新生儿重度窒息抢救中的几个问题

新生儿重度窒息系指母儿通过胎盘的血气交换发生障碍引起胎儿严重缺氧和酸中毒,导致呼吸、循环和中枢神经系统严重受抑,出生后Apgar评分0～3分,脐动脉血气显示严重的代谢性或混合性酸中毒,pH <7 0 0。这类患儿通常无自主呼吸,伴严重的心动过缓或心脏停搏,是产房最常见的新生儿急症。其抢救在美国心脏病学会(AHA)和美国儿科学会(AAP) 2 0 0 0年新版新生儿复苏教材(TNR) [1 ] 和国内有关文献[2 ] 中已有详尽叙述,本文重点讨论新生儿重度窒息抢救中临床医生常问及的几个问题。1　严格保温还是早期亚低温AHA和AAP有鉴于寒冷刺激对新生儿…     

新生儿窒息复苏——当前需要纠正的概念误区

2011年我国发布了最新的“新生儿复苏指南”,不再习惯性称为“新生儿窒息复苏指南”,这种形式上的同国际接轨却蕴含着深刻的本质意义,将带来新生儿复苏的新思维、新行为,应从3个方面加以认识.一是当前国际上“新生儿窒息”的诊断十分严格,表明窒息是复苏后事件而非复苏前事件,复苏失败才有窒息,故不宜称窒息复苏;二是新生儿复苏流程图上显示从一出生到复苏完毕从来都不提窒息与否;三是如长期受“窒息复苏”错误概念桎梏,复苏行为则往往显得十分被动和应付,虽复苏方案与国外相同,但结果却一直不同.故转变观念,首先复苏,才有利于新生儿窒息病死率降至本可达到的国际水准.     

Quality of survival after severe birth asphyxia.

Thirty-one children who survived severe birth asphyxia defined by a 1-minute Apgar score of 0, or a 5-minute Apgar score of less than 4, have been seen at age 5 to 10 years for neurological and psychological assessment. Their progress has been compared with that of controls matched for sex, birthweight, gestational age, and social class. 29(93%) of the 31 asphyxiated group and all the controls had no serious neurological or mental handicap. 2 were severely disabled and mentally retarded. Detailed studies of psychological function showed no significant differences between the two groups. 2 apparently stillborn infants have made normal progress. It was not possible to identify any perinatal factor which predicted the occurrence of serious handicap with certainty. We considered that the quality of life enjoyed by the large majority of the survivors was such as to justify a positive approach to the resuscitation of very severely asphyxiated neonates.     

Thiopentone induced coma after severe birth asphyxia.

The aim of this study was to determine the feasibility of inducing a prolonged coma in severely asphyxiated newborn babies by the infusion of high dose thiopentone. In six severely asphyxiated babies the electroencephalograph (EEG) and blood pressure were monitored continuously. Thiopentone was infused at a rate sufficient to suppress completely the EEG providing the mean blood pressure remained above 35 mm Hg; it was continued until there was no evidence of cerebral oedema for 24 hours. In two the infusion was stopped prematurely because of hypotension that was unresponsive to treatment. In the other four a deep coma was maintained for a median duration of 127 hours. All developed pharmacodynamic tolerance to the thiopentone and showed non-linear elimination kinetics. Three babies died; the three survivors have moderate to severe handicap. It was concluded that with full intensive care it is possible to induce a deep coma; the outcome does not seem to be improved, however, and the incidence of complications was high.     

Medical management of raised intracranial pressure after severe birth asphyxia.

The effects of dexamethasone and 20% mannitol infusion in reducing raised intracranial pressure were assessed in severely asphyxiated newborn infants. Intracranial pressure was measured continuously by a percutaneously placed subarachnoid catheter, and cerebral perfusion pressure was calculated from this and blood pressure data. Dexamethasone treatment, assessed in seven infants, produced an overall fall in intracranial pressure which was sustained for at least six hours, but this was coincident with a simultaneous reduction in systemic blood pressure with no change in the cerebral perfusion pressure. Mannitol, studied on nine occasions, produced a fall in intracranial pressure in each case, together with an overall rise in cerebral perfusion pressure 60 minutes after starting the infusion; this was sustained for a further four hours. We can find little to support the routine use of dexamethasone in severe perinatal asphyxia but mannitol infusion seems of value in treating raised intracranial pressure associated with cerebral oedema.     

The dangers of premature extubation after severe birth asphyxia

Abstract The records of all 91 neonates with asphyxia who were referred to the Royal Children's Hospital in 1982 and 1983 were reviewed and information was obtained on their subsequent neurological outcome. Thirty children had been extubated after their initial resuscitation, before transfer to the Royal Children's Hospital; 21 of these children had been extubated despite the fact that they had taken more than 5 min to take their first breath, and 11 (52%) of them died (while none of the nine infants who breathed within 5 min died). A paediatrician was involved with two-thirds of the 21 children who were extubated despite having more than 5 min to breathe. Twelve children required cardiac massage; seven of them were extubated and then reintubated before transfer, and six of the seven infants died. These findings suggest that many paediatricians are not aware of the importance of continuing ventilatory support in neonates who have suffered a severe asphyxial insult. Asphyxiated babies who require cardiac massage, and babies who do not start breathing within 5 min of birth, should not be extubated as soon as they have established regular respiration; they should remain intubated and be transferred to an intensive care unit.     

The dangers of premature extubation after severe birth asphyxia

The records of all 91 neonates with asphyxia who were referred to the Royal Children's Hospital in 1982 and 1983 were reviewed and information was obtained on their subsequent neurological outcome. Thirty children had been extubated after their initial resuscitation, before transfer to the Royal Children's Hospital; 21 of these children had been extubated despite the fact that they had taken more than 5 min to take their first breath, and 11 (52%) of them died (while none of the nine infants who breathed within 5 min died). A paediatrician was involved with two-thirds of the 21 children who were extubated despite having more than 5 min to breathe. Twelve children required cardiac massage; seven of them were extubated and then reintubated before transfer, and six of the seven infants died. These findings suggest that many paediatricians are not aware of the importance of continuing ventilatory support in neonates who have suffered a severe asphyxial insult. Asphyxiated babies who require cardiac massage, and babies who do not start breathing within 5 min of birth, should not be extubated as soon as they have established regular respiration; they should remain intubated and be transferred to an intensive care unit.     

Outcome of very severe birth asphyxia.

The aim of this study was to establish the outcome of very severe birth asphyxia in a group of babies intensively resuscitated at birth. 48 infants, born between 1966 and 1971 inclusive, were selected; 15 were apparently stillborn and 33 had not established spontaneous respirations by 20 minutes after birth. One-half of them died, but 3 to 7 years later three-quarters of the survivors are apparently normal. Later handicap was associated with factors leading to prolonged partial intrapartum asphyxia, while acute periods of more complete asphyxia were not necessarily harmful.     

Clinical profile of severe birth asphyxia.

In this retrospective analysis, 56 babies with Apgar score 3 and less were studied. In 33, successful bag-mask ventilation was carried out. Seventeen babies received endotracheal IPPV. In 9 out of them bag-mask ventilation was never tried whereas in 8 bag-mask ventilation had failed. In 6 babies physical stimulation and blast of oxygen on the face was adequate. Following this experience, in the subsequent years, endotracheal intubation was required mainly in extremely low birth weight babies or babies with Apgar score 0 at birth. During the study period, drugs were used in about 50% babies. In subsequent years this figure has come down to 10%, that too in special situations. This study helped us to evolve a policy in resuscitations severely asphyxiated babies. Bag-mask ventilation is the first choice. Failure to achieve progressively improving Apgar score by 1 minute, usually 4-5, is an indication for endotracheal intubation. Drugs are required in special situations only.     

Neonatal resuscitation 2: an evaluation of manual ventilation devices and face masks

BACKGROUND: The key to successful neonatal resuscitation is effective ventilation. Little evidence exists to guide clinicians in their choice of manual ventilation device or face mask. The expiratory tidal volume measured at the mask (V(TE(mask))) is a good estimate of the tidal volume delivered during simulated neonatal resuscitation. AIM: To compare the efficacy of (a) the Laerdal infant resuscitator and the Neopuff infant resuscitator, used with (b) round and anatomically shaped masks in a model of neonatal resuscitation. METHODS: Thirty four participants gave positive pressure ventilation to a mannequin at specified pressures with each of the four device-mask combinations. Flow, inspiratory tidal volume at the face mask (V(TI(mask))), V(TE(mask)), and airway pressure were recorded. Leakage from the mask was calculated from V(TI(mask)) and V(TE(mask)). RESULTS: A total of 10,780 inflations were recorded and analysed. Peak inspiratory pressure targets were achieved equally with the Laerdal and Neopuff resuscitators. Positive end expiratory pressure was delivered with the Neopuff but not the Laerdal device. Despite similar peak pressures, V(TE(mask)) varied widely. Mask leakage was large for each combination of device and mask. There were no differences between the masks. CONCLUSION: During face mask ventilation of a neonatal resuscitation mannequin, there are large leaks around the face mask. Airway pressure is a poor proxy for volume delivered during positive pressure ventilation through a mask.     

Cerebral function monitoring: a method of predicting outcome in term neonates after severe perinatal asphyxia

Thornberg E, Ekström-Jodal B. Cerebral function monitoring: a method of predicting outcome in term neonates after severe perinatal asphyxia. Acta Pædiatr 1994;83:596–601. Stockholm. ISSN 0803–5253
The cerebral function monitor (CFM), a simplified one-channel EEG monitor, was evaluated in predicting outcome after severe perinatal asphyxia in 38 term infants. Survivors were followed until 1.5–2.5 years of age. All those 17 infants who survived without major neurological handicap showed continuous activity on the CFM trace during the first and/or second day of life. Twenty of the 21 infants who either died or developed severe neurological damage had burst suppression or paroxysmal activity on the first or second day of life. Thus cerebral function monitoring can be a valuable tool in predicting prognosis for infants with severe perinatal asphyxia.     

Neonatal Pepper's syndrome. Apropos of a series of 22 cases

From 1960 to 1987, 22 neonates were treated at the Institut Gustave-Roussy for a Pepper' syndrome. During this period of time, 83 children were treated for the same syndrome, the neonatal type representing 26% of cases. Twelve of the 22 neonates presented with the rapidly evolving type, requiring an immediate aggressive treatment. In 4 of them death occurred early despite treatment. The 10 other neonates presented with a slowly progressive disease. In 5 of them treatment of the metastatic disease was not necessary to obtain remission. The survival rate of disease without relapses in 77%, with a median follow-up of 8 years. So, despite the high incidence of rapidly progressive forms, the prognosis of this disease remains favorable in neonates, provided an accurate treatment initiated early.     

Neonatal diabetes. Apropos of 2 cases

Diabetes mellitus uncommon in the newborn infant. There are two entities: a transient form and a permanent one. Differenciation is difficult. Transient diabetes, apparently the more common of the two, results in complete recovery. Permanent diabetes requires continued insulin therapy. The clinical presentations of these patients in the first days to weeks of life are similar in that the infants are small for gestational age, hyperglycemic, dehydrated and only rarely have ketonemia or ketonuria. However, the aetiology of the syndrome is unknown. The authors report two cases of permanent diabetes mellitus identified in the first two months of life, and still treated at thirty months of life.     

以腹痛为突出表现的危重病例临床分析

目的 探讨以腹痛为突出表现的危重病例的临床特点.方法 分析11例以腹痛为主要症状并伴有呕吐、面色苍白、口唇发绀等休克和多脏器功能损害表现的危重患儿的临床特征.结果 8例为暴发性心肌炎,以病情进展迅速、病死率高、心电图表现多样、心源性休克、心跳骤停多发为其特点.2例链球菌中毒休克综合征(STSS)早期无特异表现.STSS患儿病程中出现腹痛、少尿时应警惕早期休克的发生.皮疹、咳嗽、发热、白细胞进行性下降和C反应蛋白升高是STSS的临床特点.1例为大网膜囊肿,掌握手术时机是治疗本病的关键所在.结论 应提高对危重疾病引起的腹痛的认识,治疗的关键是原发病的早期发现与及时纠正休克.