新生儿心包积气诊治分析并文献复习

Neonatal pneumopericardium diagnosis and treatment analysis: a case report and literatures review

目的探讨新生儿心包积气的临床特征及治疗经过,并进行文献复习。方法选择2018年4月21日,于四川省妇幼保健院经剖宫产术分娩后约10 min时,出现气促、呻吟、面色青紫,立即在吸氧下转入四川省妇幼保健院新生儿科治疗的1例生后1 h+22 min心包积气新生儿为研究对象。采用回顾性分析方法,收集该例新生儿的临床病例资料,对其临床特征和诊治经过进行总结。本研究对新生儿心包积气文献进行复习时,设定的文献检索策略为:以"新生儿""心包积气""neonate"及"pneumopericardium"为中、英文关键词,在PubMed数据库、Wily Online Library、万方数据知识服务平台、维普中文科技期刊数据库中,检索新生儿心包积气相关文献,检索时间设定为2008年1月1日至2018年6月30日。总结心包积气新生儿的临床特点及诊治方法。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求。结果对本例心包积气新生儿的研究结果如下。①病史采集:本例新生儿为男性,出生胎龄为36周,无胎膜早破、宫内窘迫及羊水粪染病史,出生体重为2 750 g,生后1、5、10 min Apgar评分分别为9、10、10分。②入院相关检查结果:胸部X射线摄片检查结果提示湿肺合并感染可能,新生儿呼吸窘迫综合征(NRDS)待排查;动脉血气分析结果提示呼吸性酸中毒;心脏彩色多普勒超声检查及血常规、C反应蛋白、电解质检查结果,以及肝、肾功能,均未见明显异常。③治疗与转归:本例新生儿经呼吸机辅助机械通气治疗后,出现大量心包积气,合并气胸、纵隔气肿、间质性气肿、皮下气肿等其他气漏综合征症状,并且合并心包填塞、心排血量低症状。临床对该例新生儿并未立即进行常规心包穿刺术,而是采取胸腔穿刺术+高频振荡通气(HFOV)治疗,新生儿接受此方法治疗后,心包积气于24 h内被完全吸收。新生儿住院治疗30 d后,治愈出院。文献复习结果如下,共计检索14篇新生儿心包积气相关文献,涉及15例心包积气新生儿。其中,8例新生儿未合并心包填塞,除1例因为大量心包积气采取心包穿刺术治疗外,其余7例均采取吸氧处理,8例均治愈出院。另外7例合并心包填塞新生儿均进行心包穿刺术,其中6例进行穿刺术后持续引流,4例联合胸腔穿刺术,2例因放弃治疗后死亡,其余5例均治愈出院。这5例治愈出院新生儿中,2例心包穿刺术失败,失败后,其中1例采取HFOV+胸腔穿刺术及术后引流治疗,1例采取胸腔穿刺术及术后引流+间歇指令通气(IMV)治疗,均获得良好治疗效果。结论对于生命体征、心脏血液动力学稳定的心包积气新生儿,甚至合并心包填塞时,建议首先采取保守治疗策略。胸腔穿刺术+HFOV治疗,可能对改善新生儿心包积气有效,同时又可避免心包穿刺术可能导致的风险。

Objective To explore the clinical features and treatment of neonatal pneumopericardium, and review the literatures. Methods On April 21, 2018, a neonate with pneumopericardium and 1 h+22 min after birth was selected as research subject. The neonate was delivered by cesarean section in Sichuan Provincial Hospital for Women and Children and developed shortness of breath, moan and purple complexion about 10 min after birth, and then was transferred into Department of Neonatology, Sichuan Provincial Hospital for Women and Children. The clinical data of the neonate was collected by retrospective analysis method, and the clinical features, diagnosis and treatment methods of the neonate were summarized. With the following keywords of "neonate" and "pneumopericardium" both in Chinese and English, literatures related to neonatal pneumopericardium were searched from PubMed database, Wily Online Library, Wanfang Data Knowledge Service Platform, and VIP database, and literatures retrieval time was set from January 1, 2008 to June 30, 2018, and clinical features, diagnosis and treatment methods of neonatal pneumopericardium in searched literature were summarized. This study was consistent with the World Medical Association Declaration of Helsinki revised in 2013. Results The results of the neonate with pneumopericardium in this study were as follows.①Family history: the neonate was a boy with 36 weeks of gestational age, and without premature rupture of membranes, intrauterine distress or history of meconium-stained amniotic fluid. His birth weight was 2 750 g, and the Apgar scores were 9, 10, 10 points at 1, 9, and 10 min after birth, respectively.②Results of admission examinations: chest X-ray radiography showed the possibility of wet-lung complicated with infection, and neonatal respiratory distress syndrome (NRDS) to be discharged. Arterial blood gas analysis suggested respiratory acidosis. There was no obvious abnormity in color doppler ultrasound examination of heart, and examinations of blood routine, C-reactive protein and electrolyte, and liver and kidney functions.③Treatment and outcome: under the treatment of ventilator-assisted mechanical ventilation, a large amount of pneumopericardium occurred in the neonate, combined with other symptoms of air leak syndromes, such as pneumothorax, mediastinal emphysema, interstitial emphysema, and subcutaneous emphysema, and combined with pericardial tamponade and decreased cardiac output. Clinically, the neonate was not treated with routine pericardiocentesis, but was treated with thoracentesis and high frequency oscillation ventilation (HFOV) treatment. After the neonate receiving this method, the pericardial gas was completely absorbed within 24 h. After 30 d of hospitalization, the neonate was cured and discharged from hospital. The results of literatures review were as follows. A total of 14 literatures about neonatal pneumopericardium were retrieved, involving 15 cases of neonates with pneumopericardium. Among them, 8 cases were not complicated with pericardial tamponade, except 1 case with massive pneumopericardium was treated by pericardiocentesis, other 7 cases were treated with oxygen inhalation, and all the 8 cases were cured and discharged. Among the 15 cases of neonates with pneumopericardium, the other 7 cases with pericardial tamponade underwent pericardiocentesis, including 6 cases with continuous drainage and 4 cases with thoracentesis. Two neonates died after giving up treatment, the other 5 neonates were cured and discharged. Among the 5 neonates discharged from hospital, 2 neonates had pericardiocentesis failure, and then one of them received the treatment of HFOV, thoracocentesis and drainage, and the other one received the treatment of thoracocentesis and drainage and intermittent mandatory ventilation (IMV), and both of them achieved good treatment results. Conclusions Conservative treatment strategies are recommended for pneumopericardium in neonates with stable vital signs and cardiac hemodynamics, even when combined with pericardial tamponade. Thoracocentesis combined with HFOV therapy may be effective in improving the state of pneumopericardium in neonates while avoiding the risks that pericardiocentesis may cause.