PICU中神经重症的脑功能评估与监测

脑损伤是PICU最常见的疾病之一,早期发现和及时干预可以改善预后。目前临床上用于脑功能评估与监测的方法很多,主要包括颅内压监测(有创和无创)、脑血流监测(如经颅多普勒超声)、脑代谢监测(如脑氧监测、磁共振脑功能成像技术和微透析技术)和脑电生理监测(脑电图和诱发电位)。临床医生应根据患儿病情采用个体化的监测方法和治疗方案以降低神经重症患儿的伤残率,改善预后。     

新生儿脑氧合及脑功能监测的意义

围生期新生儿易发生各种类型的缺氧，导致脑损伤，严重者遗留神经系统后遗症。早期客观评价新生儿脑氧合、血流动力学、脑反应的改变，及时发现并治疗脑组织缺氧，已成为临床迫切需要解决的问题。近红外光谱技术（Near Infrared Spectroscopy，NIRS）可直接反映组织中氧与血红蛋白的氧合与解离情况，表明组织中的血氧合状态，是脑组织氧合、血流及灌注客观评价的手段，     

脑氧饱和度监测在新生儿脑损伤中的应用

在新生儿脑损伤发生过程中,脑氧饱和度的改变先于脑电图、神经功能及组织形态的改变,脑氧饱和度监测是早期预测指标。近红外光谱(NIRS)分析技术具有无创、持续、床旁监测、安全可行的特点,是脑氧饱和度监测的重要工具。采用NIRS可测定新生儿脑血流容积、脑血流流量的正常值,可用于胎儿-新生儿过渡期不良分娩和复苏效果的监测和缺氧...     

早期监测脑氧饱和度及脑血流参数在脓毒性休克患儿预后中的意义

目的 探讨脑氧饱和度(rScO 2)及脑血流参数氧合血红蛋白浓度(ΔO 2 Hb)、还原血红蛋白浓度(ΔHHb)和血红蛋白浓度指数(THI)在判断脓毒性休克患儿预后中的价值.方法 选择2017年10月—2019年10月收治的脓毒性休克患儿50例.入重症监护病房(ICU)即刻开始监测患儿血流动力学参数,包括平均动脉血压(...     

体外膜肺期间脑血流及脑代谢的研究进展

体外膜肺（ｅｘｔｒａｃｏｒｐｏｒｅａｌｍｅｍｂｒａｎｅｏｘｙｇｅｎａｔｉｏｎ,ＥＣＭＯ）是近１０余年儿科抢救危重患儿生命的一种较新的技术,发展快,效果好。但应用中仍存在许多问题,其中脑保护是目前研究热点之一。（一）ＥＣＭＯ的发展及其工作原理：自１９８...     

近红外光谱对早产儿脑组织氧饱和度监测的临床应用

与经皮血氧饱和度(percutaneous oxygen saturation,SpO 2)相比,脑组织氧饱和度(cerebral regional tissue oxygen saturation,CrSO 2)反映的是脑组织的混合氧饱和度,其变化与新生儿生后脑组织的新陈代谢密切相关。近红外光谱技...     

疾病状态下新生儿脑组织氧饱和度的测定

目的测定有围产期脑损伤的足月新生儿、不同胎龄早产儿的脑组织氧饱和度。方法应用TSNIR蛳3无创组织氧监测仪,测定44例围产期脑损伤的足月新生儿、198例不同胎龄早产儿的脑组织氧饱和度,并与90例对照组进行比较。结果脑损伤的足月新生儿脑组织氧饱和度为(54.9±5.2)%,对照组为(61.3±3.9)%,两者相比差异有统计学意义。不同胎龄早产儿脑组织氧饱和度不同,随着胎龄的增长,脑组织氧饱和度呈上升趋势,32周以上的早产儿脑组织氧饱和度接近足月儿。结论脑损伤患儿的脑组织氧饱和度低于对照组;早产儿随着脑血管发育的不断成熟,32周以上的早产儿脑组织氧饱和度已接近足月儿的水平。     

近红外光谱技术对新生儿脑组织氧检测的应用与展望

氧是维持人体组织细胞正常功能和生命活动的基础。一旦缺氧,可威胁到全身各系统的代谢与功能,尤其对中枢神经系统的危害更引人关注,因为在缺氧时脑细胞的生物氧化过程可发生障碍,可导致神经元急性坏死和凋亡,使小儿留下终生残疾。多年来,在临床工作中,机体的氧合状况始终是倍受关注的生命监测指标之一,但目前广泛应用的血气分析和经皮氧饱和度监测所得到的结果仅是血液中的氧分压和肢端搏动的小动脉血氧饱和度,而不是脑组     

近红外光谱技术对有血流动力学意义的动脉导管未闭早产儿肠道组织氧饱和度监测价值的前瞻性研究

目的 使用近红外光谱技术研究有血流动力学意义的动脉导管未闭（hemodynamically significant patent ductus arteriosus,hsPDA）早产儿肠道组织氧饱和度（regional oxygen saturation,rSO₂）的变化及规律,初步探索hsPDA早产儿肠道组织血氧水平变化的临床意义。 方法 前瞻性选取2017年10月至2020年10月深圳市龙岗中心医院新生儿科收治的胎龄<32周和/或出生体重<1 500 g的动脉导管未闭（patent ductus arteriosus,PDA）早产儿。按照hsPDA的诊断标准分为hsPDA组和无血流动力学意义的动脉导管未闭（non-hemodynamically significant patent ductus arteriosus,nhsPDA）组,将hsPDA组早产儿根据口服布洛芬后动脉导管关闭情况分为hsPDA关闭亚组和hsPDA未闭亚组。分别在诊断PDA时及治疗后测定血流动力学指标,持续监测患儿肠道组织rSO₂水平,分析其变化规律。 结果 共有241例PDA早产儿纳入研究,其中hsPDA组55例（22.8%）,nhsPDA组186例（77.2%）;hsPDA关闭亚组36例（65%）,hsPDA未闭亚组19例（35%）。hsPDA组左心房内径/主动脉根部内径值大于nhsPDA组,左室射血分数和短轴缩短率均低于nhsPDA组（P<0.05）。hsPDA组患儿肠道组织rSO₂在诊断后6 h内各时间点（1、2、4、6 h）均低于nhsPDA组（P<0.05）;hsPDA组早产儿肠道组织rSO₂随时间呈下降趋势（P<0.05）,至6 h时达最低值（0.448±0.014）。hsPDA关闭亚组左心房内径/主动脉根部内径值低于hsPDA未闭亚组,左室射血分数和短轴缩短率高于hsPDA未闭亚组（P<0.05）。hsPDA关闭亚组患儿肠道组织rSO₂在治疗后48~96 h内各时间点（48、72、96 h）均高于hsPDA未闭亚组（P<0.05）;hsPDA关闭亚组早产儿肠道组织rSO₂从治疗24 h后随时间呈上升趋势（P<0.05）,至96 h达最高值（0.578±0.031）。 结论 hsPDA对早产儿肠道组织氧合有影响,可通过近红外光谱技术持续监测hsPDA早产儿肠道组织rSO₂变化趋势指导临床管理。     

出生早期早产儿脑组织氧合的临床研究

目的采用近红外光谱技术比较早产儿和健康足月儿出生12～24 h脑组织氧合状况。方法对2011年4-6月南京大学医学院附属鼓楼医院妇产科收治的77例足月儿和2011年11月-2012年3月南京医科大学附属儿童医院新生儿医疗中心收治的61例早产儿进行出生12～24 h的脑组织氧饱和度(rSO2)监测,比较2组新生儿的临床情况及其与rSO2的关系。结果 2组新生儿分娩方式和性别比较,差异均无统计学意义(Pa>0.05)。2组新生儿胎龄、出生体质量及窒息(Apgar评分)比较,差异均有统计学意义(Pa<0.05)。2组新生儿的检测时间和外周血氧饱和度比较,差异均无统计学意义(Pa>0.05)。健康足月儿组的rSO2为(62.70±3.75)%,早产儿组rSO2为(64.66±3.93)%,二组比较差异有统计学意义(P=0.003)。健康足月儿组的动脉血二氧化碳分压[p(CO2)]为(5.26±0.36)kPa,早产儿组为(6.04±1.18)kPa,二组比较差异有统计学意义(P=0.000)。结论早期早产儿与健康足月儿相比,出生12～24 h的rSO2偏高,可能与该时期早产儿的脑血流丰富,动脉血p(CO2)分压偏高及脑组织的局部缺氧有关。     

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目的了解窒息新生儿在听觉刺激诱发脑神经活动时的脑氧合代谢和脑血流量的改变。方法1998~2003年北京中日友好医院儿科选择窒息新生儿34例为窒息组,健康新生儿40名为对照组。使用近红外光谱仪,观察听觉刺激试验诱发的脑氧合血红蛋白[HbO2]、还原血红蛋白[HbH]和总血红蛋白[Hbtot]浓度的变化,并比较两组脑氧合代谢和脑血流量的改变。根据[HbO2]、[HbH]和[Hbtot]不同的变化,将氧合代谢曲线分为A([HbO2]、[HbH]和[Hbtot]均增加);B([HbO2]和[Hbtot]增加,[HbH]降低);C([HbO2]和[Hbtot]降低,[HbH]增加)3种曲线类型。结果窒息组中25例(25/34、73·5%)显示C型变化,对照组中28例(28/40、70·0%)显示A型变化,两组中A、C两型例数比较差异显著(P<0·05)。两组[HbO2]和[Hbtot]数值变化幅度比较差异显著(P<0·05)。结论窒息新生儿听觉刺激诱发相应皮层的神经活动时,显示局部脑血流量下降、氧合代谢降低,重度窒息儿更明显。     

Surgical closure of the patent ductus arteriosus and its effect on the cerebral tissue oxygenation

Aim: Surgical patent ductus arteriosus (PDA) ligation is considered after failure or contraindication of medical treatment. Till now ligation of the PDA has been associated with low morbidity and mortality although recently concerns have been raised about the possible association of ductal clipping and neurodevelopmental abnormalities later in life. By means of near‐infrared spectroscopy (NIRS), we analysed the changes in the cerebral tissue oxygenation index (TOI) and fractional tissue oxygen extraction (FTOE) at the time of clipping as well as after clipping. Method: Ten preterm infants with a symptomatic PDA who underwent surgical ligation were continuously monitored for heart rate (HR), mean arterial blood pressure (MABP), peripheral oxygen saturation (SaO₂) and TOI from 1 h before up to 1 h after clipping. FTOE and haemoglobin difference (HbD) were calculated. Changes in parameters at 5 min after ligation represent the effect of the clipping itself whereas changes up to 1 h‐post‐clipping represent the post‐clipping effect. Results: At the exact time of clipping, over the entire group, we found a significant increase in TOI of 2.9% (p = 0.037), in HbD of 12.5 μmol/l (p = 0.047) and in HR of 6.5 bpm (p = 0.012). FTOE significantly decreased by 0.02% (p = 0.013). One hour post‐clipping, the cerebral and peripheral parameters were not significantly different from the control values before clipping. Conclusion: The ductal clipping in se has no negative effect on the cerebral oxygenation.     

Comparison of venoarterial versus venovenous access in the cerebral circulation of newborns undergoing extracorporeal membrane oxygenation

This study was designed to compare venoarterial (VA) with venovenous (VV) access in the cerebral circulation of newborn infants during extracorporeal membrane oxygenation (ECMO). Among 14 infants with VA ECMO, 7 had no intracranial complications (group 1), while the others (group 2) developed intracranial hemorrhage (ICH). In contrast, among 19 infants with VV ECMO, only 1 developed ICH. Serial echocardiograms were performed before and after 1, 6, 12, and 24 h and 2 and 3 days of ECMO. The mean cerebral blood flow (CBF) velocities were measured in the anterior cerebral artery (ACA), right and left internal carotid arteries (Rt, Lt-ICA), basilar artery (BA), and right and left middle cerebral arteries (Rt, Lt-MCA). Ejection fraction (EF), cardiac output (CO), and stroke volume (SV) were also measured using standard echography. The velocity levels in the ACA, Rt-MCA, and Lt-MCA in VA ECMO were lower than those in VV ECMO, while those in the Lt-ICA and BA in VA ECMO were higher than those in VV ECMO. The EF, CO, and SV were lower in cases of VA ECMO than in VV ECMO. In cases of VA ECMO, there were no differences between groups 1 and 2 in velocities in the ACA, Rt-ICA, or Lt-ICA. However the velocities in group 2 in the BA, Rt-MCA, and Lt-MCA were lower than those in group 1 before and during ECMO. Similarly, the EF, CO, and SV were lower in group 2 (12.0%–31.0%, 0.10–0.32 l/min, and 0.66–1.55 ml, respectively) than in group 1 (29.5%–49.3%, 0.25–0.63 l/min, and 2.15–3.85 ml) during ECMO. However, in the infants on VV ECMO the CBF was either maintained or gradually increased before and during ECMO. Their cardiac parameters were: EF 46.1%–53.0%, CO 0.43–0.52 l/min, and SV 2.72–3.84 ml during ECMO. It is concluded that in VA ECMO CBF velocities, particularly in infants who developed ICH, decreased after the onset of ECMO in association with poor cardiac function, while in VV ECMO they were stable, probably due to normal systemic hemodynamics and cardiac function.     

Effects of repeated indomethacin administration on cerebral oxygenation and haemodynamics in preterm infants: Combined near infrared spectrophotometry and Doppler ultrasound study

The objectives of this study were to evaluate the effect of repeated indomethacin administration on cerebral oxygenation in relation to changes in cerebral blood flow velocity (CBFV) and other relevant physiological variables. Fourteen preterm infants with patent ductus arteriosus were studied during three subsequent indomethacin bolus administrations with intervals of 12 and 24 h. Changes in concentration of oxyhaemoglobin (cO₂Hb), deoxyhaemoglobin (cHHb) and oxidized cytochrome aa₃ (cCyt.aa₃) in cerebral tissue and changes in cerebral blood volume (CBV) were measured by near infrared spectrophotometry; changes in mean CBFV in the internal carotid artery were measured by pulsed Doppler ultrasound. Simultaneously heart rate, transcutaneouspO₂ andpCO₂, arterial O₂ saturation and blood pressure were measured. All variables were continuously recorded until 60 min after indomethacin administration. Within 5 min after each indomethacin administration, significant decreases in CBFV, CBV and cO₂Hb and cCyt.aa₃ were observed which persisted for at least 60 min, while cHHb increased or did not change at all. There were no changes in the other variables recorded. These data demonstrate that indomethacin administration is accompanied by a reduction in cerebral tissue oxygenation due to decreased cerebral blood flow. Therefore, low arterial oxygen content, either caused by low arterial O₂ saturation or by low haemoglobin concentration, may be a contraindication for indomethacin treatment in preterm infants.