新生儿氧疗和早产儿视网膜病课件.ppt

1、新生儿氧疗Friend？Enemy？新生儿科修文龙氧毒性氧毒性:BPD的危险因素的危险因素 吸入气中的高氧浓度吸入气中的高氧浓度:直接对支气管肺泡结构有毒性作用直接对支气管肺泡结构有毒性作用 机制机制 诱发肺炎症反应诱发肺炎症反应 产生毒性氧自由基产生毒性氧自由基 保护性抗蛋白酶氧化失活保护性抗蛋白酶氧化失活 脂质过氧化反应脂质过氧化反应胎儿血中的胎儿血中的pH和和pO2 mean range pH 7.33 7.31 7.35 pO2(mmHg)24.520.2 28.5Nicolini et al,Lancet 1990 传统传统 BPD 组织病理表现为严重气道损伤组织病理表现为严重气道损

2、伤 肺节段性过度膨胀及纤维化改变肺节段性过度膨胀及纤维化改变 新型新型 BPD 体积大而且成熟的肺泡数目减少体积大而且成熟的肺泡数目减少(肺泡发育不良肺泡发育不良)毛细血管变形、减少毛细血管变形、减少 数目不定的间质纤维增生数目不定的间质纤维增生Coalson,Semin Neonatol 2019传统的传统的 BPD危险因素危险因素 肺发育不成熟肺发育不成熟 RDS严重度严重度 氧暴露氧暴露 气压伤气压伤/容量伤容量伤绒毛膜羊膜炎绒毛膜羊膜炎-胎儿暴露于细胞因胎儿暴露于细胞因子子+复苏复苏+氧毒性氧毒性+机械通气机械通气+肺部肺部/全身感染全身感染+PDA肺部炎症肺部炎症异常损伤修复异常损伤

3、修复肺泡化和血管发育受阻肺泡化和血管发育受阻新型新型BPD相继的相继的 肺损伤肺损伤出生前出生前出生后出生后Gonzlez A et al,J Pediatr 2019PDA+感染感染PDA感染感染重度重度RDS出生体重出生体重0.11.01030100BPD危险因素危险因素Odds Ratios&95%CI 胎龄胎龄26w,生后生后5天天 用低用低SaO2,FiO2 NCPAP，减少插管机械通气，减少插管机械通气,减少吸引减少吸引,尽尽早拔管早拔管 采取小潮气量，合适的采取小潮气量，合适的PEEP，允许性高碳酸，允许性高碳酸血症血症 尽早应用尽早应用PS 关闭关闭PDA:PDA持续开放和延迟

4、关闭可增加持续开放和延迟关闭可增加BPD风险风险Thomas,Speer,J Perinatol 2019,Neonatology 2019;Geary et al,Pediatrics 2019;Birenbaum et al,Pediatrics 2009 正确处理败血症和肺部感染正确处理败血症和肺部感染 早期给予营养支持，热卡早期给予营养支持，热卡150kcal/kg/day以以上上,补充氨基酸补充氨基酸 适当限液，保证尿量适当限液，保证尿量1ml/kg/小时，尿钠小时，尿钠140-145mEq/L。开始给予。开始给予60ml/kg/日液体，日液体，逐渐增加至逐渐增加至130-150ml

5、/kg/日日 咖啡因咖啡因Thomas,Speer,J Perinatol 2019,Neonatology 2019;Geary et al,Pediatrics 2019;Birenbaum et al,Pediatrics 2009Brian W.Fleck and Neil McIntosh.Retinopathy of Prematurity:Recent Developments NeoReviews,Jan 2009;10.Normal immature retinaNormal mature retinaVascularization of the retina begins

6、at approximately 16 weeks gestation at the optic nerve and proceeds peripherally.Retinal vessels reach the ora serrata(the periphery of the eye)on the nasal side at 32 weeks gestation and on the temporal side at 36 to 40 weeks gestation.The numbers in the figure are weeks of gestation.Hemisection lo

7、oking down into the left eye with the temporal side to the left and the nasal side to the right.Stage 1.Demarcation lineA flat line of demarcation occurs between the vascular and avascular retina.Stage 2.Ridge The line of demarcation acquires volume to become a ridge.Stage 3 ROP in Zone II.Extrareti

8、nal fibrovascular proliferationNeovascularization can be seen within the ridge,and extraretinal vascularization extends out of the retina.4A:extrafoveal4B:fovealStage 4 ROP Partial retinal detachmentStage 5.Total retinal detachmentFrom the United Kingdom Guidelines for the Screening and Treatment of

9、 Retinopathy of Prematurity.ROP Plus Disease:increased venous dilatationarteriolar tortuosity of the posterior retinal vessels.Two quadrants of the eye must be involved for the changes to be characterised as plus disease.Mathew MR,J Eye,2019;16(5):538-542ROP筛查筛查轻度轻度RS 5 Starts at birth lasts 4 hrs.中度中度RS is 5-8RS 4 Hrs.Low RS to begin then starts to increase重度重度RS 8Severe apnea or gaspingPrevious resuscitation or vent.requiredMorley,Recent Advances in Neonatal Medicine,Wrzburg 2019婴儿婴儿27-42 wks产房内无干预产房内无干预生后（生后（min）氧饱和度氧饱和度%123456789101020304050607080901000Median 10th and 90th centiles