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CLINICAL-MORPHOLOGICAL COMPARISONS POSSIBLE DIAGNOSTIC METHOD OF MULTIPLEORGAN-FAILURE SYNDROME IN NEWBORNS D. Shkurupiy Ukrainian Medical Stomatological Academy, Ukraine shkurupiy@list.ru

Annotation The article presents criteria for diagnostics of multiple-organ-failure syndrome (MOFS) in newborns, determined by statistical methods, basing on comparison of morphological changes presence in organs and systems of dead newborns with clinical data. Introduction During the last decades broadening of management possibilities of patients in critical condition has increased newborns survival chances, but is has led to special pathology formation called MOFS. MOFS in newborns has incidence about 55 % [7], and mortality 62% [3], which is connected to intrauteral detrimental factors effect. Notwithstanding such high MOFS rate there are no single criteria of this syndrome diagnostics. Various clinics use for the diagnostics such scales as PRISM, NEOMOD, and NTISS [2, 4, 6]. Various authors contradict each other on different systems participation in MOFS formation and in diagnostic criteria of the same system condition assessment [5,7] (.1). Table 1. Comparative characteristics of MOFS criteria in newborns System Author, publication year Morecroft I.A. at al. Shah P at al. 1994 . [5] 2004 . [7] Average arterial pressure (P av) < 40 (in Hypotension with inotropic support premature infants - < 35); during 24 hours; Heart rate (HR) <100 and >180 per min; Miocardial ischemia on ECG Inotropic support; Dependence on artificial pulmonary ventilation (APV); Oxygen proportion (Fi O2) > 0.4 for supporting 2 >50 mm Hg; Respiration rate (RR) >40 per min. Not assessed. thrombocytes<150109/l APV with Fi O2>0.4 for more than 4 hours after birth

Cardiovascular system

Respiratory system

Nervous system Homeostasis system

Not assessed. Not assessed.

Urinary system

Diuresis < 1 ml/kg/hour; Blood urea>3.0 mM/l Serum creatinine > 90 mM/l; daily weight gain >100 g/day.

Hepatobiliary Blood bilirubin >103 M/l system Microcirculation Subcutaneous sclerema system
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diuresis < 1 ml/kg/hour for more than 24 hours + serum creatinine > 100 mM/l; diuresis < 1 ml/kg/hour for more than 36 hours; serum creatinine > 125 mM/l. ALT > 100 IU/l; AST > 100 IU/l. Not assessed.

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It is known that in patients, who died of MOFS histological changes in various organs and systems are registered [8]. Thus such morphological changes comparison with clinical manifestations may be used for MOFS criteria elaboration in newborns. Research aim MOFS criteria determination in newborns. Materials and methods We completed retroperspective anamneses analysis and pathohistological protocols analysis in 31 newborns, who died at intensive care stage from asphyxia consequences at birth or from perinatal infections. Patho-morphological changes presence in newborns organs and systems was chosen as golden standard for their comparison with clinical data. As pathologic examination revealed in all children changes in two or more organs or systems, we precluded that all children at death had MOFS. We assessed statistical indices of sensitivity, and specificity to morphological changes presence in life support systems. We considered significant the criteria, which sensitivity or specificity was equal or exceeded 0.5 [1]. Results and discussion Sensitivity determines persons with positive examination result in population with the determined disease [1]. In other words, clinical sign, which has high sensitivity at negative result reliably, excludes disease presence. In this connection we selected clinical criteria with reliably high sensitivity, which absence allows excluding MOFS (Table 2). Table 2. Criteria, which absence allows excluding MOFS in a new-born Index Observations number Sensitivity 0.62 0,70 0.97 1.00 1.00 0.79 0.62 0.50 0.77 0.88 0.50 0.56 Specificity 0.20 0.50 0.00 0.00 0.00 0.50 0.50 0.71 0.80 0.20 0.40 1.00

Heart rate <100 and >180 per min; 31 Inotropic support; 31 Dependence on APV; 31 2 <50 mm Hg; 31 2 > 60 mm Hg; 31 Brain edema with muscular hypotony, hypoxic coma, 31 and cranial sutures divergence Photoreaction absence. 31 Ht <40% (from week 2 - <30); 31 Diuresis < 1 ml/kg/hour; 31 Blood urea>3.0 mM/l 31 Serum creatinine > 90 M/l; 31 Blood bilirubin >103 M/l 31

Unlike sensitivity, specificity confirms disease [1]. Thus, the criteria with sufficiently high specificity allow determining the fact of organ damage in a new-born (. 3). Table 3. Clinical signs that represent morphological affection of life-supporting systems Index Inotropic support Myocardial ischemia on ECG P av < 45 (in premature babies < 40); Heart rate disturbances Fi O2 > 0.4 for supporting 2 >50 mm Hg RR >40 per min APV with Fi O2 for more than 4 hours after birth RR <35 and >80 per min Brain edema with muscular hypotony, hypoxic coma, and cranial sutures divergence
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Observations number 31 31 31 31 7 31 31 31 31

Sensitivity 0.70 0.04 0.38 0.08 0.00 0.41 0.41 0.04 0.79

Specificity 0.50 1.00 0.60 0.80 1.00 0.50 1.00 0.67 0.50

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Convulsions Photoreaction absence. Hb <150 g/l (from day 4 - <100) Ht <40% (from week 2 - <30); Thrombocytes<150*109/l Blood coagulation start >5 min Diuresis < 1 ml/kg/hour Daily weight gain >100 g/day. Diuresis < 1 ml/kg/hour for more than 24 hours + serum creatinine > 100 mM/l Serum creatinine > 125 M/l Blood urea more than 10 mM/l Stomach stasis from 1.5 ml/hour, peristaltic and stool absence Coffee ground symptom in stomach Melena Stomach bleeding. Blood bilirubin >103 M/l ALT > 100 IU/l AST > 100 IU/l. Subcutaneous sclerema Lymphocytes <31.18%, immature neutrophiles >16.0%

31 31 31 31 31 31 31 31 31 31 31 31 31 31 31 31 31 31 31 24

(Table 3 continued) 0.10 1.00 0.62 0.50 0.33 0.86 0.50 0.71 0.42 0.71 0.13 1.00 0.77 0.80 0.12 0.80 0.19 0.37 0.38 0.38 0.00 0.00 0,00 0.56 0.04 0.04 0.25 0.44 1.00 1.00 0.40 0.57 1.00 1.00 1,00 1.00 0.75 0.75 0.59 0.87

Conclusions The newborns, who died at intensive care stage presented poly-organic damage, which were confirmed by histological analysis. These results may be used as golden standard for comparison with clinical data for MOFS criteria definition. As the result we calculated statistic indices of sensitivity and specificity, and determined diagnostic criteria and criteria for MOFS exclusion in newborns. References 1. Fletcher R.H., Fletcher S.W., Wagner E.H.. Clinical Epidemiology / Lippincott Williams & Wilkins.- 1996.-276 p. 2. Gray JE, Richardson DK et al. Neonatal Therapeutic Intervention Scoring System : a therapybased severity-of-illness index // Pediatrics.- 1992.-V.90.- P. 561-567. 3. Jackson R.J., Jochnson D.D., Maxon R.T., Thomas R., Smith S.D. A comparison of neonatal and adult mitiorgan failure in rat model //Jornal of Pediatric Surgery.-V.35.-Is. 3.-P.428-431. 4. Janota J. , Simak J. , Stranak Z. , Matthews T. , Clarke T. , Corcoran D. Critically ill newborns with multiple organ dysfunction: assessment by NEOMOD score in a tertiary NICU // Irish Journal of Medical Science.-V.177,.- N.1, P.11-17. 5. Morecroft. JA., Spitz. L, Hamilton P.A, Holmes S.J.K. Necrotizing enterocolitismultisystem organ failure of the newborn? // Acta Pdiatrica.-V. 83., Is. 396., P. 2123, 6. Pollack M., Patel R., Ruttimann U. PRISM III: An apdatated Pediatric Risk of Mortality score // Critical Care Medicine.-1996.-Vol. 24.-N.5.-P.743-752. 7. Shah P., Riphagen S., Beyene J., Perlman M. Multiorgan dysfunction in infants with postasphyxial hypoxic-ichaemic encephalopathy // Archives of Deasise in Chaldhood Fetal and Neonatal Edition.-2004.-Vol. 89.-P.152-155. 8. Smith S., Tagge E., Hannakan C., Rowe M. Characterization of neonatal multisystem organ failure in the surgical newborn //Journal of Pediatric Surgery.- 1991.-V.26.-Is.4.- P. 494-499.

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