新版新生兒心肺復(fù)蘇指南的進(jìn)展與不同課件

新版新生兒心肺復(fù)蘇指南的進(jìn)展與不同溫州醫(yī)學(xué)院附屬黃巖醫(yī)院新生兒科黃勇新版新生兒心肺復(fù)蘇指南的進(jìn)展與不同溫州醫(yī)學(xué)院附屬黃巖醫(yī)院1background2010年10月，美國(guó)心臟協(xié)會(huì)（AHA）以及歐洲復(fù)蘇委員會(huì)（ERC）和國(guó)際復(fù)蘇聯(lián)絡(luò)（ILCOR）委員會(huì)定期發(fā)出5年后最后一個(gè)版本-新的新生兒的心肺復(fù)蘇指南。TheAmericanHeartAssociation(AHA)theEuropeanResuscitationCouncil(ERC)theInternationalLiaisonCommitteeonResuscitation(ILCOR)background2010年10月，美國(guó)心臟協(xié)會(huì)（AHA）2sourceAmericanHeartAssoc-iation.2005AmericanHeartAssociation(A-HA)guidelinesforcar-diopulmonaryresusc-itation(CPR)andem-ergencycardiovascularcare(ECC)ofpediatricandneonatalpatients:pediatricbasiclifesup-port.Pediatrics.2006May;117(5):e989-1004.KattwinkelJ,PerlmanJM,AzizK,ColbyC,elal.

neonatalresuscitation:2010AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitationandEme-rgencyCardiovascularCare.Circulation.2010;122(suppl3):S909–S919.sourceAmericanHeartAssoc-iat3NewbornResuscitationAlgorithm.KattwinkelJetal.Circulation2010;122:S909-S919Copyright?AmericanHeartAssociationNewbornResuscitationAlgorith4⑴pulseoximetryApulseoximetercanprovideacontinuousassessmentofthepulsewithoutinterruptionofotherresuscitationmeasures,butthedevicetakes1to2minutestoapply,anditmaynotfunctionduringstatesofverypoorcardiacoutputorperfusion.脈搏氧飽和度監(jiān)測(cè)在新生兒心肺復(fù)蘇中是必需的其他復(fù)蘇措施不必中斷缺點(diǎn)：心輸出量不足或灌注不足，效果不佳⑴pulseoximetryApulseoximete5(2)UseofO2inthedeliveryroomTwometa-analysesofseveralrandomizedcontrolledtrialscomparingneonatalresuscitationinitiatedwithroomairversus100%oxygenshowedincreasedsurvivalwhenresuscitationwasinitiatedwithair.足月兒或接近足月兒開始復(fù)蘇可以用0.21空氣各種供氧措施，如T-復(fù)合器予1.0純氧復(fù)蘇，無助于生存率提高(2)UseofO2inthedeliver6(3)skincolorOtherstudieshavesho-wnthatclinicalassessm-entofskincolorisaverypoorindicatorofoxyh-emoglobinsaturationdu-ringtheimmediateneon-atalperiodandthatlackofcyanosisappearstobeaverypoorindicatorofthestateofoxygenationofanuncompromisedbabyfollowingbirth.皮膚顏色：評(píng)價(jià)指標(biāo)差生后存在發(fā)紺期宮外10分鐘達(dá)正常水平(3)skincolorOtherstudiesha7⑷CO2Detectors

ThenumberofstudiesonCO2detectorsinneonatesremainsverysmallandmostreportscomefromretrospectivestudies.Untilmoresolidevidenceprovesthattheiruseimprovespatientoutcome,werefrainfromrecommendingCO2detectorsaspartoftheroutineDRmanagement.

大部分報(bào)告來自回顧性研究不建議CO2探測(cè)器的日常管理需要更堅(jiān)實(shí)的證據(jù)證明他們的使用提高了病人復(fù)蘇結(jié)果⑷CO2DetectorsThenumbero8⑸RespiratorysupportPositivepressureventilation(PPV)intheDRisbestadministeredbyapressurelimitedT-pieceresuscitatorassuchdevicesallowmorecontrolofthedeliveredpressureandtidalvolumes.在產(chǎn)房正壓通氣（PPV）是最好的管理壓力有限的T型復(fù)蘇器允許壓力控制和潮氣量⑸RespiratorysupportPositive9⑹MeconiumaspirationWesuggesttocontinuewiththecurrentpracticeofclearingtheairwaybeforePPVisstartedinanyinfant,inparticularthosebornfromthick,MSAF,untilfurtherevidencebecomesavailable。正壓通氣前呼吸道應(yīng)清理特別是那些出生稠厚的胎糞污染患兒。胎糞污染吸引存在爭(zhēng)議⑹MeconiumaspirationWesugges10⑺TemperaturecontrolWerecommendtheuseofplasticcoveronlyforinfantswithaGA<28weeks.Inanycircumstances,closemonitoringoftheinfant’stemperatureismandatory,becausebothhypothermiaandhyper-thermianegativelyaffectsneonataloutcome.胎齡＜28周，使用塑料紙覆蓋強(qiáng)制執(zhí)行體溫過高與體溫過低影響復(fù)蘇結(jié)果⑺TemperaturecontrolWerecom11⑻InducedhypothermiaInducedhypothermiashouldbeofferedtoalltermornearterminfantswithevolvingHIE.胎齡＞36周中重度HIE亞低溫治療（33.5°-34.5°C間）窗口期—6小時(shí)治療期—72小時(shí)降低死亡率和殘疾率⑻InducedhypothermiaInducedh12⑼Drugsandfluids

1.epinephrineIntheabsenceofasuffcientIVaccess,anintra-osseousaccessmayalsobeused.腎上腺素心率持續(xù)＜60次／分腎上腺素1:10000溶液（0.1毫克/毫升）0.1-0.3毫升/公斤靜脈不可用時(shí)，骨內(nèi)給藥⑼Drugsandfluids

1.epineph13⑼-2.SodiumbicarbonateDuetolackofevidence,sodiumbicarbonatemayonlybeconsideredduringprolongedcardiacarrestsunresponsivetoothertherapyandonacompassionateusebasis,andonacase-by-casebasisinthepostresus-citationcareofnewlyborninfants證據(jù)缺乏指證：心跳停止，搶救無反應(yīng)⑼-2.SodiumbicarbonateDuet14⑼-3.NaloxoneNaloxoneshouldnotbeusedduringresuscitationorthepost-resuscitationcareofdepressednewlyborninfants.不應(yīng)使用⑼-3.NaloxoneNaloxoneshould15⑼-4.VolumeexpansionIsotoniccrystalloidsolutionorblood(10mL/kgIV)shouldbeusedfortheinitialIVvolumeexpansioninadepressednew-borninfantintheDRwithahistoryorclinicalsignsofsignificanthypovo-lemia,butrarelyonanempiricbasis.應(yīng)該是等滲晶體溶液或血（10毫升/公斤IV）用于產(chǎn)時(shí)血容量明顯減少，無循證醫(yī)學(xué)證據(jù)早產(chǎn)兒易引起顱內(nèi)出血⑼-4.VolumeexpansionIsotoni16⑼-5.GlucoseIVinfusionWesuggesttostartbygivinga10%glucose(dextrose)IVsolu-tionintheDRasearlyaspossible,andindepend-entlyfromresuscitationstatus(i.e.startinfusionduringresuscitation).產(chǎn)房，建議早期給予10％葡萄糖溶液獨(dú)立于復(fù)蘇狀態(tài)（即在復(fù)蘇開始輸液時(shí)）⑼-5.GlucoseIVinfusionWe17⑽Delayedcordclamping

Forterminfants,cordclampingmaybedelayedfor1–2min.

Delayedcordclampingmaybeofbenefittoterminfantsbornincountrieswithpoormaternalnutritionalstateand/orinsuffici-entpostnatalfollow-up.對(duì)于足月兒，鉗夾臍帶最好推遲1-2分鐘主要針對(duì)營(yíng)養(yǎng)狀況不佳的孕產(chǎn)婦⑽DelayedcordclampingForte18(11)EthicalconsiderationsWhenextremelypretermdeliveryorresuscitationisanticipated,theparentalwishesshouldbeobtainedafterunbiasedcounselingandtheiropinionsshouldberespected.胎齡＜23周，體重＜400克征詢父母意見(11)EthicalconsiderationsWh19謝謝你的興趣謝謝你的興趣20新版新生兒心肺復(fù)蘇指南的進(jìn)展與不同溫州醫(yī)學(xué)院附屬黃巖醫(yī)院新生兒科黃勇新版新生兒心肺復(fù)蘇指南的進(jìn)展與不同溫州醫(yī)學(xué)院附屬黃巖醫(yī)院21background2010年10月，美國(guó)心臟協(xié)會(huì)（AHA）以及歐洲復(fù)蘇委員會(huì)（ERC）和國(guó)際復(fù)蘇聯(lián)絡(luò)（ILCOR）委員會(huì)定期發(fā)出5年后最后一個(gè)版本-新的新生兒的心肺復(fù)蘇指南。TheAmericanHeartAssociation(AHA)theEuropeanResuscitationCouncil(ERC)theInternationalLiaisonCommitteeonResuscitation(ILCOR)background2010年10月，美國(guó)心臟協(xié)會(huì)（AHA）22sourceAmericanHeartAssoc-iation.2005AmericanHeartAssociation(A-HA)guidelinesforcar-diopulmonaryresusc-itation(CPR)andem-ergencycardiovascularcare(ECC)ofpediatricandneonatalpatients:pediatricbasiclifesup-port.Pediatrics.2006May;117(5):e989-1004.KattwinkelJ,PerlmanJM,AzizK,ColbyC,elal.

neonatalresuscitation:2010AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitationandEme-rgencyCardiovascularCare.Circulation.2010;122(suppl3):S909–S919.sourceAmericanHeartAssoc-iat23NewbornResuscitationAlgorithm.KattwinkelJetal.Circulation2010;122:S909-S919Copyright?AmericanHeartAssociationNewbornResuscitationAlgorith24⑴pulseoximetryApulseoximetercanprovideacontinuousassessmentofthepulsewithoutinterruptionofotherresuscitationmeasures,butthedevicetakes1to2minutestoapply,anditmaynotfunctionduringstatesofverypoorcardiacoutputorperfusion.脈搏氧飽和度監(jiān)測(cè)在新生兒心肺復(fù)蘇中是必需的其他復(fù)蘇措施不必中斷缺點(diǎn)：心輸出量不足或灌注不足，效果不佳⑴pulseoximetryApulseoximete25(2)UseofO2inthedeliveryroomTwometa-analysesofseveralrandomizedcontrolledtrialscomparingneonatalresuscitationinitiatedwithroomairversus100%oxygenshowedincreasedsurvivalwhenresuscitationwasinitiatedwithair.足月兒或接近足月兒開始復(fù)蘇可以用0.21空氣各種供氧措施，如T-復(fù)合器予1.0純氧復(fù)蘇，無助于生存率提高(2)UseofO2inthedeliver26(3)skincolorOtherstudieshavesho-wnthatclinicalassessm-entofskincolorisaverypoorindicatorofoxyh-emoglobinsaturationdu-ringtheimmediateneon-atalperiodandthatlackofcyanosisappearstobeaverypoorindicatorofthestateofoxygenationofanuncompromisedbabyfollowingbirth.皮膚顏色：評(píng)價(jià)指標(biāo)差生后存在發(fā)紺期宮外10分鐘達(dá)正常水平(3)skincolorOtherstudiesha27⑷CO2Detectors

ThenumberofstudiesonCO2detectorsinneonatesremainsverysmallandmostreportscomefromretrospectivestudies.Untilmoresolidevidenceprovesthattheiruseimprovespatientoutcome,werefrainfromrecommendingCO2detectorsaspartoftheroutineDRmanagement.

大部分報(bào)告來自回顧性研究不建議CO2探測(cè)器的日常管理需要更堅(jiān)實(shí)的證據(jù)證明他們的使用提高了病人復(fù)蘇結(jié)果⑷CO2DetectorsThenumbero28⑸RespiratorysupportPositivepressureventilation(PPV)intheDRisbestadministeredbyapressurelimitedT-pieceresuscitatorassuchdevicesallowmorecontrolofthedeliveredpressureandtidalvolumes.在產(chǎn)房正壓通氣（PPV）是最好的管理壓力有限的T型復(fù)蘇器允許壓力控制和潮氣量⑸RespiratorysupportPositive29⑹MeconiumaspirationWesuggesttocontinuewiththecurrentpracticeofclearingtheairwaybeforePPVisstartedinanyinfant,inparticularthosebornfromthick,MSAF,untilfurtherevidencebecomesavailable。正壓通氣前呼吸道應(yīng)清理特別是那些出生稠厚的胎糞污染患兒。胎糞污染吸引存在爭(zhēng)議⑹MeconiumaspirationWesugges30⑺TemperaturecontrolWerecommendtheuseofplasticcoveronlyforinfantswithaGA<28weeks.Inanycircumstances,closemonitoringoftheinfant’stemperatureismandatory,becausebothhypothermiaandhyper-thermianegativelyaffectsneonataloutcome.胎齡＜28周，使用塑料紙覆蓋強(qiáng)制執(zhí)行體溫過高與體溫過低影響復(fù)蘇結(jié)果⑺TemperaturecontrolWerecom31⑻InducedhypothermiaInducedhypothermiashouldbeofferedtoalltermornearterminfantswithevolvingHIE.胎齡＞36周中重度HIE亞低溫治療（33.5°-34.5°C間）窗口期—6小時(shí)治療期—72小時(shí)降低死亡率和殘疾率⑻InducedhypothermiaInducedh32⑼Drugsandfluids

1.epinephrineIntheabsenceofasuffcientIVaccess,anintra-osseousaccessmayalsobeused.腎上腺素心率持續(xù)＜60次／分腎上腺素1:10000溶液（0.1毫克/毫升）0.1-0.3毫升/公斤靜脈不可用時(shí)，骨內(nèi)給藥⑼Drugsandfluids

1.epineph33⑼-2.SodiumbicarbonateDuetolackofevidence,sodiumbicarbonatemayonlybeconsideredduringprolongedcardiacarrestsunresponsivetoothertherapyandonacompassionateusebasis,andonacase-by-casebasisinthepostresus-citationcareofnewlyborninfants證據(jù)缺乏指證：心跳停止，搶救無反應(yīng)⑼-2.SodiumbicarbonateDuet34⑼-3.NaloxoneNaloxoneshouldnotbeusedduringresuscitationorthepost-resuscitationcareofdepressednewlyborninfants.不應(yīng)使用⑼-3.NaloxoneNaloxoneshould35⑼-4.VolumeexpansionIsotoniccrystalloidsolutionorblood(10mL/kgIV)shouldbeusedfortheinitialIVvolumeexpansion