早产儿动脉导管未闭对脑血流动力学的影响及其与脑室周围-脑室内出血的相关性

摘要

目的 研究早产儿动脉导管未闭(PDA)对脑血流动力学的影响及其与脑室周围-脑室内出血(PIVH)的相关性.方法 对85例胎龄≤34周、出生体质量≤2 000 g的早产儿进行前瞻性病例-对照研究,在其出生后至48 h、48 ～ 96 h、96～ 120 h、120 ～ 168 h进行床旁超声心动图和颅脑超声检查,监测有无PDA发生和大脑前、中动脉(ACA、MCA)的收缩期峰流速(Vs)、舒张末期流速(Vd)、平均流速(Vm)、搏动指数(PI)和阻力指数(RI),观察有无PIVH的发生.结果 根据出生后72 h内的超声心动图结果及相应临床症状,将观察对象分为以下3组:(1)有血流动力学意义的PDA组(hsPDA组)23例;(2)无血流动力学意义的PDA组(nhsPA组)38例;(3)无PDA组(non-PDA,nPDA组)24例.3组在胎龄、体质量方面差异无统计学意义.单因素及多因素Logistic回归分析发现出生后48 h内有创机械通气与hsPDA有相关性(x2=11.182,P=0.019; OR=10.06,P=0.039);对3组脑血流动力学参数进行重复测量方差分析发现hsPDA组大脑ACA、MCA的Vd值显著低于nhsPDA组(P=0.000,P=0.001)和nPDA组(P =0.003,P =0.013),而ACA、MCA的搏动指数(PI)、阻力指数(RI)值显著高于其他2组.hsPDA组在出生后7d复查,PDA关闭组(n=7)的RI、PI值较未闭组(n=16)降低,而Vd值升高;生后7 d PDA关闭组与nPDA组(n=24)比较各血流参数的差异无统计学意义.PDA关闭与否各组间PIVH的严重程度差异无统计学意义,然而hsPDA组发生重度PIVH的比例高于其他2组(17.39％比8.33％比5.26％,x2=2.405,P=0.280).结论 早产儿出生后48 h内有创机械通气与发生hsPDA有相关性;早产儿hsPDA可造成脑血流动力学变化,并可能增加重度PIVH的发生率.%Objective To investigate the cerebral haemodynamics change and morbidity of periventricular-intraventricular hemorrhages(PIVH) in premature infants with or without patent ductus ateriosus (PDA).Methods Bedside Echocardiography and transcranial sonography (TCS) were performed on 85 cases of preterm infants in 48 h,48 to 96 h,96 to 120 h,120 to 168 h after birth (gestational age≤34 weeks and birth weight≤2 000 g).PDA,peak systolic velocity (Vs),end-diastolic velocity (Vd),pulsatility index (PI) and resistant index (RI) of anterior and middle cerebral artery(ACA and MCA) and PIVH were monitored simutaneously.Results According to the Echocardiography and clinical symptoms,all the cases were divided into 3 groups:haemodynamic significant PDA group (hsPDA group,n =23),non-hsPDA group(nhsPDA group,n =38) and non-PDA group(nPDA group,n =24).The mean birth weight and gestational age did not differ significantly among the 3 groups.Single and multiple Logistic analysis indicated that invasive mechanical ventilation less than 48 h after birth was related to hsPDA (x2 =11.182,P =0.019; OR =10.06,P =0.039).Repetitive measurement deviation analysis found that:Vd of ACA and MCA were lower in the hsPDA group than those in the nhsPDA group (P =0.000,P =0.001) and the nPDA group (P =0.003,P =0.013),while PI and RI were higher than in the other 2 groups.Compared with non-closed group,at 7 days after birth in hsPDA group,RI and PI of closed group were significantly lower,while Vd was significantly higher.Nevertheless,there was no significant difference in hemodynamic parameters when comparison with nPDA group at 7 days after birth.There was no statistical difference in the grading and severity of PIVH with or without PDA.However,the rate of severe PIVH was found higher in hsPDA group than the other 2 groups(17.39％ vs 8.33％ vs 5.26％,x2 =2.405,P =0.280).Conclusions The invasive mechanical ventilation less than 48 h after birth was probably associated with preterm hsPDA.HsPDA could result in major cerebral haemodynamic changes and increase the morbidity of severe PIVH.