新生儿脐动脉血气分析在新生儿窒息多器官损害诊断中的应用

Umbilical artery blood gas analysis in the diagnosis of multiple organ damage of neonatal asphyxia

目的探讨新生儿脐动脉血气分析与围产期高危因素、Apgar评分和窒息多器官损害的相关性。方法选择2012年11月至2014年12月课题组协作医院新生儿科和新生儿重症监护病房收治的胎龄〉34周、生后检测脐动脉血p H和BE的窒息新生儿,根据Apgar评分诊断新生儿窒息,根据脐血血气分析将轻度窒息组和重度窒息组分别分为严重代谢性酸中毒组（p H≤7和/或BE≤-16mmol/L）、非严重代谢性酸中毒组（77.2且BE〉-8）。根据围产期缺氧病史、临床表现、实验室检查和影像学检查等诊断新生儿窒息多器官损害。结果共纳入新生儿窒息患儿111例,其中轻度窒息79例,重度窒息32例。（1）脐动脉血气p H和BE与1 min Apgar评分成正相关（p H：r=0.223,P=0.016;BE：r=0.293,P=0.002）。（2）多因素分析显示胎心监护异常是影响血气p H和BE的重要因素（β=0.080,95%CI 0.010~0.160,P=0.025）。（3）重度窒息组多器官损害发生率显著高于轻度窒息组（75.0%比29.1%,χ^2=17.810,P〈0.001）。轻度窒息合并严重酸中毒、非严重酸中毒和无酸中毒组多器官损害发生率分别为52.9%、26.3%、16.7%,酸中毒组多器官损害发生率高于无酸中毒组,差异有统计学意义（χ^2=6.623,P=0.036）;重度窒息合并严重酸中毒、非严重酸中毒和无酸中毒组多器官损害发生率分别为80.0%、76.9%、50.0%,均较高,三组比较差异无统计学意义（χ^2=1.559,P=0.459）。（4）患儿1 min Apgar评分0~3分预测窒息多器官损害的敏感度和特异度分别为52.2%和87.1%;脐动脉血p H≤7和BE≤-16的敏感度分别为42.6%和38.3%,特异度分别为87.6和92.2%。（5）Apgar评分、脐动脉血p H和BE多项指标综合用于窒息后多器官损害敏感度和特异度评价,1 min Apgar评分0~3分、5 min Apgar评分≤5分、脐动脉血p H≤7和BE≤-16 mmol/L具有较高的特异度（71.9%）和敏感度（74.5%）。结论脐动脉血p H和BE可准确评价新生儿窒息和窒息多器官损害,结合生后Apgar评分有助于提高诊断新生儿窒息的准确率及预测窒息多器官损害和预后。

Objective To study the relationship between umbilical arterial blood gas analysis and perinatal high risk factors, Apgar score and multiple organ damage of neonatal asphyxia.Methods Clinical data of cases of neonatal asphyxia in from the Neonatal Department and Intensive Care Unit of our research group from November 2012 to December 2014 were studied. Full term infants and premature infants（ gestational age 34 weeks,birth weight 2 500 g） with neonatal asphyxia,whose umbilical artery blood gas analysis（ including p H and BE） were tested were enrolled in our study.Neonatal asphyxia was diagnosed according to the Apgar score,umbilical artery blood gas analysis,mild asphyxia group and severe asphyxia group were assigned into three groups respectively： severe metabolic acidosis group： p H≤7 and / or BE≤- 16 mmol / L; non-severe metabolic acidosis group： 7 p H≤7. 2,or- 16 mmol / L BE≤- 8 mmol / L,no metabolic acidosis group： p H 7. 2,BE - 8 mmol / L. The diagnosis of multiple organ damage of neonatal asphyxia was made according to the history of perinatal hypoxia,clinical manifestations,laboratory examination and imaging examination. Results There were111 cases in our study（ mild asphyxia： n = 79,severe asphyxia： n = 32）.（ 1） The p H and BE of umbilical artery blood gas were positively related to 1 minute Apgar score（ p H： r = 0. 223,P = 0. 016;BE： r = 0. 293,P = 0. 002）.（ 2） Multi-factor analysis of umbilical artery blood p H and BE showed that abnormal fetal heart rate was an important factor（ β = 0. 080,95% CI 0. 010- 0. 160,P = 0. 025）.（ 3） The incidence of multiple organ damage in severe asphyxia group was significantly higher than that in mild asphyxia group（ 75. 0% vs. 29. 1%,χ~2= 17. 810,P〈0. 001）. The incidence of multiple organ damage in patients suffering from mild asphyxia combined with severe acidosis,non-severe acidosis,and without acidosis was 52. 9%,26. 3%,and 16. 7%,respectively. The incidence of multiple organ damage in patients of mild asphyxia with acidosis was statistically higher than those patients without acidosis（ χ~2= 6. 623,P = 0. 036）. The incidence of multiple organ damage of severe asphyxia were high in all the three groups（ severe metabolic acidosis group： 80. 0%,non-severe metabolic acidosis group：76. 9%,no metabolic acidosis group： 50. 0%）,Differences among the three groups was not statistically significant（ χ~2= 1. 559,P = 0. 459）.（ 4） Apgar score,umbilical artery blood p H and BE were selected to predict the risk of multiple organ damage of neonatal asphyxia. The sensitivity and specificity of1 minute Apgar score of 0- 3 points were 52. 2% and 87. 1%. The sensitivity of umbilical artery blood p H ≤ 7 and BE ≤- 16 mmol / L were 42. 6% and 38. 3%,and the specificity were 87. 6% and92. 2%.（ 5） Comprehensive index（ 1 minute Apgar score of 0- 3 points,5 minutes Apgar score ≤ 5,umbilical artery blood p H ≤ 7 or / and BE ≤- 16 mmol / L） was used to predict multiple organ damage of neonatal asphyxia, the specificity（ 71. 9%） and sensitivity（ 74. 5%） were both high.Conclusions The umbilical artery blood p H and BE could evaluate reliably multiple organ damage of neonatal asphyxia. Combined Apgar scores with umbilical artery blood p H and BE would be help to improve the diagnostic accuracy of neonatal asphyxia and predict multiple organ damage.