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184 REVISTA MEDICALÅ ROMÂNÅ – VOL. LVI, NR. 3, AN 2009<br />

CONTROVERSE<br />

Analiza documentelor <st<strong>ro</strong>ng>medica</st<strong>ro</strong>ng>le ale pacien¡ilor<br />

cu gast<strong>ro</strong>enteritå severå transfera¡i <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> IOMC aratå<br />

faptul cå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> obicei <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> România, ace¿tia primesc,<br />

<st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> cursul abordårii ini¡iale cu antibiotice, corticoste<strong>ro</strong>izi<br />

¿i bicarbonat.<br />

Acestå abordare practicå ar trebui så disparå<br />

treptat, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>oarece nu existå dovezi <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> sprijinul ei.<br />

În anumite circumstan¡e, o astfel <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> tentativå terapeuticå<br />

poate avea efecte catast<strong>ro</strong>fale asupra<br />

pacientului, putând genera complica¡ii amenin¡åtoare<br />

<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> via¡å sau chiar <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>ces. Astfel, administrarea<br />

ira¡ionalå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> antibiotice, la to¡i pacien¡ii<br />

cu BDA afla¡i <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> situa¡ie gravå ar putea precipita<br />

apari¡ia unui sind<strong>ro</strong>m Gasser (sind<strong>ro</strong>m hemoliticuremic),<br />

prin eliberarea masivå <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> endotoxine (14).<br />

Antibioterapia nu constituie o urgen¡å majorå <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng><br />

BDA ¿i ar trebui rezervatå pacien¡ilor cu gast<strong>ro</strong>enterite<br />

suspectate pe criterii clinice (scaune cu<br />

mucus, pu<strong>ro</strong>i sau sânge, la un pacient febril, cu<br />

aspect general „toxic“) sau dovedite ca fiind bacteriene<br />

(prin cop<strong>ro</strong>culturå ¿i cop<strong>ro</strong>citogramå).<br />

Administrarea <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> bicarbonat <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> sodiu, fårå documentarea<br />

unei acidoze metabolice, refractarå la<br />

expansionarea volemicå eficace ar putea p<strong>ro</strong>duce<br />

complica¡ii cu risc letal (prin hipercapnie, hipernatremie,<br />

hipe<strong>ro</strong>smolaritate).<br />

BIBLIOGRAFIE<br />

1. Murray CJL, Lopez AD – The global bur<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>n of disease: a<br />

comprehensive assessment of mortality and disability f<strong>ro</strong>m diseases,<br />

injury and risk factors <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> 1990 and p<strong>ro</strong>jected to 2020 Geneva, WHO,<br />

1996<br />

2. *** - The World’s Forgotten Children. <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> site-ul http://www.who.int/<br />

ceh/publications/01mortality.pdf, accesat 12.03.2009<br />

3. Craiu M, Iordåchescu M, Cochino AV, Avram P, Anca AI –<br />

Intraosseous infussion, valulable tool for pediatric resuscitation. <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng><br />

site-ul http://www.kenes.com/espid2008/, (26 th Eu<strong>ro</strong>pean Society of<br />

Pediatric Infectious Diseases Annual Meeting, Graz, 2008), accesat<br />

<st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> 10.03.2009.<br />

4. Stone B – Fluids and Elect<strong>ro</strong>lytes <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> The Harriet Lane Handbook.<br />

Editors Robertson J, Shilokofski N, 17 th edition, 2005, Ed Elsevier<br />

Mosby, pag 285<br />

5. Gocht A, Colmant HJ – Central pontine and extrapontine<br />

myelinolysis: a report of 58 cases. Clin. Neu<strong>ro</strong>pathol. 1987;6 (6):<br />

262–70.<br />

6. Kleinschmidt-DeMasters BK, Norenberg MD – Rapid correction<br />

of hyponatremia causes <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>myelination: relation to central pontine<br />

myelinolysis. Science. 1981;211(4486):1068-70.<br />

7. Chiasson JL, Aris-Jilwan N, Belanger R, et al – Diagnosis and<br />

treatment of diabetic ketoacidosis and the hyperglycemic<br />

hype<strong>ro</strong>smolar state. CMAJ 2003;168(7):859-66.<br />

8. Gottschalk ME, Ros SP, Zeller WP – The emergency<br />

management of hyperglycemic-hype<strong>ro</strong>smolar nonketotic coma in the<br />

pediatric patient. Pediatr Emerg Care. 1996;12(1):48-51.<br />

În concluzie, la pacien¡ii cu <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>shidratare severå<br />

ar trebui urma¡i o serie <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> pa¿i bine <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>fini¡i, <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng><br />

func¡ie <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> natura <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>shidratårii ¿i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> vârsta ¿i comorbiditå¡ile<br />

pacientului.<br />

MESAJ PRACTIC<br />

1. Primul obiectiv al tratamentului la pacien¡ii<br />

cu BDA ¿i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>shidratare severå este refacerea<br />

volemiei.<br />

2. Normalizarea volemiei poate fi realizatå pe<br />

cale oralå cu SRO sau pe cale intravenoaså<br />

cu solu¡ii <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> cristaloizi, <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> func¡ie <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> gravitatea<br />

<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>shidratårii, <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> toleran¡a digestivå<br />

a copilului ¿i <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> starea <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> con¿tien¡å a acestuia.<br />

3. Nu vor fi folosite solu¡iile <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> glucozå (indiferent<br />

<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> concentra¡ia lor!) pentru refacerea<br />

volemiei. La pacien¡ii cu hipoglicemie,<br />

aceasta va fi corectatå ulterior refacerii volemiei,<br />

pe o altå cale venoaså.<br />

4. Folosirea antibioticelor ¿i a bicarbonatului<br />

<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> sodiu ar trebui rezervatå unor cazuri speciale,<br />

<st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> majoritatea ente<strong>ro</strong>colitelor acute ele<br />

fiind contraindicate.<br />

9. Steiner MJ, DeWalt DA, Byerley JS – Is this child <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>hydrated?<br />

JAMA. 2004;291(22):2746-54.<br />

10. Biarent D, Bingham R et al – Eu<strong>ro</strong>pean Resuscitation Council<br />

Gui<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>lines for Resuscitation 2005. Section 6. Paediatric Life<br />

Support. Resuscitation 2005; 67S1:S97-S133.<br />

11. LaRocco BG, Wang HE – Intraosseous Infussion. Prehosp Emerg<br />

Care 2003;7(2): 3-14<br />

12. *** - American Heart Association Gui<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>lines for Cardiopulmonary<br />

Resuscitation and Emergency Cardiovascular Care. Part 11. Pediatric<br />

Basic Life Support. Circulation. 2005; 112: IV 156 – IV 166.<br />

13. Hellerstein S – Fluids and elect<strong>ro</strong>lytes: clinical aspects. Pediatr Rev<br />

1993; 14(3):103-115.<br />

14. Ahn CK, Holt NJ, Tarr PI – Shiga-toxin p<strong>ro</strong>ducing Escherichia coli<br />

and the hemolytic uremic synd<strong>ro</strong>me: what have we learned <st<strong>ro</strong>ng>în</st<strong>ro</strong>ng> the<br />

past 25 years? Adv Exp Med Biol. 2009;634:1-17.<br />

15. Kosek M, Bern C, Guerrant RL – The global bur<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>n of diarrhoeal<br />

disease, as estimated f<strong>ro</strong>m studies published between 1992 and<br />

2000. Bull World Health Organ 2003;81:197—204.<br />

16. Parashar U, Hummelman E, Bresee J, Miller M, Glass R –<br />

Global Illness and <st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>aths caused by <strong>ro</strong>tavirus disease in children.<br />

Emerg Infect Dis 2003;9:565-572.<br />

17. Black RE, Morris SS, Bryce J. Where and why are 10 million<br />

children dying every year? Lancet 2003;361:2226-2234.<br />

18. Sny<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng>r JD, Merson MH – The magnitu<st<strong>ro</strong>ng>de</st<strong>ro</strong>ng> of the global p<strong>ro</strong>blem of<br />

acute diarrhoeal disease: a review of active surveillance data. Bull<br />

World Health Organ 1982;60:605-613.

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