for it. The survey was performed from August 28 to October 21, 2017. The results were presented in the format of actual numbers and/or percent out of a number of respondents. Pearson's chi-squared test (χ2) was used for defining statistically significant differences, the comparison included departments providing care both to children and adults and children only. The level of statistical significance was ascertained at the probability of error of 0.05. The applied software of Statistica 10 и SAS JMP 11 was used for statistic processing of data. Results. The replies were received from 56 departments, providing care to children with burns. 8 questionnaires were incomplete, the remaining 48 questionnaires were analyzed. The survey demonstrated the lack of the unified approach to the intensive care of children with severe burns. Conclusion. It is necessary to review organizational and methodical approaches in the routing of patients in large children burn centers where many children are concentrated, and it is necessary to continue clinical trials and to develop federal clinical recommendations with consequent development of hospital protocols based on the above

A GRAPHIC TOOL FOR ESTIMATION OF THE AREA OF BURNS IN CHILDREN

The severity of burns depends both on their size and depth of affected tissues. The existing simple methods for estimation of the injured skin area are not precise, especially in children. During last decades, attempts were made to employ information technologies for more precise estimation of the skin area affected by the burn. Usually, a special template («skitsa») is used to represent a human body in a schematic way, allowing automatic calculation of affected area with high accuracy. It is especially important in children, since proportions of their bodies vary greatly at different ages.A computer graphic tool for estimation of area of burns was designed for the Department of Pediatric Burns. It uses an algorithm that allows to adjust burn data displayed on a two-dimensional template, taking into account the three-dimensional nature of the human body. Such correction increases burn area estimation accuracy. Additionally, this system allows using digital photographs of burn area for dynamic assessment of skin condition during treatment. A special algorithm is used to compensate for possible color distortions of the photographs in series, enabling better possibility of patient’s skin condition comparison at different times

EFFICACY OF PAIN MANAGEMENT AT PREHOSPITAL STAGE IN CHILDREN WITH SEVERE THERMAL TRAUMA

To describe the frequency and type of EMS analgesic administration to burned children; to describe pain after PICU admission used specific score FLACC and Wong-Baker FACES factors associated with the administration of analgesia by EMS. This was a retrospective study of children (age < 18 years) who were transported by EMS between January 2013 and December 2014 and had a final hospital diagnosis of major burns (20% and more). Receipt of and time of parenteral analgesia were recorded and statistical studied. 232 children met the inclusion criteria. The mean (range) age of this sample was 3.7 (0.1-17) years. Only 201 patients received prehospital analgesia (87%). Opioids received analgesia in the EMS (53.23%). Tramadol received analgesia in the EMS (83.36%). Non-opioids received (nurofen, ketorol) analgesia in the EMS (65.28%). On painful scores, prehospital opioids analgesia was associated with no pain or little bit pain (2.11 ± 1.13), tramadol was associated with banging pain (5.84 ± 1.2), non-opioids group and group without analgesia was associated with really hurts (8.55 ± 0.92 and 8.83 ± 0.69). Statistically significant association was between opioids analgesia group and tramadol, non-opioids and group without analgesia (p ≤ 0.01). The need for strict guidelines for administration of opioids in children with severe burn injury, which ensures an adequate level of analgesia. Parenteral Tramadol can ensure only partial removal of pain. Unacceptable use of only non-narcotic analgesics or start transportation to hospital without analgesia. Key words: burns, pediatric, pain, prehospital.>< 18 years) who were transported by EMS between January 2013 and December 2014 and had a final hospital diagnosis of major burns (20% and more). Receipt of and time of parenteral analgesia were recorded and statistical studied. 232 children met the inclusion criteria. The mean (range) age of this sample was 3.7 (0.1-17) years. Only 201 patients received prehospital analgesia (87%). Opioids received analgesia in the EMS (53.23%). Tramadol received analgesia in the EMS (83.36%). Non-opioids received (nurofen, ketorol) analgesia in the EMS (65.28%). On painful scores, prehospital opioids analgesia was associated with no pain or little bit pain (2.11 ± 1.13), tramadol was associated with banging pain (5.84 ± 1.2), non-opioids group and group without analgesia was associated with really hurts (8.55 ± 0.92 and 8.83 ± 0.69). Statistically significant association was between opioids analgesia group and tramadol, non-opioids and group without analgesia (p ≤ 0.01). The need for strict guidelines for administration of opioids in children with severe burn injury, which ensures an adequate level of analgesia. Parenteral Tramadol can ensure only partial removal of pain. Unacceptable use of only non-narcotic analgesics or start transportation to hospital without analgesia

The potential of vacuum therapy in the treatment of a newborn infant with severe thermal injury

The paper describes a clinical case of successful combination therapy in a newborn infant with severe thermal injury. When admitted to the hospital, the infant was diagnosed with third-degree flame burn covering 75% of the body surface and shock. Specialized emergency care involved antishock measures and replacement of vital functions, stepwise surgical interventions aimed to excise necrotic tissues and to restore lost skin tissue, and antimicrobial and symptomatic therapies. Topical treatment included the use of current wound coatings. Skin autocells were used for significant skin defect. Aacuum therapy was performed to stimulate repair processes and to prepare wounds for further skin plasty. The techniques of vacuum therapy included RENAS\S-GO and PICO apparatuses. Its efficiency was evaluated by microbiological, immunohistochemical, and planimetric examinations. Analysis of the decontaminating impact of a vacuum coating could establish its substantial effect in reducing wound bacterial contamination by 65% in the study group and by an average of 21% in the comparison group. That of immunohistochemical findings during vacuum therapy could reveal the high expression of two markers characterizing wound an-giogenesis. Comparative analysis of planimetric readings showed no significant differences in the use of vacuum therapy and current wound coatings. Thus, negative-pressure therapy creates favorable conditions for a wound healing process, providing effective wound decontamination and stimulating granulation tissue maturation as a factor to prepare for skin plasty

THE PARATHYROID HORMONE LEVEL AND ITS CORRELATION WITH THE SUPPLY OF VITAMIN D IN EARLY CHILDHOOD

The literature data and the finding of our studies on the analysis of the correlation between the level of parathyroid hormone and supply of vitamin D of children (n=107) of early age are presented in the article.The serum level of vitamin D in the analyzed group of children was 24.8 [17.6–32.5] ng/ml, the median of the parathyroid hormone  was 21.0 [12.3–25.5] pg/ml. It has been established that children with optimal supply of vitamin D have significantly lower parathyroid hormone levels vs. the children with vitamin D insufficiency (25 (OH) D from 20 to 30 ng/ml) and deficiency (calcidiol values  below 20 ng/ml). The correlation between the level of vitamin D and parathyroid hormone was r=-0.18, p=0.035.The best supply of vitamin D was found in children of the first year of life – 25 (OH) D concentration was 29.95 [16.2–40.3] ng/ml.  The parathyroid hormone level (16.5 [10.7–23.8] pg/ml) in these children was reliably lower (p=0.05) vs. the children of the second  and third years of life. A positive correlation was established between the age of patients and the parathyroid hormone level (r=0.2,  p=0.05). Preventive doses of vitamin D were received by 42.1% of children. The blood serum concentration of 25 (OH) D in them  was higher (32.7 ng/ml), and the parathyroid hormone level was significantly lower (14.9 pg/ml) vs. the children who did not receive  cholecalciferol preparations (p<0.05).The obtained results demonstrate a strong correlation between vitamin D deficiency and the increased parathyroid hormone level that reflect  the importance of these hormones in the regulation of calcium-phosphorus metabolism and the opposite role in bone tissue calcification

PHYSIOLOGICAL AND BIOCHEMICAL ASPECTS OF REPRODUCING THE WILD LONG-RHIZOME MORPHOTYPE OF <i> MEDICAGO FALCATA </i> L. UNDER CULTIVATION

Morphology, nitrogen-fixing activity and seed productivity of the introduced wild long-rhizome yellow alfalfa (Medicago falcata L.) under exogenous treatment with microbial preparations and phytohormone (homobrassinolide) were studied in field experiments. It was revealed that growth activators increase seed productivity and nitrogen-fixing activity in the cultivated taproot alfalfa type and, on the whole, have no effect on metabolism in the long-rhizome morphotype plants. To solve the problem it is necessary to develop Rhizobium preparations increasing nitrogen-fixing activity of the long-rhizome alfalfa plants on the basis of natural isolates and the use of phytohormones with due regard to the peculiarities of the ontogenesis of the long-rhizome M. falcata morphotype