换血疗法和加强光疗对重度高间接胆红素血症新生儿神经系统影响的临床研究  

A clinical study on the effects of exchange transfusion and intensive phototherapy on neurodevelopment in neonates with severe hyperbilirubinemia

作　　者：葛敏 唐军 母得志 夏斌 Ge Min;Tang Jun;Mu Dezhi;Xia Bin(Department of Pediatrics,West China Second University Hospital,Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University),Ministry of Education,Chengdu 610041,China)

机构地区：[1]四川大学华西第二医院儿科/出生缺陷与相关妇儿疾病教育部重点实验室,成都610041

出　　处：《中华新生儿科杂志（中英文）》2019年第1期8-13,共6页Chinese Journal of Neonatology

基　　金：国家自然科学基金(81300524、81330016、81630038、81771634);国家临床重点专科(儿科新生儿专业)建设项目(1311200003303);四川省科技计划项目(2016TD0002).

摘　　要：目的 探讨换血疗法(exchange transfusion,ET)和加强光疗(intensive phototherapy,IPT)治疗达换血标准的重度高胆红素血症新生儿对神经系统的影响。 方法 选择2015年1月至2016年3月四川大学华西第二医院新生儿科收治的胎龄≥35周达换血标准的重度高胆红素血症新生儿为研究对象进行回顾性研究,家属了解病情和治疗方法后签字拒绝换血者纳入IPT组,签字同意换血者纳入ET组。收集两组患儿的基本资料、治疗效果、急性胆红素脑病(acute bilirubin encephalopathy,ABE)发生情况和随访情况。 结果 符合纳入标准的患儿共335例,ET组147例,IPT组188例。ET组干预前血清总胆红素(total serum bilirubin,TSB)峰值高于IPT组[(475.8±100.6)μmol/L比(398.3±39.8)μmol/L](两组TSB相差77.5 μmol/L,约5 mg/dl),伴有血型不合溶血病、败血症、头颅血肿或颅内出血等高危因素的比例高于IPT组,差异均有统计学意义(P<0.05)。出院时与入院时相比,ET组ABE比例由32.0%(47/147)上升至34.0%(50/147),其中以中度和重度ABE比例升高为主[中度ABE由2.7%(4/147)上升至10.2%(15/147),重度ABE由2.7%(4/147)上升至4.8%(7/147)],不同严重程度ABE在入院时和出院时的构成比差异有统计学意义(P<0.05)。IPT组入院时及出院时ABE比例和不同严重程度ABE构成比差异无统计学意义(P>0.05)。随访241例患儿(随访率71.9%,241/335),随访年龄20~36月龄,ET组发生听觉障碍的比例高于IPT组[0%(0/135)比5.7%(6/106)],差异有统计学意义(P<0.05);两组运动发育落后、语言发育落后及抽搐发生率差异无统计学意义(P>0.05)。两组均未观察到死亡病例。 结论 对于TSB高于我国换血标准阈值5 mg/dl以内的重度高胆红素血症新生儿,尤其不伴有高危因素及无中、重度ABE临床症状者,仅IPT治疗未增加患儿神经系统不良预后的发生率。Objective To study the effects of exchange transfusion(ET) and intensive phototherapy (IPT) on neurodevelopment in neonates with severe hyperbilirubinemia reaching ET criteria. Method From January 2015 to March 2016, neonates with severe hyperbilirubinemia reaching ET criteria with gestational age ≥35 weeks, and hospitalized in the Department of Neonatology of our hospital were enrolled in the study. The parents were informed of the risks of acute bilirubin encephalopathy (ABE) and both the advantages and disadvantages of IPT and ET. Based on the different choices of their parents, the neonates were assigned into the ET group and the IPT group. General conditions, treatment effects, the incidences of ABE and the prognosis were recorded and analyzed. Result A total of 335 patients were included in this study, 147 in the ET group and 188 in the IPT group. Before intervention,the peak of total serum bilirubin (TSB) in ET group (475.8±100.6 μmol/L) was higher than IPT group (398.3±39.8 μmol/L) (the difference of TSB between two groups was 77.4 μmol/L, P<0.001), and the incidences of high risk factors such as blood incompatibilities, sepsis, cranial hematoma and intracranial hemorrhage in ET group were higher than IPT group (P<0.05). Compared with at admission, the incidence of ABE in the ET group increased from 32.0% to 34.0% at discharge, mainly due to moderate and severe ABE (the ratio of moderate ABE increased from 2.7% to 10.2%, and severe ABE increase from 2.7% to 4.8%). Statistically significant differences existed in the proportion of ABE with different severity at admission and discharge in ET group (P<0.05), while that in IPT group wasn′t statistically significant. 241 patients were followed up (follow-up rate 71.9%), with the age ranging from 20 to 36 months. 6 cases (5.7%, 6/106) in the ET group showed hearing disorder while none (0%, 0/135) in the IPT group (P<0.05). The incidences of neuromotor dyskinesia, language development disorder and spasm in ET group were higher than IPT group (7.5% vs. 3

关 键 词：高胆红素血症 新生儿 加强光疗 换血疗法 急性胆红素脑病 预后 

分 类 号：R722.17[医药卫生—儿科]