本文選題：兩次換血治療　切入點：新生兒溶血病　出處：《重慶醫(yī)科大學》2012年碩士論文

【摘要】：目的：總結我院新生兒科兩次換血病例的臨床特點、治療情況及結果。 方法：收集我院新生兒科2008年7月至2012年1月期間入院后行兩次經外周動-靜脈換血治療的患兒病歷資料，對該些患兒的臨床病史、換血治療、部分實驗室輔助檢查、治療結果及隨訪結果進行總結。結果：10例行兩次經外周動-靜脈換血治療的患兒診斷為：5例Rh溶血癥，5例ABO溶血癥。 1換血前情況 1.1重要臨床病史：Rh溶血癥組大多生后24小時內發(fā)現皮膚黃染，最短生后2小時后發(fā)現，1例生后24小時后發(fā)現，平均發(fā)現時間17±15小時。ABO溶血癥組均為生后48小時內發(fā)現皮膚黃染，1例生后1+小時內發(fā)現，平均發(fā)現時間24±16小時。 1.2第1次換血前溶血指標：Rh溶血癥組：均存在溶血性貧血。血紅蛋白65～121g/L，均值95g/L。HCT22.5～35.9%，均值29.7%。ABO溶血癥組：2例未出現貧血。HCT均小于正常范圍底線50%，均值37.9%。 1.3第1次換血前膽紅素：Rh溶血癥組生后黃疸進展較ABO溶血癥組更快。兩組均以間接膽紅素升高為主。 1.4第1次換血前總膽紅素/白蛋白（B/A）：9例新生兒溶血病患兒第1次換血前B/A平均水平為0.83±0.06。1.5新生兒溶血病篩查：Rh溶血癥：5例均為改良直接抗體試驗（改良Coombs試驗）陽性。ABO溶血癥：4例為改良直接抗體試驗、游離抗體試驗、釋放抗體試驗陽性；1例為改良直接抗體試驗陰性，游離抗體試驗、釋放抗體試驗陽性。 2換血 2.1換血治療：均于入院第1天行換血治療。換血時間大多控制在2小時內。換血量平均水平170ml/kg。兩次換血時間間隔基本在24小時內。臨床中對新生兒溶血病的兩次換血處理過程基本相似，每一次換血處理過程也基本相似。 3換血前后的分析 3.1換血前后膽紅素變化：大部分患兒兩次換血膽紅素變化呈現相似折線圖。第1次、第2次換血前后總膽紅素變化均有統(tǒng)計學意義（P0.01，P0.01）。 3.2膽紅素換出率：第1次換血的總膽紅素換出率高于第1次換血的。兩次換血后總的膽紅素下降率平均水平為61.9±8.8%。19次有效換血，平均換出率為48.4±10.0%，最低換出率為24.6%，最高換出率為69.0%。 3.3換血前后血常規(guī)變化：第1次換血前Rh溶血癥貧血程度較ABO溶血癥更重，換血可糾正貧血。但大多患兒血紅蛋白在兩次換血間期呈下降趨勢。每次換血后WBC大多有下降，PLT均有下降。 4治療隨訪情況 4.1治療：9例患兒換血前、換血完畢后均予以藍光光療、堿化血液、補液處理，期間均有使用20%人血白蛋白或丙種球蛋白。除放棄治療的1例患兒外，連續(xù)藍光光療時間為3～5天（平均4天），膽紅素水平可降至觀察范圍內。 4.2膽紅素性腦損傷評估檢查：9例患兒住院期間完成情況：耳聲發(fā)射8/9例，BAEP3/9例，，頭顱彩超2/9例，頭顱CT1/9例，頭顱MRI1/9例，NBNA評分4/7例。 4.3換血并發(fā)癥及隨訪：Rh溶血癥組出現：心源性休克1例，胃腸道出血（應激性潰瘍、NEC？）2例，呼吸暫停1例，甲狀腺功能低下1例。ABO溶血癥組出現呼吸暫停1例。隨訪7例，2例失訪。7例患兒均無明顯異常表現。 結論：經外周動-靜脈同步換血治療是及時、有效的快速降低膽紅素、防止膽紅素腦病發(fā)生的治療手段。新生兒溶血病起病早，進展快，黃疸程度重，在臨床中可能需要兩次換血治療。及時有效的兩次換血治療，聯合藍光光療、堿化血液、補液、白蛋白、丙種球蛋白輸注等治療，可以幫助小日齡的新生兒溶血病患兒渡過溶血反應的極期及膽紅素腦病發(fā)生的高危風險期。
[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.

【學位授予單位】：重慶醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2012
【分類號】：R722.1

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