Infusion therapy is performed in the hyperhydration regime

• Solutions are injected intravenously, jet.

• Isotonic crystalloid solutions (sodium chloride, Ringer's solution, sodium chloride+

potassium chloride + calcium chloride dehydrate + sodium lactate) are injected in a dose 20-30 ml/kg during the first 20 minutes.

• Colloid solutions (dйrivвtes of hydroxethylen starch of III generation) are entered

with the speed of20-40 ml/kg/hour.

• In case of ITSH immediate infusion of crystalloid solutions 20 ml/kg during the

first 20 minutes with subsequent infusion of colloid solution in a dose 10-20 ml/kg in next 20 minutes.

• In case of fulminant forms of Ml it is expedient to connect crystalloid and colloid

solutions in correlation 2:1.

• If infusion 60-90 ml/kg of salt solution or 20-40 ml/kg of colloids during the first

hour of treatment appeared uneffective, then in such cases there is a necessity for application of sympathomimetics and respirator support.

• Stimulation of urination by saluretics in case of oliguria, anuria - (furosemide 1-2mg/kg) expedient only in case of hemodynamics stabilizing (satisfactory perfusion, arterial pressure, central venous pressure).

• Application of glucose solutions, especially water is impermissible in case of ITSH, metabolic acidosis and cerebral edema. They do not stay too long in the vessels, strengthen the edema of cells, brain edema. Water solutions of glucose can be

appointed only after stabilizing of hemodynamics, normalization of perfusion and liquidation of acidosis. By the unique testimony for infusion of glucose for patients with shock and head cerebral edema there can be hypoglycemia. The level of glucose must be supported within the limits of 3.5-8.3 mmol/1. At the level of glucose less than 3.5 mmol/1 the correction by 20-40 % glucose solution is used, at the level over 10-11 mmol/1 - insulin.

• Metabolic acidosis is corrected by intravenous infusion of sodium bicarbonate at

blood pH below 7.1-7.2.

• Infusion therapy must remove electrolyte disorders also (hypocalcaemia, hyperkalimia, hypokalimia).

• Meningitis is not an in indication for IV therapy limitation in case of effective

hemodynamics maintenance.

• After shock liquidation protracted infusion therapy is need.

• The calculation of volumes for infusion therapy is done on the basis of physiologic

necessity, correction of deficits of water and electrolytes, taking into account pathological losses, level of glucose, general albumen, state of alimentary canal, and degree of cerebral edema.

• One of aspects of infusion therapy there is a necessity of partial parenterally feed

in after shock period. Its basis is infusion of 10-20 % glucose solutions with insulin and amino acids solutions.

Sympathomimetic and inothrope support of hemodynamics.

• Application of inothrope preparations for children with refractive to infusion therapy

shock - dopamine as permanent intravenous infusion 10 мcg/kg/min, if ineffective - increase the dose to 20-30 мcg/kg/min. At decreased cardiac output Dobutaminum is appointed in the same doses, as dopamine.

• If, without regard of dopamine administration in the dose of 20-30 мcg/kg/min,

hypotension is persist, application of norepinephrinum or epinephrinum is expedient from 0.05 to 3 мcg /kg/min. If dopamine is ineffective quite often it is succeeded to obtain the substantial improvement of hemodynamics by the combined application of Dobutaminum and norepinephrinum.

Glucocorticoids

• Glucocorticoids are appointed at presence or suspicion on acute adrenal insufficiency

and/or refractivity to the sympathomimetics.

• Hydrocortisone is a medicine of choice. Possible is prednisolone application.

• Preparations are injected every 6 hours.

• The dose by prednisolone is 10 mg/kg.

Glucocorticoids are appointed as adjuvant therapy of purulent meningitis. Dexamethazonum is a medicine of choice 0.15 mg/kg x 4-6 times per day during 2-4 days.

Treatment of DIC-syndrome

• Therapy of DIC-syndrome assumes administration of heparin in a dose 50-200

EU/kg per day, under control of coagulogram indexes.

• At presence of hypercoagulability a dosage is applied to 150-200 EU'/kg, that in

combination with infusion, antibacterial and antiagregant therapy lead to the rapid normalization of coagulogram indexes.

• The criterion of heparin therapy efficiency is lengthening of coagulation time 2-3

times more than initial index.

• In transitional and hypocoagulation phases of DIC-syndrome fresh-frozen plasma

in a dose 10-20 ml/kg as a fast, jet infusion in combination with heparin in a dose 25-50 EU/kg is applied. If necessary plasma is injected again.

• The criterion of such.therapy efficiency is an increase of fibrinogen level to 1.5-2gs/1, prothrombine index increase over 60 %, stop of mucosal bleeding, and bleeding from the places of injections.

• In phase of incoagulability and fibrinolysis the inhibitors of proteases are given:

contrical in a dose of 1000 EU/kg, and other in equivalent doses.

A diet in case of intensive therapy

• For warning of translocation of intestinal microflora at the severe forms of meningococcemia early tube enteroalimentation have to begin at once after stabilizing of hemodynamics, in absence of enteroplegia displays.

• In the beginning of infants feeding optimal is application of lactose-free formulas

which also contain prebiotics.

• Formulas can be entered through a nasogastric tube.

• Infants who have breastfeeding will achieve pasteurized breast milk.

Care of skin, prophylaxis and treatment of skin necroses

• At meningococcemia is needed a careful care of skin, prophylaxis of bedsores,

treatment of skin by antiseptic fluids.

• At presence of deep skin and soft tissues defects there can be necessary a

necrectomy and plastic closing of a skin defect or amputation of distal segments of extremities.

• Expedient treatment of necrotizing surfaces by antiseptic aerosols, creams which

contain silver sulphodiasinum.

• Carotinoids applications speed up cicatrisation of necroses.

• Not deep necroses heal over independently and do not need treatment.

• At arthritis - NSAIDs, warm on joints, massage, gymnastics.

• At iridocyclitis - nicotine acid, nitrate of sodium in a temporal area.

• At pneumonia - combination of antibiotics, oxygenation, physiotherapy.

• At carditis - bed rest, cardiac glycosides, cardiothrope medicine.

• At hypertensive syndrome - diacarb (acethasolamide) + asparkam according the

syndrome severity. Discharge the patient:

• clinically healthy, with normal CSF analyses;

• with one documented negative nasopharyngeal culture which is performed in 3 days after antibiotic therapy.

Disperisarization for 2 years by paediatrician, in case of meningitis, meningoencephalitis - also neurologist.

Prophylaxis:

1. Sanation of carriers by erythromycin, chloramphenicol, ciprofloxacin or rifampin for 3-5 days;

2. Quarantine for 10 days, contacts inspection with one bacteriological test of nasopharyngeal culture;

3. Disinfection.

Keywords: meningococcal infection, Neisseria meningitidis, localized and generalized forms of meningococcal infection, meningococcemia, meningitis, meningoencephalitis, nasopharyngitis, cerebrospinal fluid (CSF), pathogenetic treatment, symptomatic treatment, discharge of the patient, dispensar ization.

Дата добавления: 2015-10-29