新生儿黄疸诊治.ppt

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Paediatrics&ChildHealth1999;4(2):161-164-02
RevisioninprogressMay2007
Paediatrics&ChildHealth2007;12(5):1B-12B-02
Guidelinesfordetection,managementandpreventionofhyperbilirubinemiaintermandlatepretermnewborninfants
参考文献
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Hyperbilirubinemiaisverycommonandusuallybenigninthetermnewborninfantandthelatepreterminfantat35to36completedweeks.
Criticalhyperbilirubinemiaisuncommonbuthasthepotentialforcausinglong-,particularlythoseinwhombreastfeedingmaynotbefullyestablished,maybeassociatedwithdelayeddiagnosisofsignificanthyperbilirubinemia.
高胆红素血症很常见,多为良性。危险的高胆红素血症并不常见,但是(dànshì)有潜在的导致长期神经损害的可能。
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胆红素水平(shuǐpíng)与胆红素脑病发生
Itisestimatedthat60%oftermnewbornsdevelopjaundiceand2%reachaTSBconcentrationgreaterthan340μmol/L().
Acuteencephalopathydoesnotoccurinfull-terminfantswhosepeakTSBconcentrationremainsbelow340μmol/LandisveryrareunlessthepeakTSBconcentrationexceeds425μmol/L().Abovethislevel,-quartersoftheinfantsintheUnitedStateskernicterusregistry(between1992and2002)hadaTSBconcentrationof515μmol/L()orgreater,andtwo-thirdshadaconcentrationexceeding600μmol/L(35mg/dl).
Evenwithconcentrationsgreaterthan500μmol/L(),therearestillsomeinfantswhowillescapeencephalopathy.
第四页,共三十四页。
Kernicterus(核黄疸):thepathologicalfindingofdeep-yellowstainingofneuronsandneuronalnecrosisofthebasalganglia(基底节)andbrainstemnuclei(脑干神经元).
Acutebilirubinencephalopathy(急性(jíxìng)胆红素脑病):aclinicalsyndrome,inthepresenceofseverehyperbilirubinemia,oflethargy(昏睡),hypotoniaand(肌张力减低)poorsuck,whichmayprogresstohypertonia(withopisthotonos(角弓反张)andretrocollis(颈后倾))withahigh-pitchedcryandfever,andeventuallytoseizures(发作)andcoma. 
Chronicbilirubinencephalopathy(慢性胆红素脑病):theclinicalsequelaeofacuteencephalopathywithathetoidcerebralpalsy(手足徐动症样大脑麻痹)withorwithoutseizures,developmentaldelay,hearingdeficit,oculomotor(眼球运动异常)disturbances,dentaldysplasia(牙发育异常)andmentaldeficiency. 
Severehyperbilirubinemia(严重的高胆红素血症):atotalserumbilirubin(TSB)concentrationgreaterthan340μmol/Latanytimeduringthefirst28daysoflife. 
Criticalhyperbilirubinemia(危险的高胆红素血症):aTSBconcentrationgreaterthan425μmol/Lduringthefirst28daysoflife.
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具有危险(wēixiǎn)因素人群中患者与非患者之比相当于不具有危险(wēixiǎn)因素人群中患者与非患者之比的倍数
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脱水,高渗,呼吸(hūxī)窘迫,水肿,早产,酸中毒,低白蛋白血症,缺氧,抽搐可增加急性脑病的发生率
与败血症的关系?
Allofthereasonsforthevariablesusceptibilityofinfantsarenotknown;however,dehydration,hyperosmolarity,respiratorydistress,hydrops,prematurity,acidosis,hypoalbuminemia,hypoxiaandseizuresaresaidtoincreasetheriskofacuteencephalopathyinthepresenceofseverehyperbilirubinemia,althoughreliableevidencetoconfirmtheseassociationsislacking.
Inaddition,someinfantswithseverehyperbilirubinemiaarefoundtohavesepsis,butbothsepsisandhyperbilirubinemiaarecommonintheneonatalperiod,andsepsisappearstobeuncommoninthewell-appearinginfantwithseverehyperbilirubinemia.
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黄疸的发生(总体(zǒngtǐ)发生情况)
Early(days1-2)-uncommon
Haemolyticjaundice(ABO,others)
Normal(days3-10)-verycommon
Uncomplicated
Complicated-seebelow
Late(days14+)
Breastmilk-common
Conjugatedjaundice-uncommon
Inheriteddeficiencyofglucuronyltransferaseenzymes-veryrare
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Investigations:
Measurementofbilirubin
经皮测并不准确(与是否光疗后,皮肤颜色及厚度(hòudù)都有关).
ThereareseverallimitationstoTcBmeasurements:theybecomeunreliableafterinitiationofphototherapy,andtheymaybeunreliablewithchangesinskincolourandthickness.
However,theresultsaremoreaccurateatlowerlevelsofbilirubin,andtherefore,useofTcBasascreeningdeviceisreasonable.
Clinicalevaluation
Kramer‘sRule
Ratherthanestimatingthelevelofjaundicebysimplyobservingthebaby'sskincolour,,,theSBRrangeassociatedwithprogressiontothezonesisasfollows:
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Clinicalmanagementofhyperbilirubinemiaininfants
TABLE1:Laboratoryinvestigationforhyperbilirubinemiaintermnewborninfants
Indicated(ifbilirubinconcentrationsreachphototherapylevels)    
Serumtotalorunconjugatedbilirubinconcentration    
Serumconjugatedbilirubinconcentration    
Bloodgroupwithdirectantibodytest(Coombs’test)    
Hemoglobinandhematocritdeterminations
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