ȫ�Զ���Ѫ���Ըߵ�����Ѫ֢������ѪҺ�ڻ���Ӱ���о�

目的探讨全自动换血术对高胆红素血症新生儿血液学指标的影响,评估其疗效与安全性以及间接胆红素和白蛋白比值的临床意义。方法 2008年1月至2010年5月南方医科大学南方医院对74例重症高胆红素血症患儿均采用周围动静脉同步换血术,监测换血前后胆红素、白蛋白、间接胆红素与白蛋白比值、电解质、血常规。结果血中胆红素、白蛋白、间接胆红素与白蛋白比值、电解质(Na+、K+、Cl-、Mg2+)、血常规换血后均较换血前明显下降,但Ca2+、P3+浓度换血后较换血前升高,差异均有统计学意义。换血术后无患儿发生不良反应。结论换血对胆红素、白蛋白、间接胆红素与白蛋白比值、Na+、K+、Cl-、Mg2+、Ca2+、P3+、白细胞、红细胞、血红蛋白、红细胞压积、血小板均有影响,应注意监测。特别要注意监测间接胆红素与白蛋白比值,该比值是评估胆红素毒性的危险指标。比值越高,其危险性越高,越需要输注白蛋白。     

影响换血疗法治疗新生儿高胆红素血症疗效及不良事件发生的多因素分析

目的 探讨影响新生儿高胆红素血症双管同步换血疗法疗效及不良事件发生的因素.方法 回顾性分析重庆医科大学附属儿童医院新生儿诊治中心2006年6月-2009年6月收治的160例经外周动静脉双管同步换血治疗的高胆红素血症患儿的临床资料.不良事件定义为发生如下情况之一:换血过程中发生血氧饱和度曾低于85%并持续5 min以上,发生低血压、呼吸暂停或抑制、心率低于100次·min-1并持续5 min以上.分析换血前患儿的疾病状态、内环境指标、换血量及换血速度对不良事件的影响.结果 本研究中不良事件发生率为30.63%(49/160例).换血过程中有不良事件组新生儿的肺动脉高压患病率高于无不良事件组(8.2% vs 0,P=0.008),有不良事件组患儿换血前血清钾、钠、氯、钙及镁离子水平、Hb水平与无不良事件组比较差异均无统计学意义(Pa>0.05),2组单位体质量换血量、单位时间单位体质量换血量比较差异也均无统计学意义(Pa>0.05).胆红素下降数值与单位体质量换血量呈正相关(r=0.330,P=0.000),与换血前胆红素数值呈正相关(r=0.829,P=0.000).结论 影响换血疗法治疗新生儿高胆红素血症胆红素下降幅度的因素为单位体质量换血量及换血前胆红素水平;影响不良事件发生的主要因素为肺动脉高压.     

EFFECT OF EXCHANGE TRANSFUSION ON SERUM RESERVE ALBUMIN FOR BINDING OF BILIRUBIN AND INDEX OF SERUM BILIRUBIN TOXICITY

ABSTRACT. Ebbesen F. (Department of Neonatology, Rigshospitalet, Copenhagen, Denmark). Effect of exchange transfusion on serum reserve albumin for binding of bilirubin and index of serum bilirubin toxicity. Acta Paediatr Scand, 70:643,.–Seventeen newborn infants, who received their first exchange transfusion due to hyperbilirubinaemia and/or rhesus haemolytic disease, were studied. The exchange transfusions were performed with fresh, citrated blood. During the exchange transfusion a marked increase in the serum reserve albumin concentration for binding of bilirubin measured by the [^,4C]-MADDS method was observed, followed by a smaller decrease after the transfusion. Plasma pH increased both during and after the exchange transfusion. During the exchange transfusion a drastic fall in index of serum bilirubin toxicity was observed, followed by a smaller increase after the transfusion. Citrate was not found to interfere in the binding of bilirubin to albumin. The results are in agreement with the clinical finding that an exchange transfusion performed with fresh, citrated blood effectively reduces the risk of bilirubin encephalopathy. The ratio in serum of binding albumin, i.e. bilirubin plus reserve albumin, to total albumin failed to be increased by the exchange transfusion, and a decrease occurred after the transfusion. These findings indicate the presence in infant serum of non-binding albumin. Donor albumin with intact binding potential is partly transformed into the non-binding variety in the course of one hour after the transfusion. In the most severely rhesus sensitized infant a drastic decline of the serum albumin binding capacity was seen during the first day of life.     

血浆置换治疗新生儿高胆红素血症（极重度）疗效评价

目的　探讨血浆置换在新生儿高胆红素血症（极重度）治疗中的有效性及安全性。方法　采用回顾性分析研究方法,选择2019年1月至2020年12月西安交通大学附属儿童医院重症医学科因新生儿高胆红素血症（极重度）行血浆置换或动静脉同步换血治疗的患儿为研究对象,收集患儿的人口学资料及治疗前后的血清相关指标变化及治疗过程中平均动脉压变化差异,并对两种治疗社会经济学因素进行比较。结果　血浆置换患儿18例,采用倾向性评分匹配同期应用外周动静脉同步换血治疗患儿36例。 两组基线资料差异均无统计学意义（均P＞0.05）;两种治疗方式使总胆红素（TBil）及间接胆红素（IBil）均值明显下降,血浆置换治疗［TBil（μmol/L）：571.21±113.31 vs．235.82±66.71,IBil（μmol/L）：529.06±107.85 vs．218.92±6.36,P＜0.05］;外周动静脉同步换血治疗［TBil（μmol/L）：567.15±99.18 vs．294.34±96.17,IBil（μmol/L）：536.25±87.79 vs．288.54±46.73,P＜0.05］,血浆置换胆红素清除率比外周动静脉同步换血治疗更高,差异均有统计学意义（均P＜0.05）;血浆置换组治疗在白蛋白、静脉免疫球蛋白、白蛋白联合静脉免疫球蛋白等使用率以及血浆使用量、红细胞悬液使用量、蓝光治疗时间、单病种住院时间等方面均低于外周动静脉同步换血组,差异均具有统计学意义（均P＜0.05）。结论　血浆置换能在维持机体内环境稳定基础上达到快速、有效、安全地清除胆红素,减少血制品的输注,节约社会资源,可能成为儿童重症医学科一项有效的临床技术。     

新生儿换血后贫血相关因素分析及干预策略

目的分析影响新生儿换血治疗后贫血的相关因素,探讨干预策略。方法回顾新生儿高胆红素血症换血治疗病例82例,比较换血后贫血组与非贫血组入院时、换血前、换血后红细胞和血红蛋白变化特点,分析影响因素。结果82例换血后血清胆红素明显下降(P<0.001),红细胞、血红蛋白上升(P<0.001)。但仍有39例(47.56%)存在贫血。两组在换血前红细胞、血红蛋白均较入院时下降,非贫血组下降较贫血组明显,经采取补输血,最终贫血均被纠正(P<0.001)。换血后贫血与换血前贫血、高胆红素血症的病因、输血达预定量后补输血等有关。结论换血治疗能有效降低血清胆红素;达到换血标准的高胆红素血症患儿入院时常存在血红蛋白“正常”假象;换血前贫血者易导致换血后贫血。ABO溶血病、G6PD缺乏并ABO溶血病患儿换血后贫血发生率较其他病因高。输血达预定量后补输血10～15ml/kg有利于纠正换血后贫血。     

Central-peripheral temperature difference,blood pressure,and arginine vasopressin in preterm neonates undergoing volume expansion

AIM—To examine the effect of intravascular volume expansion for the treatment of hypovolaemia in sick preterm neonates.METHODS—An intravenous infusion of 20 ml per kg of 4.5 % albumin was given to 14 preterm neonates. The effects on systolic blood pressure, central peripheral temperature difference (c-pT), and plasma arginine vasopressin concentration (pAVP) were measured.RESULTS—Thirteen babies showed a rise in systolic blood pressure. The six babies with the highest initial values of pAVP and c-pT showed a fall in both of these after infusion. The babies with lower initial pAVP (below 4 pmol/l) showed either a rise (two) or no change (six) after albumin infusion. There was a significant correlation between c-pT and log pAVP before (r²=0.61; p<0.05) and after infusion (r²=0.45; p<0.05).CONCLUSIONS—Plasma AVP concentration is related to c-pT in unwell preterm newborns. This study suggests that clinical assessment of hypovolaemia in preterm newborns is poor and could be improved by using c-pT.     

Bilirubin/Albumin Ratio for Predicting Acute Bilirubin-induced Neurologic Dysfunction

Objective

The aim of this study was to evaluate the bilirubin albumin (B/A) ratio in comparison with total serum bilirubin (TSB) for predicting acute bilirubin-induced neurologic dysfunction (BIND).

Methods

Fifty two term and near term neonates requiring phototherapy and exchange transfusion for severe hyperbilirubinemia in Children''s Medical Center, Tehran, Iran, during September 2007 to September 2008, were evaluated. Serum albumin and bilirubin were measured at admission. All neonates were evaluated for acute BIND based on clinical findings.

Findings

Acute BIND developed in 5 (3.8%) neonates. B/A ratio in patients with BIND was significantly higher than in patients without BIND (P<0.001). Receiver operation characteristics (ROC) analysis identified a TSB cut off value of 25 mg/dL [area under the curve (AUC) 0.945] with a sensitivity of 100% and specificity of 85%. Also, according to the ROC curve, B/A ratio cut off value for predicting acute BIND was 8 (bil mg/al g) (AUC 0.957) with sensitivity of 100% and specificity of 94%.

Conclusion

Based on our results, we suggest using B/A ratio in conjunction with TSB. This can improve the specificity and prevent unnecessary invasive therapy such as exchange transfusion in icteric neonates.     

不同血源对ABO溶血病外周动静脉同步换血疗效的比较

目的 　探讨不同血源对ABO溶血病外周动静脉同步换血的疗效。方法　对 2 3例ABO溶血病患儿依时间分为二组 ,同型血组和混合血组。同型血组采用与患儿血型相同的血为血源换血 ,混合血组采用AB型血浆和O型洗涤红细胞混合血为血源换血。换血途径均采用外周动静脉。结果　同型血组和混合血组换血后总胆红素下降显著 ,4 50 0± 1 4 4 2 4 μmol/L ,2 54 56± 87 58μmol/L ,393 4 8± 1 6 7 4 6vs2 36 6 0± 97 79μmol/L ;两组的换出率分别是 :4 2 2 5± 1 3 91 % ,38 4 6± 1 3 1 6 % ,t =0 70 ,P >0 0 5。换血后两组的血细胞 ,红细胞压积 (HCT) ,电解质 ,白蛋白改变相同。换血后无明显不良反应。结论　同型血和混合血为血源换血疗效相同 ,在紧急情况下采用同型血换血可以节约时间。     

Neonatal jaundice due to ABO incompatibility in Sri Lankan

A prospective study was carried out on 101 neonates with jaundice due to ABO incompatibility. The direct Coomb’s test was weakly positive in 4 cases. The indirect Coomb’s test using the eluate was positive in 8 cases. In the maternal blood either IgG anti-A or anti-B haemolysin was present in high titre in every case. Phototherapy was given when the indirect serum bilirubin level exceeded 9 mg/dl. Exchange transfusion was done in 39 cases, 9 babies requiring multiple exchanges. There were 2 deaths.     

Increased incidence of hyperbilirubinaemia in 'unchallenged' glucose-6-phosphate dehydrogenase deficiency in term Saudi newborns.

The incidence of severe hyperbilirubinaemia was significantly higher among the G6PD-deficient Saudi infants born at term than in non-deficient babies (34% vs 9%) (p less than 0.005). No apparent offending factors were detected in either the babies or their mothers. All babies who developed hyperbilirubinaemia did so during the 1st week of life. The highest mean bilirubin level for all jaundiced G6PD-deficient babies was recorded on the 4th postnatal day. Although the incidence of severe hyperbilirubinaemia among our neonates was relatively high, only two of them (7%), a boy and a girl, required exchange transfusions. Five of 29 jaundiced babies with G6PD deficiency were readmitted after discharge because of significant jaundice. One required exchange transfusion. Since G6PD deficiency seems to be a relatively common cause of neonatal jaundice in Saudi newborns, early detection of this enzymopathy by cord blood screening is justified to avoid morbidity and deaths.     

Effect of Additional Albumin Administration During Exchange Transfusion on Plasma Albumin-binding Capacity

A total of 33 infants undergoing exchange transfusion for hyperbilirubinaemiawas divided into two albumin-treated groups and a control group. Bothalbumin-treated groups showed significantly higher levels of plasma albumin and ofreserve albumin-binding capacity in the phase of bilirubin rebound 8 hours or moreafter exchange. It was not possible to state which method of albumin administrationwas the more efficient. Up to two-thirds of administered albumin probably diffusesinto the extravascular space of newbom infants within 2-3 hours.     

Viral infections in newborns through exchange transfusion

Preprocedure sera of thirty one neonates requiring exchange transfusion were tested for serological markers of HBV, HCV, CMV, HIV and LFT. All the babies were investigated for these parameters one week and two months after transfusion to evaluate the risk of transmission of viral infection. Serological markers for these viral infections were also studied in the mothers and donors’ blood to establish the route of infection. Donors’ blood used for transfusion was pretested for HBsAg, VDRL and anti-HIV. HBsAg was detected one week post exchange in one baby and two months post exchange in two babies. Exchange transfusion was implicated in two of them, where one donor had HBsAg and the other anti-HBc. Vertical transmission accounted for the remaining one. Out of these HbsAg positive cases, one showed evidence of recently acquired CMV infection. Vertical transmission of anti-HCV was observed in one case. None of the neonates, mothers and donors were positive for anti-HIV. In view of probable serious consequences of HBV and HCV infections, blood used for exchange transfusion ought to be screened for anti-HBc and anti-HCV, besides routine HBsAg, VDRL and anti-HIV screening.     

Effect of clofibrate in non-hemolytic indirect hyperbilirubinemia in full term neonates

Objective Jaundice is a common clinical problem in neonatal period which may result in brain damage even in healthy full term newborns, when it is severe. The aim of this study was to characterize the therapeutic effect of clofibrate in full term neonates who present with nonhemolytic jaundice. Methods A clinical controlled study was performed on 60 full term neonates who presented with non-hemolytic jaundice. 30 neonates were treated with a single oral dose of clofibrate (100 mg/Kg) plus phototherapy (case group), while 30 neonates received only phototherapy (control group). Both groups were compared in regard to post therapeutic mean total and indirect plasma bilirubin levels, admission duration and the rate of exchange transfusion. Results The reduction rate of total and indirect plasma bilirubin levels were significantly higher in the clofibrate-treated group as compared with the control group (P<0.05). The mean duration of admission was found to be reduced from 2.9 +/− 0.9 days in the control groupl to 2.2 +/− 0.6 days in clofibrate-treated group (P=0.002). The mean plasma total bilirubin level was lower in the clofibrate-treated group. No cases required phototherapy after 48 hour in clofibrate-treated group, while 9 neonates (30%) and 2 neonates (6.7%) required phototherapy after 72 hour and 96 hour respectively in the control group. There was no difference between both the groups for sex, the time of developing jaundice and the rate of exchange transfusion. Conclusion A single dose of clofibrate (100 mg/Kg) alongwith phototherapy is more effective than phototherapy alone in treating non-hemolytic hyperbilirubinemia in term healthy newborn infants.     

Clinical evaluation of Sephadex gel filtration in estimation of bilirubin binding in serum in neonatal jaundice

Clinical experience with a Sephadex gel filtration test-kit for the evaluation of bilirubin binding affinity of serum in neonatal jaundice is reported. In serial serum specimens from 166 jaundiced neonates the results of the test in most cases were in accord with the independent clinical decision to perform exchange transfusion. In all 9 cases with clinical kernicterus the Sephadex test was strongly positive (very low bilirubin binding affinity of serum).The test was positive at lower bilirubin levels and bilirubin/albumin molar ratios in preterm as compared with term neonates, especially in those in poor clinical condition. Among term infants the test indicated an increase in bilirubin binding affinity after the 5th day of life.     

不同方法对重症新生儿高胆红素血症的疗效观察

探讨不同治疗方法对重症新生儿高胆红素血症的治疗效果 ,将 43例重症新生儿高胆红素血症患儿 (达换血标准 )按治疗方法分为 3组。光疗组 1 5例 ,予以药物治疗及光疗直至退黄 ;丙球组 1 6例 ,药物及光疗同前组 ,另加静脉输注丙种球蛋白(简称丙球 )× 3d ;换血组 1 2例 ,予以换血 ,换血前后药物治疗及光疗同前二组。所有三组患儿分别于治疗前 ,治疗后第 1d、4d、7d测血胆红素。结果 :( 1 )血清胆红素值 :治疗第 1d换血组明显低于丙球组及光疗组 (P均 <0 0 1 ) ,但光疗组与丙球组之间无统计学意义 (P >0 0 5) ;治疗第 4d、7d三组间比较均有显著性差异 (P均 <0 0 1 ) ;( 2 )所需光疗时间及黄疸消退时间 :换血组明显低于丙球组及光疗组 (P均 <0 0 1 ) ,但光疗组与丙球组之间无统计学意义 (P >0 0 5) ;( 3)临床情况 :43例患儿黄疸均消退 ,换血组 1 2例无胆红素脑病、贫血发生 ;丙球组胆红素脑病 2例 ,明显贫血 5例 ;光疗组胆红素脑病 3例 ,明显贫血 5例 ,亦因拒绝输血而未予纠正。结论 :换血疗法仍然是治疗重症新生儿黄疸的最佳选择     

Neonatal polycythemia

461 consecutive inborn babies, delivered during the period September 1993–March 1994 were subjected to a microhematocrit assessment at 6 hours of age to determine the incidence of polycythemia. 47 babies (inborn and out born), admitted to the neonatal unit with confirmed polycythemia were studied for clinical and laboratory abnormalities. These 47 babies were then randomly assigned to receive partial exchange transfusion with either normal saline or fresh plasma. The incidence of polycythemia was 27 of 461 (5.8%). 23 of 27 (85.1%) were term babies and 15 of 27 (55.5%) were small for gestational age. 14 of 27 (51.1%) babies had mothers who had pregnancy induced hypertension. Feeding problems (16/47) and lethargy (25/47) were the commonest symptoms (34% and 51% respectively). 25 of 47 (51%) babies had hypoglycemia and 5 of 47 (10.6%) had hypocalcemia. Thrombocytopenia was seen in 13/47 (27.65%) of cases. 24 babies received normal saline and 23 received fresh plasma for partial exchange transfusion. The immediate post-exchange fall in hematocrit was significant in both groups and this was well sustained over the following 48 hours. However, improvement in clinical and laboratory parameters was more remarkable with fresh plasma. Polycythemia appears to be a real clinical entity in neonates in India and babies with known risk factors should be actively screened for this condition. Once diagnosis is established special attempts should be made to rule out hypoglycemia. For treatment of polycythemia fresh plasma is preferable for partial exchange transfusion but normal saline appears to be an adequate substitute.     

不同途径换血治疗新生儿重度高胆红素血症及其对内环境的影响

目的　 探讨不同途径换血治疗新生儿重度高未结合胆红素血症及其对内环境的影响。 方法 　对 5 3例符合换血指征的新生儿重度高未结合胆红素血症进行换血治疗 ,根据不同的换血途径分为桡动脉组 (A组 )和脐静脉组 (B组 )。除换血途径外 ,两组患儿的换血方法相同。换血前后行血常规、血气分析、生化、胆红素、血培养等检查 ,并分别进行比较。 结果 　两组患儿的总胆红素和未结合胆红素的换出率分别为A组 49 2 5 %和 5 0 2 8%、B组 49 64 %和 5 1 2 3% ,换血前后比较均有显著差异 (P <0 0 1) ,但两组间无显著差异 (P >0 0 5 )。A组换血前后血糖、离子钙、白细胞、血小板水平有显著变化 ,除上述外B组 ,钾离子、氯离子、镁离子亦有显著变化。 结论 　两种途径换血治疗新生儿重度高未结合胆红素血症的疗效相似 ,经挠动脉换血治疗对内环境的影响较少。     

新生儿换血术后血生化代谢的变化规律探讨

目的　探讨全部换血术对败血症、高胆红素血症的新生儿血气、电解质、生化代谢的影响。方法　检测 37例次新生儿换血前后的血气、电解质、生化代谢指标并进行分析比较。结果　血清钠、血清钙与血浆渗透压换血前后比较差异显著 (P <0 0 5 )。换血术后纠正低钠血症 8例 ,高钠血症 1例 ;纠正低血浆渗透压 11例 ,高血浆渗透压 1例 ;纠正低钙血症 5例 ,新增低钙血症 5例。低钾血症 15例 ,术后未完全纠正 ,新增 1例低钾血症。纠正高血糖 5例 ,新增 6例高血糖。无低血糖或高钙血症发生。术后胆红素、尿素、肌酐及C反应蛋白均明显降低。结论　在适当的呼吸支持下 ,采用新鲜枸橼酸抗凝血 (72h内 )换血治疗 ,对新生儿血气酸碱平衡、心、肝、肾等重要器官的影响较小。严密监测血电解质及血糖 ,及时处理低钙、低钾血症和高血糖症 ,有助于新生儿平稳度过高危期     

Neonatal polycythaemia: Effect of partial dilutional exchange transfusion with human albumin on whole blood viscosity

Haematocrit (HCT) and viscosity of whole blood were measured in ten polycythaemic hyperviscous newborn infants both before and after dilutional partial exchange transfusion with 5% albumin. This was performed in order to evaluate the effect on the lowering of HCT and whole blood viscosity. Mean umbilical HCT values decreased from 68.7% before, to 54.4% post transfusion. This decrease in HCT and viscosity was highly significant (P<0.001). Safety and lack of complications make human albumin solution superior to human plasma for exchange transfusion in neonatal polycythaemia.     

Effects of exchange transfusion on cytokine profiles in necrotizing enterocolitis

To study the effect of exchange transfusion on cytokine profiles in a patient with necrotizing enterocolitis, the levels of 12 cytokines and serum calprotectin were measured among exchange transfusion. A male extremely low birth weight infant was in non‐compensated shock and diagnosed stage 3 necrotizing enterocolitis. Exchange transfusion was performed for critical condition, refractory hypotension and disseminated intravascular coagulation. After exchange transfusion, the patient's blood pressure increased and stabilized. Then an enterostomy was performed and revealed necrosis of the ascending colon. Of the cytokines examined, interleukin‐8 and serum calprotectin were high before exchange transfusion and decreased after exchange transfusion.