外周动静脉同步换血疗法治疗新生儿重度高胆红素血症常规补钙的必要性

Necessity of conventional calcium supplement in peripheral arteriovenous synchronous blood exchange transfusion on neonatal severe hyperbilirubinemia

目的探讨外周动静脉同步换血疗法,治疗新生儿重度高胆红素血症常规补钙的必要性。方法选取2014年12月1日至2015年11月30日,四川大学华西第二医院新生儿科收治的171例新生儿重度高胆红素血症患儿为研究对象。其中,2014年12月1日至2015年4月30日,接受外周动静脉血同步换血疗法治疗时,采取常规补钙治疗的86例患儿,纳入研究组(n=86);2015年5月1日至2015年11月30日,接受外周动静脉血同步换血疗法治疗时,不采取补钙治疗的85例患儿,纳入对照组(n=85)。统计学比较2组患儿外周动静脉血同步换血疗法治疗前、后血清总钙浓度,低钙血症、高钙血症及血清钙浓度异常发生率。对研究组患儿钙剂相关不良反应发生情况进行分析。本研究遵循的程序符合四川大学华西第二医院伦理委员会制定的伦理学标准,得到该委员会的批准,并与所有患儿监护人签署临床研究知情同意书。结果 (1)2组患儿性别构成比、早产儿与足月儿构成比、出生胎龄、出生体重、日龄、治疗前血清总钙浓度等一般临床资料比较,差异均无统计学意义(P>0.05)。(2)研究组患儿接受外周动静脉同步换血疗法治疗后,血清总钙浓度为(2.51±0.33)mmol/L,高于治疗前的(2.27±0.26)mmol/L,并且差异有统计学意义(t=-8.518,P<0.001)。对照组患儿接受外周动静脉同步换血疗法治疗后,血清总钙浓度为(2.09±0.37)mmol/L,低于治疗前的(2.33±0.35)mmol/L,差异亦有统计学意义(t=5.268,P<0.001)。治疗后,研究组患儿血清总钙浓度高于对照组患儿,并且差异有统计学意义(t=-7.894,P<0.001)。(3)2组患儿接受外周动静脉同步换血疗法治疗后,血清钙浓度异常发生率比较(11.8%vs 11.6%),差异无统计学意义(χ~2=0.001,P=0.975)。研究组低钙血症发生率为2.3%(2/86),低于对照组的11.8%(10/85),2组比较,差异有统计学意义(χ~2=5.837,P=0.016);研究组高钙血症发生率为9.3%(8/86),对照组为0,2组比较,差异有统计学意义(χ~2=6.340,P=0.012)。(4)研究组86例患儿在外周动静脉同步换血疗法治疗过程中,静脉推注钙剂时,8例(9.3%,8/86)出现心动过缓,停止静脉推注钙剂后恢复;静脉推注钙剂结束后,3例(3.5%,3/86)出现局部皮肤发红,1例(1.2%,1/86)出现局部皮肤肿胀,无一例发生高钙危象。结论本研究发现外周动静脉同步换血疗法治疗新生儿重度高胆红素血症过程中,采取静脉补钙措施并不能完全预防低钙血症的发生,反而增加高钙血症、钙剂外渗风险。外周动静脉同步换血疗法治疗过程中,是否有必要采取常规补钙措施,尚需更多研究证实。

Objective To explore the necessity of conventional calcium supplement in peripheral arteriovenous synchronous blood exchange transfusion on neonatal severe hyperbilirubinemia .Methods A total of 171 cases of infants with neonatal severe hyperbilirubinemia who needed to receive blood exchange transfusion were selected as research subjects from December 1 ,2014 to November 30 ,2015 in West China Second University Hospital ,Sichuan University .And 86 cases of infants with neonatal severe hyperbilirubinemia who received conventional calcium supplement in peripheral arteriovenous synchronous blood exchange transfusion from December 1 ,2014 to April 30 ,2015 were enrolled into study group （n= 86） ,while 85 cases of infants who did not received any calcium supplement in peripheral arteriovenous synchronous blood exchange transfusion from May 1 ,2015 to November 30 ,2015 were enrolled into control group （n=85） .The total serum calcium concentrations before and after blood exchange ,the incidence rates of hypocalcemia ,hypercalcemia and abnormal serum calcium concentration of two groups were statistically compared .Adverse reactions related with calcium in study group were analyzed .The study protocol was approved by the Ethical Review Board of Investigation in Human Beings of West China Second University Hospital ,Sichuan University . Informed consents were signed with the guardians of each child .Results ①There were no statistical differences between two groups in the gender ratio ,constituent ratio of premature infants and term infants ,gestational age ,birth weight ,age of infants ,serum total calcium concentrations before blood exchange transfusion and so on （ P 〉 0 .05 ） . ② For study group , the serum total calcium concentrations before and after blood exchange transfusion were （2.27 ± 0 .26） mmol/L and （2 .51 ± 0.33） mmol/L ,respectively ,and the difference was statistically significant （t= -8 .518 ,P〈0 .001） . For control group ,the serum total calcium concentrations before and after blood exchange transfusion were （2 .33 ± 0 .35） mmol/L and （2 .09 ± 0 .37） mmol/L ,respectively ,and the difference also was statistically significant （t= 5 .268 , P〈 0 .001） .After blood exchange transfusion ,the serum total calcium concentration in study group was higher than that in control group ,and the difference was statistically significant （t= -7 .894 ,P〈0 .001） .③ There was no statistical difference between two groups in the incidence rates of abnormal serum calcium concentration （11 .8% vs 11 .6% ,χ2 =0.001 , P=0 .975） .The incidence rate of hypocalcemia in study group was 2 .3% （2/86） ,which was lower than that of 11 .8% （10/85） in control group ,and the difference was statistically significant （χ2 =5.837 ,P=0 .016） .The incidence rate of hypercalcemia in study group was 9 .3% （8/86） ,which was higher than that of 0 in control group ,and the difference was statistically significant （χ2 =6 .340 ,P=0 .012） .④ In study group ,8 cases （9 .3% ,8/86 ） of infants had bradycardia during intravenous injection of calcium supplementation in peripheral arteriovenous blood exchange transfusion therapy , and the symptom recovered when injection was stopped ;after intravenous injection of calcium supplementation ,3 cases （3 .5% ,3/86） had local skin redness ,1 case （1 .2% ,1/86） had localized skin swelling .There was no hypercalcemic crisis occured in study group .Conclusions The calcium supplement cannot completely prevent the occurrence of hypocalcemia in peripheral arteriovenous synchronous blood exchange transfusion for infants with severe neonatal hyperbilirubinemia , but increases the risks of calcium leakage and hypercalcemia .Therefore ,the necessity of conventional calcium supplement during the process of blood exchange transfusion therapy needs to be further confirmed by more studies in the future .