两次经外周动—静脉同步换血治疗新生儿溶血病10例临床分析

发布时间：2018-04-10 05:35

本文选题：两次换血治疗　切入点：新生儿溶血病　出处：《重庆医科大学》2012年硕士论文

【摘要】：目的：总结我院新生儿科两次换血病例的临床特点、治疗情况及结果。方法：收集我院新生儿科2008年7月至2012年1月期间入院后行两次经外周动-静脉换血治疗的患儿病历资料，对该些患儿的临床病史、换血治疗、部分实验室辅助检查、治疗结果及随访结果进行总结。结果：10例行两次经外周动-静脉换血治疗的患儿诊断为：5例Rh溶血症，5例ABO溶血症。 1换血前情况 1.1重要临床病史：Rh溶血症组大多生后24小时内发现皮肤黄染，最短生后2小时后发现，1例生后24小时后发现，平均发现时间17±15小时。ABO溶血症组均为生后48小时内发现皮肤黄染，1例生后1+小时内发现，平均发现时间24±16小时。 1.2第1次换血前溶血指标：Rh溶血症组：均存在溶血性贫血。血红蛋白65～121g/L，均值95g/L。HCT22.5～35.9%，均值29.7%。ABO溶血症组：2例未出现贫血。HCT均小于正常范围底线50%，均值37.9%。 1.3第1次换血前胆红素：Rh溶血症组生后黄疸进展较ABO溶血症组更快。两组均以间接胆红素升高为主。 1.4第1次换血前总胆红素/白蛋白（B/A）：9例新生儿溶血病患儿第1次换血前B/A平均水平为0.83±0.06。1.5新生儿溶血病筛查：Rh溶血症：5例均为改良直接抗体试验（改良Coombs试验）阳性。ABO溶血症：4例为改良直接抗体试验、游离抗体试验、释放抗体试验阳性；1例为改良直接抗体试验阴性，游离抗体试验、释放抗体试验阳性。 2换血 2.1换血治疗：均于入院第1天行换血治疗。换血时间大多控制在2小时内。换血量平均水平170ml/kg。两次换血时间间隔基本在24小时内。临床中对新生儿溶血病的两次换血处理过程基本相似，每一次换血处理过程也基本相似。 3换血前后的分析 3.1换血前后胆红素变化：大部分患儿两次换血胆红素变化呈现相似折线图。第1次、第2次换血前后总胆红素变化均有统计学意义（P0.01，P0.01）。 3.2胆红素换出率：第1次换血的总胆红素换出率高于第1次换血的。两次换血后总的胆红素下降率平均水平为61.9±8.8%。19次有效换血，平均换出率为48.4±10.0%，最低换出率为24.6%，最高换出率为69.0%。 3.3换血前后血常规变化：第1次换血前Rh溶血症贫血程度较ABO溶血症更重，换血可纠正贫血。但大多患儿血红蛋白在两次换血间期呈下降趋势。每次换血后WBC大多有下降，PLT均有下降。 4治疗随访情况 4.1治疗：9例患儿换血前、换血完毕后均予以蓝光光疗、碱化血液、补液处理，期间均有使用20%人血白蛋白或丙种球蛋白。除放弃治疗的1例患儿外，连续蓝光光疗时间为3～5天（平均4天），胆红素水平可降至观察范围内。 4.2胆红素性脑损伤评估检查：9例患儿住院期间完成情况：耳声发射8/9例，BAEP3/9例，，头颅彩超2/9例，头颅CT1/9例，头颅MRI1/9例，NBNA评分4/7例。 4.3换血并发症及随访：Rh溶血症组出现：心源性休克1例，胃肠道出血（应激性溃疡、NEC？）2例，呼吸暂停1例，甲状腺功能低下1例。ABO溶血症组出现呼吸暂停1例。随访7例，2例失访。7例患儿均无明显异常表现。结论：经外周动-静脉同步换血治疗是及时、有效的快速降低胆红素、防止胆红素脑病发生的治疗手段。新生儿溶血病起病早，进展快，黄疸程度重，在临床中可能需要两次换血治疗。及时有效的两次换血治疗，联合蓝光光疗、碱化血液、补液、白蛋白、丙种球蛋白输注等治疗，可以帮助小日龄的新生儿溶血病患儿渡过溶血反应的极期及胆红素脑病发生的高危风险期。
[Abstract]:Objective: To summarize the clinical features, treatment and results of the two blood exchange cases in the new Department of Pediatrics in our hospital.
Methods: in our hospital from July 2008 to January 2012 during the neonatal admission after two times after peripheral arteriovenous transfusion treatment of children blood transfusion medical records, clinical history, for the treatment of children, laboratory examination, treatment results and prognosis were analyzed. Results: 10 cases of the two peripheral artery and children the diagnosis of venous exchange transfusion treatment: 5 cases of Rh hemolytic disease, 5 cases of ABO hemolytic disease.
1 pre blood change
1.1 important clinical history: it was found that the yellowing of the skin within 24 hours of Rh hemolytic disease group mostly after birth, the shortest 2 hours after birth was found in 1 cases, 24 hours after birth and found that the average time 17 + 15 hours.ABO hemolytic disease group were within 48 hours after birth found skin stained yellow, was found in 1 cases. After 1+ hours, the average time 24 + 16 hours.
1.2 hemolysis index before first exchange transfusion: Rh hemolytic disease group: hemolytic anemia exists. Hemoglobin 65 ~ 121g/L, mean 95g/L.HCT22.5 to 35.9%, mean 29.7%.ABO hemolytic disease group: 2 cases without anemia,.HCT is less than the normal range, bottom 50%, mean 37.9%..
1.3 first times before hemolysis: the development of jaundice in the Rh hemolytic disease group was faster than that of the ABO hemolytic disease group. The two groups were mainly indirect bilirubin.
1.4 first times before the blood total bilirubin / albumin (B/A):9 cases of hemolytic disease of the newborn children first times before the blood B/A level was 0.83 + 0.06.1.5 hemolytic disease of the newborn screening: Rh hemolytic disease: 5 cases were improved direct antibody test (modified Coombs test) positive.ABO hemolytic disease: 4 cases of modified antibody test free antibody test and antibody release test was positive; 1 cases were negative. The modified direct antibody test, free antibody test, positive antibody release test.
2 change of blood
2.1: exchange transfusion treatment were first days. Blood exchange transfusion in the treatment of most of the time control in 2 hours. The average volume in the two 170ml/kg. time interval basic exchange transfusion in 24 hours. In the two clinical process of transfusion of hemolytic disease of the newborn is similar, every treatment blood transfusion is also similar.
Analysis of 3 blood exchange before and after blood exchange
3.1 the change of bilirubin before and after exchange transfusion: most of the children had two similar blood transfusion bilirubin changes. The first times, the total bilirubin before and after the second exchange transfusion all had statistical significance (P0.01, P0.01).
3.2 bilirubin exchange rate: the total bilirubin exchange rate of the first exchange transfusion is higher than that of the first exchange transfusion. After the two exchange transfusion, the total bilirubin decrease rate is 61.9 + 8.8%.19 times, the average exchange rate is 48.4 + 10%, the lowest exchange rate is 24.6%, and the highest exchange rate is 69.0%..
3.3 the change of blood routine before and after exchange transfusion: the degree of anemia of Rh hemolytic anemia is more severe than that of ABO hemolytic disease before the first exchange transfusion, and the blood transfusion can correct anemia. But most of the children have a downward trend in the two exchange interval. After the exchange transfusion, most of WBC decreases and PLT decreases.
4 follow up treatment
4.1 treatment: 9 cases before the blood transfusion, after were treated with phototherapy, alkalinization of blood, rehydration, were used during the 20% Human Albumin or gamma globulin. Except 1 cases give up treatment, continuous phototherapy time was 3~5 days (average 4 days), bilirubin level can be reduced to the observation range.
4.2 bilirubin brain damage assessment examination: 9 cases of children completed during hospitalization: otoacoustic emissions 8/9 cases, BAEP3/9 cases, color Doppler ultrasound 2/9 cases, head CT1/9 cases, head MRI1/9 cases, NBNA score 4/7 cases.
4.3 blood transfusion complications and follow-up: Rh hemolytic disease group: 1 cases of cardiogenic shock, gastrointestinal hemorrhage (stress ulcer, NEC?) in 2 cases, 1 cases with apnea, hypothyroidism in 1 cases of.ABO hemolytic disease group apnea in 1 cases. 7 cases were followed up, 2 cases of.7 patients were lost to follow-up no obvious abnormalities.
Conclusion: the peripheral arteriovenous synchronous exchange transfusion treatment is timely, rapid and effective to reduce bilirubin, prevent bilirubin encephalopathy treatment. Neonatal hemolytic disease of early onset, rapid progression, severe jaundice in clinic may need two times two times blood exchange transfusion. Timely and effective treatment, combined with phototherapy, alkalinization blood, fluid, albumin, globulin infusion therapy, high risk period of hemolytic disease of the newborn children can help young age through the hemolytic reaction polar phase and bilirubin encephalopathy.

【学位授予单位】：重庆医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R722.1

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