亞低溫治療缺氧缺血性腦病課件

亞低溫治療缺氧缺血性腦病

亞低溫治療缺氧缺血性腦病目的了解亞低溫療法的由來(lái)明確亞低溫治療對(duì)缺血缺氧性腦病的療效掌握我院亞低溫療法的方案目的HistoryofTherapeuticHypothermiaFirstscientificreportwaspublishedin1945byDr.TempleFay“Observationsongeneralizedrefrigerationincasesofseverecerebraltrauma”AlsoinvestigateduseincancerHistoryofTherapeuticHypotheHIEinNeonatesPerinatalasphyxia~3–5per1000livebirthsModerateorsevereHIE~0.5–1per1000livebirthsMortality~10-60%Morbidity~25%ofsurvivorsTherearenospecifictreatmentsproventodecreasebraindamagefromHIEHIEinNeonatesPerinatalasphy缺氧缺血性腦病HIE圍生期窒息引起的部分或完全缺氧、腦血流減少或暫停導(dǎo)致的胎兒、新生兒腦損傷

我國(guó)HIE發(fā)病率3-6‰，其中15-20%在新生兒期死亡。存活者中20-30%有不同程度神經(jīng)系統(tǒng)后遺癥缺氧缺血性腦病HIE圍生期窒息引起的部分或完全缺氧、HIEinNeonatesDiagnosticcriteriaarevagueLowApgarscoresat5minsChangeinconsciousnessSignsofsignificanthypoperfusion(ieacidosis)RequirementforventilationSeizuresOtherHIEinNeonatesDiagnosticcritPathophysiologyofBrainInjuryduetoHypoxic-IschemicInsult2phasesofneuronaldeathImmediate“Primaryneuronaldeath”cellularhypoxiawithexhaustionofthecell’shighenergystores(primaryenergyfailure)Latent(>6hours)“Delayedneuronaldeath”MultiplemechanismsHyperemia充血Cytotoxicedema細(xì)胞毒性水腫Mitochondrialfailure線粒體·損傷Accumulationofexcitotoxins興奮性氨基酸ActivecelldeathNitricoxidesynthesisNO失衡FreeradicaldamageandcytotoxicactionsofactivatedmicrogliaSignificantproportionoftotalinjuryPathophysiologyofBrainInjur亞低溫治療缺氧缺血性腦病課件Copyright?RadiologicalSocietyofNorthAmerica,2006Chao,C.P.etal.Radiographics2006;26:S159-S172Figure2.PatternsofbraininjuryinmildtomoderatehypoperfusionCopyright?RadiologicalSocietPathophysiologyofBrainInjuryduetoHypoxic-IschemicInsultLatentphaseprovideswindowoftherapeuticinterventionPathophysiologyofBrainInjurWagner,2002–RatsWagner,2002–RatsGunn,1997-LambsGunn,1997-LambsTooley,2003–PigletsTooley,2003–PigletsSummaryMultiplelinesofevidencesuggesttherapeutichypothermiamaybeneuroprotectiveRecentlythistherapyhasemergedastherapyforinfantssufferingHIErelatedtobirthSummaryMultiplelinesofevideTherapeuticHypothermiainBabiesSmallhumanstudieswithencouragingresultsGunn,1998;22patients,headcooling–noadverseeffectscomparedwithcontrolAzzopardi,2000;16patients,wholebodycooling–noadverseeffectsThoresen,2000;9patients,bothmethods–non-hazardouscardiovascularchangesnoted,particularlywithover-coolingorShankaran,2002;19patients,wholebodycooling–noadverseeffects2recent,randomizedcontrolledtrialsof~500infantsCoolCapNICHDwhole-bodyhypothermiaTherapeuticHypothermiainBabCoolCapSelectiveheadcoolingwithmildsystemichypothermiaafterneonatalencephalopathy:multicentrerandomisedtrialGluckmanPD,WyattJS,AzzopardiD,BallardR,EdwardsAD,FerrieroDM,PolinRA,RobertsonCM,ThoresenM,WhitelawA,GunnAJLancet.2005Feb19-25;365(9460):663-70CoolCapSelectiveheadcoolingCoolCapInclusioncriteria:>35weeksEGAApgarscore≤5at10mins;orpH<7orbasedeficit>16mmol/Lwithin60minsofbirthSarnatscoreandamplitude-integratedEEGconsistentwithdiagnosisofmoderatetosevereHIECoolCapInclusioncriteria:CoolCapIntervention:CoolingCapfittedtoheadfor72hSmallthermostaticcoolingunitwithapumptocirculatewaterthroughthecapInitialwatertemperature8°to12°CRadiantwarmer,servo-controlledtoabdominalskintemperature,adjustedtomaintaintherectaltemperatureat34–35°CInitially,warmerofffor20-30minstospeedcoolingRewarmed<0.5°C/huntiltemperaturewasnormalCoolCapIntervention:亞低溫33-34℃亞低溫33-34℃亞低溫治療缺氧缺血性腦病課件CoolCapCoolCapCoolCapCoolCapCoolCap–SubgroupAnalysisCoolCap–SubgroupAnalysisWhole-BodyHypothermiaWhole-BodyHypothermiaforNeonateswithHypoxic–IschemicEncephalopathySeethaShankaran,etalNEnglJMed.2005Oct13;353(15):1574-84Whole-BodyHypothermiaWhole-BoWhole-BodyHypothermiaWhole-BodyHypothermiaWhole-BodyHypothermiaInterventionPlacedonaninfant-sizeblanketprecooledto5°CEsophagealprobewasinsertedEsophagealtemperaturewasloweredto33.5°Cbytheblanket'sservomechanismNeededasecondblanketasathermalsinkNoothersourcesofwarmingprovidedduringthecoolingperiodWhole-BodyHypothermiaIntervenWhole-BodyHypothermiaAfter72hoursSetpointofthecoolingsystemwasincreasedby0.5°CperhourforsixhoursEsophagealprobethenremovedThereafter,skintemperaturewascontrolledbytheradiantwarmer'sservomechanismWarmertempwasset0.5°Chigherthantheskintemperatureandincreased0.5°Ceveryhouruntilthesetpointofthewarmerreached36.5°CWhole-BodyHypothermiaAfter72亞低溫治療缺氧缺血性腦病課件Whole-BodyHypothermiaWhole-BodyHypothermiaWhole-BodyHypothermiaWhole-BodyHypothermiaCochraneReviewCochraneReviewCochraneReviewCochraneReviewShah,ArchPediatrAdolescMed.2007;161(10):951-958Shah,ArchPediatrAdolescMed亞低溫治療缺氧缺血性腦病課件Tooley,2003–PigletsTooley,2003–Piglets亞低溫治療缺氧缺血性腦病課件亞低溫治療缺氧缺血性腦病課件準(zhǔn)入條件

1胎齡大于36周，生后6小時(shí)內(nèi)進(jìn)入亞

低溫程序。2圍生期窒息缺氧史。35分鐘Apgar小于6。4臍血或生后1小時(shí)內(nèi)PH小于7。5生后需要通氣支持超過(guò)10分鐘。

準(zhǔn)入條件

1胎齡大于36周，生后6小時(shí)內(nèi)進(jìn)入亞排除標(biāo)準(zhǔn)

1六小時(shí)內(nèi)不能進(jìn)行亞低溫治療。2.嚴(yán)重先天畸形。3嚴(yán)重宮內(nèi)發(fā)育遲緩出生體重小于1800千克。4嚴(yán)重染色體缺陷病5＜35周早產(chǎn)兒

排除標(biāo)準(zhǔn)

1六小時(shí)內(nèi)不能進(jìn)行亞低溫治療。醫(yī)囑

1特級(jí)護(hù)理告病危

2多功能心電監(jiān)護(hù):心率維持在80-140次/分，

3監(jiān)測(cè)SpO285-99%。4亞低溫毯溫度設(shè)置33-34攝氏度醫(yī)囑

1特級(jí)護(hù)理告病危監(jiān)測(cè)監(jiān)測(cè)患兒體溫Q15分鐘×2-4小時(shí)，以后Q2小時(shí)至低溫療法結(jié)束。監(jiān)測(cè)血糖Q8h×1day，Q12h×2day，Qd×4day，血?dú)夥治鯭1day，肝腎功能電解質(zhì)Qd×3day，凝血相Qd×3day。監(jiān)測(cè)監(jiān)測(cè)患兒體溫Q15分鐘×2-4小時(shí)，以后Q2小時(shí)至低溫療注意事項(xiàng)

1亞低溫治療時(shí)除尿片外全身裸露2亞低溫治療時(shí)患兒會(huì)表現(xiàn)為皮膚發(fā)紺和蒼白氧飽和度報(bào)警值設(shè)在85%3必須保持血?dú)?，電解質(zhì)平衡注意事項(xiàng)

1亞低溫治療時(shí)除尿片外全身裸露亞低溫治療期間皮膚顏色為灰色或發(fā)暗，如果血?dú)庋躏柡投日？刹挥杼幚怼喌蜏刂委熎陂g皮膚顏色為灰色或發(fā)暗，如果血?dú)庋躏柡投日？刹粊喌蜏仄陂g患兒心率會(huì)低于90bpm，心電監(jiān)護(hù)心率報(bào)警值設(shè)定為80bpm。亞低溫期間患兒心率會(huì)低于90bpm，心電監(jiān)護(hù)心率報(bào)警值設(shè)定為呼吸機(jī)調(diào)節(jié)無(wú)特殊，三支持（血?dú)?、血糖、血壓），三?duì)癥同未用亞低溫時(shí)查血?dú)鈺r(shí)注意標(biāo)注當(dāng)時(shí)體溫。呼吸機(jī)調(diào)節(jié)無(wú)特殊，三支持（血?dú)?、血糖、血壓），三?duì)癥同未用亞復(fù)溫

72小時(shí)亞低溫治療后進(jìn)入復(fù)溫程序復(fù)溫

72小時(shí)亞低溫治療后進(jìn)入復(fù)溫程序復(fù)溫1移除低溫毯。2開(kāi)啟輻射式搶救臺(tái)，設(shè)定溫度高于患兒身體溫度0.5攝氏度。3每小時(shí)升溫0.5攝氏度，持續(xù)6小時(shí)到正常溫度。4多功能心電監(jiān)護(hù)，并監(jiān)測(cè)血糖，血?dú)夥治霰ＷC電解質(zhì)穩(wěn)定。復(fù)溫1移除低溫毯。注意事項(xiàng)

1復(fù)溫時(shí)發(fā)生抽搐、呼吸暫停的可能性增大2生后7天查MRI注意事項(xiàng)

停止亞低溫治療指征

1經(jīng)積極呼吸機(jī)輔助通氣SPO2仍低于80%，積極支持治療和血管活性藥物后平均動(dòng)脈壓低于35mmH2O。

2出現(xiàn)心律失常或心率持續(xù)低于80bpm。停止亞低溫治療指征

1經(jīng)積極呼吸機(jī)輔助通氣SPO2仍低于8護(hù)理-體溫監(jiān)測(cè)降溫期間每15分鐘測(cè)體溫，達(dá)到目標(biāo)溫度后2小時(shí)一次。復(fù)溫期間1小時(shí)一次。

體溫高于或低于目標(biāo)溫度1℃或患兒出現(xiàn)煩躁、顫抖應(yīng)通知醫(yī)師。護(hù)理-體溫監(jiān)測(cè)降溫期間每15分鐘測(cè)體溫，達(dá)到目標(biāo)溫度護(hù)理Q4H檢查皮膚、Q2H變動(dòng)體位保持冰帽干燥減少冷凝水護(hù)理Q4H檢查皮膚、Q2H變動(dòng)體位Medicalcentersofferinghypothermiashouldbecapableofprovidingcomprehensiveclinicalcare,includingmechanicalventilation;physiologic(vitalsigns,temperature)andbiochemical(bloodgas)monitoring;neuroimaging,includingMRI;seizuredetectionandmonitoringwithaEEGorEEG;neurologicconsultation;andasysteminplaceformonitoringlongitudinalneurodevelopmentaloutcome..MedicalcentersofferinghypotInfantsofferedhypothermiashouldmeetinclusioncriteriaoutlinedinpublishedclinicaltrials(seeTable1).EligibilitycriteriaincludeapHof≤7.0orabasedeficitof≥16mmol/Linasampleofumbilicalcordbloodorbloodobtainedduringthefirsthourafterbirth,historyofanacuteperinatalevent,a10-minuteApgarscoreof<5,orassistedventilationinitiatedatbirthandcontinuedforatleast10minutes.Inaddition,aneurologicexaminationdemonstratingmoderatetosevereencephalopathyisessential.Ifpreferentialheadcoolingisused,anabnormalbackgroundactivityoneitherEEGoraEEGalsoisrequired.InfantsofferedhypothermiashTrainingprogramsandinfrastructureneedtobeestablishedandmaintainedinahighlyorganizedandreproduciblemannertoensurepatientsafety.Eachcenterofferinghypothermiatherapyneedstodevelopawrittenprotocolandmonitormanagementandoutcomes.Trainingneedstoincludeawarenessandtimelyidentificationofinfantsatriskforencephalopathyandanappropriateassessmentofinfantswhohaveencephalopathy.Educationalendeavorsneedtoinvolveobstetriccareproviders;labor,delivery,nursery,andpostpartumpersonnel;andpediatriccareproviders.TrainingprogramsandinfrastrOutreacheducationtocommunityhospitalsneedstobeimplemented.Specificissuesincludetheawarenessandtimelyidentificationofinfantsatriskforencephalopathyandpreventionofextremehypothermiaandhyperthermia.OutreacheducationtocommunitCoolinginfantswhoarebornatlessthan35weeks’gestationorthosewhohavemildencephalopathy,coolingforlongerthan72hours,coolingatatemperaturelowerthanthatusedinpublishedclinicaltrials,andtheuseofadjuvanttherapiesshouldonlybeperformedinaresearchsettingandwithinformedparentalconsentCoolinginfantswhoareborna進(jìn)展Thereareseveralongoingrandomizedclinicaltrialsthataredesignedtoassesstheefficacyof1initiatingcoolingbetween6and12hoursofage,usingadeeperdepthofcooling(32°C),orcoolingforalongerduration(120hours)(NCT01192776,NCT00614744).2lessthan35weeksofgestationalagemaybeavailableinthenearfuture(NCT1793129).進(jìn)展Thereareseveralongoingr進(jìn)展clonidinetherapyNCT01862250xenon(NCT00934700,NCT01545271)topiramate(NCT01241019,NCT01765218)erythropoietin1000U/kgintravenously(NCT01913340)Darbepoetinalfa進(jìn)展clonidinetherapyNCT0NCT01192776fourwhole-bodycoolingtreatmentsforinfantsbornat36weeksgestationalageorlaterwithHIE:(1)coolingfor72hoursto33.5°C;(2)coolingfor120hoursto33.5°C;(3)coolingfor72hoursto32.0°C;and(4)coolingfor120hoursto32.0°C.Theobjectiveofthisstudyistoevaluatewhetherwhole-bodycoolinginitiatedatlessthan6hoursofageandcontinuedfor120hoursand/oradepthat32.0°Cinwillreducedeathanddisabilityat18-22monthscorrectedage.NCT01192776fourwhole-bodycooNCT00614744Hypothermiainitiatedbetween6-24hoursofageandcontinuedfor96hoursininfants≥36weeksgestationalagewithhypoxic-ischemicencephalopathywillreducetheincidenceofdeathordisabilityat18-24monthsofage.Thestudywillenroll168infantswithsignsofhypoxic-ischemicencephalopathyat16NICHDNeonatalResearchNetworksites,NCT00614744Hypothermiainitia.Amongneonateswhowerefull-termwithmoderateorseverehypoxicischemicencephalopathy,longercooling,deepercooling,orbothcomparedwithhypothermiaat33.5°Cfor72hoursdidnotreduceNICUdeath.Theseresultshaveimplicationsforpatientcareanddesignoffuturetrials.

JAMA.2014Dec24-31;312(24):2629-39.Amongneonateswhowereful早產(chǎn)兒亞低溫Thistrialwillassesssafetyandeffectivenessofwholebodyhypothermiafor72hoursinpreterminfants33-35weeksgestationalage(GA)whopresentat<6hrspostnatalagewithmoderatetosevereneonatalencephalopathy..NCT01793129早產(chǎn)兒亞低溫Thistrialwillassesss早產(chǎn)兒亞低溫Infants330/7to356/7weeksGA(bestobstetricalestimate)andgreaterthanorequalto1500gramsbirthweight(selectedtominimizepotentialdifficultiesplacingesophagealprobe)whomeetclinical,biochemicalandneurologiccriteriaformoderatetosevereNEwillberandomizedtoeitherwholebodyhypothermiaorparticipateinanon-cooledcontrolgroup早產(chǎn)兒亞低溫Infants330/7to356/7早產(chǎn)兒亞低溫Theprimaryoutcomewillbedeathormoderatetoseveredisabilityat18-22monthscorrectedage.ThepresenceorabsenceofdisabilitywillbedeterminedbythestandardNRNinterdisciplinaryfollow-upexam.早產(chǎn)兒亞低溫Theprimaryoutcomewill早產(chǎn)兒亞低溫withatargetesophagealtemperatureof33.5°Cfor72hoursFirstreceived:February13,2013早產(chǎn)兒亞低溫withatargetesophagealHIE相關(guān)Feasibilityofautologouscordbloodcellsforinfantswithhypoxic-ischemicencephalopathy.JPediatr.2014May;164(5):973-979.HIE相關(guān)Feasibilityofautologous亞低溫治療缺氧缺血性腦病

亞低溫治療缺氧缺血性腦病目的了解亞低溫療法的由來(lái)明確亞低溫治療對(duì)缺血缺氧性腦病的療效掌握我院亞低溫療法的方案目的HistoryofTherapeuticHypothermiaFirstscientificreportwaspublishedin1945byDr.TempleFay“Observationsongeneralizedrefrigerationincasesofseverecerebraltrauma”AlsoinvestigateduseincancerHistoryofTherapeuticHypotheHIEinNeonatesPerinatalasphyxia~3–5per1000livebirthsModerateorsevereHIE~0.5–1per1000livebirthsMortality~10-60%Morbidity~25%ofsurvivorsTherearenospecifictreatmentsproventodecreasebraindamagefromHIEHIEinNeonatesPerinatalasphy缺氧缺血性腦病HIE圍生期窒息引起的部分或完全缺氧、腦血流減少或暫停導(dǎo)致的胎兒、新生兒腦損傷

我國(guó)HIE發(fā)病率3-6‰，其中15-20%在新生兒期死亡。存活者中20-30%有不同程度神經(jīng)系統(tǒng)后遺癥缺氧缺血性腦病HIE圍生期窒息引起的部分或完全缺氧、HIEinNeonatesDiagnosticcriteriaarevagueLowApgarscoresat5minsChangeinconsciousnessSignsofsignificanthypoperfusion(ieacidosis)RequirementforventilationSeizuresOtherHIEinNeonatesDiagnosticcritPathophysiologyofBrainInjuryduetoHypoxic-IschemicInsult2phasesofneuronaldeathImmediate“Primaryneuronaldeath”cellularhypoxiawithexhaustionofthecell’shighenergystores(primaryenergyfailure)Latent(>6hours)“Delayedneuronaldeath”MultiplemechanismsHyperemia充血Cytotoxicedema細(xì)胞毒性水腫Mitochondrialfailure線粒體·損傷Accumulationofexcitotoxins興奮性氨基酸ActivecelldeathNitricoxidesynthesisNO失衡FreeradicaldamageandcytotoxicactionsofactivatedmicrogliaSignificantproportionoftotalinjuryPathophysiologyofBrainInjur亞低溫治療缺氧缺血性腦病課件Copyright?RadiologicalSocietyofNorthAmerica,2006Chao,C.P.etal.Radiographics2006;26:S159-S172Figure2.PatternsofbraininjuryinmildtomoderatehypoperfusionCopyright?RadiologicalSocietPathophysiologyofBrainInjuryduetoHypoxic-IschemicInsultLatentphaseprovideswindowoftherapeuticinterventionPathophysiologyofBrainInjurWagner,2002–RatsWagner,2002–RatsGunn,1997-LambsGunn,1997-LambsTooley,2003–PigletsTooley,2003–PigletsSummaryMultiplelinesofevidencesuggesttherapeutichypothermiamaybeneuroprotectiveRecentlythistherapyhasemergedastherapyforinfantssufferingHIErelatedtobirthSummaryMultiplelinesofevideTherapeuticHypothermiainBabiesSmallhumanstudieswithencouragingresultsGunn,1998;22patients,headcooling–noadverseeffectscomparedwithcontrolAzzopardi,2000;16patients,wholebodycooling–noadverseeffectsThoresen,2000;9patients,bothmethods–non-hazardouscardiovascularchangesnoted,particularlywithover-coolingorShankaran,2002;19patients,wholebodycooling–noadverseeffects2recent,randomizedcontrolledtrialsof~500infantsCoolCapNICHDwhole-bodyhypothermiaTherapeuticHypothermiainBabCoolCapSelectiveheadcoolingwithmildsystemichypothermiaafterneonatalencephalopathy:multicentrerandomisedtrialGluckmanPD,WyattJS,AzzopardiD,BallardR,EdwardsAD,FerrieroDM,PolinRA,RobertsonCM,ThoresenM,WhitelawA,GunnAJLancet.2005Feb19-25;365(9460):663-70CoolCapSelectiveheadcoolingCoolCapInclusioncriteria:>35weeksEGAApgarscore≤5at10mins;orpH<7orbasedeficit>16mmol/Lwithin60minsofbirthSarnatscoreandamplitude-integratedEEGconsistentwithdiagnosisofmoderatetosevereHIECoolCapInclusioncriteria:CoolCapIntervention:CoolingCapfittedtoheadfor72hSmallthermostaticcoolingunitwithapumptocirculatewaterthroughthecapInitialwatertemperature8°to12°CRadiantwarmer,servo-controlledtoabdominalskintemperature,adjustedtomaintaintherectaltemperatureat34–35°CInitially,warmerofffor20-30minstospeedcoolingRewarmed<0.5°C/huntiltemperaturewasnormalCoolCapIntervention:亞低溫33-34℃亞低溫33-34℃亞低溫治療缺氧缺血性腦病課件CoolCapCoolCapCoolCapCoolCapCoolCap–SubgroupAnalysisCoolCap–SubgroupAnalysisWhole-BodyHypothermiaWhole-BodyHypothermiaforNeonateswithHypoxic–IschemicEncephalopathySeethaShankaran,etalNEnglJMed.2005Oct13;353(15):1574-84Whole-BodyHypothermiaWhole-BoWhole-BodyHypothermiaWhole-BodyHypothermiaWhole-BodyHypothermiaInterventionPlacedonaninfant-sizeblanketprecooledto5°CEsophagealprobewasinsertedEsophagealtemperaturewasloweredto33.5°Cbytheblanket'sservomechanismNeededasecondblanketasathermalsinkNoothersourcesofwarmingprovidedduringthecoolingperiodWhole-BodyHypothermiaIntervenWhole-BodyHypothermiaAfter72hoursSetpointofthecoolingsystemwasincreasedby0.5°CperhourforsixhoursEsophagealprobethenremovedThereafter,skintemperaturewascontrolledbytheradiantwarmer'sservomechanismWarmertempwasset0.5°Chigherthantheskintemperatureandincreased0.5°Ceveryhouruntilthesetpointofthewarmerreached36.5°CWhole-BodyHypothermiaAfter72亞低溫治療缺氧缺血性腦病課件Whole-BodyHypothermiaWhole-BodyHypothermiaWhole-BodyHypothermiaWhole-BodyHypothermiaCochraneReviewCochraneReviewCochraneReviewCochraneReviewShah,ArchPediatrAdolescMed.2007;161(10):951-958Shah,ArchPediatrAdolescMed亞低溫治療缺氧缺血性腦病課件Tooley,2003–PigletsTooley,2003–Piglets亞低溫治療缺氧缺血性腦病課件亞低溫治療缺氧缺血性腦病課件準(zhǔn)入條件

1胎齡大于36周，生后6小時(shí)內(nèi)進(jìn)入亞

低溫程序。2圍生期窒息缺氧史。35分鐘Apgar小于6。4臍血或生后1小時(shí)內(nèi)PH小于7。5生后需要通氣支持超過(guò)10分鐘。

準(zhǔn)入條件

1胎齡大于36周，生后6小時(shí)內(nèi)進(jìn)入亞排除標(biāo)準(zhǔn)

1六小時(shí)內(nèi)不能進(jìn)行亞低溫治療。2.嚴(yán)重先天畸形。3嚴(yán)重宮內(nèi)發(fā)育遲緩出生體重小于1800千克。4嚴(yán)重染色體缺陷病5＜35周早產(chǎn)兒

排除標(biāo)準(zhǔn)

1六小時(shí)內(nèi)不能進(jìn)行亞低溫治療。醫(yī)囑

1特級(jí)護(hù)理告病危

2多功能心電監(jiān)護(hù):心率維持在80-140次/分，

3監(jiān)測(cè)SpO285-99%。4亞低溫毯溫度設(shè)置33-34攝氏度醫(yī)囑

1特級(jí)護(hù)理告病危監(jiān)測(cè)監(jiān)測(cè)患兒體溫Q15分鐘×2-4小時(shí)，以后Q2小時(shí)至低溫療法結(jié)束。監(jiān)測(cè)血糖Q8h×1day，Q12h×2day，Qd×4day，血?dú)夥治鯭1day，肝腎功能電解質(zhì)Qd×3day，凝血相Qd×3day。監(jiān)測(cè)監(jiān)測(cè)患兒體溫Q15分鐘×2-4小時(shí)，以后Q2小時(shí)至低溫療注意事項(xiàng)

1亞低溫治療時(shí)除尿片外全身裸露2亞低溫治療時(shí)患兒會(huì)表現(xiàn)為皮膚發(fā)紺和蒼白氧飽和度報(bào)警值設(shè)在85%3必須保持血?dú)?，電解質(zhì)平衡注意事項(xiàng)

1亞低溫治療時(shí)除尿片外全身裸露亞低溫治療期間皮膚顏色為灰色或發(fā)暗，如果血?dú)庋躏柡投日？刹挥杼幚?。亞低溫治療期間皮膚顏色為灰色或發(fā)暗，如果血?dú)庋躏柡投日？刹粊喌蜏仄陂g患兒心率會(huì)低于90bpm，心電監(jiān)護(hù)心率報(bào)警值設(shè)定為80bpm。亞低溫期間患兒心率會(huì)低于90bpm，心電監(jiān)護(hù)心率報(bào)警值設(shè)定為呼吸機(jī)調(diào)節(jié)無(wú)特殊，三支持（血?dú)狻⒀?、血壓），三?duì)癥同未用亞低溫時(shí)查血?dú)鈺r(shí)注意標(biāo)注當(dāng)時(shí)體溫。呼吸機(jī)調(diào)節(jié)無(wú)特殊，三支持（血?dú)?、血糖、血壓），三?duì)癥同未用亞復(fù)溫

72小時(shí)亞低溫治療后進(jìn)入復(fù)溫程序復(fù)溫

72小時(shí)亞低溫治療后進(jìn)入復(fù)溫程序復(fù)溫1移除低溫毯。2開(kāi)啟輻射式搶救臺(tái)，設(shè)定溫度高于患兒身體溫度0.5攝氏度。3每小時(shí)升溫0.5攝氏度，持續(xù)6小時(shí)到正常溫度。4多功能心電監(jiān)護(hù)，并監(jiān)測(cè)血糖，血?dú)夥治霰ＷC電解質(zhì)穩(wěn)定。復(fù)溫1移除低溫毯。注意事項(xiàng)

1復(fù)溫時(shí)發(fā)生抽搐、呼吸暫停的可能性增大2生后7天查MRI注意事項(xiàng)

停止亞低溫治療指征

1經(jīng)積極呼吸機(jī)輔助通氣SPO2仍低于80%，積極支持治療和血管活性藥物后平均動(dòng)脈壓低于35mmH2O。

2出現(xiàn)心律失?；蛐穆食掷m(xù)低于80bpm。停止亞低溫治療指征

1經(jīng)積極呼吸機(jī)輔助通氣SPO2仍低于8護(hù)理-體溫監(jiān)測(cè)降溫期間每15分鐘測(cè)體溫，達(dá)到目標(biāo)溫度后2小時(shí)一次。復(fù)溫期間1小時(shí)一次。

體溫高于或低于目標(biāo)溫度1℃或患兒出現(xiàn)煩躁、顫抖應(yīng)通知醫(yī)師。護(hù)理-體溫監(jiān)測(cè)降溫期間每15分鐘測(cè)體溫，達(dá)到目標(biāo)溫度護(hù)理Q4H檢查皮膚、Q2H變動(dòng)體位保持冰帽干燥減少冷凝水護(hù)理Q4H檢查皮膚、Q2H變動(dòng)體位Medicalcentersofferinghypothermiashouldbecapableofprovidingcomprehensiveclinicalcare,includingmechanicalventilation;physiologic(vitalsigns,temperature)andbiochemical(bloodgas)monitoring;neuroimaging,includingMRI;seizuredetectionandmonitoringwithaEEGorEEG;neurologicconsultation;andasysteminplaceformonitoringlongitudinalneurodevelopmentaloutcome..MedicalcentersofferinghypotInfantsofferedhypothermiashouldmeetinclusioncriteriaoutlinedinpublishedclinicaltrials(seeTable1).EligibilitycriteriaincludeapHof≤7.0orabasedeficitof≥16mmol/Linasampleofumbilicalcordbloodorbloodobtainedduringthefirsthourafterbirth,historyofanacuteperinatalevent,a10-minuteApgarscoreof<5,orassistedventilationinitiatedatbirthandcontinuedforatleast10minutes.Inaddition,aneurologicexaminationdemonstratingmoderatetosevereencephalopathyisessential.Ifpreferentialheadcoolingisused,anabnormalbackgroundactivityoneitherEEGoraEEGalsoisrequired.InfantsofferedhypothermiashTrainingprogramsandinfrastructureneedtobeestablishedandmaintainedinahighlyorganizedandreproduciblemannertoensurepatientsafety.Eachcenterofferinghypothermiatherapyneedstodevelopawrittenprotocolandmonitormanagementandoutcomes.Trainingneedstoincludeawarenessandtimelyidentificationofinfantsatriskforencephalopathyandanappropriateassessmentofinfantswhohaveencephalopathy.Educationalendeavorsneedtoinvolveobstetriccareproviders;labor,delivery,nursery,andpostpartumpersonnel;andpediatriccareproviders.TrainingprogramsandinfrastrOutreacheducationtocommunityhospitalsneedstobeimplemented.Specificissuesincludetheawarenessandtimelyidentificationofinfantsatriskforencephalopathyandpreventionofextremehypothermiaandhyperthermia.OutreacheducationtocommunitCoolinginfantswhoarebornatlessthan35weeks’gestationorthosewhohavemildencephalopathy,coolingforlongerthan72hours,coolingatatemperaturelowerthanthatusedinpublishedclinicaltrials,andtheuseofadjuvanttherapiesshouldonlybeperformedinaresearchsettingandwithinformedparentalconsentCoolinginfantswhoareborna進(jìn)展Thereareseveralongoingrandomizedclinicaltrialsthataredesignedtoassesstheefficacyof1initiatingcoolingbetween6and12hoursofage,usingadeeperdepthofcooling(32°C),orcoolingforalongerduration(120hours)(NCT01192776,NCT00614744).2lessthan35weeksofgestationalagemaybeavailableinthenearfuture(NCT1793129).進(jìn)展Thereareseveralongoingr進(jìn)展clonidinetherapyNCT01862250xenon(NCT00934700,NCT01545271)topiramate(NCT01241019,NCT01765218)erythropoietin1000U/kgintravenously(NCT01913340)Darbepoetinalfa進(jìn)展clonidinetherapyNCT0NCT01192776fourwhole-bodycoolingtreatmentsforinfantsbornat36weeksg