新生儿肺动脉高压管理教学课件.ppt

表面活性物质的应用 随机对照实验的Meta 分析 降低气胸危险 降低需要ECMO的危险 对总体的死亡率没有影响 用药方式有争议 多次用药* 持续输入^ 稀释后灌洗° *Lotze 1998, ^Findlay 1996, ° Wiswell 2002 Should we give Surfactant (mainly for MAS)? Term or near term newborns may have surfactant deficiency, inactivation, or both Large multicenter study- use of surfactant (if used early) reduced need for ECMO NOT without risk- should be reserved for severe cases, and potentially done at an ECMO center 血管扩张剂 for PPHN ET1 sildenafil milrinone bostentan Prostacyclins + + Nitric Oxide- an endogenously produced gas- a treatment for PPHN 一氧化氮 指征：OI 25 大型随机实验：iNO 对ECMO 的需求 禁忌症－左心流出道的阻塞 (先天性主动脉弓断离, 严重主动脉瓣狭窄， 左心发育不良综合征), 严重左心室功能不良 起始剂量- 20 ppm, 缓慢减量 Delivery of NO Don’t forget- the bag needs NO too! 昔多芬 for PPHN Shah PS, Ohlsson A. Cochrane Database Syst Rev. 2011; (8): CD005494 体外膜肺氧合法（人工肺） ????????????????????????????????????????????????????????????????????????????????? ECMO- Use of ECMO decreased mortality from 60% to 30% in a UK study Variable Odds of neonatal death Odds ratio 95% confidence interval P value Gestational age 37 wk 1.7 1.2–2.5 0.01 pH?≤?7.20 1.5 1.1–2.1 0.02 SaO2 ≤ 65% 1.5 1.1–2.1 0.01 ECMO initiated?≥?DOL 5 1.8 1.2–2.6 0.01 Duration of ECMO ≥ 7 d 3.4 2.5–4.7 0.01 The use of ECMO for persistent pulmonary hypertension of the newborn: A decade of experience. Lazar et al. J Surg Res 2012 (177):263-267 ECMO for PPHN: ELSO Data UK collaborative randomised trial of neonatal extracorporeal membrane oxygenation: follow-up to age 4 years. Bennett CC et al. Lancet. 2001;357:1094. ECMO for PPHN:并发症 不同治疗方法的治疗结果 Walsh-Sukys MC. Pediatrics. 2000 Jan;105(1 Pt 1):14-20 总结 减少刺激 维持体温 建立动静脉通路 监测动脉导管前后血氧饱和度 纠正酸中毒／低血钙／低血糖 维持足够BP – 扩容及升压药 PaO2 70-100 PCO2 low 40s 供氧 考虑用表面活性物质 考虑使用高频通气 Echo 除外先心 iNO if OI 25 OI 40 考虑使用ECMO As I’ve alluded to, the seminal event in the transition to extra-uterine circulation is a drop in the PVR. The