《新生儿肺出血-LYJ》PPT课件.ppt

新生儿肺出血,概述 临床表现 早期诊断线索 诊断及鉴别诊断 预防,概述（1）,发病率 -活产婴儿的1-5%（尸检的1-40%） -与胎龄有关 6% of infants 1700 g (Garland 1994) 1989-1992 (US) 12% of 1500 g infants (Pandit 1999) 1990-1994 (Canada) 15% of 1250 g infants (Baier 2002) 1997-1998 (US),Pandit et al 1999,概述（2）,发病时间 -2个高峰时间 （生后第一天；生后6-7天） 死亡率 -50-80%,预后 Pandit et al 1999 All degrees of PH Severity based on FiO2 increment 0.3 Severe Mortality 15% moderate 64% severe BPD 64% (moderate and severe),Baier et al 2002 Clinically significant PH (moderatesevere) Mortality 27% Majority from respiratory failure Not acutely BPD 50% of survivors Greatly increased duration of MV and oxygen 100% were on Oxygen at 28 days Survival without BPD 33% CNS morbidity increased IVH 53% Increased severity of IVH PVL 13%,Alfaleh K, Pediatrics. 2008,原发病表现 全身症状 呼吸障碍 原发病症状基础上临床表现突然加重 Acute deterioration of patient who was improving post surfactant 出血表现 -鼻腔、口腔流出或喷出血性液体，或于气管插管后流出或吸出泡沫样血性 肺部体征： -呼吸音减低或有湿哕音,辅助检查,胸部X线动态表现 广泛的斑片状阴影，大小不一，密度均匀，有时可有支气管充气征。 肺血管淤血影：两肺门血管影增多两肺或呈较粗网状影。 心影轻至中度增大，以左室增大较为明显严重者心胸比06。 大量出血时两肺透亮度明显降低或呈“白肺 征。 或可见到原发性肺部病变 血气分析 PaO2，PaCO2 血常规 Hb、Plt ,Pulmonary Hemorrhage Clinical Course and Outcomes Among Very Low-Birth-Weight Infants,Maria Tomaszewska, Arch Pediatr Adolesc Med. 1999,PH,NRDS,Pneumonia,早期诊断线索,高危因素 临床症状、体征突然变化 用原发疾病难以解释 胸片动态变化,蔡琍璇，中国妇幼保健，2007,陈克正，中华儿科杂志，1997,评分3分者，无肺出血危险； 评分7分者，尽管使用CPPV亦全部肺出血死亡 而46分者，虽于气管插管后不久发现气管内有少量 血性液但使用CPPV后均全部存活 故建议对肺出血高危儿及早评分，分值达4-6分时可考虑早期肺出血并立即使用CPPV,诊断及分度,诊断标准 -参照新生儿肺出血的诊断与治疗方案，中华儿科杂 志，2001年 临床分度 根据 FiO2较基础水平增加情况 mild FIO2 0.3 根据治疗方案 Mild PH no change of treatment Moderate PH ventilator support or oxygen Severe PH require transfusion of blood product,Alfaleh K, Pediatrics. 2008 Pandit et al 1999,鉴别诊断,气道损伤 出生时吸入血性羊水 UGIB NRDS 新生儿肺炎 肺水肿 DIC,预防,去除诱因（Golden hour) 积极治疗原发病 预防性治疗PDA？,PH and PDA, 60% of PH had clinical PDA (vs 30%, P=0.03) 92% of PH had PDA size 1.6mm,Pediatric1994; J Pediatr 2000,Question, Does prevention of patent ductus arteriosus reduce the incidence of pulmonary hemorrhage in preterm infant ?,EBM PICO P (population) preterm infant I (intervention) Indomethacin or ibuprofen C (compare) placebo O (outcome) 1. patent ductus arteriosus 2. pulmonary hemorrhage 3. mortality,Literature Search Pubmed: Clinical queries: patent ductus arteriosus Preview: prophylaxis AND pulmonary hemorrhage limit: language English Age newborn (birth-1 month),Result of literature searching Cochrane systemic review articles 1. Prophylactic intravenous indomethacin for preventing mortality and mordity in preterm infant (19 trials) (n=2872) Cochrane Database Rev. 2002;(3):CD000174 2. Ibuprofen for the prevention of patent ductus arteriosus in preterm and/or low birth weight infants (4 trials) (n=672) Cochrane Database Rev. 2006;(1):CD004213,Result of literature searching Prevention and 18- month Outcomes of Serious Pulmonary Hemorrhage in Extremely Low Birth Weight Infants: results from the trial of indomethacin prophylaxis in preterms (TIPP) Pediatrics 2008; 121(2), e233-238,Intervention Indomethacin prophylaxis: (6-24hr) 2 trial: 0.2-0.1-0.1mg/kg ivd q12hr (Bandstra,Domancio) 1 trial: 0.1mg/kg ivd q24hr (TIPP) 1 trial: 0.1mg/kg ivd q24hr x 6 doses (Couser) Ibuprofen prophylaxis: (24hr) 10mg/kg ivd then 5mg/kg at 24, 48 hr,Indomethacin prophylaxis Reduction of symptomatic PDA ; RR:0.44 0.38,0.50 RD:-0.24 -0.28,-0.21 NNT 4 Reduction of Gr 3 or 4 IVH RR0.66 0.53,0.82 No significant reduction of PH RR=0.84 0.66,1.08, RD -0.02 -0.06, 0.01 No difference in mortality, RR=0.96 0.81 to 1.12 Increase incidence of oliguria RR1.90 1.45,2.47,Ibuprofen prophylaxis Significant reduced incidence of PDA RR0.37 0.29,0.49, RD-0.29 -0.35,-0.22, NNT 3 Only 1 trial report incidence of PH (8% vs 3%) No difference in mortality, Gr 3/4 IVH, urine output One trial (Gournay 2002) stopped due to 3 cases severe pulmonary hypertension,Definition of PH in in TIPP TIPP define PH as blood-tingle tracheal aspirates Severity: Mild PH no change of treatment Moderate PH ventilator support or oxygen Severe PH require transfusion of blood product Serious PH include moderate 121(2), e233-238,35%,23%,Conclusion, Prophylactic Indomethacin and Ibuprofen had significant reduction of incidence of PDA ; Both showed no difference in mortality. Only indomethacin group provided incidence of PH; No enough data from ibuprofen trial. Indomethacin significant reduced 35% of pulmonary hemorrhage only in first week of life. Side effect: Oliguria (indomethacin) Pulmonary hypertension (ibuprofen),临床表现,原发病表现 全身症状 -低体温，皮肤苍白，发绀活动力低下，呈休克状态，或可见皮肤出血斑，穿刺部位不易止血 呼吸障碍 -呼吸障碍：呼吸暂停，呼吸困难，吸气