容量复苏对早期严重创伤性休克患者血流动力学和氧输送的影响

目的 探讨大容量复苏对早期严重创伤性休克患者血流动力学和氧输送的影响.方法 监测24例严重腹部创伤患者不同容量复苏时的血流动力学和氧代谢指标.结果 容量复苏收缩压从80～90mm Hg(1 mm Hg=0.133 kPa)上升到100～120 mm Hg时,平均复苏容量分别为(2286±521)ml(1 h)和(3486±758)ml(2 h).心脏指数(CI)从(2.0±0.5)L/(min·m2)上升为(3.2±0.6)L/(min·m2)(P<0.05),体循环阻力指数(SVRI)从(1857.6±750.2)dyn·s/(cm5·m2)上升为(3741.5±862.1)dyn·s/(cm5·m2)(P<0.05),与之相对应,氧输送指数(DO2)从(301.1±74.1)ml/(min·m2)升为(554.1±80.0)ml/(min·m2)(P<0.05),氧耗指数(VO2)为(99.7±51.4)ml/(min·m2)升为(147.2±60.1)mL/(min·m2)(P<0.05),氧摄取指数(O2ext)为(33.1±9.1)%下降至(26.6±8.0)%(P<0.05).结论 在急诊抢救中,早期大容量复苏能改善血流动力学和氧代谢.     

去甲肾上腺素与多巴胺改善感染性休克血流动力学及氧代谢的效果比较

选取笔者所在医院2011年2月~2012年2月74例感染性休克患者为研究对象,抽签随机分为NE组与DA组,每组37例。NE组与DA组分别用NE与DA干预治疗,比较两组心率(HR)、心排出量指数(CI)、平均动脉压(MAP)、体循环血管阻力指数(SVRI)等血流动力学指标及乳酸清除率、混合静脉血氧饱和度(Sv O2)≥60%的比例。结果治疗12、24、48h后NE组HR分别为(106.0±10.0)次/min、(95.0±9)次/min、(92.0±10.0)次/min,CI分别为(4.28±0.46)L/(min·m)、(4.23±0.36)L/(min·m)、(4.18±0.41)L/(min·m),均低于DA组,SVRI分别为(104.36±12.35)k P/(L·m)、(115.36±11.65)k P/(L·m)、(113.57±12.67)k P/(L·m),均高于DA组,差异明显(P0.05);两组MAP比较无统计学意义(P0.05)。治疗后12、24、48h NE组乳酸清除率及Sv O2≥60%的比例均高于对照组,有统计学意义(P0.05)。NE能更有效维持感染性休克患者血流动力学稳定,显著提高乳酸清除率及Sv O2≥60%的比例,改善氧代谢,NE较DA更适合感染性休克的临床治疗。     

袋鼠式护理对极低出生体质量早产儿喂养及发育的影响

目的探讨袋鼠式护理对极低出生体质量早产儿喂养、行为及体格发育的影响,以寻求早产儿早期干预的有效措施。方法选择2017年2月—2019年2月收治于南京医科大学附属妇产医院新生儿科的162例极低出生体质量早产儿为研究对象。按入院先后时间分为观察组(n=81)和对照组(n=81)。对照组给予常规护理,观察组实施袋鼠式护理。干预14 d后,比较两组患儿喂养相关指标、体格发育情况及神经行为测定评分结果。结果观察组患儿平均加奶速度为(7.4±1.4) m L/(kg·d),大于对照组的(9.9±1.1) mL/(kg·d)(t=8.593, P0.05);观察组患儿达全肠内营养日龄为(25.6±1.3) d,早于对照组(30.9±2.4) d(t=17.476, P0.05)。干预后观察组患儿身长、体重及头围的增长值及行为能力、被动肌张力、主动肌张力、非条件反射以及一般反应能力5项神经行为测定评分均优于对照组(均P0.05)。结论针对极低出生体质量早产儿实施袋鼠式护理,能有效提高患儿的母乳喂养效率,促进其体格及行为能力发展,且干预过程中不良反应少、安全性高,有一定临床推广应用价值。     

米力农改善心脏手术后心力衰竭所致低心排血量综合征患者的肾功能

目的评价正性肌力药米力农在治疗体外循环(CPB)心脏手术后心力衰竭所致低心排血量综合征时对患者肾脏的影响。方法选取2018年1月至2020年6月间在我院心胸外科治疗的CPB心脏手术患者,在患者心脏停跳后30 min(基线期)和60 min(治疗后)进行肾脏和全身血流动力学检测。CPB术后30 min发生低心排血量综合征患者接受米力农治疗,根据患者CPB心脏手术后是否应用米力农,将患者分为米力农组(n=59)和对照组(n=82)。比较两组患者血流动力学指标和肾血流动力学指标基线期值、治疗后值、治疗后较基线期变化值。比较治疗后两组患者预后指标及并发症发生率。结果治疗后米力农组患者心脏指数变化值[(0.55±0.26) L/(min·m²) vs.(-0.35±0.28) L/(min·m²),t=19.394,P <0.001]、心搏容量指数变化值(t=8.776,P <0.001)、氧释放系数变化值(t=8.143,P <0.001)、混合静脉血氧饱和度变化值(t=9.935,P <0.001)与对照组比较显著提高,周身血管阻力指数变化值(t=10.574,P <0.001)、肺血管阻力指数变化值(t=10.654,P <0.001)与对照组比较显著降低。治疗后米力农组患者肾血流量变化值[(117.30±153.82) m L/min vs.(-63.73±157.64) m L/min,t=6.795,P <0.001]、肾脏供氧量变化值(t=4.248,P <0.001)与对照组比较显著提高,肾小球滤过分数变化值(t=6.382,P <0.001)、肾血管阻力变化值[(-0.06±0.05) mm Hg/(m L·min) vs.(0.03±0.06) mm Hg/(m L·min),t=9.407,P <0.001]和肾氧摄取率变化值(t=7.625,P <0.001)与对照组比较显著降低。结论米力农在心脏手术后早期用于治疗急性心力衰竭所致低心排血量综合征,可以增加患者心输出量和肾血流量,扩张肾血管。米力农可以改善患者易感肾脏的氧合作用,但不会引起肾小球滤过率的显著变化。     

脑电双频指数在小儿丙泊酚复合瑞芬太尼静脉麻醉剂量监测中的应用

目的分析脑电双频指数(BIS)在小儿丙泊酚复合瑞芬太尼维持静脉麻醉剂量中的应用。方法选取手术患儿78例,按丙泊酚复合瑞芬太尼静脉麻醉剂量的多少将其分为A组[丙泊酚初始剂量4 mg/(kg·h)]和B组[丙泊酚初始剂量6 mg/(kg·h)],每组39例。术中应用BIS监测麻醉深度,将瑞芬太尼的剂量控制在0.05~0.1μg/(kg·h),统计两组的麻醉剂量。结果两组麻醉维持平稳,未出现不良反应;A组苏醒时间、丙泊酚用量分别为(8.95±2.50)min、(9.12±2.30)mg/(kg·h),B组分别为(6.92±0.99)min、(11.38±3.20)mg/(kg·h),两组比较差异有统计有意义(P0.05)。结论临床术中使用BIS监测麻醉深度能稳定血流动力学,减少丙泊酚使用量,值得推广应用。     

甲状旁腺切除对维持性血液透析患者肾性贫血的影响

目的探讨甲状旁腺切除对维持性血液透析患者肾性贫血的影响。方法回顾性分析25例因继发性甲状旁腺功能亢进而行甲状腺切除术的维持性血液透析患者术后血清钙,磷及全段甲状旁腺激素(intact parathyroid hormone,i PTH)等的变化,分析术后1月,3月和6月血红蛋白及红细胞生成素用量变化情况。结果 1与术前相比[(1825.44±936.92)pg/L],患者术后1月[(156.25±149.80)pg/L],3月[(104.53±131.21)pg/L]和6月[(110.01±143.85)pg/L]i PTH水平均显著下降[1月:t=7.994,P=0.000;3月:t=8.430,P=0.000;6月t=8.289,P=0.000],差异具有统计学意义;与术前相比[(2.29±0.41)mmol/L],患者术后1月[(1.57±0.59)mmol/L],3月[(1.73±0.64)mmol/L]和6月[(1.46±0.46)mmol/L]血磷水平均显著下降[1月:t=5.341,P=0.000;3月:t=4.050,P=0.000;6月t=7.749,P=0.000],差异具有统计学意义。2与术前相比,患者术后1个月、3个月、6个月血红蛋白(hemoglobin,Hb)水平差异无统计学意义(P0.05);但与术前相比,术后EPO用量逐渐减少,术后3个月、6个月差异具有统计学意义[3个月:(149.77±35.98)IU/(kg·周)比(226.18±65.47)IU/(kg·周),t=4.672,P=0.000;6个月:(121.53±26.50)IU/(kg·周)比(226.18±65.47)IU/(kg·周),t=6.606,P=0.000]。3红细胞生成素用量与患者i PTH水平呈正相关(r=0.48,P=0.00)有统计学差异。结论甲状腺切除能明显改善维持性血液透析患者肾性贫血,减少红细胞生成素用量。     

小儿外科重症监护病房先天性消化道畸形患儿营养状况调查

目的了解小儿外科重症监护病房(pediatric surgical intensive care unit,PSICU)先天性消化道畸形患儿住院期间营养不良及营养摄入情况。方法分析2014年10月—2017年11月入住上海交通大学医学院附属新华医院PSICU、住科时间 72 h的先天性消化道畸形患儿458例的临床资料。记录患儿相关人体测量指标、入科后营养摄入等情况,并分析导致患儿营养不良的相关因素。结果本组入科时营养不良119例(26. 0%),其中68例(14. 8%)为重度营养不良;出科时营养不良127例(27. 7%),其中81例(17. 7%)为重度营养不良。出生体重及住科天数是先天性消化道畸形患儿入科前营养不良的独立危险因素。所有患儿在我科住科期间平均总能量摄入量为(161. 1±84. 0) kJ/(kg·d),肠内营养摄入量为(75. 0±29. 3) kJ/(kg·d),平均蛋白质摄入量为(1. 3±0. 9) g/(kg·d);住院期间手术、住科天数、总能量摄入量、肠内营养摄入量是先天性消化道畸形患儿住科期间营养不良的独立危险因素。结论 PSICU先天性消化道畸形患儿营养不良发生率高,且住院期间患儿能量供给量常不能达到目标需求,会使营养状况进一步恶化,延长住院时间,因此术后早期合理的喂养途径对改善患儿能量摄入具有积极意义。     

慢性肾脏病一体化管理门诊患者的营养状况与饮食调查

目的调查慢性肾脏病(chronic kidney disease,CKD)一体化管理门诊患者的饮食及营养状况,为更好的开展CKD营养管理工作提供依据。方法调查北京大学第一医院肾内科CKD一体化管理门诊患者,搜集患者一般资料。测量并计算体质量指数,并通过主观综合性营养评估问卷评定患者营养状况。饮食情况通过3天饮食日记的方法获得,计算患者每日热量和蛋白质,优质蛋白质摄取情况,同时营养师给予推荐摄入量。结果患者总数120人,年龄(60.491±14.167)岁,随访时间(3.403±2.707)年,以CKD3~4期患者为主。在营养指标中,体质量指数低于18.5kg/m2的有8人(6.667%);主观综合性营养评估评估达到B级轻-中度营养不良16人(13.333%)。患者实际每日每公斤体质量热量摄入量显著低于营养师推荐量[分别为26.798±6.236 kcal/(kg·d)与28.677±2.584kcal/(kg·d),t=-3.194,P=0.002]。患者实际每日每公斤体质量蛋白摄入量高于营养师推荐量[分别为(0.963±0.281)g/(kg·d)与(0.736±0.090)g/(kg·d),t=9.053,P0.001],其中优质蛋白的摄入比例为(44.230±12.933)%,显著低于营养师推荐的(60.000±0.000)%(t=-13.355,P0.001)。结论 CKD门诊随访患者营养不良的比例偏高、饮食情况与指南推荐有一定差距,需加强对CKD门诊随访患者的营养治疗的管理。     

老年人肾功能与肺部感染的临床研究

目的 研究老年人肾功能损害与罹患肺部感染的关系.方法 选择年龄＞ 65岁老年患者224例,根据慢性肾脏病分期及估算肾小球滤过率(eGFR)分为5组:≥90 ml/(min·1.73 m2)为对照组(A组)65例、60～89 ml/(min·1.73 m2)组(B组)55例、30 ～ 59 ml/(min·173 m2)组(C组)27例、15～29 ml/(min·1.73 m2)组(D组)28例和＜15 ml/(min·1.73 m2)组(E组)49例.采用Logistic回归分析肾功能与肺部感染之间的关系.结果 与A组比较10.8％ (7/65),C组63.0％ (17/27)(x2=26.95,P＜0.05),D组85.7％ (24/28) (x2 =49.46,P ＜0.05)及E组100％(49/49)(x2=89.00,P＜0.01)患者肺部感染发生率均明显升高,差异均有统计学意义.吸烟(Waldx2=17.66,P＜0.01),呼吸道基础疾病(Waldx2=14.38,P＜0.01),侵袭性操作史(Waldx2=4.50,P＜0.05),糖尿病(Waldx2=3.86,P＜0.05),住院满2周(Waldx2=18.18,P＜0.001),性别(Waldx2=4.12,P＜0.05),eGFR(Waldx2=13.57,P＜0.01)是老年人患呼吸道感染的危险因素.Logistic回归分析显示,调整影响肺部感染危险因素后,eGFR水平≥90 ml/(min·1.73m2)(Waldx2=0.053,P＞0.05),60 ～89 ml/(min·1.73 m2)(Waldx2=0.046,P＞0.05),30 ～ 59 ml/(minl·1.73 m2)(Waldx2=7.61,P＜0.05),15～29 ml/(min·1.73 m2)(Waldx2=4.38,P＜0.05),＜15 ml/(min·1.73 m2)(Waldx2=13.57,P＜0.01),罹患肺部感染风险随eGFR的降低而增加.结论 年龄＞65岁老年患者肾功能损害是其患肺部感染的一个独立危险因素.     

优化饮食蛋白质摄入对腹膜透析患者的作用研究

目的分析优化饮食蛋白质摄入对腹膜透析(peritoneal dialysis,PD)患者营养及其相关指标的作用,探讨优质蛋白摄入率的独立相关因素。方法回顾性分析重庆医科大学附属成都第二临床学院成都市三人民医院肾脏科稳定PD治疗1个月以上患者,优质蛋白摄入率≥50%为优化组51例;优质蛋白摄入率50%为非优化组41例。比较分析两组教育模式、3日饮食日记,饮食中蛋白质、热量、磷蛋白比值低的鸡蛋白质摄入量及摄入比,血清白蛋白、血红蛋白、血磷、成纤维细胞生长因子(fibroblast growth factor 23,FGF23)等,计算尿素清除指数、残余肾功能、周肌酐清除率、标准蛋白分解率,多元逐步回归法分析PD患者优质蛋白摄入率的独立相关因素。结果优化组与非优化组相比,每日蛋白摄入量[(1.09±0.41)比(0.86±0.25)g/(kg·d),t=3.097,P=0.003]、优质蛋白质量[(0.64±0.22)g/kg·d比(0.40±0.11)g/(kg·d),t=6.321,P0.001]、鸡蛋白摄入比[(8.01±3.90)比(5.80±4.32)%,χ2=80.126,P=0.012]、血清白蛋白[(39.54±4.09)g/L比(36.08±4.71)g/L,t=3.769,P0.001]、周尿素清除指数[(1.99±0.48)比(1.76±0.38),t=2.500,P=0.014]、周肌酐清除率[(62.21±15.73)L比(54.96±16.01)L,t=2.176,P=0.032]、残余肾功能[2.62(0.60,3.37)ml/min比1.52(0.44,3.00)ml/min,z=4.093,P=0.043]及接受强化微信管理[(76.47%)比(26.83%),χ2=22.574,P0.001]更高,有统计学意义。优化组与非优化组相比血磷、血FGF23无统计学意义[磷:t=0.646,P=0.519,FGF23:z=1.701,P=0.192]。多元逐步回归分析显示优质蛋白摄入量(回归系数10.589,P=0.001)、鸡蛋白摄入比(回归系数0.358,P=0.033)、血清白蛋白(回归系数0.328,P=0.031)、标准蛋白分解率(回归系数6.123,P=0.009)、微信管理(回归系数6.380,P0.001)、透析龄(回归系数4.54,P=0.002)是本研究中优质蛋白摄入率的独立相关因素。结论常规教育PD患者以磷/蛋白比值低的鸡蛋白为基础蛋白质摄入,并结合微信管理,进行摄入率至少50%优质蛋白质的优化饮食,可使PD患者获得更好的血清白蛋白,不增加高磷血风险,更好保护残余肾功能,且透析更充分,优质蛋白摄入率的独立相关因素可作为指导临床实施PD优化饮食蛋白质摄入的参考依据。     

Ibuprofen pharmacokinetics in preterm infants with patent ductus arteriosus.

OBJECTIVE: Our objective was to study the pharmacokinetics of ibuprofen in premature infants with patent ductus arteriosus on day 3 and day 5 after birth. METHODS: Ibuprofen was administered on days 3, 4, and 5 by a 15-minute intravenous infusion of 10, 5, and 5 mg/kg, respectively, with the aim of closing the ductus arteriosus. Blood samples were drawn at time zero and at 0.5, 1, 2, 4, 12, and 24 hours after the first and third doses. Ibuprofen plasma concentrations were assayed by HPLC. RESULTS: A total of 27 premature infants were included (gestational age, 28.6 +/- 1.9 weeks; birth weight, 1250 +/- 460 g; values are mean +/- standard deviation). Ibuprofen pharmacokinetics followed a 2-compartment open model. Between the first and third doses (day 3 and day 5) there was a significant decrease of the volume of distribution of the central compartment (Vd(c)) (0.244 versus 0.171 L/kg; P =.03) and area under the plasma concentration-time curve (524 versus 447 mg. h/L; P =.01). The decrease in Vd(c) was most pronounced in patients with a closing ductus. Total body clearance and plasma half-life did not change significantly. No significant differences were observed in ibuprofen peak plasma concentrations after the first and third doses in relation to ductal status after treatment. CONCLUSION: Ibuprofen pharmacokinetics showed a large interindividual variation in premature infants during treatment for patent ductus arteriosus, and significant changes may occur between day 3 and day 5 after birth in those infants with a closing ductus. These findings may have implications for the treatment schedule with ibuprofen in patients with patent ductus arteriosus.     

彩色多普勒血流会聚法评估动脉导管未闭分流程度

用彩色多普勒血流会聚法对２０例动脉导管未闭患者的左向右分流率Ｆ进行测定，并根据Ｆ值计算出动脉导管的横截面积Ａ。结果表明，血流会聚法所测分流率Ｆ与频谱Ｄｏｐｐｌｅｒ法所测的分流量Ｑｐ－Ｑｓ、Ｑｐ／Ｑｓ以及导管两端的压差△Ｐ和左室内径ＤＬＶ之间均具有很好的相关性（ｒ分别为０．８１，０．６２，０．６９和０．５３，Ｐ值分别小于０．００１，０．００５，０．００１和０．０１）。根据Ｆ值计算出的导管横截面积Ａ与两组切面上直接测得的导管内径Ｄｄ也具有极好的相关关系（ｒ＝０．８１，Ｐ值＜０．００１）。Ｑｐ／Ｑｓ≥２１所对应的Ｆ值明显高于Ｑｐ／Ｑｓ＜２１所对应的Ｆ值（Ｐ值＜０．００５）。彩色多普勒血流会聚法能够较为快速、准确地评估动脉导管未闭的左向右分流程度     

The use of ibuprofen in neonates in the treatment of patent ductus arteriosus

Indomethacin has long been used to treat patent ductus arteriosus but it is associated with a relatively high risk of adverse effects; recent evidence suggests that ibuprofen is effective and may be safer. In a randomised trial to compare the efficacy and safety of ibuprofen and indomethacin in the treatment of patent ductus arteriosus, 144 infants received three doses of ibuprofen lysine (10, 5 and 5 mg/kg) at 24-hour intervals or indomethacin 0.2 mg/kg at 12-hour intervals. Ductal closure occurred in 70% of children treated with ibuprofen and 66% of those given indomethacin on the first treatment (P = 0.41). Nineteen children underwent surgical ligation, equally distributed between the treatment groups (P = 0.81). Urine production was significantly greater than in children given indomethacin from day 3 to day 7 and the serum creatinine concentration was significantly lower from day 7. Ductal closure was associated with higher serum concentrations of ibuprofen and a concentration of 10-12 mg/l appears to be the minimum level for efficacy. In a randomised, placebo-controlled, double-blind trial of prophylaxis with ibuprofen, the rate of patent ductus arteriosus associated with ibuprofen was 19% compared with 42% with placebo. Urine output was comparable in the two groups except on day 1, when it was significantly lower among infants given ibuprofen. Ibuprofen is therefore as effective as indomethacin in the treatment of patent ductus arteriosus, and effective as prophylaxis, in premature infants.     

Quantification of Left to Right Shunt in Patent Ductus Arteriosus by Color Doppler

Ultrasound is a reliable tool to diagnose patent ductus arteriosus in premature infants but no reliable noninvasive method exists to quantify ductal flow. The aim of this study was to quantify the size of the shunt via persistent ductus arteriosus from pixel counts in color Doppler flow images. A cotton band was placed around the ductus arteriosus of newborn lambs to adjust the magnitude of flow. For flow measurements, ultrasonic transit time flow probes were applied around the ascending aorta and ductus arteriosus. Twenty-four different flow states were attained in four newborn lambs. An Acuson Sequoia scanner equipped with a 7 MHz transducer was used to register Doppler data and images with maximal color distribution during diastole in the pulmonary artery longitudinal sections (PALS). Each image-pixel was matched with the color velocity bar and the pixels were assigned to the corresponding flow velocity. The total area showing color relative to the area of the PALS correlated well with the amount of ductal flow (r = 0.87, r² = 0.75, p < 0.001). When Qp/Qs was >1.4:1, more than 40% of the area in PALS in diastole exhibited color information. Similarly, the color pixel velocities squared correlated with the size of the shunt. Quantification of the percentage of pixels in a color Doppler registration via a computer-based analysis shows a high correlation with the size of ductal shunting. (E-mail: solweig.harling@med.lu.se)     

早产儿动脉导管未闭的药物治疗时机探讨

目的探讨药物治疗早产儿动脉导管未闭（PDA）的时机。 方法回顾性分析2016年1月至2018年12月四川锦欣妇女儿童医院新生儿科收治的符合入选标准的早产儿（胎龄<32周）151例。根据布洛芬的使用情况分成3组,其中症状时治疗组43例、症状前治疗组32例、对照组76例。根据是否诊断为有血流动力学意义的PDA（hsPDA）,分为hsPDA组和非hsPDA组,症状时治疗组属于hsPDA组,症状前治疗组及对照组属于非hsPDA组。出生第1天检测血常规、生化、血气分析等。出生满3 d筛查超声心动图,记录当日脉压差及尿量。两治疗组,口服布洛芬10 mg/kg,24 h及48 h后各予5 mg/kg,治疗72 h后复查超声心动图。对照组,未予布洛芬治疗,出生后7 d复查超声心动图。复查PDA患儿,出生后30 d再次复查超声心动图。采用χ²检验比较症状时治疗组、症状前治疗组、对照组3组间性别、孕母使用过激素的比例、胎膜早破>18 h比例、剖宫产比例、小于胎龄儿比例、动脉导管7 d关闭率、动脉导管30 d关闭率、脓毒症发生率及呼吸窘迫综合征、脑室内出血、支气管肺发育不良、坏死性小肠结肠炎发生率等的差异;采用单因素方差分析比较胎龄、出生体质量、尿量、脉压差、血pH值的差异;采用Kruskal-Wallis H法比较5 min Apgar评分、正压通气时间、吸氧时间等的差异。 结果性别、胎龄、孕母使用过激素、胎膜早破、剖宫产、出生体质量、小于胎龄儿,5 min Apgar评分、血pH值、尿量、呼吸窘迫综合征发生率,动脉导管生后30 d关闭率、正压通气时间、吸氧时间,发生脑室内出血、支气管肺发育不良、坏死性小肠结肠炎情况,在症状时治疗组、症状前治疗组、对照组3组之间比较,差异均无统计学意义（P>0.05）。症状前治疗组、症状时治疗组和对照组3组间脉压差分别为（22.13±13.83）mmHg（1 mmHg=0.133 kPa）、（24.24±9.72）mmHg、（16.22±8.81）mmHg,症状前治疗组高于对照组,差异无统计学意义（t=0.732、P=0.639）,症状时治疗组高于症状前治疗组和对照组,差异均具有统计学意义（t=3.25、4.710,P=0.002、<0.001）。3组脓毒症发生率分别为9.38%（3/32）、27.91%（12/43）和10.53%（8/76）,症状前治疗组低于对照组,差异无统计学意义（χ²=0.033,P=0.856）;症状时治疗组高于症状前治疗组和对照组,差异均具有统计学意义（χ²=5.933、4.230,P=0.015、0.040）。动脉导管生后7 d关闭率,症状时治疗组和症状前治疗组均高于对照组［65.63%（21/32）vs 60.47%（26/43）vs 32.89%（25/76）］,差异均具有统计学意义（χ²=8.524、9.866,P=0.004、0.002）。动脉导管生后30 d关闭率组间差异均无统计学意义（P>0.05）。 结论口服布洛芬可以促进动脉导管早期闭合,但对远期闭合率并无明显优势。预防性布洛芬干预不能缩短PDA早产儿的正压通气、吸氧时间及降低脑室内出血、支气管肺发育不良、坏死性小肠结肠炎等并发症的发生率。而对hsPDA,布洛芬干预能否减少呼吸支持依赖及并发症的发生仍有待于进一步的研究。     

The use of renal Doppler ultrasonography to diagnose patent ductus arteriosus in preterm infants.

OBJECTIVE: To prospectively study the diagnostic usefulness of altered renal waveforms in patent ductus arteriosus. METHODS: We studied preterm infants undergoing echocardiography for a suspected patent ductus arteriosus. A spectral Doppler display was acquired for both renal arteries, and a resistive index was obtained. Sensitivity, specificity, and likelihood ratios were calculated using a clinically significant patent ductus arteriosus (>1.5-mm diameter on color Doppler ultrasonography) as the standard of reference. RESULTS: Fifty infants had 78 scans. A significant patent ductus arteriosus was present on 39 scans. When the renal resistive index was greater than 1.0, the likelihood ratio for a significant patent ductus arteriosus was 24.8 (specificity, 97.2%; SD, 3.8%). When the renal resistive index was 1.0 or less, the likelihood ratio for a significant patent ductus arteriosus was 0.2 (sensitivity, 77.2%; SD, 9.4%). CONCLUSIONS: Renal resistive index measurement is a simple investigation that can predict a significant patent ductus arteriosus in patients without congenital heart disease or other causes of diastolic runoff when echocardiography is unavailable.     

Changes in transmitral and pulmonary venous flow patterns in the first day of life

The purpose of this study was to see the relationship between changes in pulmonary venous flow velocities and those in transmitral flow velocities during the first day of life. A serial Doppler echocardiography was performed in 24 normal neonates at 2, 12, and 24 hours of age. The size of the ductus arteriosus was 4.3 ± 0.5 mm at 2 hours and 2.1 ± 0.7 mm at 12 hours, and closed in 21 of 24 neonates at 24 hours. The peak systolic pulmonary venous flow (peak S), peak diastolic pulmonary venous flow (peak D), peak D/S, peak velocity at early diastolic filling (peak E), and peak E/A, which were high at 2 hours, decreased significantly at 12 hours but remained constant thereafter. The size of the ductus arteriosus was found to be correlated with peak S, peak D, and peak D/S. There was a direct correlation between peaks E and D (r: 0.64, p < 0.01) as well as a direct correlation between peaks E/A and D/S (r: 0.36, p < 0.05). These results indicate that the diastolic pulmonary venous flow is determined by the same factors that influence the transmitral flow. These waveforms may reflect the increase in pulmonary circulatory volume by left-to-right shunting through the ductus arteriosus. © 1995 John Wiley & Sons, Inc.     

动态监测极早产儿血25(OH)D水平及其对肺部疾病的影响

目的 动态监测极早产儿维生素D水平并探讨其对极早产儿肺部疾病的影响。方法 选取2019年6月-2020年12月期间于青岛大学附属医院新生儿重症监护室(neonatal intensive care unite,NICU)住院、并经得家长知情同意的胎龄<32周的极早产儿共126例,于生后24 h、1月、2月(或出院时)检测血清25-(OH)D水平。根据生后血清25-(OH)D水平,将极早产儿分为3组,维生素D缺乏组(n=71),25(OH)D<12 ng/ml;维生素D不足组(n=46),25(OH)D 12～<20ng/ml;维生素D充足组(n=9),25(OH)D>20～≤100 ng/ml。所有早产儿在喂养耐受后给予维生素AD(其中维生素D 500 IU,维生素A 1500 IU)每日1粒,及维生素D3 400 IU;收集早产儿一般临床资料,比较各组间呼吸窘迫综合征(respiratory distress syndrome,RDS)、呼吸机使用时间、住院时间、早期肺高压、动脉导管未闭(patent ductus arteriosus, PDA)、支气管肺发...     

Tolerance of simulated amniotic fluid in premature neonates

OBJECTIVE: To assess the tolerance of simulated amniotic fluid enterally administered in premature neonates. DESIGN: A multicentered, Phase I, dose-escalation trial was accomplished among 30 preterm neonates. Groups of 10 patients received 5, 10, or 20 mL/kg/d enterally of the amniotic fluid solution, divided into every-3-hour dosing, for 3 days. MAIN OUTCOME MEASURES: Amount and character of emesis, stools, and gastric residuals; changes in abdominal girth; presence of a skin rash; blood pressure instability; the diagnosis of necrotizing enterocolitis (NEC) or intestinal perforation. RESULTS: Thirty patients were studied: 10 received 5 mL/kg/d, 10 received 10 mL/kg/d, and 10 received 20 mL/kg/d of amniotic solution. Gestational ages ranged from 25 to 31 weeks. The Data Safety and Monitoring Board met after each group of 10 patients completed the study, reviewed the outcome measurements, and recommended continuance of the study. Dosing was discontinued for 3 patients prior to receiving all 24 doses because of gastric residuals (n = 1; 5 mL/kg), stage I NEC (n = 1; 10 mL/kg), or symptomatic patent ductus arteriosus (n = 1; 20 mL/kg). The remaining patients completed the doses with no evidence of intolerance: specifically, no increased gastric residuals, increased abdominal girth, diarrhea, blood pressure change, rash, NEC, or intestinal perforation. CONCLUSIONS: Enteral administration of an amniotic fluid-like solution to preterm neonates is well tolerated in doses 相似文献   

Swan-Ganz catheterization in the critically ill newborn.

The authors placed Swan-Ganz catheters in 11 preterm and 2 term infants with severe cardiopulmonary distress. The infants ranged in weight from 1100-4000 g. The procedure was performed in the neonatal ICU by jugular venous cutdown. Intracardiac pressures and oxygen saturations were measured in each chamber entered. The authors also evaluated the presence of right to left shunting through the patent ductus arteriosus and assessed the degree of pulmonary arterial hypertension. In 5 hypoxemic infants, the authors found a patent ductus arteriosus with pulmonary hypertension. Intermittent measurement of PAP served as a guide to further therapy. In 2 infants, the unexpected diagnosis of cyanotic congenital heart disease was made. The placement of flow directed pulmonary arterial catheters in critically ill infants can be performed safely at the bedside and can provide useful diagnostic and therapeutic information.