HIE新生兒缺氧缺血性腦病課件

Hypoxic-ischemicencephalopathy(HIE)新生兒缺氧缺血性腦病HIE新生兒缺氧缺血性腦病OutlineNeonatalasphyxia→oxygen-poor→ischemia→braininjured

inperinatalperiodCurrentlybirthtrauma↓，O2deficiency&asphyxia↑Severeconsequence：neonataldeathorchildrendisablement,oneofreasonofcerebralpalsyinchildrenhood.Commoninfulltermbb,alsoinprematureHIE新生兒缺氧缺血性腦病causes

mothers

fetus

antepartum

intrapartum

postpartum

20％35％35％10％hypoxiaPlacenta&umbilicalcordAnte-&intrapartumHIE新生兒缺氧缺血性腦病CausesofHIE

alsocausesofasphyxia:

Maternalfactors：illnesses，obstetricdeseases，smokingordrugaddiction,teenagepregnancies,olderthan35yearsIntrapartumfactors：umbilicalcore，malposition,placentalinsufficiency,placentalabruptionFetalfactors：congenitalanomalies,IUGR，hydropsfetalis，intrauterineinfectionInfantfactors：apnea,HMD,MAS,PPHN,shock.HIE新生兒缺氧缺血性腦病EtiopathogenesisofHIECerebralbloodflow(CBF)：1.failincompensation：2stepsofredistributionHIE新生兒缺氧缺血性腦病DivingreflexThefirsttime---skin

Adrenalgland

MaintainCBF

butleadtomultiorganicdamage,HIE新生兒缺氧缺血性腦病SecondaryredistributionAnteriorcerebralartery,ACAmiddlecerebralartery,MCAPosteriorcerebralartery,PCAHIE新生兒缺氧缺血性腦病BranchofACABranchofMCABranchofPCAHIE新生兒缺氧缺血性腦病

terminfant：皮層矢狀旁區(qū)受損

preterminfant：腦室周圍的白質(zhì)區(qū)受損Consequenceof

secondaryredistributionHIE新生兒缺氧缺血性腦病HIE新生兒缺氧缺血性腦病腦室旁白質(zhì)軟化periventricularleukomalacia,PVLHIE新生兒缺氧缺血性腦病Suddenly&completelyasphyxia2.Non-compensation：ganglion-brainstemdamageCerebralbloodflow(CBF)：HIE新生兒缺氧缺血性腦病3.autoregulation↓→Pressure-passivecerebralcirculation(PPCC)Cerebralischemia,HIEBrainedemacerebralhemorrhageBPCBFPPCCCerebralbloodflow(CBF)：HIE新生兒缺氧缺血性腦病Changeofbrainmetabolism:

1.oxygenfreeradicals→ruptureofcellmembrane

destroyBBB

(1)overproduction：

cytochrome-oxydase↓；

reperfusion：xanthineoxidase↑

hypoxanthine----------------→urea+oxyradicals

(2)removenotenough：超氧化物歧化酶（SOD）↓HIE新生兒缺氧缺血性腦病Changeofbrainmetabolism:

2.imbalanceofNa&Ca：anaerobicglycolysis→lactic

acid↑,ATP↓→

pumpoutoforder→Ca++inflow→chaosofsignal

→Na++

inflow→intra-cellularedema

3.excitableneurotransmitter:

glutamicacid；β-opioidpeptideHIE新生兒缺氧缺血性腦病neuropatholgy：

腦細(xì)胞水腫(edema)腦細(xì)胞壞死(necrosisofbraincells)腦細(xì)胞凋亡(apoptosis）

commonlyoccurafter6-24

h,keepinseveraldaystowks

promptlyinterventioncould

decreasedamageCelldeathprimarilyneuronnecrosisdelayedneuroninjuretimeHIE新生兒缺氧缺血性腦病Clinicalmanifestation

history：asphyxia

nervoussystem：

basic:consciousdisturbance,tensionofmuscle,primitivereflex

severe：convulsions,bulgefontanel,irregularrespiration,pupilsdisorderHIE新生兒缺氧缺血性腦病HIE新生兒缺氧缺血性腦病CriteriaofSarnatgradesforHIEMild：alert,irritable,buthasnormaltoneandnoseizuresModerate：lethargic,hypotonic,oftenhasseizuresSevere：stuporousorcoma,flaccidorlimp,oftenapneic,withpersistentseizuresHIE新生兒缺氧缺血性腦病Attention:部分患兒在宮內(nèi)已發(fā)生HIE,

出生時Apgar評分正常,多臟器受損不明顯

但生后數(shù)周或數(shù)月逐漸出現(xiàn)神經(jīng)系統(tǒng)受損癥狀。HIE新生兒缺氧缺血性腦病investigation

ultrasound：水腫，實質(zhì)病變，腦室，腦血流速度及指數(shù)等CT：CTvalue<20huaslowdensityMRI：可判斷矢狀旁區(qū)丘腦、基底節(jié)梗死等MRS(spectroscopy):可檢測高能磷酸代謝物的相對濃度，便于判斷預(yù)后

HIE新生兒缺氧缺血性腦病investigationsElectroencephalogram(EEG):--maybenormalduringfirstfewday--poorprognosis:suppressedorfrequentseizureactivityHIE新生兒缺氧缺血性腦病investigationsImagingassessment:--cranialultrasound--brainCTscan--MRIandspectroscopy

HIE新生兒缺氧缺血性腦病HIE輔助檢查

腦電圖：判斷病情、預(yù)后及對驚厥的鑒定血生化：肌酸磷酸激酶同工酶（CPK-BB）、

神經(jīng)元特異性烯醇化酶(NSE)

最好生后24小時內(nèi)采血血氣、血糖等HIE新生兒缺氧缺血性腦病

diagnose：HistoryofasphyxiamanifestationofnervousdisorderinvestigationHIE新生兒缺氧缺血性腦病

objective

1.增強(qiáng)代償性生長

2.建立新的神經(jīng)網(wǎng)絡(luò)

3.糾正錯誤的傳導(dǎo)與支配treatmentHIE新生兒缺氧缺血性腦病發(fā)育中腦的可塑性Plasticityduringgrowthofbrain樹突增長、增多Dendronsgrowinlengthandnumber軸突延伸Axonselongation突觸增加Increasesynapse

建立新的神經(jīng)傳導(dǎo)回路Rebuildloopsofnerveconduction——代償性生長----compensationgrowthHIE新生兒缺氧缺血性腦病Hypoxic-ischemia

necrosis

neurons

damage&apoptosis

cellbody

dendron&axon

neuralnetworksynapse

gliocytestrauma(microenvironment)

HIE新生兒缺氧缺血性腦病國家“九五”攻關(guān)項目簡介：（治療方案于1999.9南京全國第九屆圍產(chǎn)新生兒研究第12次會；1999.10大連第五屆全國新生兒學(xué)術(shù)會上討論并修改）

治療原則therapeuticprinciple：早治early階段stage綜合combination足程enoughcourse信心

confidenceHIE新生兒缺氧缺血性腦病Within3dof

age

(criticalperiod)4-10dAfter10dAfterneonatalperiod4stagesofHIEHIE新生兒缺氧缺血性腦病within3d：

purpose：stabilizeinternalenvionment&controlnervoussymptom1、三項支持療法：血氣bloodgas血循環(huán)circulation血糖bloodsugarHIE新生兒缺氧缺血性腦病within3d：2、三項對癥處理：

控制驚厥：phenobarbital,diazepam

降顱壓：furosemide,mannitol

消除腦干癥狀：納絡(luò)酮naloxone指征indication：①severeHIE

②pupildisorder

③shock④frequentconvulsion3．improvemetabolismofcells：

cerebrolysin,胞二磷膽堿citicoline,復(fù)方丹參SalviamiltiorrhizahyperbaricoxygenationHIE新生兒缺氧缺血性腦病HIE新生兒缺氧缺血性腦病4-10dofage：

purpose:4-5d開始好轉(zhuǎn)，7-9d明顯好轉(zhuǎn)method:improvemetabolismofcellsAfter10d：鞏固療效，防止后遺癥

purpose:Consolidatetherapeuticeffect&preventesequelae

method:ifneonatalbehaviornervousassessment(NBNA)<35

1.促神經(jīng)細(xì)胞代謝

2.新生兒期干預(yù)inte