生儿氧疗和早产儿视网膜病课件.ppt

1、新生儿氧疗Friend？Enemy？新生儿科修文龙生儿氧疗和早产儿视网膜病1生儿氧疗和早产儿视网膜病2生儿氧疗和早产儿视网膜病3生儿氧疗和早产儿视网膜病4生儿氧疗和早产儿视网膜病5生儿氧疗和早产儿视网膜病6生儿氧疗和早产儿视网膜病7生儿氧疗和早产儿视网膜病8生儿氧疗和早产儿视网膜病9生儿氧疗和早产儿视网膜病10生儿氧疗和早产儿视网膜病11生儿氧疗和早产儿视网膜病12生儿氧疗和早产儿视网膜病13生儿氧疗和早产儿视网膜病14氧毒性氧毒性:BPD: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

2、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pHpH和和pOpO2 2 mean mean range range pH pH 7.33 7.33 7.31 7.35 7.31 7.35 pOpO2 2(mmHg)(mmHg)24.524.520.2 28.520.2 28.5Nicolini et al,Lancet 1990 生儿氧疗和早产儿视网膜病15传统传统 BPDBPD 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

3、型 BPDBPD 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 2003生儿氧疗和早产儿视网膜病16生儿氧疗和早产儿视网膜病17传统的传统的 BPDBPD危险因素危险因素 肺发育不成熟肺发育不成熟 RDS RDS严重度严重度 氧暴露氧暴露 气压伤气压伤/容量伤容量伤生儿氧疗和早产儿视网膜病18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

4、PDA肺部炎症肺部炎症异常损伤修复异常损伤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BPDBPD相继的相继的 肺损伤肺损伤出生前出生前出生后出生后生儿氧疗和早产儿视网膜病19生儿氧疗和早产儿视网膜病20生儿氧疗和早产儿视网膜病21生儿氧疗和早产儿视网膜病22Gonzlez A et al,J Pediatr 1996Gonzlez A et al,J Pediatr 1996PDA+PDA+感染感染PDAPDA感染感染重度重度RDSRDS出生体重出生体重0.10.11.01.010103030100100BPDBPD危险因素危险因素Odds Ratios&95%CI Odds Rat

5、ios&95%CI 生儿氧疗和早产儿视网膜病23生儿氧疗和早产儿视网膜病24胎龄胎龄26w,26w,生后生后5 5天天生儿氧疗和早产儿视网膜病25生儿氧疗和早产儿视网膜病26生儿氧疗和早产儿视网膜病27生儿氧疗和早产儿视网膜病28 用低用低SaOSaO2 2,FiO,FiO2 2 NCPAPNCPAP，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PEEPPEEP，允许性高碳酸，允许性高碳酸血症血症 尽早应用尽早应用PSPS 关闭关闭PDA:PDA:PDAPDA持续开放和延迟关闭可增加持续开放和延迟关闭可增加BPDBPD风险风险

6、Thomas,Speer,J Perinatol 2007,Neonatology 2008;Geary et al,Pediatrics 2008;Birenbaum et al,Pediatrics 2009生儿氧疗和早产儿视网膜病29 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/day150kcal/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130-1

7、50ml/kg/日日 咖啡因咖啡因Thomas,Speer,J Perinatol 2007,Neonatology 2008;Geary et al,Pediatrics 2008;Birenbaum et al,Pediatrics 2009生儿氧疗和早产儿视网膜病30生儿氧疗和早产儿视网膜病31生儿氧疗和早产儿视网膜病32生儿氧疗和早产儿视网膜病33生儿氧疗和早产儿视网膜病34生儿氧疗和早产儿视网膜病35生儿氧疗和早产儿视网膜病36Brian W.Fleck and Neil McIntosh.Retinopathy of Prematurity:Recent Developments

8、NeoReviews,Jan 2009;10.Normal immature retinaNormal mature retina生儿氧疗和早产儿视网膜病37Vascularization of the retina begins 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

9、and on the temporal side at 36 to 40 weeks gestation.The numbers in the figure are weeks of gestation.生儿氧疗和早产儿视网膜病38生儿氧疗和早产儿视网膜病39Hemisection looking down into the left eye with the temporal side to the left and the nasal side to the right.生儿氧疗和早产儿视网膜病40生儿氧疗和早产儿视网膜病41生儿氧疗和早产儿视网膜病42Stage 1.Demarcatio

10、n lineA flat line of demarcation occurs between the vascular and avascular retina.生儿氧疗和早产儿视网膜病43生儿氧疗和早产儿视网膜病44生儿氧疗和早产儿视网膜病45Stage 2.Ridge The line of demarcation acquires volume to become a ridge.生儿氧疗和早产儿视网膜病46生儿氧疗和早产儿视网膜病47Stage 3 ROP in Zone II.Extraretinal fibrovascular proliferationNeovasculariz

11、ation can be seen within the ridge,and extraretinal vascularization extends out of the retina.生儿氧疗和早产儿视网膜病48生儿氧疗和早产儿视网膜病49生儿氧疗和早产儿视网膜病504A:extrafoveal4B:fovealStage 4 ROP Partial retinal detachment生儿氧疗和早产儿视网膜病51生儿氧疗和早产儿视网膜病52生儿氧疗和早产儿视网膜病53Stage 5.Total retinal detachment生儿氧疗和早产儿视网膜病54From the United

12、 Kingdom Guidelines for the Screening and Treatment of Retinopathy of Prematurity.生儿氧疗和早产儿视网膜病55ROP 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.生儿氧疗和早产儿视网膜

13、病56Mathew MR,J Eye,2002;16(5):538-542ROP筛查筛查生儿氧疗和早产儿视网膜病57生儿氧疗和早产儿视网膜病58生儿氧疗和早产儿视网膜病59生儿氧疗和早产儿视网膜病60生儿氧疗和早产儿视网膜病61生儿氧疗和早产儿视网膜病62生儿氧疗和早产儿视网膜病63生儿氧疗和早产儿视网膜病64轻度轻度RS 5 Starts at birth lasts 4 hrs.RS 5 Starts at birth lasts 4 hrs.中度中度RS is 5-8RS is 5-8RS 4 Hrs.RS 4 Hrs.Low RS to begin then starts to inc

14、reaseLow RS to begin then starts to increase重度重度RS 8RS 8Severe apnea or gaspingSevere apnea or gaspingPrevious resuscitation or vent.requiredPrevious resuscitation or vent.required生儿氧疗和早产儿视网膜病65生儿氧疗和早产儿视网膜病66生儿氧疗和早产儿视网膜病67Morley,Recent Advances in Neonatal Medicine,Wrzburg 2008婴儿婴儿27-42 wks27-42 wks

15、产房内无干预产房内无干预生后（生后（minmin）氧饱和度氧饱和度%1 12 23 34 45 56 67 78 89 910101010202030304040505060607070808090901001000 0Median 10th and 90th centiles生儿氧疗和早产儿视网膜病68生儿氧疗和早产儿视网膜病69生儿氧疗和早产儿视网膜病70生儿氧疗和早产儿视网膜病71生儿氧疗和早产儿视网膜病72生儿氧疗和早产儿视网膜病73生儿氧疗和早产儿视网膜病74生儿氧疗和早产儿视网膜病75生儿氧疗和早产儿视网膜病76生儿氧疗和早产儿视网膜病77生儿氧疗和早产儿视网膜病78生儿氧疗和早产儿视网膜病79生儿氧疗和早产儿视网膜病80生儿氧疗和早产儿视网膜病81生儿氧疗和早产儿视网膜病82生儿氧疗和早产儿视网膜病83生儿氧疗和早产儿视网膜病84生儿氧疗和早产儿视网膜病85生儿氧疗和早产儿视网膜病86生儿氧疗和早产儿视网膜病87生儿氧疗和早产儿视网膜病88生儿氧疗和早产儿视网膜病89生儿氧疗和早产儿视网膜病90生儿氧疗和早产儿视网膜病91