新生兒英用藥課件

NeonatalMedicine

--IntroductionXiaopingLuo,MDProfessorandChairmanDepartmentofPediatrics,TongjiHospitalDirector,CenterfortheDiagnosisofGeneticMetabolicDiseasesTongjiMedicalCollegeHuazhongUniversityofScienceandTechnologyAdjunctProfessorDepartmentofPaediatricsFacultyofMedicineUniversityofTorontoToronto,Canada新生兒英用藥HistoricalPerspectivesEarlyHistoryofCareofInfants(1900~-smallinfantswerenotexpectedtolive-temperature:hot-waterbottles,heatedcribs-feeding:tubefeeding,dilutedcowmilk-separatedfacilities,isolation,washinghands-hyalinemembranediseases---respiratorydistresssyndrome-1940s,modernizedincubator,moreoxygen-1940s,retrolentalfibroplasia-1945,《ThePhysiologyoftheNewbornInfant》--C.Smith

新生兒英用藥HistoricalPerspectivesRapidAdvancesinNeonatalCare(1955~1970)-1959,surfactantdeficiency,AveryME,MeadJ.AmJDisChild-1960,《DiseaseoftheNewborn》-Neonatology-A.Schaffer

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culture,bloodcounts,urinalyses,radiographs,biopsies-milkformulas,breastmilkbank-ivglucose&bicarbonate-bloodgasanalysis-improvedincubators-earlyattemptsofmechanicalventilation新生兒英用藥HistoricalPerspectivesEmergenceofneonatalIntensiveCare(1971~1989)

-1971,continuouspositiveairwaypressure(CPAP)--Gregory-neonatalintensivecareunit(NICU)-designatedbylevelaccordingtotheintensityofserviceI:normalbirthingandNBcare,II:commonobstetriccomplications&intermediateNBcare

III:highriskmaternalcareandNICU-transferringofhighriskinfantsormothers-highriskandlongtermoutcome-1980s,extracorporealmembraneoxygenation(ECMO)新生兒英用藥HistoricalPerspectivesExpansionofClinicalTrialstoAssessTherapy:theSurfactantEra(1980~1996)-1970s~1990s,glucocorticoidstoacceleratelungmaturation-1980,firstsurfactantreplacementtherapyinhumans-totalparenteralnutrition(TPN)-highfrequencyoscillators-inhalednitricoxide-prenataldiagnosisandgeneticcounseling-prospective,controlledclinicaltrialsforintervention-“quietprematurenursery”to“abustlingspacestation”新生兒英用藥LeTourd’abandon(DecertionTower)新生兒英用藥CenturyofProgressInternationalExposition

ChicagoWorld'sFair,Chicago,Illinois新生兒英用藥新生兒英用藥TheDionnequintupletsMay28,1934,13pounds6ounces,Alltogether!Emelie,Cecile,Marie,Annette,YvonneJuliusHess“quietprematurenursery”新生兒英用藥新生兒英用藥Howsmallistoosmall?Howmuchistoomuch?Lifesupport:Tocontinueordiscontinue?新生兒英用藥DefinitionsofTermsNewbornorneonatereferstoainfantperiodfrombirthto28days.Neonatology—healthcare,pathophysiologyandmanagementEarlyNeonate

referstothefirst7completeddaysoflife.LateNeonate

referstoaperiodbetween8to28daysoflife.Perinatalperiodextendsfromthe28thcompletedweekofpregnancytothe7thdayoflife.PerinatologyorPerinatalMedicine新生兒英用藥DefinitionsofTermsTermdefinesbirthsthatoccurfrom37thtolessthan42completedweeks,measuredfromthedayofonsetofthelastnormalmenstrualperiod(259~293days,withanaverageof280days).

Pretermisdefinedaslessthan37completedweeks’,or259days,gestation.(37weeksofgestation≈birthweightof3000g)Post-termreferstobirthsthatoccursat42ormorecompletedweeks(294days).新生兒英用藥StillbirthandFetalDeath.

Earlyfetaldeathoccursat<20completedweeksofgestation,

intermediatefetaldeathoccurs>20and<28completedweeks,

latefetaldeathoccursafter28weeks,ortermedasstillbirth.LiveBirth.WHOdefineslivebirthasThecompleteexpulsionorextractionfromitsmotherofaproductofconception,irrespectiveofthedurationofpregnancy,whichaftersuchseparation,breathesoranyotherevidenceoflife,suchasbeatingoftheheart,pulsationoftheumbilicalcord,ordefinitemovementofvoluntarymuscles,whetherornottheumbilicalcordhasbeencutortheplacentaisattached;eachproductofsuchabirthisconsideredliveborn.DefinitionsofTerms新生兒英用藥BirthWeight(BW)

BW<2500g---LowBirthWeight(LBW);

<1500g---VeryLowBirthWeight(VLBW);

<1000g---Extremely

LowBirthWeight(ELBW);>4000g---FetalMacrosomia

(Beckwith-WiedemannsyndromeInfantofDiabeticMother,IDM)DefinitionsofTerms新生兒英用藥BirthWeightvsGestationalAge(GA)

BW<the10thpercentile

---smallforgestationalage(SGA)intrauterinegrowthrestriction(IUGR)10~90thpercentile---appropriateforgestationalage(AGA)>the90thpercentile---largeforgestationalage(LGA)

ponderalindex=BW(g)X100/Length3(cm3)(>2~2.2)Length/HeadCircumference(HC)(>1.36)symmetricorunsymmetricSGADefinitionsofTerms新生兒英用藥BirthweightCurvesCaliforniamalesingletonCaucasiannon-Hispanicbirthweightsbygestationalage:10th,50th,and90thpercentiles.新生兒英用藥PregnanciesinwhichfactorsexistthatincreasethelikelihoodofmaternalorfetaldiseasesEconomic,cultural-behavioral,biologic-genetic,reproductiveandmedicalfactors10~20%ofpregnantpatientcanbeidentifiedashighrisk~50%ofallperinatalmortalityandmorbidityisassociatedwithhighriskpregnancyHighRiskPregnancy新生兒英用藥Aninfantwhoshouldbeundercloseobservationbyexperiencedphysiciansandnurses.~9%ofallbirthsrequireintensivecareFetalorneonatalfactors:

prematurelabor,postdates,fetaldistrass,breechpresentation,meconium-stainedfluid,nuchalcord,Cesareansection,forceps

lowApgarscore,BW<2500or>4000,SGAorLGA,congenitalmalformation,tachypnea,cyanosis,pallor,plethora,petechiaeHighRiskInfant新生兒英用藥FetalGrowthandMaturity

embryonicperiod(1~8wks):earlyembryogenesisfetalperiod(9wks~birth):growthandmaturationFactorsAffectingFetalGrowth

genetic,geographic,socialandeconomicfactorsmaternalconditions:stature,age,diseaseandmedicationfetal:sex,multiplepregnancy,geneticdisease,infectionFetalMonitoring

maternalserum,chorionvilli,amnioticfluid,placenta,fetalheartrate,ultrasound,bloodgasandpHFetalGrowthandMonitoring新生兒英用藥PhysicalCriteria

SkinLanugohairPlantarsurfaceBreastHairFingernailEar/EyeGenitalsNeuromuscularCriteria

PostureSquarewindow(wrist)ArmrecoilPoplitealangleScarfsignHeeltoear

NewBallardScore(NBS)forMaturityRating

BallardJL,etal,JPediatr1991;119:417PhysicalandNeuromuscularCriteriaforMaturity新生兒英用藥Dubowitz/BallardExam

forGestationalAge新生兒英用藥SuckingPalmargraspResponsetotractionMororeflexCrossedextensionAutomaticwalkingRoofreflexPupillaryresponse

NeurologicalReflexes新生兒英用藥Bodytemperature

heatlossbyevaporation,radiationandconvectionNeutralthermalenviroment

Therangeofambienttemperatureandhumidityatwhichheatlossisminimalandmetabolicdemandsandoxygenconsumptionarethelowest.Dependsonbodyweightandage

31to34oCat50%humidityforundressednormalterminfantSkintemperaturevscentralorcoretemperature(rectal)Re-warmingahypothermicinfantatmoderaterate(2~4hrs)Thermalregulation

PhysiologicalCharacteristics新生兒英用藥CardiopulmonaryFunction

heartrate:120~130bpm

tachycardia/bradycardia;transitionfromFCbloodpressure:65~95/30~60mmHg,

lowerinpreterm,PDAinpretermlungfluid:30~35ml/kg

“excretion/re-absorption”,“wetlung”respiratoryrate:60~80/mininthe1sthour,40/minafter

briefpausesinrespiration(<5~9’s)apnea(>20’s,withbradycardia<100bpm)PhysiologicalCharacteristics新生兒英用藥

GastrointestinalFunction

vomitingandabdominaldistension

swallowedmaternalblood,GImalformation,infection

firstfeeding

nutritionalissues,

tracheo-esophagealfistula,jaundicepassageofmeconium

70%within12h,25%in12~24h,5%by48hdistalintestinalobstruction,meconiumplugsyndrome,Hirschsprung’sdisease,sepsis,hypothyroidism,nacorticnecrotizingenterocolitis(NEC)

premature,hypoxiaandischemia,infection,feedingPhysiologicalCharacteristics新生兒英用藥UrinaryFunction

urinate

68%within12h,25%in12~24h,7%by48hpre-renalcauses:dehydration,shockrenalabnormality:renalagenesis,tubularnecrosisobstructionofurinaryoutflow:urethralvalves

lateonsetmetabolicacidosisinprematureinfant

cowmilkfeedingwithhighproteinload

PhysiologicalCharacteristics新生兒英用藥HematologicalSystem

hemoglobin:cordblood170g/L,changewithage

Fetalhemoglobin:HbF70%,HbA30%

WBC:15~20X109/Lfortermbaby6~8X109/Lforpretermbaby

Platelet:150~250X109/L

Bloodvolume:50~100ml/kgfortermbaby89~105ml/kgforpretermbabyPhysiologicalCharacteristics新生兒英用藥NeurologicalSystem

brain:300~400g,

10~20%ofbodyweight(adult2%)

headcircumference:33~34cm,increaseby~1cm/month

spinalcord:endsatL3~4,cautionforlumbarpuncture

physiologicalreflexes:rooting,sucking,grasp,Moro

Pathologicalreflexes:Kernig