应激状态下新生儿对不同剂量外源性脂肪代谢的研究

为了探讨应激状态下新生儿应用两种不同剂量脂肪乳剂时的脂肪代谢情况，以指导临床合理应用。将１７例胎龄＞３５周，手术后需ＴＰＮ＞１周的新生儿，随机分成低剂量脂肪乳剂组（１ｇ·ｋｇ~（－１）／ｄ）８例，普通剂量对照组（２ｇ·ｋｇ~（－１）／ｄ）９例。在ＴＰＮ前、ＴＰＮ第３天和第７天分别观察ＴＧ、ＴＣ、ＰＬ、ＦＦＡ、ＨＤＬ－Ｃ、ＬＤＬ－Ｃ、Ａｐｏ－Ａ_１和Ａｐｏ－Ｂ变化，结果低剂量组ＴＰＮ１周期间，ＴＧ、ＴＣ、ＰＬ变化不明显，而对照组ＴＧ、ＴＣ在ＴＰＮ第３天升高（但＜１．５０ｇ／Ｌ），第７天回到基值；ＰＬ持续升高，Ａｐｏ－Ａ_１／Ａｐｏ－Ｂ的比值１周变化为：低剂量组１．４７→１．６０→１．４１，对照组１．２０→０．８５→０．９６，它的变化与ＴＧ、ＴＣ等血脂变化相一致。从研究中得出，足月新生儿ＴＰＮ时选用１ｇ·ｋｇ~（－１）／ｄ对血脂几乎没有影响，用２ｇ·ｋｇ~（－１）／ｄ虽然有一过性升高，但仍＜１．５０ｇ／Ｌ，是安全的。     

全营养混合液静脉营养支持在新生儿外科的应用

目的：介绍新生儿周围静脉用全营养混合液的配制和在围手术期的应用。方法：１９９３－１９９５年５８例新生儿和成熟儿围手术期用全营养混合液（ＴＮＡ）行静脉营养支持介绍ＴＮＡ的配方设计，配制步骤，应用方法，监测指标，溶液稳定性和治疗效果。本配方含总热量７４－８３ｋｃａｌ３０９－３４７ｋＪ（７４－８３ｋｃａｌ）．ｋｇ＾－１．ｄ６－１，氮热比（Ｎ／Ｑ）＝１：１９７－２２０，脂肪供热占非蛋白热量４２－４９％，结     

原发性肾病综合征患儿血浆脂质及脂蛋白的变化

为了解小儿原发性肾病综合征（ＮＳ）时脂代谢的特点，观察了２０例原发性单纯型ＮＳ患儿的血脂、脂蛋白及载脂蛋白的变化。结果：（１）全部ＮＳ患儿血浆总胆固醇（ＴＣ）、低密度脂蛋白胆固醇（ＬＤＬ－Ｃ）和脂蛋白（ａ）［Ｌｐ（ａ）］均明显升高；兼有ＴＣ、甘油三酯（ＴＧ）升高者，其极低密度脂蛋白胆固醇明显升高，高密度脂蛋白胆固醇明显降低。（２）ＮＳ患儿２４小时尿蛋白定量与血浆ＴＣ、ＴＧ和ＬＤＬ－Ｃ呈正相关（Ｐ＜０．０１）。提示：（１）ＮＳ患儿存在脂代谢异常，兼有ＴＣ、ＴＧ同时升高者，伴有更严重的脂蛋白及载脂蛋白的紊乱，存在着多种致动脉硬化及肾损伤的因素。（２）ＮＳ患儿脂代谢异常的程度与蛋白尿严重程度高度正相关。     

1,6-二磷酸果糖治疗新生儿缺氧后心肌损害

本文应用１，６－二磷酸果糖（ＦＤＰ）治疗新生儿缺氧后心肌损害３０例，收到较好效果。总有效率为９０％，其中显效１５例（５０％），有效１２例（４０％），无效３例（１０％），用药组显效率及总有效率明显高于对照组，提示１．６－ＦＤＰ可作为治疗新生儿缺氧后心肌损害的主要药物之一。     

超小剂量肝素钙治疗新生儿肺炎

本文对１８例死于重症肺炎及肺出血的新生儿行尸检，肺组织特殊纤维染色发现重症肺炎肺泡间隔毛细篾这内有微血栓，表明重症肺炎存在严重的肺微循环障碍。鉴此，在综合治疗新生儿肺炎的基础上常规皮下注射超小剂量肝素钙（１Ｕ／ｋｇ＾－＾１．ｈｏｕｒ＾－＾１），明显降低了新生儿重症肺炎的病死率。用药期间不需监测，操作方便，便于推广。     

川芎嗪对肾病综合征血脂及载脂蛋白变化的临床研究

目的：探讨川芎嗪对肾病综合征(NS)患儿血脂及载脂蛋白的影响。方法：将42例NS患儿随机分为治疗组与对照组各21例,治疗组在常规治疗(激素+对症处理)基础上,加用大剂量川芎嗪(每日8～10 mg/kg)静脉点滴,对照组只给常规治疗,不用川芎嗪。两组患儿均于治疗前及治疗后两周取晨空腹静脉血2 ml监测血脂及载脂蛋白变化。结果：治疗组与对照组治疗后血清总胆固醇(TCH)、甘油三脂(TG)、低密度脂蛋白胆固醇(LDL-C)、极低密度脂蛋白胆固醇(VLDL-C)、载脂蛋白B(apoB)均明显降低,高密度脂蛋白胆固醇(HDL-C)、载脂蛋白A-1(apoA-1)明显升高,差异有显著性意义(P<0.01)。两组间治疗后比较差异有显著性意义(P<0.05)。结论：川芎嗪具有调节肾病综合征患儿血脂及载脂蛋白的作用,可以降低血清总胆固醇、甘油三脂、低密度、极低密度脂蛋白胆固醇及载脂蛋白B,升高高密度脂蛋白胆固醇及载脂蛋白A-1;大剂量川芎嗪配合激素治疗NS患儿脂代谢紊乱是一种疗效显著、安全、可靠的方法。     

新生儿全胃肠外营养致脂肪超载综合征二例

新生儿全胃肠外营养致脂肪超载综合征二例蔡威，陈方，佘亚雄例１男，１天，出生体重２５４０ｇ，孕３６周，疑肠闭锁收入院。急诊手术见十二指肠膜状闭锁，裁剪后端端吻合。术后第１天起应用全胃肠外营养（ＴＰＮ），脂肪乳剂剂量为３ｇ．ｋｇ－１·ｄ－１，持续２周。Ｔ...     

围产期窒息新生儿血浆内皮素的变化

应用放射免疫分析法观察３４例围产期窒息新生儿血浆内皮素（ＥＴ－１）的动态变化，其中轻度窒息１９例，重度窒息１５例，９例合并颅内出血，并与３３例正常新生儿进行对照。结果表明窒息组血浆ＥＴ－１测定值高于对照组，重度窒息组显著高于轻度窒息组，９例合并颅内出血患儿血浆ＥＴ－１升高更为显著，经过复苏及治疗后ＥＴ－１渐下降至正常水平。提示内皮素参与围产期窒息的病理生理过程，并与窒息的严重程度有关。     

280名健康儿童血脂,脂蛋白及载脂蛋白的研究

研究目的探讨正常健康儿童血脂、脂蛋白及载脂蛋白的水平。研究方法280名健康儿童禁食12h，采静脉血。血载脂蛋白（APO）检测采用联合免疫电泳法，总胆固醇（TC）、甘油三酯（TG）用酶法测定，高密度脂蛋白（HDL）用磷钨镁沉淀及酶法分析，低密度脂蛋白（LDL）按Friedwald公式计算。结果血中APOA－1水平13～15岁组明显低于其它组（P＜0．01），且该组APOA－Ⅰ含量男低于女，4岁～6岁、10岁～12岁组APOA－Ⅰ水平明显增高。HDL／APOA－Ⅰ与APOA－Ⅰ水平呈负相关。TC水平随年龄增大呈逐渐下降趋势。13岁～15岁组HDL、LDL均为男低于女。高TC、TG血症检出率分别为3．2％、1．7％。结论在健康儿童中，13岁～15岁组男性儿童血APOA－Ⅰ水平最低，该年龄组儿童发生动脉粥样硬化的危险较小。在保健工作中应将血脂、脂蛋白及APO作为常规检测项目。     

肝素化血治疗中、重度新生儿硬肿症132例临床疗效观察

肝素化血治疗中、重度新生儿硬肿症１３２例临床疗效观察徐州医学院第二附属医院（２２１００６）刘敏１资料及方法１．１临床资料全部病例符合１９９０年沈阳会议制定的《新生儿硬肿症诊疗常规》诊断标准［１］，并按此标准评分及分度。治疗组１３２例中男１０４例，女２...     

Randomized controlled trial of heparin for prevention of blockage of peripherally inserted central catheters in neonates

Aim: To determine whether the addition of heparin to total parenteral nutrition (TPN) fluid would prevent blockage of peripherally inserted central catheters (PICCs) in neonates. Methods: This was a randomized, double-blind, controlled study of 66 eligible neonates with PICCs inserted for the administration of TPN. Infants were randomized to receive TPN containing either 1 IU ml 31 of heparin (n = 35) or no heparin (n = 31). Results: There was no significant difference in the incidence of blocked catheters between the two groups of infants (heparin: 14.3%; no-heparin: 22.6%, p = 0.4). Although a higher percentage (62.9%) of infants in the heparin group received a complete course of TPN successfully via PICC than those in the no-heparin group (48.4%), the difference was not statistically significant ( p = 0.3). There were no significant differences in the incidence of catheter-related sepsis, hypertriglyceridaemia, hyperbilirubinaemia, coagulopathy or intraventricular haemorrhage between the two groups. Conclusion: Addition of heparin to TPN fluid was not associated with a significant reduction in the incidence of blocked PICCs. However, the sample size of this study was too small to exclude even rather marked differences between the groups.     

A safe and efficacious preventive strategy in the high-risk surgical neonate: cycled total parenteral nutrition

Introduction

Hepatic dysfunction in patients reliant on total parenteral nutrition (TPN) may benefit from cycled TPN. A concern for neonatal hypoglycemia has limited the use of cycled TPN in neonates less than 1 week of age. We sought to determine both the safety and efficacy of cycled TPN in surgical neonates less than 1 week of age.

Methods

A retrospective chart review was conducted on surgical neonates placed on prophylactic and therapeutic cycled TPN from January 2013 to March 2016. Specific emphasis was placed on identifying incidence of direct hyperbilirubinemia and hypoglycemic episodes.

Results

Fourteen neonates were placed on cycled TPN; 8 were prophylactically cycled and 6 were therapeutically cycled. Median gestational age was 36 weeks (34, 37). Sixty-four percent (n?=?9) had gastroschisis. There was no difference between the prophylactic and therapeutic groups in incidence of hyperbilirubinemia?>?2 mg/dL (3 (37%) vs 5 (83%), p?=?0.08) or the length of time to development of hyperbilirubinemia [24 days (4, 26) vs 27 days (25, 67), p?=?0.17]. Time on cycling was similar though patients who were prophylactically cycled had a shorter overall time on TPN. Three (21%) infants had documented hypoglycemia, but only one infant became clinically symptomatic.

Conclusion

Prophylactic TPN cycling is a safe and efficacious nutritional management strategy in surgical neonates less than 1 week of age with low rates of hypoglycemia and a shorter total course of TPN; however, hepatic dysfunction did not appear to be improved compared to therapeutic cycling.

     

出生畸形低体重儿围手术期处理十年回顾

目的 通过对10年来外科畸形低体重儿的围手术期治疗进行回顾性分析,为进一步提高外科畸形低体重新生儿的治愈率提供资料.方法 1996年1月～2006年8月期间上海交通大学医学院附属新华医院和上海儿童医学中心小儿外科收治的外科畸形低体重儿共104例,男69例,女35例,平均出生体重(2244±261)g(1 040～2490g),平均胎龄36+1周.分为2000年前(A组)共34例,2001年后(B组)共70例.结果 外科畸形低体重儿占同期收治新生儿的9.5%,总治愈率为67.3%.41例患儿应用机械通气,平均机械通气时间为6.2 d,45例患儿应用全胃肠外营养(TPN),平均TPN应用时间9.5 d.A组的治愈率为58.8%,12例患儿应用机械通气,平均机械通气时间3.2 d;7例患儿应用TPN,平均应用TPN时间7.5 d.B组的治愈率为71.4%,29例患儿应用机械通气,平均机械通气时间8.4 d;38例患儿应用TPN,平均应用TPN时间19.4 d.比较两组的发病率、治愈率和围手术期的基本处理,两组在治愈率、机械通气和TPN的使用率、平均机械通气时间和TPN平均应用时间上差异存在统计学意义(P＜0.05).结论 在围手术期应用合理、规范、有效的呼吸管理和营养支持,可以提高低体重儿畸形的治愈率.     

Urinary lithogenic and inhibitory factors in preterm neonates receiving either total parenteral nutrition or milk formula

The aim of this study was to evaluate prospectively the influence of nutrition on certain factors which may inhibit or promote nephrocalcinosis in two groups of preterm infants, receiving total parenteral nutrition (TPN) and special preterm milk formula respectively, but not furosemide. A total of 37 preterm infants, 15 on TPN and 22 fed a special preterm formula were studied at the end of the 1st, 2nd and 3rd weeks of life, at which time serum and 8 h urine specimens were collected. High ratios of urinary calcium to urinary creatinine (UCa/cr), urinary oxalate to urinary creatinine (Uox/cr) and urinary calcium to urinary citrate (UCa/cit) indicates an increased risk for nephrocalcinosis while high urinary citrate to urinary creatinine (Ucit/cr) ratio indicates protection. Uox/cr increased significantly (P<0.05) in those infants fed preterm formula, from the end of 2nd week of life and was two-fold higher than in the TPN group of preterm infants (P<0.01). Ucit/cr was higher throughout the study period in the formula fed than in the TPN preterm infants. UCa/cit was five-fold higher (P<0.01) in the TPN group, by the end of the 3rd week. Urinary calcium and magnesium was similar in both groups during the study period. Two of the infants studied (5.4%), one from each group, developed nephrocalcinosis.CONCLUSION: In preterm neonates on total parenteral nutrition, urinary oxalate -to-creatinine ratio (a potent lithogenic factor) was lower and urinary citrate -to-creatinine ratio (a lithoprotective factor) also lower than in formula fed neonates. The type of feeding (total parenteral nutrition or special preterm milk formula) seems to affect urinary oxalate and citrate but not calcium and magnesium in non-furosemide treated preterm infants during the first 3 weeks of life.     

The efficacy of heparin in maintaining peripheral infusions in neonates

Abstract The study set out to determine the survival times of peripheral total parenteral nutrition (TPN) infusion sites in neonates using a prospective, single blind, randomised trial design. The effects of various concentrations of co-administered heparin was measured using survival analysis, and of other continuous variables using multivariate analysis, against a non-heparinized control group. The study was conducted in special care baby unit located within a specialist maternity hospital in London, United Kingdom. Heparin at 0.1, 0.25, 0.5 and 1 IU/ml was added to TPN infusions delivered through peripheral veins and the survival times of the infusions determined. For infusion sites receiving heparinized fluids, the relative risk of failure decreased and the median survival time increased as the heparin concentration increased, with a maximal effect at a heparin concentration of 0.5 IU/ml (P<0.001). Multivariate analysis using the Cox proportional hazard model confirmed the efficacy of heparin and high-lighted a history of infusion therapy and the co-administration of gentamicin (from a range of drugs analysed) as being risk factors associated with infusion site failure.Conclusion Intravenous infusion survival time can be prolonged using heparin additive at an optimal concentration of 0.5 IU/ml. This should also be of additional interest to paediatricians as heparin is an ubiquitous drug on neonatal units and its clinical use needs to be rationalised.     

Erythromycin establishes early oral feeding in neonates operated for congenital intestinal atresias

Purpose  The recovery of gastrointestinal function following surgery for congenital intestinal atresias can be prolonged and may increase morbidity and hospital stay. This study was conducted to investigate the prokinetic effect of erythromycin in neonates undergoing surgery for small bowel atresias. Methods  A randomized-controlled trial was conducted at the Departments of Paediatrics and Paediatric Surgery, Military Hospital, Rawalpindi, Pakistan, from January to December 2007 to study the prokinetic effect of erythromycin (3 mg/kg per dose 4 times daily). Thirty consecutive neonates undergoing primary anastomosis for congenital small bowel atresias were randomly divided into two groups: group I (erythromycin) and group II (control). The groups were similar in terms of gestational age, sex, mode of delivery, birth weight and types of atresias. Postoperative recovery of intestinal functions was measured as time taken to achieve full enteral feed (150 ml/kg per 24 h), duration of total parenteral nutrition (TPN) and hospital stay. Results  Neonates receiving oral erythromycin achieved full enteral feeding early (13.07 vs. 16.13 days) required TPN for shorter duration (10.53 vs. 13.73 days) and their hospital stay was less (16.2 vs. 18.0 days) as compared to the neonates in the control group who did not receive any erythromycin. The differences were statistically significant. Conclusion  The administration of oral erythromycin following primary anastomosis for small intestinal atresias results in early recovery of intestinal function, fewer days on TPN and a trend for shorter hospital stay.     

Pharmacokinetics of ceftriaxone in neonates and infants with meningitis

The pharmacokinetics of ceftriaxone was studied in the plasma, urine, and cerebrospinal fluid of seven neonates and seven infants with meningitis. In addition, plasma and urine data were obtained in five neonates and one infant receiving ceftriaxone for other serious infections. All neonates younger than 14 days received daily doses of 50 mg/kg ceftriaxone; all other patients but two received 100 mg/kg. The average weight-corrected values for total body clearance (ClT), volume of distribution (Vdss), and biologic half-life (t 1/2) were 0.37 ml/min/kg, 0.45 L/kg, and 16.2 hours in neonates younger than 1 week; 0.77 ml/min/kg, 0.48 L/kg, and 9.2 hours in neonates older than 1 week; and 1.03 ml/min/kg, 0.39 L/kg, and 7.1 hours in older infants, respectively. There was a significant difference in ClT and t 1/2 between the neonates younger and both neonates older than 1 week, and infants. The Vdss was not significantly different among the three age groups. The average renal clearance in neonates younger than 1 week (0.28 ml/min/kg was 70%, in neonates older than 1 week (0.54 ml/min/kg) was 77%, and in older infants (0.49 ml/min/kg) was 47% of ClT, indicating that nonrenal elimination was less developed in neonates. The quantitation of CSF diffusion of ceftriaxone was assessed by comparison of the areas under the CSF and plasma concentration-time curve. The mean ceftriaxone penetration into the CSF in neonates and infants with bacterial meningitis was 17%. On the other hand, penetration in patients with aseptic meningitis amounted to only 4%. Mean ceftriaxone concentrations in the CSF in patients with bacterial meningitis were 2.8 mg/L after 24 hours, exceeding by many times the minimum inhibitory concentration of the common meningitis pathogens at this time.     

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目的总结胎盘早剥晚期早产儿的临床特点与治疗方案。方法从2009年10月至2011年5月从北京军区总医院附属八一儿童医院早产儿重症监护中心患儿资料中,根据入选条件,选取患儿83例,其中胎盘早剥37例为观察组,非胎盘早剥46例为对照组,进行回顾性分析。结果观察指标中,两组患儿比较,胎龄、多胎、胎膜早破史、出生体重、体重与胎龄匹配情况(小于胎龄儿或否)、母亲年龄、母亲妊娠糖尿病、新生儿窒息史、入院时活化部分凝血活酶时间(APTT)、D-二聚体(D-D)、输注悬浮红细胞、输注血浆及使用肝素指标差异有统计学意义(P<0.05)。结论胎盘早剥属于胎盘功能不全,多继发早产儿凝血功能异常,使用小剂量肝素、输注血浆防治效果理想。     

Lipid metabolism in parenterally alimented neonates: carnitine blood concentrations and fat utilization

Carnitine plays an important role in the oxidation of fatty acids by facilitation their transport across the mitochondrial membrane. Premature infants are known to have a limited capacity for fatty acid oxidation. To investigate the relationship between carnitine blood concentrations and the ability to utilize exogenous fat, plasma concentrations of total carnitine, free carnitine, free fatty acids and triglyceride were measured in 29 parenterally alimented neonates, including 10 pre-term infants and 19 full:term infants, prior to and during TPN. The pre-term infants achieved very high plasma levels of free fatty acids and very low levels of free carnitine during TPN. There was a highly negative correlation between plasma concentrations of free fatty acids and those of free carnitine. The present study suggests the possible therapeutic advantages of supplementing carnitine in intravenously alimented neonates, especially in pre-term infants.     

Lumbar puncture frequency and cerebrospinal fluid analysis in the neonate

A prospective study was performed to assess the frequency and diagnostic utility of lumbar punctures in neonates both during their first week of life and thereafter. During the two 6-month periods from January 1, 1985 to June 30, 1985, and February 1, 1986 to July 31, 1986, 712 neonates underwent 728 lumbar punctures during their first week of life primarily as part of the evaluation for suspected infection, either congenital or postnatal. There were eight patients with positive spinal fluid cultures in the first week of life, but only one patient simultaneously had a positive blood culture and a clinical course consistent with meningitis. In contrast, a considerably higher yield, approximating five times that of the first week of life, was obtained in patients undergoing a lumbar puncture after the first week of life.