早产儿脐静脉导管相关性肝损伤的临床分析

Liver injury associated with umbilical venous catheter in preterm infants： a clinical research

目的探讨早产儿脐静脉导管（UVC）相关性肝损伤的临床表现、影像学特点、预后及可能危险因素。方法选择2012年12月至2015年11月我院新生儿重症监护病房（NICU）行UVC置管术早产儿并发肝损伤的临床资料。对其性别、胎龄、出生体重、UVC留置时间、置管深度、管端位置、辅助检查结果、治疗、随访及预后进行分析。结果研究期间行UVC置管早产儿共322例，发生UVC相关性肝损伤10例（3．1％），9例为液体外渗肝实质，1例为肝血肿。10例患儿胎龄（28．5±1．7）周，出生体重（1184±207）g，X线检查UVC管端位于T9～T11，9例管端位置低于右侧膈肌水平。10例均经UVC输注肠外营养液。发生肝损伤的中位时间为生后6．0d。有临床表现6例，无临床表现4例。最常见的临床表现为腹胀（5例）、肠鸣音减弱（5例）和肝肿大（4例）。l例肝血肿患儿出现进行性血红蛋白下降（最低34g/L）及休克。肝损伤超声表现为不规则混杂回声区，边界清，内部为液性暗区或低回声区，周围为窄的高回声带。9例液体外渗肝实质的患儿拔除UVC后1周内临床症状好转，l例肝血肿患儿生后9d死亡。肝脏超声随诊8例于生后52d-3．5个月恢复正常，1例于生后9个月仍遗留钙化点。结论早产儿UVC置管后可能并发肝损伤，正确的管端位置有利于减少此类并发症。液体外渗肝实质患儿若早期识别、及时行超声检查并积极治疗，预后较好。

Objective To study the clinical presentations, radiologic features, prognosis, and possible causes of liver injury associated umbilical venous catheter （UVC）. Methods We reviewed database of our NICU from December 2012 to November 2015 and identified preterm infants with liver injury while UVC in place. The gestational age, birth weight, gender, days of UVC in place prior to liver injury, the depth of UVC （ cm）, UVC tip position, ultrasound findings of liver injury, laboratory tests, treatment and outcomes were collected. Results During study period, 322 infants received UVC insertion. Ten cases （3.1% ） of liver injury associated with UVC were diagnosed. Of the ten infants, nine were diagnosed as extravasation of fluid to liver parenchyma, and one was diagnosed as liver hematoma. The mean birth weight was （1 184_＋207） g, mean gestational age was （28.5 -＋ 1.7） weeks. The UVC tip was at thoracic （T） vertebrae T 9 to T 11 level, nine UVC tips were below the right diaphragm level. All UVCs were used for total parenteral nutrition before liver injury was diagnosed. Six infants had clinical manifestations, and four infants were free of clinical manifestations. The most prominent clinical signs were abdominal distension （ n = 5 ）, weak bowel sounds （ n = 5 ） and hepatomegaly （ n = 4 ）. One infant who was diagnosed with liver hematoma also had progressive hemoglobin decline （minimum 34 g/L） and shock. Abdominal ultrasound showed well-limited, irregular, hyperechoic rimmed lesions with heterogeneously hypoeehoic centers or anechoic liquid dark space. Extravasation of fluid to liver parenchyma will restorate within one week after the UVC was remove. One baby who was diagnosed as liver hematoma passed away at 9 days of life. Liver ultrasound of eight returned to normal in 52 days to 3.5 months, and one had calcified lesions at 9 months of age. Conclusions Liver injury is an unusual complication of UVC insertion and usage. Proper positioning of the UVC tip may help to avoid this complication. Early recognition, prompt diagnosis with liver uhrasound examination and timely treatment can lead to better outcome in newborns with extravasation of fluid to liver parenchyma.