Indian J Pediat 47 : 385-387, 1980

Semiprone position and continuous intragastric drip in conservative management of tetanus neonatorum Y. S. Verma, M.S., M.A.M.S., Jagmohan Singh Verma, M.B.B.S., and M.S. Dattal M.D., D C.H.

Abstract In non-trachestomised paficnts of tetanus neonatorum adoption of semiprone position and continuous intragastric drip led to a marked decrease in the rate of aspiration and a six-fold decrease in the rate of chest infections as compared with the patients managed in supine position and given bulk feeds. Key words : Semiprone position, Continuous intragastric drip, Tetanus. Currently conservative management of tetanus largely depends on use o f sedatives x'2 or eurarisation and intermittent positive pressure respiration ([PPR) till the disease s u b s i d e s ) There are no reports in the literature regarding the posture and the feeding method to be adopted in these patients. Usually intragastric feeds of 10 to 30 ml each are given every 2 to 4 hours. Such bulk feeds remain in the stomach for some time and are likely to be regurgitated during spasms. In the supine position the regurgitated material will be aspirated into the lungs. The present study was therefore planned to see how far the rate of aspiration and infection can be decreased if the semiprone position is adopted and periodic bulk feeding is replaced by continuous drip feeding.

Material and Methods Sixty two patients of tetanus neonaFrom the Department of Anaesthesia, and Department of Medicine. Post-graduate Institute of Medical Education and Research Chandigarh-160012. Reprints requests: Dr. Y.S. Varma. Associate Professor in Anaesthesia, P.G.I.ME.R., Chandigarh - 160012.

torum admitted to our wards were divided into two groups (Table I). No premature infant was included in the study, All patients were over 37 weeks gestation and more tb_an 2.3 kg weight. Mean incubation period for group A was 5.1 days while of group B was 4.5 days (vide infra). Group A. These 30 patients we1'o nursed in the usual supine position by ward sisters, and the daily requirement of fluid and calories was given by intermittent bulk feeds (2 to 3 hourly) by intragastric drip. Group B. These 32 patients were managed by ward sisters, but a patient's relative always stayed with the infant Io maintain the semiprone position as instructed. Continuous intragastrie drip o f milk feed was given through an ordinary drip set to provide the 24-hour requirement, in order to minimise the accumulation of food in the stomach at any one time. Drug treatment consisted of diazepam, chlorpromazine and meprobamate with usual care of the patient, for both groups. 4 Respiratory complications were assessed clinically and radiolo-

386

THE INDIAN JOURNAL OF PEDIATRICS

Table 1. Distribution of Cases of Tetanus Neonatorum and Rate of Complications

(% of cases)

Vol. 47, No. 388 Discussion

Aspiration and respiratory infections are the two major problems in tetanus. An incidence of 50 to 70 per cent for Groups A B (control) (study) pneumonia has been demonstrated in autopsies) During spasms, the abdoComplications n = 30 32 minal muscle spasm raises the intragastric pressure. As a result of increased Aspiration 7 ~23%) 0 Bronchitis* 22 (66%) 3 (10%) pressure on the stomach, the gastric contents are forced upwards into the Pneumonia esophagus and pharynx. During the and collapse* 12 (40%) 1 (3%) spasm the patient cannot breath and is hypoxic. When the spasm goes away, *P value between group A and B <0.01 the hypoxic patient takes a deep breath and pharyngeal contents are sucked into gically. The patient's chest was radiothe lungs. In the supine position the graphed on alternate days as a routine trachea slopes downwards from the and daily if necessary. Semiprone larynx to the carina and gravity then aids position adopted was a lateral position aspiration into the trachea. If patients with head and body turned forward so are given 2 or 3 hourly feeds (bulk feeds) that body-bed angle was 45 ~ Mouth then immediately after the feed the in this position is the most dependent stomach is full. lt'at that time a spasm part and all secretions, saliva, sputum, occurs, the gastric contents are forced vomitus and regurgitated material is into the esophagus and then into the drained out of lower angle of the mouth. trachea and the lungs. Aspiration of Both the lower limbs were partly flexed large vorume of gastric contents (frank at the hip and the knee joints, a n d upper a~piration) is detected as it causes one was kept in front of the lower one cyanosis and bronchospasm due to the to keep body angle of 45 ~ to the bed, acid contents. Aspiration of smaller This position is like 'tonsil position' amount o f feed may go undetected, but except that the lower arm is not p u t show up later as patchy collapse of lungs, behind the body. bronchitis or pneumonia. This explains Results the increased incidence of aspiration and Rate of frank aspiration and respira- lung infections in group A. tory infection are set out in Table 1. In group B no ca~e of frank a~p?raIn group A there were seven cases tion was seen. One case of pneumonia of frank aspiration with four deaths while and three cases of bronchitis showed there was no a~pira~ion in Group B. chest infection in this group. When In G r o u p A infection of respiratory tract 24-hours feed is given by a continuous was much higher than group B (P<0.01 intragastric drip, the accumulation of for both bronchitis and for pneumonia gastric contents is minimal and so little of and collapse of the lungs). these can come up in esophagus during

387

Y.S. VERMA El" AL ; MANAGEMENT OF TETANUS

spasms. Continuous intragastric drip feeding prevents aspiration to a much 1. greater extent than 'bulk feeds'. Use ofsemiprone 'tonsil position' is another major safe-guard as compared to the 2. supine position. The trachea in semiprone position slopers' so that oarina is higher than larynx and the chance of 3. aspiration is eliminated. Gravity now acts against ahy aspiration into trachea. Higher level of carina also aids movement of secretions towards larynx and 4, then to pharynx, from where they drain out or are sucked out. This gravity 5. drainage of secretions prevents respiratory infections in group B.

References

BodmanRI, Marten HJV, Thomas ET: Treatment of tetanus with chlorpromazitae and nitrous o~ide. Lancet 2 : 230, 1955 Kelly RE, Lawrence D R : Effect o f chlorpromazine on convulsions of experimental and clinical tetanus. Lance.' I : 118, 1956 Wright R, Sykes MK, Jackson BG, Mann N M , Adams EB : Intermittent positive pressure ventilation in tetanus neonaterum. Lancet 2 : 678, 1961 Varma YS, Varma JMS, Kohli JB : Conservative management of tetanus. Arch Anaesth and Resus U o d e r publication Deaty RN, Petersdrop PG : Tetanus. In Harrison's Principles of Internal Medicine, McGraw Hill. 7 e d m 1974. p 847

BOOK REVIEW Textbook of Child Neurology. By JOHN H. MENKES. 2nd editon. Lea and Febiger, Pheladelphia 1980, pp. 695. lthustrated Price US $ 38.00. Children with neurologic disorders form a large component of pediatric practice in India. Recent advances in this field especially in metabolic disorders, computer assisted tomography, control of seizures have revolutionised this field. This excellent book focuses on the newer aspdets of pediatric neurolqgy. It excludes the neurological examination of children for which the reader is .referred to the 'Neurologic Examination of Children' by Paine and Oppe. There ase detailed chapters o n metabolic disorders, heredo-degenerative

disorders, malformations, perinatal trauma, infections and postinfectious diseases, trauma, toxic disorders, tumours, paroxysmal disorders, and shorter chapters on chromosomal disorders, muscle diseases and disorders of mental development. All chapters are written lucidly and exhaustively. Newer advances covered are disorder of pyruvate metabolism in Fredriech's ataxia, abnormal long chain fatty acid metabolism in adrenoleuko dystrophy, sodium valproate in the management of epilepsy especially of minor motor attackL This book is recommended for all libraries catering to postgraduate students in pediatrics. New Delhi

LC. Verma