【摘要】：目的 通過對重癥高膽紅素膽紅素值、臨床表現(xiàn)、治療手段及短期預后進行分析，了解本中心有無過度換血的現(xiàn)象。 方法 收集本中心2011年1月~2012年12月達到換血標準但未進行換血療法的重癥高膽紅素血癥新生兒的臨床資料，根據(jù)基線控制的方法，選擇各時段性別、胎齡、總膽紅素值、膽紅素/白蛋白比值等主要特點與未換血患兒無統(tǒng)計學差異的接受換血治療患兒，組成換血組，對兩組入院情況、診療過程及預后進行回顧性分析。 結果 共納入270例，換血組與未換血組各135例，每組根據(jù)入院時齡分為：24小時組，24~48小時組，48~72小時組，72時組。四時段性別比例、胎齡、陰道分娩比例、出生體重、入院體重、體質量丟失,換血組與未換血組比較，均無統(tǒng)計學差異（P0.05）。全部換血組、未換血組血清總膽紅素分別為（411.38±70.38）μmol/L，（412.78±69.68）μmol/L，兩組無統(tǒng)計學差異（t=0.16，P=0.87）。72小時時段，換血組BIND評分（1.77±2.12）高于未換血組（1.07±1.28），差異有統(tǒng)計學意義（t=2.46，P=0.02）。本研究中，ABO溶血病（55.6%）是新生兒重癥高膽紅素血癥最主要的原因，其次為血管外溶血（7.0%）。換血組的新生兒溶血病84例，31例（36.9%）輸注靜脈丙種球蛋白，其中換血前使用者5例（5.9%）。未換血組新生兒溶血病73例，55例（75.3%）輸注靜脈丙種球蛋白。兩組BAEP異常率（χ2=1.17，P=0.28）和NBNA評分異常率（χ2=1.97，P=0.16）無統(tǒng)計學差異。換血組完善頭顱MRI15人，異常者9人，未換血組完善MRI檢查5人，3例異常。129/135發(fā)生換血相關不良反應，大部分是血液生化指標異常，嚴重不良反應發(fā)生率僅為5.2%（7/135）。24小時、48~72小時、72小時三時齡段換血組住院時間均值均大于未換血組住院時間，其中72小時組差異有統(tǒng)計學意義（t=3.84,P0.001）。 結論 換血療法是高風險的侵入性治療，在對重癥高膽紅素血癥患者選擇干預方案時不能過于依賴國內(nèi)外制訂的膽紅素參考值，，尤其當患兒時齡大于72時，要綜合考慮病因、臨床表現(xiàn)、一般情況等；對無明顯膽紅素腦損傷表現(xiàn)的新生兒溶血病患兒可嘗試高強度光療聯(lián)合靜脈免疫球蛋白輸注，降低換血的頻率。
[Abstract]:Objective to analyze the hyperbilirubin value, clinical manifestations, treatment methods and short-term prognosis of severe hyperbilirubin. Methods the clinical data of severe hyperbilirubinemia neonates with severe hyperbilirubinemia who met the exchange standard from January 2011 to December 2012 were collected. According to the baseline control method, the sex and gestational age of each period were selected. The main characteristics of total bilirubin, bilirubin / albumin ratio were not significantly different from those of children without hemodialysis. The two groups were divided into two groups. The admission, diagnosis and treatment process and prognosis of the two groups were analyzed retrospectively. Results 270 cases were included, 135 cases in each group. According to the age of admission, each group was divided into four groups: 24 hours group, 24 hours group, 48 hours group, 72 hours group. The sex ratio, gestational age, vaginal delivery ratio, birth weight, admission weight, body mass loss, and no significant difference were found between the two groups (P0.05). The serum total bilirubin was (411.38 鹵70.38) 渭 mol/L, (412.78 鹵69.68) 渭 mol/L, in all and no exchange group (412.78 鹵69.68) 渭 mol/L, respectively (t = 0.16, P < 0. 87). At 72 hours, the BIND score in the exchange group (1. 77 鹵2. 12) was higher than that in the control group (1. 07 鹵1. 28), and the difference was statistically significant (t = 2. 46, P < 0. 02). In this study, ABO hemolytic disease (55.6%) was the most important cause of severe hyperbilirubinemia, followed by extravascular hemolysis (7.0%). Among 84 cases of neonatal hemolytic disease, 31 cases (36.9%) were infused with intravenous immunoglobulin (IVG), among which 5 cases (5.9%) were users before exchange of blood. Among 73 cases of hemolytic disease of newborns, 55 cases (75.3%) were infused with intravenous immunoglobulin. There was no significant difference between the two groups in the abnormal rate of BAEP (蠂 2 + 1.17) and the abnormal rate of NBNA score (蠂 2 1. 97 P 0. 16). There were 9 cases of abnormal head MRI15 in the exchange group, 5 cases of perfect MRI examination in the non-exchange group, 3 cases were abnormal. 129R / 135 related adverse reactions occurred, most of them were abnormal in blood biochemical index. The incidence rate of severe adverse reactions was only 5.2% (7 / 135). The mean hospitalization time of 24 hours, 48 minutes 72 hours, 72 hours at 03:00 was higher than that of non-exchange group, and the difference of 72 hours group was statistically significant (t = 3.84, P 0.001). Conclusion Exchange therapy is a high risk invasive therapy. When choosing intervention regimen for patients with severe hyperbilirubinemia, we should not rely too much on the reference value of bilirubin made at home and abroad, especially when the age of children is more than 72. It is necessary to consider the etiology, clinical manifestation, general situation and so on. The high intensity phototherapy combined with intravenous immunoglobulin infusion can be used to reduce the frequency of hemolysis in neonates without obvious bilirubin brain injury.
【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】：2014
【分類號】：R722.1

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