新生儿缺氧性脑病课件

Hypoxic- Ischemic Encephalopath y (HIE) 1 Introduction lHypoxia（低氧）: refers to an arterial concentration of oxygen that is less than normal. lIschemia (缺血）: refers to blood flow to cell and organ that is insufficient to maintain their normal function. 1 lrefers to a hypoxic-ischemic insult during the process of labor and delivery(分娩),which include fetal acidosis (pH34 week and term infant) l Cerebral edema （脑水肿） lNeuronal necrosis of the cortex lParasagittal(矢状窦旁） ischemia injury lFocal or multifocal cortical infarct 5. Clinical manifestation lPallor, cyanosis, apnea, bradyrhythmia (心律过缓）, and unresponsiveness to stimulation lCerebral edema may develop during the next 24 hr and result in profound brain stem depression. 1 ) General symptom 2) Neurological symptom 1 Level of consciousness：Hyperarousal （易激 惹），Somnolence(嗜睡） ，Stuporous（昏 睡），coma 2 Moro reflex：Strong，Weaker ，Absent 3 Muscle tone ： normal ，Hypertonic ，Flaccid 4 Seizure：take placed after delivery 12hour， from local seizure to general seizure, SignStage 1stage2stage3 Level of consciousness HyperalertLethargic昏睡Stuporous, coma Muscle toneNormalHypotonicFlaccid PostureNormalFlexion(屈曲）Decerebrate（去脑脑 状态态) Tendon reflexes/clonus HyperactiveHyperactiveAbsent MyoclonicPresentPresentAbsent Moro reflexStrongweakAbsent HIE in term infantHIE in term infant SignStage 1stage2stage3 PupilsMydriasis (瞳孔散大） Miosis （瞳孔缩缩小） Unequal, poor light reflex SeizureNonecommonDecerebration （去脑脑强直） Electroenceph alographi（ EEG) Normal lower Voltage changing to seizure activity Burst suppression to isoelectric(等电电 位趋势趋势 ？） Duration50-70mmHg， PCO240mmHg 2. Correct acidosis ：5%NaHCO3 2-5ml/kg 3. Correct hypoglycemia: glucose 6- 8mg/kg.min 4. keep the hydroelectric balance ：60- 80ml/kg.day Treatment -Seizure: l Phenobarbital(苯巴比妥）：loading dose 20mg/kg Intravenously ,Supplemental dose 5mg/kg, If Seizure persist, up to a total 30mg/kg. lDiazepam（安定）: 0.1-0.3mg/kg iv，time of IV should be more than 3 minites Treatment -Cerebral edema 1. Limited fluid intaked：60ml/kgd 2. Lasix（速尿） 0.5-1mg/kg Iv，30 minites 3. Mannite（甘露醇）20% Mannite, 0.25-0.5/kg ，2-3 dose/day 4.20% albumin: 0.5-1g/kg Iv 1-2 dose/day 4. Dexamethasone？0.5-1mg/kg，1-2 dose/day Prognosi s lSerious： epilepsy, cerebral palsy （ 脑瘫）or mental retardation. lMild: mild cerebral function disturbance Prevention lPrevent from perinatal asphyxia lUse new resuscitation related to asphyxia Intracranial hemorrhage(ICH) of the newborn Liping Li Introduction l Intracranial hemorrhage may result from trauma （外伤）or asphyxia（缺 氧) and, rarely from a primary hemorrhagic disturbance or vascular anomaly. Etiology and pathogenesis l1.related to Blood vessel l2.related to Pressure l3. Trauma l4. Others 1. Blood vessels : lin the subependymal germinal matrix (室管 膜下胚胎生发基质GM） in premature, Which is Immature blood vessel with poor tissue vascular area, easy to be subjected to various force, to be sensitive to hypoxia, by term, the germinal matrix has become attenuated and the tissue vascular support has strengthened ,So predispose premature infant to intraventricular hemorrhage( IVH) (1) Predisposing factor for IVH lCerebral blood flow or lReperfusion(再灌注） of damaged vessels; lReduced vascular integrity(完整性）, due to venous pressure lHypertension These factor result in rupture of These factor result in rupture of germinal matrix blood vesselgerminal matrix blood vessel (2)Predisposing event for IVH lRespiratory distress syndrom (RDS)呼 吸窘迫综合征） lHypoxia-Ischemic encephalopathy (HIE) lPerinatal asphyxia. (围产期窒息） Asphyxia or acidosis etc Cerebrovascular Auto-regulation is damaged Capillary broken Cerebral hemorrhage Pressure passive circulation Hypertension or hypertransfusion 2 pressure2 pressure 2 pressure-related event lCongenital heart disease lQuickly transfuse a lot of fluid? lConvulsion(惊厥） lSerious acidosis lPneurmothorax (气胸） lMechanical ventilation These factor result in rupture of Capillary 3.Trauma: (1) Traumatic epidural（硬膜外）, subdural（硬膜 下）,or subarachnoid hemorrhage is especially likely when the fetal head is large in proportion to the side of mothers pelvic outlet; labor is prolonged or in breech(臀位产） or precipitated deliveries（急 产） ; mechanical assistance with delivery（器件助 产）. 3.Trauma (2) lMassive subdural hemorrhage（ 硬膜下 出血）often associated with tears in the tentorium falx cerebri(大脑镰)、cerebelli( 小脑幕）, but are encountered more often in full-term（足月儿) than in premature(早产儿）. 4.Other s(1) lPrimary hemorrhagic disturbance and vascular malfomation (血管畸形)are rare and give rise to subarachnoid hemorrhage （SAH 蛛网膜下腔出血) or intracerebral hemorrhage（ICH，小脑出 血） 4.Others(2 ) lmay be associated with disseminated intravascular coagulation （DIC), lthrombocytopenia isoimmune(同族免疫性 血小板减少症）, l neonatal vitamin K deficiency (especially in born to mother receiving phenobabital （苯巴比妥） or phenytoin 苯妥英) Clinical manifestation Related to Hemorrhagic locus and quantity: Mild : No Massive: died General : hypothermia(低体温), anemia , jaundice（黄疸), apnea（呼吸困难） , hemorrhagic shock（出血性休克） Neurological manifestation lIncreased intracranial pressure(颅内压增 高）: hypertension（高血压）, convulsion（惊厥), bulging fontanel (前囟 隆起）, opisthotonos（角弓反张), cephalic cry (脑性尖叫), irritability（易激 惹） Neurological manifestation lRespiratory insufficiency/polypnea（呼 吸急促） , bradypnea/apnea（呼吸暂 停） lConciousness: hyperalert, (高度警觉） lethargic(昏睡）, stuporous, coma Neurological manifestation lFixation（凝视）heterotropia (斜视） Nystagmus(眼球震颤） lPupils: mydriasis(瞳孔扩大) miosis( 瞳孔缩小） unequal（不等大）, poor light reflex or disappear lReflex: weaken or absent lCerebral spinal fluid: light yellow colour 1Periventricular- intraventricular hemorrhage (PVH-IVH) lOccur in premature (GA32 ,BW1500g) lRegion: in germinal matrix (GM)- spread to ventricular aqueduct（中脑导水管） -posterior cerebellomedullary cistern(小脑延髓池） subarachnoid cavity lRelated to factor : Respiratory distress syndrom(RDS), Hypoxia-Ischemic encephalopathy (HIE) Periventricular-intraventricular hemorrhage (PVH-IVH) Glassfied by transfontanel cranial ultrasonography or computed tomography(CT) lGrade 1：bleeding confined to the germinal matrics- subependymal region lGrade 2: intraventricular bleeding without ventriculomegaly(脑室扩大） lGrade 3: intraventricular bleeding with ventriculomegaly lGrade 4: intraventricular bleeding with intraparenchymal hemorrhage(脑实质出血） Clinic feature (PVH-IVH) l 80-90% of case between birth and the 3rd day of life, the most common symptoms is apnea, somnolence, decreased muscle tone, or paralyses, moro reflex (-) lDecreased hematocrit (血细胞容积） 2 Primary subarachoid hemorrhage(SAH) lMost associated with trauma lBleeding from bridge vein(桥静脉） lTypical clinical feature : after 2 day of life take place convulsion ; Csf: blood lObstructive arachnoiditis (阻塞性蛛网膜炎)- communicating hydrencephalus (交通性脑积水) obstructive hydrencephalus(阻塞性脑积水) Primary Primary subarachnoidsubarachnoid hemorrhage(SAHhemorrhage(SAH) ) 3 Intraparenchymal hemorrageI(IPH) lDue to small vein embolism carpilary pressure lBleeding in brainstem：pupil , respiratory, bradycardia (心动过缓） lDyscinesia(运动障碍）: most lower limb, trunk, upper limb, face lSequelae: cerebral palsy (脑瘫), epilepsy, mental retardation 5 Subdural hemorrage lMost occurs in macrosomia lMost associated with trauma lClinic manifestation: 24 hours of life , convulsion, hemiparalysis, heterotropia(斜视） lMild: no symptom 6 Cerebellar hemorrhage lIn premature GA32 week lFrequently Apnea (呼吸暂停） and bradycardia (心动过缓） intracerebellar hemorrhage diagnosis lHistory: lClinic manifestration lCfs lCT or MRI lUltrasound examination Treatment- General suporting l Keep quiet l Fluid balance, blood pressure lHemostasia(止血）: frozen plasma 5- 10ml/kg,Vitamin K 5-10mg/kg, ethamsylate(止 血敏）100mg/kg.d，reptilase (立止血) lControl Seizure : Phenobarbital (苯巴比妥） lAnemia shork : transfusion with packed red blood cell or frozen plasma Treatment- anticonvulsant lPhenobarbital：loading dose 20mg/kg,Intravenously ,Supplemental dose 5mg/kg, If Seizure persist, up to a total 30mg/kg. lDiazepam: 0.1-0.3mg/kg iv，time of IV should be more than 3 minites Reduce intracranial pressure(ICP) Lasix（速尿） 0.5-1mg/kg Iv，30 minites 3 dose/day Albumin: 0.5 g/kg.day 1-2 dose/day 4. Mannite（甘露醇）: rarely, 20% Mannite, 0.25-0.5/kg，2-3 dose/day (rarely) Prognosis lLocation and volume of bleeding lGrade 1-2 : 90% alive, 20% hydrocephalus, lGrade 3-4: 40% alive, 2/3 hydr