一例新生儿胎粪吸入综合征合并肺动脉高压的循证治疗

Evidence-Based Treatment for a Newborn with Meconium Aspiration Syndrome Combined with Persistent Pulmonary Hypertension

目的探讨新生儿胎粪吸入综合征合并肺动脉高压的循证治疗方法。方法针对患儿的临床问题,以肺动脉高压、新生儿、胎粪吸入综合征、治疗为主题词和自由词,计算机检索Cochrane图书馆(2009年第2期)、MEDLINE(1980～2009.6)、ACP Journal Club(1991年1月～2009年9月)和中国期刊全文数据库(1994～2009年6月),查找相关的系统评价、随机对照试验和临床回顾性研究等,并评价所获证据的质量和适用性。结果共纳入2个系统评价、1个Meta分析,9个随机对照试验和1个卫生经济学评价。所获证据显示:①使用体外膜肺治疗可减少患儿的病死率,但会增加治疗成本;②吸入一氧化氮可显著升高患儿的动脉血氧分压、减少使用体外膜肺;③目前尚无评价过度通气、高频通气、控制性碱血症、扩血管药物(硫酸镁、妥拉苏林、前列腺素与前列环素、米力农)及肺表面活性物质治疗新生儿持续肺动脉高压临床效果的随机对照试验;④口服西地那非可降低持续肺动脉高压患儿的氧合指数,降低住院期间患儿的病死率。结合医院现有条件、患儿情况及其家属的意愿,口服西地那非治疗后患儿给氧浓度降低,逐渐撤离呼吸机,一般情况可,1个月后治愈出院。结论采用循证治疗方法,为胎粪吸入综合征合并肺动脉高压的新生儿制定合理的治疗方案,可有效提高治疗效果,提高患儿生存率。

Objective To make an individualized treatment plan concerning a newborn with meconium aspiration syndrome combined with persistent pulmonary hypertension. Methods Based on the clinical questions raised by a newborn with meconium aspiration syndrome combined with persistent pulmonary hypertension, we searched The Cochrane Library （Issue 2, 2009）, MEDLINE （1980 to June 2009）, ACP Journal Club （1991 to June 2009）, and Chinese Journal Fulltext Database （1994 to June 2009） for systematic reviews, randomized controlled trials （RCTs） and case-control studies. The quality of the included studies was assessed. Results A total of 9 RCTs, 1 health economic evaluation, 1 meta analysis, and 2 systematic reviews were considered eligible. The evidence indicated that the use of ECMO in infants of PPHN had shown a decreased risk of death, but not cost-saving from a societal perspective; iNO treatment could improve the PaO2 and resulted in a reduction in the incidence of requirement for ECMO; there were not randomized controlled trials regarding the treatment of PPHN by hyperventilation, high-frequency ventilation, alkali infusion, pulmonary vasodilators （magnesium sulfate, tolazoline, prostaglandin or prostacyclin, milrinone）, surfactant therapy; oral sildenafil could lower oxygenation index （OI） and result in a reduction in the incidence of death. The individualized treatment plans of oral sildenafil were developed based on the available evidence, existing conditions of the hospital, and the values of children with families. After 1 month of treatment, the FiO2 returned to normal and symptoms were alleviated. Conclusion The treatment efficacies and the survival rates in meconium aspiration syndrome combined with PPHN have been improved by determining an individualized treatment plan according to evidence-based methods.